Hemodialysis complications

Hypotension is the most common complication seen during hemodialysis. It has been reported to occur with approximately 10% to 30% of dialysis sessions, but maybe as frequent as 50% of sessions in some patients.46... 

Evaluate the patient for complications associated with dialysis. Does the patient develop hypotension or cramps during hemodialysis Does the patient have symptoms consistent with peritonitis or a catheter infection ... 

The medical equipment of this subdivision enables providing the whole complex of measures necessary for implementation of autologous and allogeneic transplantations and correction of post-transplantation complications, including the reanimation and intensive therapy, and hemodialysis. 

Hemodialysis may be used after an overdose and when the patient is having complications (eg, severe metabolic acidosis, electrolyte imbalances, renal failure). 

Hemoperfusion is like hemodialysis except that blood is circulated extracorporeally through a column with adsorbent material like resin or charcoal, which binds molecules electrostatically. The molecules likely to be removed are characterized as poorly dialyzable, lipid-soluble, protein bound. Among the indications for hemoperfusion in the management of poisoning include the presence of a poison in a patient with impairment of excretory system (i.e. damaged kidneys), intoxication of a drug known to produce delayed toxicity or metabolized to a more toxic metabolite (i.e. paraquat or methotrexate), deterioration of the clinical state of the poisoned patient despite conservative therapy (i.e. convulsions or cardiac arrhythmias following theophylline intoxication), or development of coma as a complication. 

Epoprostenol is the natural occurring prostacyclin which is formed in vascular endothelial cells. It increases cyclic AMP in the thrombocyte and is a strong platelet aggregation inhibitor. It is used to prevent thrombotic complications during hemodialysis when heparin is contraindicated. As its duration of action is no longer than 30 minutes it has to be given as an intravenous infusion. 

A 64-year-old African-American man developed worsening renal insufficiency, raised creatine kinase activity, diffuse muscle pain, and severe muscle weakness. He had been taking simvastatin for about 6 months and clarithromycin for sinusitis for about 3 weeks. He was treated aggressively with intravenous hydration, sodium bicarbonate, and hemodialysis. A muscle biopsy showed necrotizing myopathy secondary to a toxin. He continued to receive intermittent hemodialysis until he died from infectious complications 3 months after admission. 

Generally, hemodialysis is easier to perform and is associated with fewer complications. It is ideal for low-molecular-weight, polar, water-soluble molecules such as alcohol, salicylate, or lithium. Hemoperfusion is used for drugs that are poorly soluble in water or relatively higher in protein binding. 

Hemoperfusion differs from hemodialysis in that the blood is passed over a resin or charcoal column. The drug becomes bound to the column and the clean blood returned to the body. Hemoperfusion units have adsorptive surface areas of several thousand square meters while hemodialysis devices have an effective dialysis surface limited to several square meters. Obviously, relatively sophisticated technology is required for these procedures and there is the need to prevent clotting in the circuit, which can produce complications. 

A literature review of permanent neurological complications of acute lithium toxicity noted that a cerebellar syndrome is quite common and that neuroleptic drugs can worsen toxicity, as might rapid reduction of raised serum lithium concentrations (182). However, the latter point is speculative at best hemodialysis remains the treatment of choice for severe lithium poisoning. 

There has been a 10-year review of lithium overdose in 304 patients (544). The circumstances were accidental ingestion, mistakes in the quantity of ingested tablets, raised lithium concentrations due to diuretic therapy, renal insufficiency or dehydration, and suicide attempts. About half the patients required management in an intensive care unit, 5% needed hemodialysis, 10% had cardiac disturbances or neurological complications, and 2% died. The authors concluded that modified-release... 

Complications of hemoperfusion include platelet and leukocyte depletion, hypocalcemia, and a mild reduction in body temperature (50). In many cases, these complications are outweighed by the fact that intoxicants are removed more rapidly by hemoperfusion than by hemodialysis. However, an additional consideration is that hemoperfusion clearance tends to decline during therapy as column efficiency declines, presumably reflecting saturation of adsorbent sites (53). In addition, intercompartmen-tal clearance from skeletal muscle and other slowly equilibrating tissues can limit the extent of drug removal by hemoperfusion and result in a rebound of blood levels and possible toxicity at the conclusion of this procedure (54). In some instances, alternative therapies have been developed that are even more efficient than hemoperfusion. For example. 

Central venous catheters are reluctantly used as blood access for hemodialysis because of safety concerns and frequent complications, for example sepsis, thrombosis, and vessel stenosis. Nevertheless, 20% or more of all patients rely on atrial catheters for chronic dialysis because of lack of other access. Potentially fatal risks related to central venous catheters include air embolism (1), severe blood loss (2), and electric shock (3). These specific risks have been substantially eliminated by the inherent design and implantation of Dialock (Biolink Corporation, USA). Dialock is a subcutaneous device consisting of a titanium housing with two passages with integrated valves connected to two silicone catheters. The system is implanted subcutaneously below the clavicle. The tips of the catheters are placed in the right atrium. The port is accessed percutaneously with needle cannulas. 

Marten D, Holtzmuller K, Julia F. Bacterial infections complicating hepatitis C infected hemodialysis dependent patients treated with interferon alfa. Am J Gastroenterol 2002 97(Suppl) 163. ... 

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. 

Severe complications, mostly bone marrow suppression and related complications, occurred in three patients on regular hemodialysis for end-stage renal disease (130). 

Nickel poisoning is well defined in occupational medicine and is occasionally experienced as a complication of exposure to nickel (or nickel-plated) medical devices. Use of nickel-plated dialysis equipment gave rise to nickel poisoning in 23 patients in one hemodialysis unit. They developed nausea, vomiting, weakness, headache, and palpitation, all of which remitted 3-13 hours after the end of dialysis (SEDA-6, 225). 

With double-lumen intravenous catheters for acute hemodialysis, hemperfusion, and plasma exchange, the most common complications are bleeding, hematomas, catheter failure, risk of infection, central vein thrombosis and stenoses, and rarely, air embohsm. Femoral placement is the site associated with the fewest non-in-fectious comphcations [16]. Comphcations of treatment will be discussed below. 

El Minshawy O, Abd El AzizT, Abd El Ghani H. Evaluation of vascular access complications in acute and chronic hemodialysis. Vase Access. 2004 5 76-82... 

Hemodialysis with infusion of a chelator (cysteine, A-acctylcystcinc. NAP) has been reported to be effective in some severe cases of poisoning where renal failure is a complication (Berlin 1986 Goldfrank et al. 1990 Haddad and Winchester 1990). It has been reported to be advantageous to begin the hemodialysis before substantial renal damage has occurred (Haddad and Winchester 1990). 

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