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dialysis complications

in review 4 min read Updated 2026-08-24
nephrology dialysis haemodialysis peritoneal dialysis complications
Contents
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.
emergencies
  • Bleeding AVF/AVG — vascular emergency → direct pressure, call vascular surgery
  • Air embolism — rare (damaged PermCath); terminate HD immediately → left lateral decubitus, Trendelenburg
  • 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; NS 250 mL boluses PRN
Increase refilling25% albumin 100 mL; increase dialysate Na
Increase PVRHold antihypertensives pre-HD; midodrine 5–10 mg 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 options

ProtocolDoseMethod
BlockCathflo 1 mg per portInstil post-dialysis, dwell in catheter
DwellCathflo 1 mg IVDwell for duration of dialysis
AdvanceCathflo 1 mg IVAdvance into catheter for dialysis
SystemicCathflo 4 mg in 50 mL NSSystemic infusion once on machine

Contraindications: recent stroke, major surgery, active bleeding.

Persistent dysfunction despite tPA → interventional radiology catheter study or catheter 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)
  • Catheter removal: generally required

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).

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

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