Complications During Hemodialysis and Necessary Interventions

Intradialytic Hypotension

Intradialytic hypotension occurs in approximately 25% of all hemodialysis sessions and requires immediate intervention to prevent serious cardiovascular complications including myocardial ischemia, stroke, and vascular access thrombosis 1
The American Journal of Kidney Diseases recommends that patients at highest risk for intradialytic hypotension include diabetic patients with autonomic dysfunction, elderly patients (≥65 years), those with pre-dialysis systolic blood pressure <100 mm Hg, patients with cardiovascular disease, and those with severe anemia or hypoalbuminemia 1, 3, 4

Stop or reduce ultrafiltration immediately to prevent further blood pressure decline 2
Administer intravenous normal saline bolus (typically 100-250 mL) to rapidly expand plasma volume 2
Place patient in Trendelenburg position (head down, legs elevated) to improve venous return 2
Provide supplemental oxygen to improve tissue oxygenation and reduce symptoms 2
Increase dialysate sodium concentration to 148 mEq/L to maintain vascular stability, particularly early in the session 2
Reduce dialysate temperature from 37°C to 34-35°C to increase peripheral vasoconstriction and cardiac output 2
Switch from acetate-containing to bicarbonate-containing dialysate to prevent inappropriate decreases in total vascular resistance 2
Administer midodrine (oral α1-adrenergic agonist) 30 minutes before dialysis initiation to prevent hypotension 2
Review and adjust antihypertensive medications taken before dialysis, as these frequently contribute to intradialytic hypotension 2
Slow the ultrafiltration rate by extending treatment time when possible 2
Reevaluate the patient's estimated dry weight, as hypotension may indicate it is set too low 2

Catheter-related bloodstream infections carry an 8.5 times higher risk compared to arteriovenous fistulas and require strict adherence to infection prevention protocols 5
Perform hand hygiene before all catheter manipulations 4, 5
Disinfect catheter hubs with antiseptic (soak for 3-5 minutes in povidone-iodine, then allow to dry) when accessing or disconnecting 4, 5, 6
Use alcohol-based chlorhexidine at the catheter exit site during dressing changes 4, 5
Both patient and staff must wear surgical masks during all catheter procedures that remove caps and access the bloodstream 6
Apply dry gauze dressings with povidone-iodine and mupirocin ointment at the exit site to reduce infection rates, especially in patients with nasal Staphylococcus aureus carriage 6

All patients, particularly diabetics and elderly patients, must be monitored for limb ischemia following arteriovenous access construction, as this can lead to tissue loss if not recognized emergently 6
Assess subjectively for coldness, numbness, tingling, and impaired motor function not limited by postoperative pain 6
Assess objectively for skin temperature, gross sensation, movement, and distal arterial pulses compared to the contralateral side 6
Refer emergently to vascular access surgeon if new findings suggestive of ischemia develop 6
Avoid trauma to vessel intima during all access procedures 6

Sudden onset dyspnea during hemodialysis most commonly results from myocardial ischemia, fluid overload, or pulmonary embolism and requires immediate assessment 7
Assess vital signs immediately, including oxygen saturation 7
Obtain 12-lead ECG to evaluate for ischemia or arrhythmias 7
Examine for signs of fluid overload (crackles, elevated jugular venous pressure) 7
Order chest X-ray to identify pulmonary edema, infiltrates, or pneumothorax 7
For suspected cardiac ischemia: obtain ECG immediately and transfer to acute care setting by EMS 7
For fluid overload: adjust ultrafiltration goals and reassess dry weight 7
For rapid ultrafiltration-induced dyspnea: slow ultrafiltration rate 7

Basilar airspace opacification and pulmonary edema in hemodialysis patients typically represent volume overload requiring adjustment of dry weight and ultrafiltration strategy 3
Perform echocardiography to measure cardiac filling pressures and volume status noninvasively 3
Reevaluate and gently probe the prescribed target dry weight to address potential volume overload 3
Increase ultrafiltration with every dialysis treatment while maintaining hemodynamic stability 3
Decrease dialysate sodium concentration to 135-140 mmol/L to reduce thirst, fluid gain, and hypertension 3
Implement strict dietary sodium restriction (typically <2g/day) to reduce interdialytic weight gain 3

Do not use sodium profiling techniques, as they aggravate thirst and fluid gain despite theoretical benefits 3
Avoid overly aggressive ultrafiltration, which can cause intradialytic hypotension and damage residual kidney function 3
Be aware that increased dialysate sodium may lead to increased thirst, interdialytic weight gain, and hypertension 2
Do not allow patients to eat immediately before or during hemodialysis, as this decreases peripheral vascular resistance and promotes hypotension 2