NephrologyTier 2Topic

Chronic renal failure - complications of dialysis

Overview

Complications specific to renal replacement therapy itself, distinct from complications of the underlying CKD - spans haemodialysis (HD) and peritoneal dialysis (PD) specific issues
Cardiovascular disease remains the leading cause of death in dialysis patients, substantially exceeding general population risk at every age

HD-specific: intradialytic hypotension (rapid fluid shifts), dialysis disequilibrium syndrome (rapid urea clearance -> cerebral oedema, more common with the first dialysis/high pre-dialysis urea), vascular access complications
PD-specific: peritonitis (the most common serious complication), catheter-related infection, membrane failure over time (loss of ultrafiltration capacity), hernias (raised intra-abdominal pressure)
Shared: accelerated cardiovascular disease, renal bone disease (CKD-MBD), dialysis-related amyloidosis (beta-2-microglobulin, more with long-term HD)

PD peritonitis - cloudy dialysate + abdominal pain + dialysate WCC >100/microL with >50% neutrophils; send dialysate for Gram stain/culture
Vascular access complications (HD) - clinical exam (thrill/bruit for AVF/AVG patency), Doppler ultrasound for stenosis, blood cultures for catheter-related bloodstream infection
Dialysis disequilibrium - a clinical diagnosis of exclusion in a patient with headache/confusion/seizure around dialysis, especially early in the dialysis course

PD peritonitis - empirical intraperitoneal antibiotics covering Gram-positive and Gram-negative organisms pending culture; catheter removal if refractory/fungal
Vascular access stenosis/thrombosis - angioplasty or surgical revision to preserve access; access preservation is a central nephrology priority given limited sites
Dialysis disequilibrium - prevented by slower, gentler initial dialysis sessions in patients with very high pre-dialysis urea
CKD-MBD - phosphate binders, vitamin D analogues, calcimimetics

CKD-MBD (renal bone disease), cardiovascular disease, dialysis amyloidosis, catheter-related bloodstream infection

Access-related complications and infection are the leading causes of dialysis-related hospitalisation
Long-term HD (>10-15 years) carries a cumulative risk of dialysis-related amyloidosis and access exhaustion (running out of usable sites)

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