Dr. Ahmed MowafyNephrology Specialist

Mansoura International Hospital

1-common complication2-less common but serious3-non medical complication4-visual and hearing loss

Hypotension (20-30%)Cramps (5-20% )Nausea and vomiting (5-15%)Headache (5%)Chest pain (2-5%)Back painItching (5%)Fever and chills (1%)

Disequilibrium syndromeDialyser reactionArrythmiaCardiac tamponadeIntracranial bleedingHaemolysisAir embolism

Causes(a) volume related - large weight gain - short dialysis time -low target dry weight -non volumetric dialysis -low dialysis solution Na

(B) inadequate vasoconstriction -high dialyser solution temperature -autonomic neuropathy -anti hypertensive medication -eating during treatment -anemia -acetate buffer

(C) cardiac factors -diastolic dysfunction -atrial fibrillation -ischemia(D) uncommon causes -pericardial tamponade - MI -occult Hge -septicemia -dialyser reaction -haemolysis - air embol

A- volume related (1)-use ultrfiltration controller (2)-avoid large intra dialytic weight gain(limit salt

intake) (3)-avoid short term dialysis (4)-choose the patient dry weight carefully (by

bioimpendece devices –ivc dimension u/s – serum ANP level

or by clinical assesment (5)-use an appropriate dialyser solution Na (you can gradually decrease dialyser sodium over the

session starting with 155 then 150 then 145 till 135

(B)- lack of vasoconstriction -low dialysis solution temperature(35.5* with adjusting up or

low) -avoid eating during dialysis -treatment of anemia to avoid tissue ischemia (hypotension

lead to ischemia then adenosine release which impair noreepinephrine leading to VD and hypotension

-drug therapy -midodrine in refractory cases (a -use anti HTN medication after dialysis -use bicarbonate containing dialysis solution (C)- hypotension due to cardiac factors

Make the patient flat (trendelberg position)Saline infusion(100ml bolus or more as nesses)Reduce ultrafiltration rateCheck the patient vital signsBp monitoring 4 times per session

The exact pathogenesis is unknown -but predisposing factors are -hypotension -hypovolemia(pt. below DW) -high ultrafiltration rate -use of low Na dialyser sol. All these factors favors vasoconstriction resulting in

muscle hypoperfusion impairing relaxation.

a- prevention -avoid attacks of hypotension -drugs b-treatment - stritching exercises -Saline infusion (you can use hypertonic sol.

As glucose ) -nefidepine 10mg

Causes

multifactorial -hypotesion -disequilibrium syndrome -dialyser reaction -gastroparesis -diabetes

Management a-prevention of common causes (hypotension ,high blood glucose,.) b-treatment of causes(as hypotension) c-anti emetics should be given -especially in

hypotension induced vomiting associated with reduction of conciousness(aspiration)

Cause are multifactorial -hypotension,HTN,anemia, - disequilibrium syn -neurologic causes(especially hge due to

heparin)Mnagement -acetaminophen can be given

-mild chest and back pain occur in 1-4% of patient and has no ovious cause

-anginal pain Causes are numerous (myocardial ischemia,air embolism, pericarditis,…….)

Is acommon problem to dialysis patient. *causes -low grade hypersensitivity(to dialyzer and

blood circuits) -sitting for aprolonged period of time. -viral or drug induced hepatitis.

Management -antihistaminics is useful -moisturing and lubrication of the skin using

emulient is recommended -reduction of ca po4 product and PTH to the

lower normal range is indicated

Definition. is a set of systemic and neurologic symptoms often

associated with characteristic electroencephalographic findings that can occur either during or following dialysis.

symptome-Early nausea, vomiting, restlessness, headache.- More serious manifestations seizures, and coma.

Etiology (controvesial) -an acute increase in brain water content (or)- acute changes in the pH of the cerebrospinal fluid

during dialysis

Mild disequilibrium -Treatment is symptomatic. - the blood flow rate should be reduced (to

decrease the rate of fluid removal and pH change, -consideration should be given to terminating the

dialysis session earlier than planned.- Hypertonic sodium chloride or glucose solutions

can be administered as for treatment of muscle cramps.

Severe disequilibrium dialysis should be stopped. *The differential diagnosis of severe disequilibrium

syndrome should be considered Treatment of seizures.

The management of coma is supportive. The airway should be controlled and the patient ventilated if necessary.

. Intracranial bleeding Subdural Subarachnoid Intracranial-Metabolic disorders Hyperosmolar states Hypercalcemia Hypoglycemia Hyponatremia-Cerebral infarction-Hypotension Excessive ultrafiltration Cardiac arrhythmia Myocardial infarction Anaphylaxis -Aluminum intoxication (subacute)

Type A (anaphylactic type) -Manifestations. are those of anaphylaxis. Dyspnea, a sense of impending

doom, and a feeling of warmth at the fistula site or throughout the body are common presenting symptoms. Cardiac arrest and even death may supervene.

- TYPE B (Milder cases) present only with itching, urticaria, cough, sneezing,

coryza, or watery eyes. Gastrointestinal manifestations, such as abdominal cramping or diarrhea, may also occur. Patients with a history of atopy and/or with eosinophilia are prone to develop these reactions. Symptoms usually begin during the first few minutes of dialysis, but onset may occasionally be delayed for up to 30 minutes or more.

Etiology -Ethylene oxide -contaminated dialysis solution. -heparin

Management -identification of the cause is difficultSo,it is safest to stop the session immediately -clamp blood lines.anddiscard blood circuits without

returning blood -immediate cardiorespiratory support may be required.

Arrhythmias during dialysis are especially common in patients receiving digitalis and those with coronary artery disease

Prevention and management

Is acatastrophic event that can lead to death unless discovered rapidly and treated

Manifestation

-in setting patient (air tends to travel through cerebral circulation without entering the heart leading to

convulsion,death,loss of conciouss

-in recumbent patient - air reaches heart generating afoam in right ventricle

and pass to lung leading to dyspnea ,cough,chest tightness,arrythnia

- further passage of air to left heart lead to embolisation of arteries of heart and brain

EitiologyThe most common causes of air entry are-arterial needle -prepump arterial tubing -

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