Cureus. 2021 Jan; 13[1]: e12641. Monitoring Editor: Alexander Muacevic and John R Adler Introduction Hemodialysis is a vital management option for end-stage renal disease [ESRD] patients. With adequate hemodialysis, patients can have a good quality of life but complications do occur during the session,
which can be minor to life-threatening. The objective of this study was to assess the frequency of acute complications during this procedure.Abstract
Material and methods
An observational, cross-sectional study was conducted at Jinnah Postgraduate Medical Centre, Karachi, Pakistan. Patient data were collected about access, comorbid conditions, frequency and duration of hemodialysis, and intradialytic complications. Those with acute kidney injury were excluded.
Results
There was a total of 94 patients, with a mean age of 45.51±13.29 years, of which 62 [66%] were males and 32 [34%] were females. Diabetes mellitus was the most common cause of ESRD [47.9%, n=45]. Patients on twice and thrice-weekly sessions were 51 [54.3%] and 43 [45.7%], respectively. The most common complication was hypotension [28.7%], followed by hypertension [17%], and nausea/vomiting [11.7%]. The arteriovenous fistula was the most common access used [75.5%, n=71]. Most patients were found to be on hemodialysis for more than five years [51.1%, n=48].
Conclusion
Blood pressure changes are critical while performing hemodialysis, just like we found hypotension as the most common intradialytic complication in our results, followed by hypertension. Others were fever, muscle cramps, and nausea/vomiting. a prospective follow-up study shall be done to have comparative and long-term results related to the acute and chronic complications of dialysis.
Keywords: hemodialysis, arteriovenous fistula, hypotension, seizures, dialyzer reaction
Introduction
Globally, the prevalence of kidney diseases has increased in the last two decades, currently standing at 11-13% [1]. This might be due to the increasing burden of diabetes mellitus [DM] [the leading cause of kidney disease], hypertension, glomerular diseases, renal stone diseases, and the use of over-the-counter medications. Treatment for end-stage renal disease [ESRD] is renal replacement therapy [RRT] in the form of dialysis [either hemodialysis or peritoneal] or renal transplantation. Hemodialysis is one of the most common medical facilities used in the world, with more than two million patients enrolled for regular hemodialysis annually [2]. The entire procedure takes three to four hours, given thrice a week in the developed world and twice a week in the developing countries [3].
They are likely to have comorbid disorders like ischemic heart disease, peripheral vascular disease, cerebrovascular disease, and chronic obstructive pulmonary disease, all of which are associated with increased morbidity and mortality. Though hemodialysis is a life-saving treatment for ESRD patients, it is one of the relatively safe procedures having a mortality of 1/75,000 treatments. However, it is associated with various complications, some of which are acute, occurring during or immediately after the session, while others are chronic complications [4].
Although the etiology of these complications is multifactorial and poorly understood, some are machine and procedure-related factors like the type of dialyzer, dialysis solution [acetate or bicarbonate], conductivity, blood flow, volume, and rate of ultrafiltration, an anticoagulant used, and contamination of Reverse Osmosis water. We call them technical complications. These are rare nowadays because of the advancement in technologies and equipment of hemodialysis. Other causes are patient-related factors like the primary disease, comorbid conditions, medications, intradialytic weight gain, frequency, length of the session, and duration of hemodialysis [5].
Among the acute complications reported worldwide, the most common is hypotension [25-55%]. The National Kidney Foundation-Kidney Disease Outcomes Quality Initiative defines hypotension as a decrease in systolic blood pressure [SBP] >20 mm Hg or a decrease in mean arterial pressure by 10 mm Hg [5]. Other complications are arrhythmias [50%], nausea/vomiting during and after the session [15%], muscle cramps [20%], headache, chest pain [5%], back pain [5%], hypertension, fever, and chills due to dialyzer reaction [6,7]. There is a difference in the frequencies and pattern of acute complications during hemodialysis in different regions of the world, depending upon genetic and ethnic variations, and the primary cause of ESRD. Moreover, few local studies reported differences in the percentage of complications as well [8].
The prevalence of ESRD in Pakistan is 14.6% [9]. Moreover, with the highest growing incidence of chronic diseases ultimately leading to ESRD, it is crucial to evaluate the pros and cons of the management options [9]. The purpose of this study is to determine the various complications that most commonly occur during hemodialysis so that precautionary steps can be sorted out. This will enhance the knowledge about the complications of hemodialysis in the medical staff as well as the patients to help them in deciding for treatment.
Materials and methods
This is a cross-sectional study conducted at the Department of Nephrology, Jinnah Postgraduate Medical Center, Karachi, Pakistan from March to August 2020, after approval from the ethical review board of the institution [N0.F.2-81-IRB/2020-GEN/49836/JPMC]. Informed consent was taken from the patients for enrollment in the study.
All the patients above the age of 18 years on hemodialysis for more than three months were included. Pregnant patients, those with acute kidney injury, dementia or disorientation, or those on hemodialysis for less than three months were excluded. A total of 94 patients were registered in the specified time duration.
Patient data was filled on a self-designed questionnaire regarding age, gender, cause of ESRD, frequency, and duration of hemodialysis. Blood samples were taken for hemoglobin, serum calcium, phosphate, uric acid, albumin, iron, creatinine, urea, vitamin D, and intact parathyroid hormone [iPTH] as per schedule and recommendations. Adequacy of hemodialysis was calculated as urea reduction ratio [URR] and single pool [Sp] Kt/V [where Kt/V shows dialysis adequacy by incorporating dialyzer clearance of urea-K, dialysis time-t, and volume of distribution of urea-V]. Each patient’s number and type of complications were noted.
Data were analyzed by IBM Statistical Package for the Social Sciences [SPSS] Statistics for Windows, version 21.0 [IBM Corp., Armonk, NY]. Mean with standard deviations were calculated for age, blood sample values, URR, Sp Kt/V, and duration of hemodialysis, while frequency and percentages were calculated for all the categorical ones. Stratification was done according to gender, dialysis access, duration, and sessions per week. Post-stratification, the chi-square test was applied, with a p-value of