COMPLICATIONS OF DIALYSIS

2. COMPLICATIONS OF DIALYSIS Dr

3. OBJECTIVES Intra-dialysis complications. Post-dialysis complications. Management of complications. Preventions.

4. The incidence of ESRD is likely to be higher than that reported from the developed world reported annual incidence from developing countries varies from 34 to 240 per million population which is in contrast to an incidence between 98 and 198 pmp per year reported from ESRD registries maintained in the developed countries less than 10% of all patients receive any kind of renal replacement therapy

7. INTRA-DIALYSIS COMPLICATION Hypoxemia --- 90% (5-30% sat. falls) Hypotension � 25 to 55 percent of treatments Cramps � 5 to 20 percent Nausea and vomiting � 5 to 15 percent Headache � 5 percent Chest pain � 2 to 5 percent Back pain � 2 to 5 percent Itching � 5 percent Fever and chills � Less than 1 percent

8. POST-DIALYSIS COMPLICATIONS Infection. Disequilibrium syndrome. Malnutrition. Hemorrhage. Gastrointestinal Effects. Psychiatric Illness (Depression).

9. INTRA DIALYSIS COMPLICATIONS

10. HYPOTENSION Hypotension. Excessive ultra filtration with inadequate vascular refilling Impaired vasoactive or autonomic responses Osmolar shifts Overuse of anti HTNsive drugs Reduced cardiac response Acetate buffer(HCO3) Treat Hypotension. immediately discontinue dialysis and place the patient in a trendelenburg position Infusion of Saline (isotonic/hypertonic)

11. HEADACHE, NAUSEA VOMITING Hypotension.� Longer treatment times. Ultra filtration in association with a large degree of solute removal. Other Causes� Metabolic disturbances (hypoglycemia, hypernatremia, and hyponatremia) Uremia. Subdural hematoma. Medication-induced headaches.

12. CRAMPS Occur toward the end of the dialysis procedure. Because of Significant fluid volume removal by ultra filtration Use of low Na containing dialysate Immediate treatment restoring intravascular volume through the use of small boluses of isotonic saline Prevention Reduced volume removal during dialysis Use of hi conc. of Na in dialysate Has been attempted with the prophylactic use of quinine sulfate at least 2 hours prior to dialysis

13. CHEST PAIN Associated with Hypotension or dialysis disequilibrium syndrome. Additional possibilities should always be considered angina hemolysis rarely air embolism

14. Decision to continue or stop the dialysis treatment because of chest pain is based upon clinical findings, such as Hemodynamic stability, The history Physical examination

15. Angina History, physical examination, electrocardiogram and cardiac enzyme evaluation should be performed. If dialysis is continued administration of oxygen and aspirin reduction of the desired ultra filtration administration of nitrates or morphine�should be considered. Prevented with the administration of nitrates and/or beta blockers.(hypotension)

16. Hemolysis Findings suggestive of hemolysis C/O chest pain, shortness of breath or back pain Port wine appearance of the blood in the venous line Pink color of the plasma in centrifuged specimens Cause Overheating Hypotonicity Kinking of dialysis tubing. Biochemical/toxin insult Decreased life span Management stop dialysis immediately clamp the blood lines (do not return the blood, K ) prepare to treat hyperkalemia and the potentially severe anemia

17. AIR EMBOLISM Rare Symptoms Neurological Cardiovascular Treatment Clamping the venous line and stopping the blood pump. Cardio respiratory support. Left sided�supine position with the chest and head tilted downward. Prevention Adequate function of monitoring devices on dialysis machine

18. ARRHYTHMIAS In pts. on maintenance dialysis Ventricular, SVT arrhythmias Risk Factors coronary artery disease, advanced age, myocardial dysfunction, and left ventricular hypertrophy Incidence of arrhythmias enhanced because of rapid fluctuations in fluid, electrolyte and pH, induction of hypoxemia. Treatment same as non-dialysis person, with appropriate dosing according to renal status.

19. Hypoxemia A fall in arterial PO2 is a frequent complication of hemodialysis that occurs in nearly 90% of patients. The drop ranges from 5 to 35 saturation, and reaches its peak between 30 - 60 minutes after beginning dialysis. Increase risk for patients with underlying cardiopulmonary disease. Oxygen Inhalation.

20. POST DIALYSIS COMPLICATIONS

21. INFECTIONS Infections are common d/t: inadequate dialysis Malnutrition frequent use of blood transfusions to correct anemia Impaired host immunity Peritonitis Vascular access Bacteremia Sepsis Generally immunocompromised, more risk of developing UTI, Fungal infections etc Use of Topical Antimicrobials Mupirocin, Povidone-iodine Triple agents - bacitracin, gramicidin, and polymyxin B

22. Disequilibrium syndrome Neurologic symptoms of varying severity headache, nausea disorientation, restlessness blurred vision, and asterixis confusion, seizures, coma, and even death Cause: Cerebral edema due to, a reverse osmotic shift induced by urea removal fall in cerebral intracellular pH Treatment by raising the plasma osmolality with either 5 mL of 23 percent saline or 12.5 g of hypertonic mannitol

23. Prevention (in high-risk patients) Prophylactic use of phenytoin hypertonic mannitol High Risk Patients: New patients, particularly if the BUN is markedly elevated ( > 175 mg/dL) severe metabolic acidosis older age presence of other central nervous system disease i.e. seizures.

24. Hemorrhage Peptic Ulcer Hemorrhagic Esophagitus Angiodysplasia Haemorrhagic Pericarditis (3-5% of Dialysis pt) Sub Dural Haematoma Spontaneous retroperitoneal bleeding (Rare)

25. GIT EFFECTS Dyspepsia Peptic Ulcer Disease (PUD) UGIB (PUD/Angiodysplasia) Gastroparesis Idiopathic Dialysis Ascities Straw-colored appearance High protein content (3 to 6 gm/dL) Leukocyte count -25 to 1600 cells/mm3

26. PSYCHIATRIC ILLNESS Account for a 1.5 to 3.0 times higher rate of hospitalization among dialysis patients compared to those with other chronic illnesses. Affective disorders, particularly depression Organic brain diseases (eg, dementia and delirium) Schizophrenia and other psychoses

27. DEPRESSION Exclude uremia and assure adequate dialysis before diagnosing depression, since the symptoms of depression and those originating from a somatic process or disorder are similar: Signs and symptoms of under-dialysis, including anorexia and failure to thrive, may mirror those of depression. Correction of fluctuating blood pressure, nausea, or other gastrointestinal complaints may improve quality of life and lift spirits in chronically ill patients; thus, such therapy may effectively treat psychosocial markers suggesting depression. Common complaints in the dialysis patient, such as chronic fatigue, weakness, and constipation, may reflect a psychosocial disturbance. mental status exam is required to help distinguish an encephalopathy from depression Antidepressants

28. FISTULA RELATED COMPLICATION Infections Thrombus Aneurysm Vascular Steal syndrome Venous Hypertension (Sore thumb Syndrome) High cardiac output failure (shunting of blood)

31. MEDICATIONS S/E Erythropoietin Hypertension Encephalopathy with Seizure Hyperkalemia Skin irritation Vascular access thrombosis

32. MALNUTRITENT A variety of causes have been implicated in the development of malnutrition Malabsorption and gastrointestinal motility disorders Impaired taste acuity Anorexia Chronic constipation Depression Several dialytic and hormonal-metabolic factors Drugs Effect

33. Dialysis Related Amyloidosis The carpal tunnel syndrome is one of the most frequent presenting manifestations DRA. Average time to onset being approximately 8 to 10 years after the initiation of dialysis.

34. Mortality in dialysis pt annual mortality rate of dialysis patients is 20- 30% Together, uremic complications and infections account for 57% of all deaths ischemic heart disease�<30% prevalence of hepatitis B and C virus infections varies between 4 to 12% and 4 to 16%, respectively