Longterm

complications in HD
anand
1. Cardiovascular complications
• The major cause of death in ESRD patients
• AMI, sudden cardiac death, and CHF
• Atherosclerosis is present
• 5 to10 times higher than in general population, and it accounts
for at least half of all patients’ deaths
• Death mainly due to coronary heart disease
• Poorly controlled hypertension is a major risk factor for CVD
Risk factors for CVD
• Hyper-phosphatemia and elevated calcium-phosphorus product with
calcium deposition in the coronary arteries, the cardiac conduction
system, - heart valves and blood vessels elsewhere.
• Anemia, hypertriglyceridemia, low HDL-cholesterol, increased LDL
lipoprotein, insulin deficiency or resistance, high homocysteine in
blood, endothelial dysfunction, inflammation and elevated C-reactive
protein, and smoking
• High-output heart failure from fistula placement occurs if fistula flow
exceeds 20% of cardiac output. This complication is extremely rare
Management
• Improved fluid control can prevent worsening heart function
• Fluid removal with dialysis and patient adherence to a low-salt diet
• More frequent hemodialysis and nocturnal hemodialysis may lead to
regression of LVH
• To achieve blood pressure control, maintaining euvolemia is crucial
• Hypertension control by drugs is very necessary.
• Adequate and prolonged HD is recommended, and it should be carried to
control hypertension in HD patients.
• Reducing LDL-cholesterol concentration is of great importance to minimize
the risk of myocardial cardiac infarction in non-renal and HD patients with
coronary heart disease.
• Vitamin E has been suggested as a means of reducing oxidative
stress and cardiovascular mortality .
• Achieving lower plasma LDL-cholesterol with statins that has
also anti-inflammatory effect may reduce long term HD
complications in HD-patients
• Low calcium dialysate content and selective vitamin D analogues
use helps to minimize and improve bone and vascular
calcification complications
• PTCA, stenting and bypass surgery are indicated in HD patients
• Interventional measures have higher risk mortality, recurrence
and restenosis than general population
2.Anemia
• Decrease in quality of life, impairment in cardiac function, and
mortality
• Transfusions- cause iron overload or sensitization to future
transplants and risks of hepatitis B and C
• Erythropoietin and darbepoetin, are now used to treat anemia
• High doses of ESAs can cause hypertension, vascular access
problems, and strokes
• No long-term data concerning IV iron formulations and mortality
3. Osteodystrophy
• Osteodystrophy is commonly associated with secondary HPTH
• Characterized by high plasma PTH despite of normal serum calcium
and phosphate
• Hip fractures frequency is more and serious in long-term HD patients
• Osteomalacia, a disease of defective bone mineralization sometimes
associated with aluminum toxicity
• Low-turnover bone disease is associated with low PTH levels and
high serum calcium levels
• Bone biopsy is the only definitive way to diagnose
• maintaining a normal serum phosphorous and reducing severely
elevated PTH levels will improve overall bone health
4. Malnutrition
• Undernutrition is often common
• May be due to chronic metabolic acidosis, or decreased physical
activity
• Occurrence of adynamic bone disease also appears to relate to
malnutrition
• Survival rate is correlated with serum albumin and prealbumin
levels
• Zinc and selenium deficiency is mostly due to malnutrition and
reverse osmosis water treatment
• Preventing malnutrition improves the quality of life
• Due to enhanced muscle breakdown, inadequate caloric intake, and
protein losses due to dialysis itself
• Comprehensive assessment of nutritional status includes serial weight
measurements, serum markers (albumin, prealbumin, or creatinine),
questionnaires (Subjective Global Assessment), dietary interviews,
anthropomorphic measurements, and possibly urine collections to
measure nitrogen excretion (an estimate of daily protein intake)
• Serum albumin alone is not sufficiently sensitive or specific enough to
diagnose PEM
• It is crucial to ensure that dialysis patients maintain normal serum
bicarbonate levels
5. Vascular Access
• Native arteriovenous fistula (AV) is always recommended whenever
possible
• Complications of vascular access as infection, malfunction, stenosis,
disfigurement and lead to inadequate dialysis
• Hemodialysis vascular access infection is common causes for
hospitalization in HD patients-serious cause
• Several weeks antibiotics course needed
• The persistence of fevers, an elevated WBC in the blood, or
constitutional symptoms, all can indicate antibiotic treatment failure
• When AV grafts become infected, it is usually due to
hematoma formation that spreads to graft material
• Strict hygienic sterile methods should be applied to reduce the
risk
6. Infection transmission
• Dialysis-predisposes these patients to blood borne infections, partly
due to an abnormal immune system function
• In dialysis patients, WBC count may be normal, but the white blood
cells are typically not functioning
• Has led to more risk of staphylococcus infection
• HD dependent patients have increased incidence of viral and fungal
infections due to lymphocyte malfunctioning
• Vaccinations against these infections decrease the severity of these
infections
• The spread of infectious agents from the dialysis machine or
other dialysis related procedures –currently less
• Dialysate fluid might be contaminated with an infectious agent
• Higher prevalence of HBV, HCV and HIV in HD than geberal
population
• Due to dialysis machines sharing, inappropriate preparation of
parenteral drugs and inadequate infection control methods in
dialysis units
• HCV infected patients are usually asymptomatic
• HCV transmission in dialysis units is mainly a result of
environmental contamination
• The lack of an effective HCV-vaccine has led to higher risk
• Despite negative HBs-Ag, patients may have positive HBV-
DNA and may infect others
Miscellaneous
 1. Ischemic steal syndrome
• Ischemic steal syndrome secondary to a HD arteriovenous access occurs in
approximately 5 to 10% of cases
• The pathophysiological basis of this condition is a marked decrease or reversal of flow
in the arterial segment distal to the AVF or AVG, induced by the low resistance of the
fistula outflow
• Mild cases can be observed closely, as most of them will reverse in a few weeks;
however, severe cases require immediate intervention to prevent severe ischemic
complications including ischemic neuropathy and ischemic gangrene with the potential
need for amputation.
• Several surgical and endovascular treatments have been used including: access ligation,
banding, elongation, distal arterial ligation, and distal revascularization-interval
ligation
• The best reported results, for treatment of dialysis access-associated steal syndrome
with maintenance of access function and reversal of symptoms, have been obtained
with the distal revascularization-interval ligation (DRIL) 11 and the endoluminal-
2. Aneurysms and pseudoaneurysms
• Aneurysms and pseudoaneurysms, resulting from improper needle site
rotation or as complications of more proximal stenosis, are less frequent
complications of vascular access
• AVG peudoaneurysms can develop profuse bleeding and require
emergency surgical intervention.
• Appropriate selection of dialysis staff for access cannulation together with
cannulation training and education for staff members and patients may
reduce the risk of this complication
• In addition, visibly tortuous access shape is a major cosmetic concern for
many patients
3. Venous hypertension
• Venous hypertension occurs in approximately 3% of fistulas
and grafts and is usually related to central vein stenosis (CVS)
• Percutaneous transluminal angioplasty of a CVS,
supplemented by stent placement as needed, is effective
• It is considered the primary treatment for such lesions due to
the lack of viable and safe surgical options
4. Hematoma
• Hematomas result from needle infiltration
• Needle infiltration of new fistulae is a relatively frequent
complication, which occurs most commonly in older patients
• If the access has been assessed as mature for venipuncture,
poor cannulation skills are often the root cause of infiltrations.
5. Prolonged access bleeding
• Prolonged access bleeding should not be overlooked, and should
raise suspicion of high intra-access pressure, outflow stenosis or
local inflammation
• Prolonged bleeding may also be caused by excessive
heparinization of the blood circuit, access laceration during
previous cannulation or skin atrophy
• Clinical examination of the site should be performed and previous
static or dynamic venous pressure measurements should be
reviewed.