Hemodialysis complications

Sajedah Al Haddad
219036767
Pharm.D Student | College of Clinical
Pharmacy
King Faisal Universit
Contents

Introduction
Complications

Management of Case
complications
Access
Arteriovenous fistula

Arteriovenous graft

Catheters
Arteriovenous fistula: ( preferred access)
Natural, formed by anastomosis of artery and vein.

Lowest incidence of infection and thrombosis, lowest cost,

longest survival
Fistula maturation often takes weeks or months to establish
adequate blood flow.
Arteriovenous graft:
Usually synthetic (polytetrafluoroethylene).

Often used in patients with vascular disease.

Catheters:
Commonly used if permanent access unavailable.

Problems include high infection and thrombosis rates. Low

blood flow leads to inadequate dialysis.
Factors that affect the efficiency of HD
Type of dialyzer used (changes in membrane surface area
and pore size).
Length of therapy.

Dialysis flow rate.

Blood flow rate.

Contents

Introduction
Complications

Management of Case
complications
 HD complications:
The common complications for HD divided into two categories:
1. Intradialytic complications.
2. Vascular access complications.

Complications
 Intradialytic complications
It is the complications that occurred or carried out during hemodialysis.
The most common complications include:
1. Hypertension.
2. Hypotension.
3. Electrolytes imbalances.
4. Cramps.
5. Nausea and vomiting.
6. Headache, chest pain, or back pain.

Complications
 Vascular access complications:
1. Infection.
2. Thrombosis.
3. Bleeding.

Complications
Contents

Introduction
Complications

Management of Case
complications
 Hypertension

Intradialytic complications Hypotension

management:
Cramps

Nausea and vomiting

Headache, chest pain, or back

pain
Management
of
complications
 The pathogenesis is unclear. Hypertension

BP target is <140/80 mmHg

Hypotension
The following interventions, which may
be used in combination but should be Cramps
initiated or adjusted singly, may be
effective:
Nausea and vomiting
1. Reducing target dry weight.
2. Antihypertensive medications.
3. Using a dialysate sodium Headache, chest pain, or back
pain
Management concentration that is lower than
of the patient's serum sodium.
complications
 Reducing target dry weight: Hypertension
Reduce the weight by approximately 0.5kg per dialysis
session or in patient who are unable to tolerate this
0.2kg per session. Hypotension
The reduction in dry weight is best done gradually; we
reduce the target dry weight over days to weeks
Cramps
An important component of successfully attaining a lower
dry weight is to minimize fluid accumulation, which, for
patients on hemodialysis, predominantly occurs in the
intradialytic period. By limiting dietary salt intake to 1500 Nausea and vomiting
to 2000 mg/day.

Avoid or minimized weight gain Headache, chest pain, or back

pain
Management in between dialysis session.
of Increase dialysis time (the length or frequency).
complications
 Antihypertensive medications: Hypertension
It is required when the patient achieve the optimal dry
weight but the BP is high.
Hypotension
First choice is beta blockers (prefer atenolol) 25 or 50 mg
postdialysis trice weekly depending upon the severity of
hypertension ( maximum dose 100mg).
Cramps
Second choice is dihydropyridine ca channel blocker
(CCB) such as amlodipine 10mg as add on therapy or
alternative for beta-blockers.
Nausea and vomiting
Third choice is ACE inhibitor or
ARB as add on when BB and
CCB did not work. Headache, chest pain, or back
pain
Management of
complications
 Is defined as a decrease in systolic Hypertension
blood pressure by 20mmHg or more or
decrease in mean arterial pressure by
10mmHg or more, during or within one Hypotension
hour after HD session.

Cramps
Common in older adults and in people with
diabetes mellitus
Nausea and vomiting

Headache, chest pain, or back

pain
Management
of
complications
 Is defined as a decrease in systolic Hypertension
blood pressure by 20mmHg or more or
decrease in mean arterial pressure by
10mmHg or more, during or within one Hypotension
hour after HD session.

Cramps
Common in older adults and in people with
diabetes mellitus
Nausea and vomiting
The symptoms of intradialytic
hypotension can vary but Headache, chest pain, or back
commonly include dizziness, pain
Management
lightheadedness, nausea, vomiting,
of
muscle cramps, and in severe
complications
cases, loss of consciousness.
 Causes of hypotension includes: Hypertension
1. Fluid removal: Rapid removal of fluid during dialysis
can result in a decrease in blood volume, leading to low
blood pressure. Hypotension
2. Ultrafiltration rate: The rate at which fluid is removed
during dialysis can impact blood pressure. Higher
ultrafiltration rates increase the risk of IDH. Cramps
3. Dry weight: Dry weight refers to the ideal weight of a
patient without excess fluid. If a patient's dry weight is
set too low, excessive fluid removal during dialysis can Nausea and vomiting
occur, leading to IDH.
4. Coexisting medical conditions: Conditions
such as heart disease, autonomic dysfunction, Headache, chest pain, or back
diabetes, hemorrhage and advanced age can pain
Management increase the susceptibility to IDH.
of 5. Medications: Certain medications, such as antihypertensives, may contribute to
complications lowering blood pressure during dialysis.
 Acute management includes: Hypertension
1. Ultrafiltration rate should be decreased or stopped,
depending upon the severity of hypotension.
2. The patient should be placed in the Trendelenburg Hypotension
position, where the body is laid flat on the back (supine
position), with the feet higher than the head by 15 to 30
degrees. Cramps
3. We give an intravenous fluid bolus of 250 to 500 mL.
The optimal replacement fluid is not known. Common
replacement fluids include isotonic saline, hypertonic Nausea and vomiting
glucose, 5 percent dextrose, or albumin solutions.
4. Oxygen should be administered.
Headache, chest pain, or back
pain
Management
of
complications
 Prevention of recurrence: First line Hypertension
1. Reassessing the target weight.
2. Avoiding food intake during dialysis.
3. Withholding antihypertensive agents prior to dialysis. Hypotension
4. Limiting interdialytic sodium intake to reduce
ultrafiltration requirements to 1 to 2 g/day.
5. Make sure that dialysate calcium and magnesium are Cramps
≥2.25 mEq/L and ≥1.0 mEq/L, respectively. Low-
dialysate calcium and magnesium have been associated
with intradialytic hypotension. Nausea and vomiting

Headache, chest pain, or back

pain
Management
of
complications
 Prevention of recurrence: second line Hypertension
1. Cardiac evaluation.

2. Use of cool dialysate may increase hemodynamic Hypotension

stability.

3. Increasing dialysis time by increasing the time per Cramps

sessions or by adding an additional treatment per week.

Nausea and vomiting

Headache, chest pain, or back

pain
Management
of
complications
 Prevention of recurrence: third line Hypertension
1. Medications like:
• Midodrine (selective alpha-1 adrenergic agonist) 2.5
to 5mg, 15 to 30 minutes prior to dialysis. Hypotension
• Hydrocortisone 100mg IV.

2. Change to other mode of dialysis. Cramps

Nausea and vomiting

Headache, chest pain, or back

pain
Management
of
complications
Contents

Introduction
Complications

Management of Case
complications
Subjective Objective Assessment Plan Recommendation

Case
 Objective Assessment Plan Recommen
Subjective dation

65 year old female came to the hospital

complaints of epigastric abdominal pain, vomiting
and nausea, diarrhea, no fever, and patient is not
tolerating orally. The vomitus is not associated
with mucus or blood, and the diarrhea is watery
around 4-5 times per day with back pain patient
said the pain started 7days ago but increase in the
Case
last 3 days.
 Objective Assessment Plan Recommen
Subjective dation

Past Medical History:

1. HTN.
2. DMT2 with complication: History of diabetic foot:
• Ray’s amputation of right big toe and surgical debridement of posterior heel wound of the right
foot in 31/10/2023 on a wheel chair.
• History of right LL angiography and balloon angioplasty right foot debridement in 2/11/2023 on
VAC / Apixaban.
• History of +ve tissue culture Bacteroides fragilis, which completed metronidazole/daptomycin/
Augmentin for total 8 weeks.
• Atonic bladder (Diabetic Cytopathy).

Case 3. ESRD on HD 3 times a week via right U vein-permcath after failure of AVF.
4. History of right eye cataract cataract and pseudo exfoliation.
5. Stroke in 2019.
 Objective Assessment Plan Recommen
Subjective dation

Hemodialysis medications:
• UF 1-1.5 L of tolerate, check pre & post weight re-assess dry
weight.
• IV darbepoetin 50mcg once weekly.
• 0.9% NS 100ml IV bolus three times a week if SBP <90
mmHg during HD.
• Acetaminophen IV 1000mg over 15min PRN.

Case
• Alfacalcidol IV 1mcg push 1/week.
• Alfacalcidol capsules 1mcg PO 1/week.
 Objective Assessment Plan Recommen
Subjective dation

Home medications:
• Captopril tab (LASA) 25mg PO OD.
• VAC
• Apixaban 2.5mg PO BID.
• Aspirin 81mg PO OD.
• Atorvastatin 40mg PO OD.
• Esomeprazole 40mg

Case •
•
Glargine 8U sub OD.
Multivitamins renal formula PO OD.
Subjective Objective Plan
Assessment Recommen
dation

Physical examination:
Review of system:
1. General appearance: Conscious, alert, anxious, no fever or
cough, look ill, pale, not jaundice or cyanosis.
2. HEENT: Normal
3. Cardiovascular: Normal
4. Respiratory: Normal no SOB
5. Gastrointestinal: Vomiting
Cae3 6. Genitoinurinary / Muscle skeletal/ Neurology/ Endocrine: N
7. Abdomen: Soft & lax
8. Lower limb: No edema
Subjective Objective Plan
Assessment Recommen
dation

Vital signs:
General exam: • BP: 124/65 mmHg.
• Height: 155cm • Mean BP: 90 mmHg
• Weight: 65.2kg • Temp: 36.6 C
• BMI: 27 kg/m2 • HR: 82 b.p.m
• RR: 18 b.m
Cae3 • O2Sat: 99
 Subjective Objective Plan
Assessment Recommen
dation

BUN 12.4 mmol/L Phosphorus 1.78 Neutrophil 8.2 Feritin

Lab results: (high) (high)
Day 1 Cr 490 umol/L (high) CO2 19 HGB 12.1g/L (low) 25Dec 1293.4
EGFR 8 mL/min (low) CRP HS 142.7 Albumin-creatinine 7Dec 1550
(high) ratio 6.9 A1
Adj Ca 2.63 mmol/L Uric acid 335 Platelet count 522 HbA1c 5Sep 7.8%
10^9
Na 131 mmol/L (low) Glu R 18.9 (high) PTH 6 Jun 10.2%
K 5.6mmol/L (high) Albumin 38 7Dec 12.53 pH 7.39
Cae3 Cl 94 mmol/L AGAP 26 (high) 5Sep 49.94 PCO2 40
Mg 1.02 mmol/L WBC 10.50 6Jun 25.13 HCO3 24.2 mEq/L
10^9/L
Subjective Objective Plan
Assessment Recommen
dation

• Binary toxin: Neg

• Toxigenic C difficle HS: Neg
• PCR: Covid-19.
• Blood culture: No growth 2days.
• Fecal culture: No salmonella, Shigelle,
Compylobacter, Aeromonas, phsiomonas or vibrio
isolated.
Cae3 • ECG: Normal sinus rhythm. Nonspecific T wave
abnormalities.
Subjective Objective Plan Recommen
Assessment dation

Problem list:
 Acute gastroenteritis secondary to Covid-19 infection.
 Mild hyperkalemia.
 ESRD
 HTN
 DM
Case  DVT prophylaxis.
Subjective Objective Assessment
Plan
Recommen
dation

On the emergency room:

 Acetaminophen 1000mg IV over 15min STAT.
 NS 1000ml/hr STAT.
 Esomeprazole 40 mg IV mix with NS STAT.
 Granisetron 1mg IV STAT.

Case
Subjective Objective Plan Recommen
Assessment dation

Acute gastroenteritis secondary to Covid-19 infection:

 Epigastric abdominal pain, vomiting and nausea, diarrhea, not
tolerated orally.
 PCR: Covid-19.
 CRP HS 142.7 (high)

Case
Subjective Objective Assessment
Plan
Recommen
dation

Management:
 Granisetron 1mg IV PRN.
 Esomeprazole 40mg IV (change to orally once tolerated).
 Acetaminophen 1000mg IV PRN.
 NS 60ml/hr IV today and tomorrow.
 Start ceftriaxone 2g IV for 5 days (increase risk of CFD).
 Sodium bicarbonate 1300mg BID for 3 days.

Case
Subjective Objective Assessment
Plan
Recommen
dation

Acute gastroenteritis secondary to Covid-19

infection:
 After 3 days the pain & nausea still present and the patient
had constipation so order abdomen/KUB X-rays the result
showed fecal loaded colon.
Add therapy:
 Lactulose enema one day STAT
Case  Add maalox plus suspension 10ml TID for 5 days
Subjective Objective Assessment
Plan
Recommen
dation

Acute gastroenteritis secondary to Covid-19

infection:
 The sixth day the nausea still present and the patient want
DAMA
GI consultation:
 Continue PPI therapy and start cyclizine 50mg TID PO.
 EGD as out-patient.
Case  H.pylori test with abdominal U/S.
 OPD for follow up after 4 months or next available.
Subjective Objective Assessment Plan Recommendation

• The pH, PCO2, and HCO3 lab test

were order once the firs day only. I
recommend to monitor them every
day for any changes and
development.

Case
Subjective Objective Plan Recommen
Assessment dation

Mild hyperkalemia:
 K 5.6mmol/L (high)

Case
Subjective Objective Assessment
Plan
Recommen
dation

Management:
 Sodium polystyrene sulfonate (kayxalate) powder 15mg
right after dinner every other day STAT.
 It was controlled after 2 days.
 Low K diet.

Case
Subjective Objective Plan Recommen
Assessment dation

ESRD:
 HD
 Monitor BP any antihypertensive pre dialysis.
 Allow fluids 800-1000ml daily (avoid dehydration).
 Hydrocortisone 100mg IV.
• IV darbepoetin 50mcg once weekly.
• 0.9% NS 100ml IV bolus three times a week if SBP <90 mmHg during HD.
• Acetaminophen IV 1000mg over 15min PRN.
Case • Alfacalcidol IV 1mcg push 1/week.
• Alfacalcidol capsules 1mcg PO 1/week.
Subjective Objective Assessment Plan Recommendation

• I recommend to stop Alfacalcidol oral & IV because it is

causing PTH suppression last PTH result 12.53 (very low)
• PTH test

Case
Subjective Objective Plan Recommen
Assessment dation

HTN:
 On Captopril 25mg PO OD. It was controlled until the
second day she refused to take the medications
 Day1: 124/65 mmHg.
 Day2: 176/73 mmHg.
 Day3: 160/77 mmHg.
Case  Day4: 143/65 mmHg.
 Day5: 136/90mmHg.
Subjective Objective Assessment
Plan
Recommen
dation

Management:
 Start hydralazine 25mg PO OD STAT on second day.
 Nifedipine 30mg PO OD.
 The BP is controlled from day 5.

Case
Subjective Objective Assessment Plan Recommendation

• I recommend to stop hydralazine and nifedipine after the BP is

control because the high BP is due to not adherence not the
medication not working.

Case
Subjective Objective Plan Recommen
Assessment dation

DM:
 Insulin was not given as patient not tolerating orally.
 Keep on glargine 8U for now with sliding scale OD.
 Insulin Aspart recombinant (Lispro) TID with sliding
scale.
 Encourage oral intake as tolerated.
Case
Subjective Objective Plan Recommen
Assessment dation

DVT and GI prophylaxis:

 Apixaban 2.5mg PO BID.
 Aspirin 81mg PO OD.
 Atorvastatin 40mg PO OD.
 Esomeprazole 40mg PO OD.
 Multivitamins renal formula PO OD.
Case
Subjective Objective Assessment Plan Recommendation

Discharged medications:
 cyclizine 50mg TID PO.
 Apixaban 2.5mg PO BID.
 Aspirin 81mg PO OD.
 Atorvastatin 40mg PO OD.
 Esomeprazole 40mg PO OD.
 Multivitamins renal formula PO OD.
 Captopril 25mg PO OD.
 Glargine 8U sub OD.
Case  HD
Subjective Objective Assessment Plan Recommendation

Hemodialysis medications:
• UF 1-1.5 L of tolerate, check pre & post weight re-assess dry
weight.
• IV darbepoetin 50mcg once weekly.
• 0.9% NS 100ml IV bolus three times a week if SBP <90
mmHg during HD.
• Acetaminophen IV 1000mg over 15min PRN.
Case
Thank you