Dialysis: Muath Alismail Reviewed With: Dr. Munir

Dialysis
Muath Alismail
Reviewed with: Dr. Munir
Outlines
● Definitions
● Major modalities
● Indications
● Complications
● ED evaluation of dialysis patients

Definition
Dialysis can normalize fluid balance, correct electrolyte and other solute
abnormalities, and remove uremic toxins or drugs from the circulation
when the patient’s kidneys are unable to do so
How it works?
Movement of solute from an area of higher concentration to an area lower concentration

Major modalities
Hemodialysis
It requires special access to the patient’s

circulation, generally through a surgically
created arteriovenous fistula or
implanted artificial graft or through a
surgically placed tunneled catheter.
Peritoneal Dialysis
The patient’s peritoneum functions as

the dialysis membrane. Dialysate is
infused through a surgically implanted
Silastic catheter (Tenckhoff catheter) that
penetrates the lower abdominal wall.
Fluid exchanges are performed several
times daily, typically by the patient at
home.
Graft
Fistula
Fistula vs Graft
Central Venous Catheter (CVC)
Indications
High Creatinine, BUN?
The serum creatinine and BUN levels themselves are not considered definitive
indications for dialysis.
A creatinine level of 10 mg/dL or BUN level of 100 mg/dL often is used as a

guideline for beginning chronic dialysis in the patient with progressive renal failure.
COMPLICATIONS OF DIALYSIS
Bleeding
Bleeding from the dialysis puncture site can occur hours after a hemodialysis
treatment, either spontaneously or after inadvertent minor trauma to the site.
Hemorrhage can result from aneurysms, anastomosis rupture, and over-

anticoagulation.
Such bleeding can usually be stopped by applying firm pressure to the access site.
The access device should not be forcefully manipulated or irrigated because

rupture of the vessel or venous embolization may result.
Vascular Access Related Complications

Bleeding

Bleeding

Inadequate dialysis flow
Thrombosis and stenosis of the vascular access are the most common causes of
inadequate dialysis flow.
“Grafts” generally have a higher rate of stenosis than do fistulas.
Stenosis or thrombosis presents with loss of bruit and thrill over the access.
It can be treated within 24 hours by angiographic clot removal or angioplasty.

Thrombosis of vascular access can also be treated with direct injection of alteplase,
usually in conjunction with a vascular surgeon.

Infection
-Most infections are caused by staphylococci typical of skin flora. Infections are more likely to occur in
grafts than in native fistulae.
-Redness, hotness, and tenderness over the site often are obvious, but in many cases localizing findings
are absent, and the patient has only fever or a history of recurrent episodes of fever and documented
bacteremia.
- IV vancomycin, 1 to 1.5 g, given as a single loading dose, is the drug of choice in this case because most
access infections are staphylococcal and because this drug is only minimally hemodialyzable and needs to
be given only every 5 to 7 days in the chronic dialysis patient. If a gram- negative infection also is thought
to be likely, as in a patient who has had recent episodes of gram-negative bacteremia, a loading dose of a
second drug (eg, a third-generation cephalosporin or aminoglycoside) also can be administered. Patients
can be reloaded with these drugs at the end of their next hemodialysis session if culture results prove to
be positive.

Hypotension
Hypotension that occurs after dialysis is usually the result of an acute reduction in
circulating intravascular volume and failure of the patient’s homeostatic
mechanisms to compensate for it. Because hemodialysis is episodic, each treatment
must remove the excess fluid that has accumulated over the period since the last
dialysis (generally, 2–3 days), and patients often are relatively volume-overloaded at
the beginning of each treatment. With rapid removal of extracellular fluid, there is
inadequate time for transcellular fluid shifts to replace intravascular volume.
Antihypertensive medications that are required when the patient is in a volume-
expanded state, particularly β-blockers, can contribute to the hypotension when
intravascular volume is normalized.
Non-Vascular Access Related Complications

Acute blood loss
When a hemodialysis patient presents symptomatic angina, or CHF. Dialysis patients are
commonly treated with epoetin or darbepoetin to prevent severe anemia
Serum levels of clotting factors are normal in CKD, but patients are routinely anticoagulated for
each hemodialysis treatment and, although transient thrombocytopenia may occur during the
dialysis procedure, the qualitative platelet defect characteristic of renal failure is an important
factor in bleeding that continues beyond the peridialytic period. This abnormality is only partially
reversed by dialysis but can be corrected by the administration of desmopressin (DDAVP), which
increases the release of factor VIII–von Willebrand factor polymers from vascular endothelium.
Cryoprecipitate and conjugated estrogen both have been shown to produce similar effects for a
longer period.

Shortness of breath
in dialysis patients generally is caused by volume overload. In the patient who

becomes short of breath while being dialyzed, however, other causes must be
sought primarily sudden cardiac failure, pericardial tamponade, pleural effusion, or
pleural hemorrhage. Air embolism and anaphylactoid reactions are unusual causes.
Often, pneumonia or underlying reactive airway disease is responsible.

Chest Pain
Cardiovascular disease is a leading cause of death in patients with CKD, and most
episodes of chest pain occurring during dialysis are likely to be ischemic in origin.
Most dialysis patients have risk factors for coronary artery disease, related to CKD
itself or the underlying condition that led to renal failure, and many have well
documented coronary artery disease.
CKD is commonly associated with hypertension, hyperlipidemia, carbohydrate

intolerance, and disturbances of calcium and phosphorus metabolism

Neurologic dysfunction
Neurologic dysfunction manifesting during or immediately after hemodialysis may

be caused by disequilibrium syndrome, results from rapid changes in body fluid
composition and osmolality during hemodialysis.
It usually occurs only in patients with high BUN levels who are just starting
hemodialysis; the syndrome does not occur with peritoneal dialysis.
Typically, patients have headache, malaise, nausea, vomiting, and muscle cramps
but, in more severe cases, features may include altered mental status, seizures, or
coma. Symptoms resolve over several hours as fluid and solutes are redistributed
across cell membranes.

What is the most common complication of hemodialysis?
(A) Air embolism
(B) Hyperphosphatemia
(C) Hypocalcemia
(D) Hypoglycemia
(E) Hypotension
The answer is (E) Hypotension occurs in up to 30% of hemodialysis treatments,
usually caused by excessive ultrafiltration after underestimating the patient’s ideal
(dry) weight. Other complications that occur less frequently include air
embolism,cerebral edema from dialysis disequilibrium, hemorrhage from accessing
the vascular access site, hypercalcemia, hypermagnesemia, and hypoglycemia.
Peritonitis
It is the most common complication of peritoneal dialysis. Fortunately, it is

generally much less severe than other types of peritonitis and can be treated
readily on an outpatient basis
Most cases of peritonitis are caused by Staphylococcus aureus or Staphylococcus

epidermidis, and most of the remainder (≈30%) by gram- negative enteric
organisms.
Peritoneal Dialysis Complications

Take home message
• The most common problems with vascular access devices used for hemodialysis are thrombosis, hemorrhage,
and infection.
• Peritoneal dialysis associated peritonitis typically presents with cloudiness of the peritoneal dialysis. The
diagnosis is made by a positive Gram stain or finding of more than 100 WBC/mm3 , with at least 50% polys.
• Chest pain in the dialysis patient should be presumed initially to be due to acute coronary syndrome, although
other potentially serious causes may also be responsible.
• Hypotension in CKD patients is often caused by infection, but may also be the result of rapid fluid removal
during dialysis.
• Altered mental status is most commonly due to causes similar to patients without renal disease, but is
sometimes the result of overrapid shifts in intravascular fluid and solutes during dialysis, termed disequilibrium
syndrome.
References

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Dialysis

● ED evaluation of dialysis patients

Movement of solute from an area of higher concentration to an area lower concentration

It requires special access to the patient’s

The patient’s peritoneum functions as

A creatinine level of 10 mg/dL or BUN level of 100 mg/dL often is used as a

Hemorrhage can result from aneurysms, anastomosis rupture, and over-

The access device should not be forcefully manipulated or irrigated because

Vascular Access Related Complications

Vascular Access Related Complications

Vascular Access Related Complications

“Grafts” generally have a higher rate of stenosis than do fistulas.

It can be treated within 24 hours by angiographic clot removal or angioplasty.

Vascular Access Related Complications

Vascular Access Related Complications

Non-Vascular Access Related Complications

Non-Vascular Access Related Complications

in dialysis patients generally is caused by volume overload. In the patient who

Non-Vascular Access Related Complications

CKD is commonly associated with hypertension, hyperlipidemia, carbohydrate

Non-Vascular Access Related Complications

Neurologic dysfunction manifesting during or immediately after hemodialysis may

Non-Vascular Access Related Complications

(A) Air embolism

It is the most common complication of peritoneal dialysis. Fortunately, it is

Most cases of peritonitis are caused by Staphylococcus aureus or Staphylococcus

Peritoneal Dialysis Complications

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