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dialysis complications

in review 6 min read Updated 2026-08-24
nephrology dialysis haemodialysis peritoneal dialysis complications
HD complications centre on access (infection, dysfunction, hypotension) and PD complications on peritonitis and catheter issues. Catheter removal decisions in HD require extra caution — the catheter may be the patient’s last viable access.
HD catheter infection workup
  • blood cultures × 2 (one peripheral, one from each catheter lumen) — draw before antibiotics
  • CBC, exit site swab if purulent
  • inspect tunnel tract for inflammation extending along the subcutaneous tunnel (tunnel infection → likely needs catheter removal)
  • empiric: vancomycin 20–25 mg/kg IV load (give during last hour of HD session; subsequent dosing guided by pre-HD levels) + ceftazidime 2 g IV (gram-negative cover)
  • narrow antibiotics to culture and sensitivity within 48–72 h
  • duration: uncomplicated CRBSI 2–3 weeks; S. aureus or metastatic infection 4–6 weeks
  • if exit site only (no bacteraemia) → cefazolin 1–2 g IV post-HD; catheter stays
  • if uncomplicated CRBSI → catheter exchange over guidewire ± antibiotic lock therapy
  • remove catheter for: persistent bacteraemia, haemodynamic instability, metastatic infection, tunnel infection, Pseudomonas, or fungal organisms
  • before removing → confirm alternative access plan (catheter may be patient’s last option)
PD peritonitis workup and treatment
  • PD fluid: cell count + differential (WBC >100 × 10⁶/L with >50% PMN after dwell ≥2 h = peritonitis) + culture (send in blood culture bottles)
  • blood cultures, CBC, exit site swab
  • empiric IP antibiotics: cefazolin 1 g IP daily + ceftazidime 1 g IP daily × 2 weeks (extend to 3 weeks for severe, S. aureus, or Pseudomonas)
  • if MRSA or PCN allergy: vancomycin IP, redose to maintain trough >15 µg/mL (~every 3–5 days depending on residual renal function)
  • if Pseudomonas → dual anti-pseudomonal therapy (e.g. ceftazidime + IP aminoglycoside or oral ciprofloxacin)
  • oral nystatin prophylaxis during antibiotic course (prevent fungal peritonitis)
  • catheter removal for: fungal peritonitis, Pseudomonas, refractory (not clearing by day 5), relapsing peritonitis, concurrent exit-site/tunnel infection with same organism
emergencies
  • Bleeding AVF/AVG — vascular emergency → direct pressure, call vascular surgery
  • Air embolism — rare (damaged PermCath); terminate HD immediately → left lateral decubitus, Trendelenburg
  • Dialyser reaction — Type A (IgE-mediated anaphylactoid): stop HD, do not return blood, epinephrine/steroids/antihistamine; Type B (milder chest/back pain): supportive
  • Severe intradialytic hypotension unresponsive to fluid — consider sepsis, cardiac tamponade, anaphylaxis

intradialytic hypotension

Excessive ultrafiltration relative to intravascular refilling rate. Most common acute HD complication.

Assessment: volume status and target weight accuracy, sepsis, cardiac dysfunction (new or worsening).

Management — stepwise:

StrategyIntervention
Reduce fluid removalLower UF rate (lengthen session if needed); NS 250 mL boluses PRN
Reduce iatrogenic vasodilationHold antihypertensives pre-HD
Increase PVRMidodrine 10 mg 15–30 min pre-HD; cool dialysate (35.5°C)

If recurrent → reassess dry weight (may be set too low), consider longer/more frequent sessions, or isolated UF + HD split runs.

catheter dysfunction

Causes: fibrin sheath (most common), venous stenosis, volume depletion, catheter malposition.

tPA

Instil tPA (alteplase 1 mg/port, dwell) for suspected fibrin sheath/thrombosis. Contraindicated with recent stroke, major surgery, or active bleeding. Persistent dysfunction despite tPA → IR catheter study or exchange over wire.

HD catheter infections

catheter removal calculus

Removing an HD catheter is not a simple decision. For some patients, the catheter is their last viable access — removal = no dialysis. Always weigh infection severity against access options.

Obtain CBC, wound swab, and line cultures for all suspected infections.

exit site infection

Erythema/warmth/tenderness <2 cm from exit site, with or without fever/bacteraemia.

  • MRSA-negative: cefazolin 1–2 g IV post-HD
  • MRSA-positive/unknown/cefazolin allergy: vancomycin 20–25 mg/kg IV load post-HD, then per-HD dosing guided by levels
  • Catheter removal: generally not required

tunnel infection

Erythema/warmth/tenderness >2 cm from exit site, tracking along subcutaneous tunnel.

  • Gram-positive: cefazolin 2 g IV or vancomycin 20–25 mg/kg post-HD
  • Gram-negative: ceftazidime 2 g IV daily or piperacillin-tazobactam 4.5 g IV q6h
  • Catheter removal: generally required

Positive blood culture with or without local signs.

  • Coverage as per tunnel infection (dual gram-positive + gram-negative)
  • Uncomplicated CRBSI: catheter exchange over guidewire (preserves the vein) is often preferred
  • Remove catheter for: haemodynamic instability, persistent bacteraemia/sepsis, metastatic infection, concurrent tunnel infection, or Pseudomonas/fungal organisms

AVF/AVG complications

  • Dysfunction — absent thrill/bruit and/or inadequate dialysis → fistulogram (IR)
  • Infection — treat as per catheter infections + ultrasound to rule out abscess; may need IR or surgical intervention
  • Bleeding — direct pressure; if uncontrolled → vascular emergency
  • Steal syndrome — hand ischaemia distal to fistula → vascular surgery referral

PD complications

PD peritonitis

Diagnose with 2 of 3:

  1. Abdominal pain and/or cloudy effluent
  2. PD fluid WBC >100 x 10^6/L with >50% PMN
  3. Positive PD fluid culture

Workup: CBC, exit site swab, PD fluid cell count + culture (in blood culture bottles), blood cultures.

Empiric treatment: cefazolin 1 g IP daily + ceftazidime 1 g IP daily x 2 weeks (extend to 3 weeks if Pseudomonas). Consider oral nystatin antifungal prophylaxis during antibiotic treatment to prevent secondary fungal peritonitis (ISPD recommendation).

PCN allergy or MRSA: vancomycin 2 g IP every 5 days x 3 doses.

Catheter removal indications: fungal peritonitis, Pseudomonas, refractory peritonitis (failure to clear after 5 days of appropriate antibiotics), relapsing peritonitis, refractory exit-site/tunnel infection.

PD peritonitis pearls

Cloudy bag + abdominal pain in a PD patient = peritonitis until proven otherwise. Send PD fluid before starting antibiotics but do not delay treatment. Intraperitoneal dosing is preferred over IV.

exit site and tunnel infections

  • Exit site — purulent discharge with or without erythema → cephalexin 500 mg PO TID x 2 weeks (3 weeks if Pseudomonas)
  • Tunnel — clinical inflammation + ultrasound fluid along tunnel → cephalexin 500 mg PO; may need catheter removal

catheter dysfunction

Number one cause: constipation. Confirm catheter position on AXR, then uptitrate laxatives (sometimes requires full bowel prep).

PD hyperglycaemia

Dianeal dextrose solutions deliver a significant glucose load → adjust insulin. Extraneal (icodextrin) has minimal glucose effect — preferred for diabetics and long dwells.

traps

  • Repeating lytes immediately post-HD → they will be transiently abnormal; only recheck if concerned about dialysis adequacy or persistent hyperkalaemia
  • Ordering PICC/CVL in a CKD or dialysis patient → destroys future access sites
  • Correcting mild hypokalaemia in a dialysis patient → risk of rebound hyperkalaemia; only treat if K <2 mmol/L or symptomatic
  • Removing HD catheter reflexively for infection without checking if alternative access exists
  • Forgetting constipation as the cause of PD catheter dysfunction — it is the most common cause

Key references

Suggest a correction dialysis complications