Hemodialysis adverse effects

Water-soluble vitamins removed by hemodialysis (HD) contribute to malnutrition and vitamin deficiency syndromes. Patients receiving HD often require replacement of water-soluble vitamins to prevent adverse effects. The vitamins that may require replacement are ascorbic acid, thiamine, biotin, folic acid, riboflavin, and pyridoxine. Patients receiving HD should receive a multivitamin B complex with vitamin C supplement, but should not take supplements that include fat-soluble vitamins, such as vitamins A, E, or K, which can accumulate in patients with renal failure. 

The uses and adverse effects of raloxifene have been reviewed (8-12). Current work seems to show an altogether positive effect of raloxifene (for example 60 mg/ day) on bone metabolism and serum lipids in post-meno-pausal women on chronic hemodialysis, without significant adverse effects in the short term. However, even the authors of very promising work in this connection point to the difficulty in assessing the long-term safety of the treatment in such women (13). Longer-term work elsewhere has pointed particularly to the occurrence of thromboembolic disease, but also of hot flushes, influenza-like symptoms, peripheral edema, and leg cramps. With the exception of thromboembolism these are unpleasant rather than serious, but they still need to be recorded and studied in this very susceptible group of users. 

As 70% of baclofen is excreted unchanged in the urine (29), accumulation and overdosage of baclofen can occur in patients with end-stage renal disease. Confusion, drowsiness, and coma after standard doses have been reported (30). In addition, abdominal pain was a common adverse effect of baclofen in patients with severe renal insufficiency (31). Toxic reactions characterized by a psychotic syndrome and myoclonus have also been reported (32). Patients with severely impaired renal function typically present with altered consciousness after very small doses of baclofen (31). Symptoms of overdose may resolve after hemodialysis (30,31). 

A 4.6 kg infant with Wiskott-Aldrich syndrome received an accidental overdose of busulfan during preparation for allogeneic stem cell transplantation (37). Hemodialysis was immediately performed and resulted in accelerated clearance of busulfan. There were no acute neurological or hepatic adverse effects, and after cough and by rales for 2 months pulmonary symptoms resolved. There was stable partial donor chimerism after transplantation, but the patient was well 12 months later. 

In contrast, published case reports and case series have provided more insight into the potential nephrotoxicity associated with COX-2-selective inhibitors. Taken together, these case reports suggest that COX-2 inhibitors, like non-selective NSAIDs, produce similar and consistent renal adverse effects in patients with one or more risk factors that induce prostaglandin-dependent renal function (that is patients with renal and cardiovascular disease and taking a number of culprit medications, such as diuretics and ACE inhibitors). Acute renal insufficiency, disturbances in volume status (edema, heart failure), metabolic acidosis, hyperkalemia, and hyponatremia have been commonly described. The duration of treatment with COX-2 inhibitors before the development of chnically recognized renal impairment ranged from a few days to 3-4 weeks. Withdrawal of COX-2 inhibitors and supportive therapy most often resulted in resolution of renal dysfunction, but in some patients hemodialysis was required (102,108-112). 

Anaphylaxis as an adverse effect of hemodialysis has been analysed from records of about 260 000 courses of dialysis... 

Watson AJ. Adverse effects of therapy for the correction of anemia in hemodialysis patients. Semin Nephrol 1989 9(1 Suppl l) 30-4. 

A hemodialysis patient developed refractory pleural effusion with prolonged leukopenia and thrombocytopenia, and another developed sudden cyanotic dyspnea with subsequent death after G-CSF administration for drug-induced neutropenia (93). The authors suggested that hemodialysis patients receiving G-CSF may have an increased risk of adverse effects. 

In an open trial, 7-day triple therapy with omeprazole 30 mg bd, amoxicillin 500 mg tds, and clarithromycin 400 mg bd was safe and effective in eradicating H. pylori in 12 of 13 patients undergoing hemodialysis (10). There were adverse effects in two patients (compared with three of 27 patients not undergoing hemodialysis) and treatment had to be discontinued in one, owing to severe nausea and vomiting. 

Anemia in hemodialysis (10) and mainly in renal transplant patients has been reported (11-13). The suggested mechanism is by an action on erythropoietin, similar to that of ACE inhibitors, which produce the same adverse effect. However, in a small uncontrolled but prospective study, losartan given for 3 months to 15 patients on chronic hemodialysis with anemia, neither altered plasma erythropoietin concentrations nor aggravated the anemia (14). In those taking losartan there was no need for higher doses of co-administered r-Hu Epo in order to correct anemia, in contrast to controls. 

Losartan was evaluated in 406 patients with end-stage renal insufficiency undergoing hemodialysis (24). Only 15 patients discontinued losartan because of adverse effects. In seven the adverse reaction was hypotension. Two patients reported a possible anaphylactoid reaction on treatment with AN69 dialysis membranes. However, nine patients with a history of previous anaphylactoid reactions on treatment with AN69 have not shown this complication with losartan and AN69. 

Polystyrene sulfonic acid has been used as sodium, potassium, and calcium salts. Sodium polystyrene sulfonate has been used to treat hyperkalemia in patients with renal insufficiency and as an adjuvant during hemodialysis. It can be given orally or rectally in all age groups (1). It has also been added to feeding formulae and nutritional supplements to reduce their potassium contents and so prevent hyperkalemia however, the reduction in potassium content was more than balanced by a concomitant increase in sodium content, presumably because of exchange of the sodium with calcium and magnesium (2,3). The uses and adverse effects of sodium polystyrene sulfonate have been reviewed (4,5). 

Tetracyclines are removed by hemodialysis, but significantly less than creatinine or urea (100,116). Severe adverse effects of tetracyclines occur almost exclusively with doses over 1.0 g/day (101) or in the treatment of pyelonephritis with concomitant renal insufficiency. 

Coevoet B, Sebert JL, DeGueris J, et al. Adverse effect of vitamin D metabohtes on osteitis fibrosa in patients on chronic hemodialysis critical role of induced hyperphosphatemia. Miner Electrolyte Metab 1979 2 217. 

Indapamide did not significantly affect the function of patients with renal impairment and did not accumulate in the blood. In addition, the calculated half-life for indapamide in hypertensive hemodialysis patients is found to be very similar to the half-life observed in hypertensive patients with normal and compromised renal function (30). No adverse effect of indapamide on renal function is evident in normal volunteers, hypertensive patients or geriatric hypertensive patients after monitoring glomerular filtration rate or effective renal plasma flow (24). 

Thrombotic complications are frequently encountered when blood is exposed to the surfaces of hemodialysis devices, heart-lung machines, arterial grafts, artificial heart components and other prosthetic devices. The blood platelets are particularly vulnerable to these adverse effects which may include a decrease in platelet count, shortened platelet survival and attendant higher platelet turnover, and altered platelet function. However the interaction of platelets with an artificial surface exposed to blood must be preceded by the interaction of the molecular components of plasma, particularly the plasma proteins, with the surface (1,2). This is due to the prepon-... 

Altmann, P. Barnett, M. E. et al. (2007). "Cognitive function in Stage 5 chronic kidney disease patients on hemodialysis no adverse effects of lanthanum carbonate compared with standard phosphate-binder therapy." Kidney Int, 71(3), 252-9. 

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