Acute Complication During
AcuteHemodialysis
complication during
hemodialysis
Nephrology unit, Phramongkutklao Hospital
F1 Pacharapon Sinchairojkul
Nephrology Unit, Phramongkutklao Hospital
Frequency of intradialytic
complication
Intradialytic hypotension
Intradialytic
hypertension
Cramps
Dialyzer reaction
Hemolysis
Air embolism
Dialysis disequilibrium
syndrome
Ali M, et al. Cureus. 2021;
13(1):e12641.
Dialysis-associated
hypotension
Dialysis-associated hypotension
Chronic persistent hypotension Intra-dialytic hypotension
Predialysis SBP< 100 -mmHg
Decrease in supine SBP >20
mmHg
- Decrease in MAP >10 mmHg
- Dizziness, Frequent yawning
Muscle cramp
Ischemic brain, ischemic heart,
ischemic bowel
Predialysis SBP>160➡️
mmHg nadir SBP<100
Predialysis SBP<160➡️
mmHg nadir SBP<90 } Associate with
mortality
Clinical Kidney Journal, 2020, vol. 13, no. 6,
Consequence Risk Factors
-⬆️Mortality
-⬆️Morbidity -Age ≥ 65
-Inadequate dialysis -Pre-SBP <100 mmHg
-Suboptimal ultrafiltration
-Residual kidney function
-Diabetes
decline
–AV access thrombosis -CVD (CHF, valvular heart
disease)
– Neurocognitive impairment -Autonomic dysfunction
-Severe anemia
stroke -Malnutrition
white matter change
-Hypoalbuminemia
New-onset dementia
-MI -Uremic neuropathy
-LVH -Shorter dialysis vintage
-Bowel ischemia -Greater volume removal
-Interdialytic hypertension
• Flythe JE, et al. Am J Kidney Dis 2012;
59:409.
Perazella MK, et al. Am J Kidney
Dis,2001:S26-S36
JASN March 2015, 26 (3) 724-734
Etiology of IDH
⬇️MAP= ( Preload x %EF ) x HR x
TPR Volume Cardiac Vasodilatation
>High UF rate >13 >Mechanical *Antihypertensives
mL/kg/hr -Myocardium: *Sepsis
>Dialyzer reaction
-⬆️IDWG MI, diastolic >Dialysis temperature⬆️
-Short dialysis dysfunction >⬇️Dialysate Na, Ca
>Low target dry weight -Pericardium: >Food ingestion
Tamponade (Onset 30min, duration 2h)
-Trial and error >Tissue ischemia
(Hemopericardium
-Bioelectric impedance Adenosine-mediated: anemia
in uremic patient)
analysis >Automomic neuropathy
>Electrical Alpha-receptor
-U/S IVC
-Arrhythmia downregulation
-Plasma volume monitor
⬇️Diastolic filling Bezold-Jarisch reflex
>Hypovolumic state, activation
time
hemorrhage >De Jager-Kroch phenomenon
UF rate DOPPS: UFR>10ml/h/kg ⬆️elevated risk of mortality (RR 1.09, p=0.02) , ⬆️30% odds of IDH (P= 0.045)
Kidney International (2006) 69, 1222–1228
Flythe J. et al .Kidney Int. 2011 January ; 79(2):
Bezold-Jarisch reflex De Jager-Kroch
phenomenon
Blood Purif 2020;49:158–
Modification of dialysate composition
Johnson RJ, et al. Comprehensive Clinical
Dialysate sodium
Clinical Kidney Journal, 2020, vol. 13, no. 6,
Acute Management
-Stop ultrafiltration
-Trendelenberg position
-Adjust dialysate Na, Ca , Set ⬇️Temp 0.5-1 C (RR 0.52,
⬆️MAP~12mmHg)
-Fluid replacement NSS 100-250ml (~circulating blood circuit
volume)
Albumin vs Saline
5% albumin is no more effective than normal saline for the
treatment of IDH in chronic hemodialysis patients
-Oxygen therapy
-Vasoconstrictors
-Sodium profile
-Terminate HD if persistent hypotension
Knoll GA, et al. J Am Soc Nephrol. 2004;15(2):487-
92.
European Best Practice in Hemodialysis
-Clinical dry weight reassessment
-Sodium restriction, diuretics
-Appropriate antihypertensive
First-line Approach agents
-No food during dialysis
-HCO3: Dialysis buffer
-Dialysate Temp: 36.5 C
-Assess dry weight
-Cardiac evaluation
-Dialysate Ca 3.0 mg/dL
Second-line Approach -Gradual ↓ of dialysate Temp from 36.5 C (lowest 35 C) or
isothermic treatment
-Blood volume controlled feedback
-↑ in dialysis time and/or frequency
-Midodrine (2.5-5 mg) 30 minutes
Third-line Approach before HD
-L-carnitine supplementation
-Shift to peritoneal dialysis
Prevention of IDH
1.Probing dry weight (Trial&error, Bioimpedance analysis, BVA)
2.Avoid excessive IDWG > 0.5-1 kg/d (Na restriction, dialysate
Na adjustment)
3.Diuretics if presence of RRF
4.Limit UF < 13mL/kg/hr —> ⬆️Session length, Frequency
5.Set low dialysate temperature T 35-36 C
6.Withdraw antihypertensive drugs in dialysis day
7.Avoid food ingestion while dialysis
8.Na profile in some situation
9.⬆️Dialysate Ca
10.Correct anemia if Hct <20-25%
11.Midodrine 5-10 mg before HD 30min (C/I MI patient)
Dialysis-associated cramp
HD-associated Cramps
-Plasma volume contraction
after HD
-compensatory
vasoconstriction
-Impaired muscle
oxygenation
-Skeletal muscle cramp
Associate Factor
-⬇️Na,K,Ca,Mg
-Carnitine deficiency
Physiological Reports. 2021;9:e15114.
Canzanello, VJ, Burkart, JM. Semin Dial 1992;
HD-associated Cramps: Management
-adjust UF
-Forced stretching
-Nifedipine 10mg po (optional)
-Increase plasma osmolarity
-NonDM: 50% glucose 25-50ml iv push
-DM: -Hypertonic NaCl
Disadvantage:post-dialysis thirst, ⬆️IDWG and fluid overload
-Mannitol infusion: 12.5-37.5 gm/dialysis
Canzanello, VJ, Burkart, JM. Semin Dial 1992;
5:299.
HD-associated Cramps: Prevention
Nonpharmacologic Pharmacologic
-Adjusted dry weight, dialysis -Quinine sulfate 250-300 mg po 2 hr
prescription before HD
-Minimize IDWG -Oxazepam 5-10 mg po 2 hr before HD
-Force Stretching of the muscle -Gabapentin 300 mg po before HD
Optional -Vitamin E (400 mg) and vitamin C
-Biofeedback program (250 mg) daily
-Dialysate Na profile/UF profile -L-carnitine (20 mg/kg) IV after HD
-Isolated UF or sequential UF
-Hemodiafitration
-More frequent, short session
Dialysis dysequilibrium
syndrome
Dialysis dysequilibrium syndrome
Urea 100 Urea 100 Urea 70 Urea 40
H2O 100 H2O 100 H2O 40 H2O 40
UT-B expression
⬇️50% Rate urea: intra➡️
extracellular➡️ extracellular <
dialysate
AQP4,9 ⬆️50%
Mistry K. International Journal of Nephrology and Renovascular
Disease 2019:12 69–77
Dialysis dysequilibrium syndrome
Risk factor Symptom
1.First dialysis -N/V, Headache,
2.Children/Elderly Dizziness
3.⬆️BUN >175 mg/dL
4.⬇️Hyponatremia, ⬆️⬆️Hypernatremia
-Muscle cramps
5.Hyperglycemia -Disorientation
6.Metabolic acidosis Confusion
7.Preexisting neurologic abnormalities -Tremor
(head trauma, stroke, seizure, CNS -Visual disturbances
infection)
8.Preexisting cerebral edema -Asterixis
(Hyponat, Hepatic encep, HT -Seizures
emergency) -Coma
9.Conditions associated with ⬆️BBB -Death
permeability
(CNS infection, tumor, inflammation)
Mistry K. International Journal of Nephrology and Renovascular
Disease 2019:12 69–77
Dialysis dysequilibrium syndrome: Prevention
1. Decreased clearance —> ⬇️reduction of plasma osmolality —> ⬇️osmotic gradient post
dialysis
2. Increased time over which clearance is performed
3. Adding another osmotically active agent like sodium or mannitol
Prescription: low flux, low efficiency dialyzer
-1st HD: SL 2 hr, BFR 150-250 mL/min, DFR = 2 x BFR
-2nd HD: ⬆️BFR 50 mL/min and ⬆️SL 30 minutes
High osmolar agents Target URR<40%
-Glucose 450mg/dL = 2-3 mOsm/kg Osmol reduction< 20-24
-Mannitol 1g/kg = 8.5 mOsm/kg mOsm/kg
-Higher DNa (from plasma) 1 mEq/L = BUN 12 mg/dL
Mistry K. International Journal of Nephrology and Renovascular
Disease 2019:12 69–77
Dialyzer reaction
Dialyzer reaction
Diagnosis
Definite: 3 Major, 2Major+1 minor
Probable: 2 Major, 1Major+1
minor, 3 Minors
Type A (4/100000) Type B (3-5%)
-Onset: < 30 minutes -Onset: 20-40 minutes
-Anaphylaxis (IgE)/
-Maybe complement
Anaphylactoid
Symptoms (mild -> severe) activation
-Itching, burning, urticaria, Symptoms
flushing -headache, back and -back and chest pain
chest pain -N/V ,Dyspnea
-N/V , fever, and chills. -hypotension
-Wheezing,Dyspnea
-hypotension
Manish Saha. Clin J Am Soc Nephrol 12: 357–369,
TypeA
TypeB
Comprehensive Nephrology 7th
Dialyzer reaction: management
Management Prevention
**Stop dialysis -Rinse the dialyzers prior to use
-Clamp blood lines -eliminate residual ETO and
-Discard dialyzer and other putative allergens
blood lines -Use steam-sterilized or
-Do not return blood irradiated dialyzer and blood
-Antihistamine lines
-Steroids Check medication
-Epinephrine -Heparin(Anaphylactoid, HIT)
-O2 supplement -ESA
-IV ferrous
Intradialytic hemolysis
Intradialytic hemolysis
Management
-Stop blood pump
-clamp venous blood
lines
-Do not return blood
-Oxygen supplement
-Blood transfusion
-Complications
(hyperkalemia)
-Analysis of for
metal contaminants
Air Embolism
Air embolism
Vulnerable areas
-Arterial needle
-Pre-pump arterial tubing
segment
-Dialyzer
-Opened end of central venous catheter
High BFR —>facilitate rapid
air entry
Air detector:
-detect air bubble (size 50-
200 μm)
-Lethal dose 100-300 ml
-Investigation
>CT brain
>Echocardiography
Level of detection
≥ 0.05 ml/kg (for TTE)
≥ 0.02 ml/kg (for TEE)
Safety Limit of air infusion
Comprehensive Nephrology 7th
0.1mL/kg [bolus infusion] edition
0.03 mL/kg/min
[continuous infusion]
Thank you
