1. Reynel Dan L. Galicinao
HD Nurse Trainee
Nephrology Center of St. Alexius

2. Common Complications during Dialysis
Hypotension
25-60% of treatment sessions
Cardiac arrhythmias
Cramps
Nausea & vomiting
Headache
Back pain
Chest pain
Itching
Fever
5-60% (usually asymptomatic)
5-25%
5-15%
5-10%
2-5%
2-5%
1-5%
1%

3. Less Common Complications
• Air embolism
• Seizures
• Hemolysis
• Severe dialysis disequilibrium
• 1st use syndromes
• Acute urticaria
• Cardiac tamponade

4. • Occur in ARF or CRF if blood urea levels are reduced
too fast, in those with very marked uremia, or preexisting alterations in mental state
• Manifestations:
• headache, nausea, disorientation, restlessness,
blurred vision, asterixis, fits, coma
• even death, occurring during or after dialysis
• Milder symptoms :
• cramps, nausea, dizziness

5. • Probably caused by cerebral edema due to osmotic
influx of water into the brain after removal of urea by
dialysis, before equilibration across cell membranes
occurs.
• Cerebral acidosis may play a role
• Rare in pts initially dialyzed for 2 h at low BFR
• Slow removal of urea minimizes risk
• Initial blood urea reduction during a 1st dialysis should be
<30%.

6. Prophylactic phenytoin
• Used in pts at highest risk (severe uremia, abnormal
mental state)
• 1000 mg loading dose, then 300 mg/day
• Symptoms are self-limiting over a few hrs.
• Pts with severe fitting can be treated with IV mannitol
(10-15 g) or hypertonic saline (5 ml of 23%).

7. •
•
•
•
Occurs in 15-50% of HD sessions
Can be episodic or persistent (less common)
More frequent in pts with lower body mass, cardiac disease
Intradialytic hypotension forms part of a vicious cycle
maintaining HPN & fluid overload
• The response to a drop in BP is frequently to infuse NS or
hypertonic saline, leaving the pt hypertensive, necessitating
further use of antihypertensive agents, which in turn worsen
intradialytic hypotension by inhibiting appropriate reflexes
(tachycardia, vasoconstriction)
• Other s/sx: N&V, cramps, yawning

8. Common Causes of Hypotension
Patient-specific causes
Diabetes
Autonomic neuropathy
Reduced cardiac reserve (especially LVH & diastolic dysfunction)
Arrhythmias
Poor nutritional state
High wt gain
Ingestion of food during HD (increased splanchnic venous pooling)
Antihypertensive agents impairing cardiac stability & reflexes
Septicemia
Release of adenosine during organ ischemia (e.g. induced by hypotension;
adenosine is a vasodilator & inhibits norepinephrine release)

9. Common Causes of Hypotension
Treatment-specific Causes
Rapid fluid removal (high UF rate)
Antihypertensive agent use
Rapid reduction in plasma osmolality (leading to water movement from the
vascular into interstitial compartment)
Warm dialysate
Low sodium dialysate
Low dialysate osmolarity
Use of acetate as buffer (a vasodilator)
Bioincompatibility

10. Less Common Causes of Hypotension
• Pericardial effusion or tamponade
• Reactions to dialysis membranes
• Increased dialysate magnesium
• GI bleeding
• Disconnection of blood lines
• MI
• Hemolysis
• Air embolism

11. Hypotension from excessive UF
• During UF, as water is removed from the vascular
compartment, blood volume is maintained by movement of
water from tissues (refilling).
• This can only occur until the true dry wt is achieved.
• Hypotension will be induced if UF is too rapid or excessive,
as adequate refilling will not occur
• Most pts with ESRD also have diastolic dysfunction, which
impacts on cardiac output especially under conditions of
reduced vascular filling

12. Factors contributing to uncontrolled UF
• HD machines without volumetric control of UF can lead to rapid
fluctuations in UF rates
• Pts who drink too much between HD sessions have excessive
(unachievable) UF requirements during the HD
• This is usually driven by salt consumption (often hidden in foods).
• Salt intake of 0.5 g/day will lead to a 1.5 kg wt gain on average in a 70
kg anuric pt
• Wt gain should be 1 kg/day
• Excess BFR is a rare cause of hypotension
• Too low EDW will lead to hypotension. This occurs especially during
recovery from an acute illness when lost muscle wt is being
recovered.

13. Management of Hypotension
• Episodes of hypotension are uncomfortable & distressing for
pts
• Hypotension lead to morbidity, contribute to cardiovascular
mortality.
• Immediate management requires volume resuscitation:
• place pt head-down
• administer 100 ml bolus of NS (some units use 10 ml of 23% saline,
30 ml 7.5% saline, 50 ml 20% mannitol or albumin solutions)
• reduce UF rate to zero
• if BP does not normalize rapidly, further saline may be given

14. • Hypertonic saline may increase thirst, prevent achievement
of dry wt, worsen fluid overload
• Albumin is very expensive
• In most cases hypotension is due to excess UF, rapidly
corrected
• Other explanations should be sought if BP does not respond
to reasonable saline replenishment, especially cardiac
causes, GI bleeding, sepsis

15. • If hypotension occurs repeatedly, review:
• Dry wt (too low?)
• Use of short-acting antihypertensive agents pre-HD (give drugs
post HD; doesn’t apply to most modern long-acting agents)
• UF rate
• Wt gains between sessions (counsel pt about salt, limit wt gain to
1 kg/day, look for hidden fluids (soup, salt intake)
• Dialysate sodium (keep above plasma sodium)
• Use bicarbonate not acetate dialysate
• Lower dialysate temperature to 34-36°C (makes some pts feel
uncomfortable)
• Increase Hb
• Avoid food intake during HD

16. • If all else fails the following drug treatments can
sometimes help:
• Carnitine 20 mg/kg/treatment IV
• Midodrine 2.5-30 mg 30 min before dialysis;
increases peripheral vascular resistance, increases
venous return & cardiac output; can give second dose
in middle of session;
• Sertraline 50-100 mg/day PO

17. Prevention of hypotension
• Hypotension is unpleasant for pts, makes achievement
of euvolemia difficult, leads to persistent fluid overload
& HPN
• As cardiovascular disease is the major cause of
mortality in ESRD, controlling HPN is of paramount
importance.
• Episodic intradialytic hypotension prevents this
happening.

18. • Time on dialysis
• Slower, longer HD often cures episodic hypotension but is
not favored by pts.
• Pts need educating.
• Sodium ramping or profiling
• Used to minimize symptoms of hypotension & cramping
by optimizing vascular refilling-dialysate sodium is set at a
high level (e.g. 155 mmol/l) during the 1st hr (or 2) of
dialysis, then either stepped downwards in intervals or
reduced gradually over the next 3 h

19. • Sequential UF & isovolemic dialysis
• Helps some pts achieve dry wt without hypotension
• Less effective than sodium profiling
• UF is performed initially without dialysis during the first hr
or 2 of a session, ensuring fluid loss occurs while plasma
urea & sodium concentrations may be highest, and
allowing most rapid refilling of the vascular compartment
• Subsequent dialysis is performed with minimal further UF
• Tends to increase HD session time

20. • Temperature modelling
• The pt's temperature is kept 0.5°C below normal by
reducing the dialysate temperature
• This essentially leads to cutaneous vasoconstriction,
which helps maintain BP during dialysis
• Very effective in preventing hypotension
• Carnitine
• There is some evidence that carnitine deficiency may
contribute to hypotension on dialysis (muscle fatigue,
cardiomyopathy, anemia), and may be helped in some
pts by regular IV carnitine therapy

21. • Occur in up to 90% of HD treatments, mainly towards the
end of dialysis
• A significant cause for early termination & underdialysis
• Cause not entirely clear
• Associated with hyponatremia, hypotension,
hypovolemia, hypoxia, carnitine deficiency.
• Cramps are increased in pts using low sodium dialysate
& requiring increased UF

22. Management of Cramps
• Minimize interdialytic wt gain & need for excessive UF,
prevent dialysis hypotension, higher sodium dialysate, or
sodium profiling.
• IV saline (normal or hypertonic); IV 50% dextrose are very
effective (but saline will contribute to HPN & volume overload)
• Local massage offers some relief
• Carnitine supplementation & quinine sulphate may help
some pts. Quinine is best used 2 h before dialysis. Vitamin E
(400iu)
• Some pts respond to diazepam, carbamazepine,
amitriptyline, phenytoin, or alcohol

23. • Common
• Usually associated with hypotension
• May be a minor manifestation of disequilibrium syndrome
due to excess urea removal in pts with persistent marked
uremia
• Rarely precipitated by caffeine or alcohol withdrawal
during HD

24. Management of N&V, headache
• Treat & prevent hypotension
• Antiemetics & paracetamol may help if not precipitated
by hypotension
• Reduction of BFR (by 25-30%) during 1st hr of HD
sometimes useful (but overall dialysis time must be
lengthened to maintain dose of dialysis)
• Use bicarbonate rather than acetate dialysis

25. • Commonly caused by angina, but also by hypotension,
DDS, hemolysis, air embolism
• Recurrent angina during HD should be investigated
cardiologically, can be treated with nitrates or Β²blockers
• Both agents may cause hypotension

26. • Rare, air detectors will clamp venous blood lines if air is
detected in the return circuit
• May occur while manipulating CVCs
• Introduction of 1 ml/kg air may be fatal
• In sitting pts air tends to move upwards into cerebral venous
circulation and cause fitting & coma.
• In recumbent pts it causes chest pain, dyspnea, chest
tightness, cough; may pass through the pulmonary vascular
bed and embolize into arterioles causing acute neurologic signs
• Foam is usually seen in the venous blood line
• Churning sound may be heard on cardiac auscultation

27. Management of Air Embolism
• Clamp venous line; stop blood pump
• Place pt in left lateral position, with head & chest down
• Administer 100% O2 (enhances nitrogen diffusion out of air
bubbles), cardiopulmonary support as necessary
• Rarely, percutaneous aspiration of air from the ventricle
necessary

28. • Severe hemolysis is rare
• S/sx: chest pain, abdominal or back pain, chest tightness,
headache, nausea, malaise
• Life threatening hyperkalemia can occur if unrecognized
• Should especially be considered if several pts complain
of similar symptoms simultaneously
• Venous blood may develop a darker appearance, plasma
will appear pink in clotted or spun blood samples
• Hb falls

29. Causes of Hemolysis
• Overheating of dialysate
• Contamination with bleach, formaldehyde, or
peroxide from water purification or reprocessing
• Chloramine, nitrates, or copper from water supply
• Hypotonic dialysate
• Kinks in blood tubing
• Malfunctioning blood pump

30. Management of Hemolysis
• Stop blood pump immediately; clamp lines
• Risk of severe hyperkalemia
• Check potassium & Hb
• Hemolysis may continue for several hrs after removal of
precipitant
• Seek cause urgently, as multiple pts may be affected if it
is due to water or a central dialysate problem

31. • AKA: first use syndromes
• Can occur with reused dialyzers
• Severe anaphylactic reactions (type A) typically occurring
within the first few min of HD (but can occur up to 30 min)
• Milder reactions (type B) occur min to hrs after starting
HD

32. Type A Anaphylactic
Type B Mild
Incidence
Rare (max 5/100 000 dialyses)
Common (3-5/100
dialyses)
Onset
Usually 1st 5 min
Up to 30 min 30-60 min
Symptoms Moderate-severe
Anaphylaxis
Mild
Chest pain, back pain
Itching, urticaria, cough, abdominal cramps,
dyspnea, burning, collapse, death
Causes
•Ethylene oxide (previously common, now rare; •Unknown
pts often have IgE anti-ethylene oxide
•Complement activation
antibodies)
•ACE inhibitors & AN69 membranes (activation
of bradykinin system by membrane amplified by
ACEI
•Bacterial contamination of dialysate in high flux
dialysis
•Reused dialyzers (bacterial contamination,
endotoxin, unknown causes)

33. Type A Anaphylactic
Exclude other causes of chest
pain
Supportive
CPR if necessary
O2
IV antihistamines, steroids, adrenaline
(SC/IM) if severe
Outcome
Stop dialysis immediately
Clamp lines & discard
Treatment
Type B Mild
Continue HD
Can be fatal
Seek cause
Symptoms usually resolve
after 30-60 min
Prevention •Seek cause
•Avoid ethylene oxide sterilized dialyzers
•Rinse all dialyzers well, with increased
volumes
•Stop ACE inhibitors, especially if using
AN69 or PAN membrane
•Change membrane type
•If occurs with different dialyzers on
several occasions, try heparin-free dialysis
•Change from cellulose to
modified cellulose or synthetic
membrane
•Reusing dialyzers may help

34. • Contact between blood & the various plastic surfaces within
the extracorporeal circuit initiates platelet adherence,
activation of the intrinsic clotting pathway, thrombosis.
• Clotting is promoted by slow BFR, high Hb, high UF rate,
intradialytic BT, or parenteral nutrition containing lipid.
• Most HD sessions require anticoagulation, usually with
heparin.
• Low MW heparin, prostacyclin, regional anticoagulation
with citrate, heparin-protamine
• Heparin-free dialysis is possible

35. Clotting during dialysis
• Can contribute to anemia & necessitate BT (with risk of HLA
sensitization).
• Leads to underdialysis
• Features:
• Blood becomes very dark in circuit
• Streaking in dialyzer
• Visible clots in bubble trap
• Visible clots in venous lines
• Clots in arterial end of dialyzer (not just small strands)
• Venous pressure will drop if clot forming in dialyzer, or rise
if clot distal to monitor
• Arterial pressure may rise

36. • Aluminum toxicity
• Occurs as a result of aluminum in the water sources used in
the dialysate, ingestion of aluminum-containing antacids
(phosphate binders)
• Assessment:
• Progressive neurological impairment
• Mental cloudiness
• Speech disturbance
• Dementia
• Muscle incoordination
• Bone pain
• Seizures

37. Management of Dialysis Encephalopathy
• Monitor for s/sx
• Notify the physician if dialysis encephalopathy occur
• Administer aluminum-chelating agents as prescribed so
that the aluminum is freed up & dialyzed from the body

38. LEARNING ACTIVITY

39. 1. A client is diagnosed with CRF and told she
must start HD. Client teaching would include which
of the following instructions?
1.
Follow a high potassium diet
2.
Strictly follow the HD schedule
3.
There will be a few changes in your lifestyle.
4.
Use alcohol on the skin and clean it due to
integumentary changes.

40. 2. A client receiving HD treatment arrives at the
hospital with a BP of 200/100, a HR of 110, a RR
of 36. O2 saturation on room air is 89%. He
complains of SOB, +2 pedal edema is noted. His
last HD treatment was yesterday. Which of the
following interventions should be done first?
1.
Administer oxygen
2.
Elevate the foot of the bed
3.
Restrict the client’s fluids
4.
Prepare the client for HD.

41. 3. The client with CRF is at risk of developing
dementia related to excessive absorption of
aluminum. The nurse teaches that this is the
reason that the client is being prescribed which of
the following phosphate binding agents?
1.
Alu-cap (aluminum hydroxide)
2.
Tums (calcium carbonate)
3.
Amphojel (aluminum hydroxide)
4.
Basaljel (aluminum hydroxide)

42. 4. The client newly diagnosed with CRF recently
has begun HD. Knowing that the client is at risk for
DDS, the nurse assesses the client during dialysis
for:
1.
Hypertension, tachycardia, fever
2.
Hypotension, bradycardia, hypothermia
3.
Restlessness, irritability, generalized
weakness
4.
Headache, deteriorating LOC, twitching

43. 5. A client with CRF has completed a HD
treatment. The nurse would use which of the
following standard indicators to evaluate the
client’s status after dialysis?
1.
Potassium level, wt
2.
BUN, creatinine levels
3.
VS, BUN
4.
VS, wt.

44. 6. The client with CRF returns to the nursing unit
following a HD treatment. On assessment the
nurse notes that the client’s temp is 100.2. Which
of the following is the most appropriate nursing
action?
1.
Encourage fluids
2.
Notify the physician
3.
Monitor the site of the shunt for infection
4.
Continue to monitor vital signs

45. 7. The nurse is performing an assessment on a
client who has returned from the dialysis unit
following HD. The client is complaining of a
headache & nausea and is extremely restless.
Which of the following is the most appropriate
nursing action?
1.
Notify the physician
2.
Monitor the client
3.
Elevate the head of the bed
4.
Medicate the client for nausea

46. 8. The client with CRF who is scheduled for HD
this morning is due to receive a daily dose of
enalapril (Vasotec). The nurse should plan to
administer this medication:
1.
Just before dialysis
2.
During dialysis
3.
On return from dialysis
4.
The day after dialysis

47. 9. The client being hemodialyzed suddenly becomes
short of breath and complains of chest pain. The client
is tachycardic, pale, anxious. The nurse suspects air
embolism. The nurse should:
1.
Continue the dialysis at a slower rate after
checking the lines for air
2.
Discontinue dialysis and notify the physician
3.
Monitor VS every 15 minutes for the next hr
4.
Bolus the client with 500 ml of normal saline to
break up the air embolism.

48. 10. Which of the following nursing interventions
should be included in the client’s care plan during
dialysis therapy?
1.
Limit the client’s visitors
2.
Monitor the client’s BP
3.
Pad the side rails of the bed
4.
Keep the client NPO