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   Intradialytic Hy...
   Intra-Dialytic M...
  Nausea and Vomiting
   Dialysis Disequi...
  Dialyzer Reactions
  Air Embolism
   Chest Pain and B...

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  Table of Contents  
Year : 2020  |  Volume : 30  |  Issue : 7  |  Page : 74-76

Complications and their management

Date of Web Publication15-Jul-2020

Correspondence Address:
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0971-4065.289822

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How to cite this article:
. Complications and their management. Indian J Nephrol 2020;30, Suppl S1:74-6

How to cite this URL:
. Complications and their management. Indian J Nephrol [serial online] 2020 [cited 2021 May 7];30, Suppl S1:74-6. Available from:

The HD session is fraught with an increased risk of several complications. These are related to the physiological changes in dialysis, procedural aspects, dialysis treatment dynamics, and procedure.

  Intradialytic Hypotension Top

  1. We recommend that every dialysis session in every patient be monitored for hypotension, with special attention to patients at higher risk.
  2. It is one of the most common complications seen in 25%–60% (depending on the definition) of treatment sessions and can range from asymptomatic-to-severe drop in BP.
  3. It is more common in females, elderly, and those with CVD and neuropathy.
  4. Often related to excessive UF (patients with excessive weight gain or erroneous target weight).
  5. It is accompanied by symptoms such as abdominal discomfort, yawning, sighing, nausea, vomiting, muscle cramps, restlessness, dizziness, syncope, or simply as extreme anxiety. It can precipitate cardiac or cerebral ischemia.


We recommend that intradialytic hypotension be managed in the following steps:

Immediate steps

The dialysis nurse/therapist must immediately initiate the following remedial interventions:

  1. Stop UF
  2. Place the patient in the Trendelenburg/head-down position
  3. Administer 100–200 ml bolus of IV isotonic saline
  4. Do not reduce BFR

Reassess BP after 10 min.

  1. Administer another 100–200 mL normal saline bolus if needed
  2. Continue monitoring BP and heart rate
  3. If the BP does not improve, inform the doctor for medical assessment for refractory hypotension.

After BP restored:

  1. Resume UF at a lower rate if the BP improves
  2. Evaluate antihypertensive medicine intake before dialysis
  3. Consider reassessing the dry weight.

We recommend the following preventative steps in patients with recurrent intradialytic hypotension:

  1. Lower the dialysis solution temperature to 35.5°C or set dialysis solution temperature at 0.5°C below patient's predialysis body temperature
  2. Minimize the UF requirement by reviewing the dietary intake of sodium and fluid.
  3. Minimize the intake of fluid to <1 L/day and thus keep weight gain below 1 kg/day
  4. Target UF rate <10 ml/kg/h by extending duration of the dialysis session if necessary.
  5. UF or sodium profiling programs setting might be helpful in some cases
  6. Consider keeping dialysate sodium above the serum sodium level. In refractory cases, a trial of higher (140–145 mM) dialysis sodium may be tried if interdialytic weight gain is reasonable.
  7. Reassess and consider raising the patient's dry weight.
  8. Administer antihypertensive medications after the dialysis session or change the predialysis drugs to shorter-acting ones.
  9. Maintain predialysis hemoglobin level of at least 10 g/dL
  10. Avoid feeding during or immediately prior to the dialysis session.
  11. Consider using a blood volume monitor
  12. Consider using midodrine 2.5–10 mg 15–30 min before dialysis. Can try carnitine 20 mg/kg/treatment IV or sertraline 25–50 mg orally daily.
  13. Consider using 3.0 or 3.5 mM potassium dialysate solution if predialysis potassium levels permit.
  14. Suggest a cardiac evaluation

  Intra-Dialytic Muscle Cramps Top

Cramps are very common on dialysis. The four most important predisposing factors are intradialytic hypotension (discussed above), hypovolemia, setting of a high UF rate, and use of low-sodium dialysis solution.

As cramps usually accompany or precede hypotension, we recommend that the dialysis nurse/therapist initiate the following remedial interventions:

  1. Minimize or stop UF
  2. Administer IV bolus of 100–200 mL of isotonic saline or 10 ml of 7.5% sodium chloride solution or 25–50 ml of 25%–50% dextrose solution
  3. Forced muscle stretching, or massage may provide relief.
  4. Quinine tablet 2 h before dialysis, Vitamin E (400 IU), carnitine replacement (20 mg/kg IV after each session), oral carbamazepine, and oral amitryptiline can also be tried to help recurrent cramps.
  5. Preventive measures are same as intradialytic hypotension.
  6. Regular exercise regimen on and off dialysis will help

  Nausea and Vomiting Top

About 10% of dialysis sessions are accompanied by nausea or vomiting. This is often associated with hypotension, gastroparesis, dialysis disequilibrium, dialyzer reactions, or incorrectly administered high sodium or calcium in the dialysate.

We recommend that intradialytic vomiting be managed as follows:

  1. Treat intradialytic hypotension as detailed above.
  2. Milder cases may be treated with 10–20 mg of oral domperidone
  3. Antiemetics such as ondansetron 4–8 mg or metoclopramide 5–10 mg may be administered orally or intravenously. Avoid long-term antiemetic therapy
  4. Those who develop recurrent nausea/vomiting can be premedicated with 10 mg of oral domperidone or metoclopramide.
  5. Recurrent vomiting mandates dialysis adequacy assessment, treated water quality check, and gastroenterology evaluation for cause
  6. The nurse/therapist must watch out to prevent aspiration in those who have decreased level of consciousness.

  Dialysis Disequilibrium Syndrome Top

Dialysis disequilibrium syndrome (DDS) most often occurs in first few dialysis sessions if blood urea levels are reduced rapidly, especially those with severe uremia.

DDS manifests with nausea, vomiting, restlessness, headache, blurred vision, seizures, decrease in the level of consciousness, and coma.

We recommend the following management of suspected DDS.

Mild DDS requires symptomatic treatment alone. If suspected to occur while the dialysis session is ongoing, the BFR should be reduced and dialysate flow should be reversed to co-current configuration to decrease the efficiency of solute removal and pH change. Dialysis may be terminated earlier than planned.

If seizures, obtundation, or coma occur, treatment is supportive for seizures and coma.

We suggest that seizures and coma be treated in consultation with neurology specialists and patients may need intensive care support. IV mannitol (10–20 g) or hypertonic saline may be given.

Prevention of DDS is the most important intervention:

Based on the principle for incremental dialysis, especially for those with much advanced azotemia, we recommend the following steps to prevent DDS:

  1. Keep dialysis efficiency low in initial few sessions
  2. Start with a target for URR of 30%. Formal (UKM) urea kinetic modeling may be used here, to decide dialysis time.
  3. Gradually increase blood flow from 150 to 300, duration from 1.5 h to 4 h over three to four dialysis sessions in 1 week if clinical situation permits
  4. Small dialyzer size, co-current dialysate flow, and higher dialysate sodium may be instituted.

  Dialyzer Reactions Top

There are two varieties of dialyzer reactions: an anaphylactic type (type A) and a nonspecific type (type B), with the latter being extremely uncommon.

  1. The type A (anaphylactic type) usually presents in the initial few minutes of dialysis, with features of anaphylaxis. Dyspnea, a sense of impending doom, warmth at the fistula site, urticaria, dyspnea, and collapse are the common presenting symptoms. There may be cardiac arrest and even death. Mild cases may presently only with itching, urticaria, cough, sneezing, coryza, watery eyes, abdominal cramping, or diarrhea.

  2. We recommend the following management of Type A dialyzer reactions:

    1. Dialysis must be stopped immediately, blood lines should be clamped, and the dialyzer and blood lines should be discarded without returning the contained blood. The patient should be treated with immediate administration of IV antihistamines, steroids, and epinephrine and may require supportive care.
    2. The reaction is prevented by ensuring proper rinsing of dialyzers. It is no longer recommended to use EtO sterilized dialyzers.

  3. The nonspecific type B dialyzer reactions present with chest pain, sometimes accompanied by back pain. These typically occur 20–40 min after starting dialysis. Subclinical hemolysis must be ruled out. Typically, the symptoms settle in an hour, allowing dialysis to be continued.

  Air Embolism Top

Air embolism is a potentially fatal condition unless recognized and treated immediately. It is due to introduction of air in bloodsteam via machine or dialysis access. Introduction of 1 ml/kg air is fatal.

The presentation varies with the posture the patient. In the dialysis patient who is lying down, air tends to enter the heart and foam is produced in the right ventricle and may cause arrhythmias. Upstream passage of the foam into the lungs produces dyspnea, cough, and constriction of the chest. The air may embolize into the brain and cause varied neurological dysfunctions acutely, resembling cerebrovascular accidents. The air may embolize into the coronary arteries and cause MIs and heart failure. In those who are seated, the air enters the cerebral venous system, obstructing the venous return and can cause decreased level of consciousness, seizures, and death. We suggest continuous vigilance on the part of the dialysis therapist in monitoring the venous bubble chamber even with an armed air detector.

The dialysis nurse/therapist must recognize foam and air bubbles in the venous blood line as a possible indicator of this catastrophe accompanying the sudden onset of symptoms. Air may inadvertently enter from the arterial needle, arterial tubing, or open end of a dialysis catheter in the presence of a malfunctioning or bypassed air detector.

The nurse/therapist must immediately clamp the venous blood line, stop the blood pump, and tilt the patient to the left side with head and chest facing downward. Medical support is to be obtained immediately with 100% oxygen by rebreather mask, cardiopulmonary resuscitation, or ventilation if required. Depending on the volume of air, rarely the air may need to be aspirated from the heart. We recommend that this complication be prevented by ensuring that the air detector is functioning and that the self-test including the air detector has been passed. The self-test should never be skipped or the air detector disarmed.

  Hemolysis Top

Acute hemolysis during dialysis is usually a medical emergency. The clinical symptoms are back pain, chest constriction, and breathlessness, sometimes accompanied by deepening of skin pigmentation. The other manifestations are port-wine-colored hemolyzed blood in the venous blood line, pink discoloration of plasma in centrifuged blood samples, and a marked fall in the hematocrit. Massive hemolysis can cause severe hyperkalemia with muscle weakness, EKG abnormalities, and ultimately, cardiac arrest.

Narrowing, obstruction, or kinking of blood line or catheter is the usual culprit. Dialysis solutions that are too warm, hypotonic, or contaminated with formaldehyde, bleach, chloramine, copper, fluoride, nitrates, zinc, or hydrogen peroxide may lead to subclinical hemolysis. We recommend that the following actions be performed in case of suspected hemolysis.

The nurse or therapist should be stopped immediately and clamp the blood lines immediately. The hemolyzed blood has very high potassium content and should not be reinfused. The patient is managed conservatively for hyperkalemia and anemia. Hospitalization may be needed, and dialysis is repeated to correct the potassium. Cation exchange resins may suffice for mild cases. The degree of hemolysis may be severe enough to necessitate blood transfusions.

  Headache Top

Many patients develop headache during HD and is usually mild. It rarely may be a manifestation of dialysis disequilibrium. Other causes are reduction of blood caffeine in coffee drinkers or precipitation of migraine or BP changes which may be induced by dialysis. Often the cause is not evident. Treatment with 500 to 1000mg of Acetaminophen is usually sufficient.

We suggest that severe or persistent headache especially one occurring during a dialysis session with heparin anticoagulation must be evaluated by non-contrast computerized tomography of the skull.

We recommend obtaining a history of fall or unreported head injury for dialysis patients in every session prior to administering anticoagulant.

  Chest Pain and Back Pain Top

Mild chest or back pain may occur in less than 5% of dialysis sessions.

If it does not settle with non-specific treatment, we recommend that the patient must be evaluated for other more serious conditions such as angina, hemolysis, air embolism, or pericarditis.

BLACK BOX WARNING: In any apparently well patient with rapid unexplained deterioration, always do the following:

  1. Stop dialysis
  2. Do not return the blood that is in the circuit
  3. Isolate dialysis machine and ensure its proper functioning
  4. Collect dialysate sample for biochemical check
  5. Restart dialysis once all checks are cleared


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Indian Journal of Nephrology
Published by Wolters Kluwer - Medknow
Online since 20th Sept '07