Pakistan J. Med. Res.

Vol. 41, 3, 2002

 

The frequency of complications during haemodialysis

 Abrar Ahmad, Arif Rahim Khan, Ghulam Mustafa,  Misbah Ul Islam Khan

Nishtar Medical College/Hospital, Multan, PMRC Research Centre, Nishtar Medical College, Multan

 

SUMMARY

 

The commonly used renal replacement therapy for the end stage renal disease is the maintenance haemodialysis. Only 30% are having approach to renal transplantation, a gold standard treatment. The maintenance haemodialysis is the substitute for kidney functions. On one hand it is blessing for chronic renal failure patients, the complications may also occur on the other hand.

This prospective study was conducted at Nephrology section of Medical Unit-II, Nishtar Hospital, Multan. The objective of the study was to determine the frequency of different complications during haemodialysis in patients having end stage renal disease. The patients with acute renal failure having haemodialysis were excluded from the study. The most frequently observed complications were depressive illness, vomiting, fever, itching and hypotension. The causative relations of the complications with other parameters were also assessed. Results indicate that predialysis, thorough work up of patients and certain steps help to decrease the frequency of complications.

 

Key Words: Acute renal failure, chronic renal failure, haemodialysis. Complications of haemodialysis.

 

INTRODUCTION

 

C

hronic renal failure may be defined as a glomerular filtration rate (GFR) below 30 ml per minute1. Symptoms and complications of uremia often occur when GFR is less than 15 ml per minute. Chronic renal failure affects every aspect of life of the patients who suffer it. Over 165000 patients in United States were treated for end stage renal disease during 19902.

               

Patients with end stage renal disease require replacement treatment. This can be provided by maintenance haemodialysis, peritoneal dialysis or kidney transplantation. In Europe, over 250 per million population are given replacement treatment for end stage renal failure. Only about 30% of these patients undergo renal transplantation, which is considered as the gold standard of renal replacement therapy3.

               

The dialysis is only a part of end stage renal management because it cannot replace all the improvement functions of kidney. During haemodialysis, the patient may develop complications. As for example, hypotension during dialysis is very common. It is due to many factors like size of extracarporeal circulation, degree of ultra-filtration, changes in serum osmolality, autonomic neuropathy and alteration in body temperature due to dialysis temperature4. Vomiting is another common complication during dialysis. It may be due to gastritis, hypotension and hypercalcemia. Rapid change in osmolality and electrolyte imbalance during dialysis is responsible for fits.

"First use" syndrome is because of extra-corporal circulation especially seen with new dialyzer. The clinical features include shivering with anaphylactic reaction of varying intensity from mild respiratory distress to anaphylactic shock.  It is because of substance released by extra-corporal circuit (mainly sterilizing agents) and some patients are thought to be intolerant of dialysis membrane made up of cuprophane, which may be due to brisk complement activation5.

 

Disequilibrium syndrome is due to rapid flux in osmolality, with haemodialysis. The clinical features include confusion, clouding of consciousness and fits6. The occurrence of dialysis demenita, low turn over, osteomalacia and mucrocytic anaemia may be secondary to aluminium contamination of dialysis water or from increased oral intake of aluminium hydroxide. These complications have nearly disappeared with awareness of the risk of aluminium exposure and its avoidance

Mechanical and estrogenic complications are less common with improved equipment. These complications are air embolism, haemolysis, blood leaks and contaminated dialysate. Complications related to vascular access problems are infection at the site of AV fistulae6 or infection due to subclavian or femoral vein catheterization, stenosis of fistula, haemorrhage, thrombosis, inflammatory complications, aneurysm and undesirable consequences of fistulae7.

 

Purpose of study was to determine the frequency of the complications during haemodialysis at this institution. In the light of the results of this study, the guidelines may be formulated for future to prevent these complications and save the lives of many patients by timely management.

 

MATERIALS AND METHODS

 

This prospective study was conducted at Nephrology Section of Medical Unit-II of Nishtar Hospital, Multan. All the patients, haemodialyzed for maintenance dialysis from December 1997 to May 1998 were included in this study. The patients were interviewed in detail during haemodialysis for the symptoms occurring and thorough physical examination specifically oriented for physical signs of complications of haemodialysis. The symptoms and complications were, hypertension, vomiting, shivering, cramps, fits, hypotension, dialysis disequilibrium, headache, bleeding, air embolism, nausea, arrhythmia, breathlessnees, chest pain, itching, fever, haematemesis and clotting in blood tubing/dialyzer. Laboratory investigation, X-ray chest, ECG with reference to complication were performed accordingly. Data were analyzed using SPSS-8 to determine frequencies and percentage of complications.

 

RESULTS

 

Two hundred and twenty seven patients were haemodialyzed from December 1997 to May 1998. One hundred and twenty three patients were male and 104 were female. The demographic data are given in Table 1.

 

Table 1:    Demographic data

 

Sex

No. of cases

Percentage

 

Male

123

54.2

 

Female

104

45.8

               

The mean age of the patients was 33.3 + 10.5 years. The youngest patient was of 13 years and the oldest patients of 65 years as shown in Table 2.

 

Table 2:  Age distribution

 

Age (Years)

Male

Female

 

11-20

02

10

21-30

44

42

31-40

53

45

41-50

12

07

>

12

-

 

The psychological complications were observed in 180 patients. The most common complication, depressive illness was observed in 140 (M=80,F=60) patients (61.6%). The second most common psychological complication was impotence which was found in 40 (17.8 %) male patients. (Table 3).

 

Table 3:   Psychological complications

 

Complications

Male

Female

Total

 

Depression

80 957.2%)

60  (42.8%)

140

 

Impotence

40 (17.8%)

-

40

 

Gastrointesitnal tract (GIT) related complications were next to psychological complications. One hundred and seventeen (56.3%) patients had GIT related complications. The vomiting, abdominal pain, nausea and haematemesis were the common ones (Table 4).

 

Table 4:  GIT related complications

 

Complications

Male

Female

Total

 

Vomiting

60 (60.0%)

40 (40.0%)

100

Pain abdomen

04 (40.0%)

06 (60.0%)

10

Nausea

03 (60.0%)

02 (40.0%)

05

Haematomesis

01 (50.0%)

01 (50.0%)

02

 

The cardiovascular complications were present in 82 patients (36.1%). The commonly observed complications were hypotension, arrhythmia, hypertension and air embolism (Table 5).

 

Table 5:  Cardiovascular complications

 

Complications

Male

Female

Total

 

Hypotension

25 (45.4%)

30 (54.6%)

55

Arrythmia 

09 (60.0%)

06 (40.0%)

15

Nausea

06 (60.0%)

04 (40.0%)

10

Haematomesis

01 (50.0%)

01 (50.0%)

02

 

Thirty-four patients (14.9%) suffered from neurological complication. These were headache, fits, disequilibrium and dementia. These are summarized in Table 6.

 

Table 6:  Neurological complications

 

Complications

Male

Female

Total

 

Headache

5 (35.7%)

9 (64.3%)

14

Fits

3 (37.5%)

5 (62.5%)

08

Disequilibrium

4 (57.1%)

3 (42.9%)

07

Dementia

3 (60.0%)

2 (40.0%)

05

 

Shivering and fever were observed in 103 (45.3%) and 101 patients (44.4%) respectively as shown in table 7. Itching was observed in 52 patients (22.8%).

 

Table 7:  Miscellaneous complications

 

Complications

Male

Female

Total

 

Shivering

59 (57.3%)

44 (42.7%)

103

Fever

63 (62.4%)

38 (37.6%)

101

 

Haematological complications like bleeding and clotting diathesis were present in 11 patients (4.9%) and are shown in Table 8.

 

Table 8:  Haematological complications

 

Complications

Male

Female

Total

 

Bleeding

2 (40.0%)

3 (60.0%)

5

 

Clotting diathesis

2 (33.3%)

4 (66.7%)

6

 

DISCUSSION

 

The major renal replacement therapy is haemodialysis worldwide in the management of end stage renal disease (ESRD)8,9. It is either sole replacement therapy or prior to renal transplantation. European studies show that over 250 million populations are given renal replacement therapy. The bulk of these patients (about 70%) are getting maintenance haemodialysis while only 30% get the opportunity of renal transplantation3.

 

The haemodialysis services are offered through social welfare department or on payment basis at Nishtar Hospital, Multan. The patients are haemodialyzed twice a week for maintenance dialysis and dialysis duration is 4 hours, so 8 hours/week. While the patients are having improved quality of life with maintenance haemodialysis, it is also accompanied with  complications.

               

In this study the complications of the haemodialysis occurred in 80% of the patients, either a major one or a minor. The psychological complications were at the top with reference to the frequency. These were observed in 79% of the patients. The most common psychological complication was depressive illness, occurring in 61% of the dialyzed patients, which is in line to that observed by Granord and Lef Bure in United Kingdom and Canada respectively10,11. They have reported the depressive illness in the patients of maintenance haemodialysis with frequency of 58% and 42% respectively. In general, depression is the most common psychological problem of all medical illnesses, at the very least depression in combination with anxiety belongs in the first place. Cause of depression can be viewed as a response to real, threatened or phantasized loss, that one can see why depression is not an uncommon psychological complication in dialysis patients. This study pointed out that the common factors responsible for depressive illness in these patients, were unplanning at the time of the start of haemodialysis, unbearable cost of haemodialysis, meager resources of the population in this part of Pakistan, and under education of the patients. It is recommended that, prior to maintenance dialysis, the patients and the close family members must have the complete information about the expenditure and the patient's professional adjustment.

               

Clinicians have long observed that male patients with haemodialysis have the problem of impotence. Abram and his associates conducted semi-structured interviews on 32 male haemodialyzed patients at a Veteran Administration Hospital of America. The views of all these patients were separately interviewed. The reported frequency of impotence was 38%12. Levey in 198413 reported the prevalence of impotence in men on haemodialysis in excess of 70%. In this study 17.8% of male patients reported the impotence. This low figure in comparison with international data is due to the concealing facts about sexual abnormalities in our society.

               

The commonly observed GIT related complications during haemodialysis are vomiting; pain in abdomen and haematemesis, 48% of the patients had vomiting during or after dialysis. These results are comparable to the results of the study conducted by David and Cambi8. Heparinization during haemodialysis can precipitate upper gastrointestinal bleeding responsible for haematemesis, though it is not a very common problem. In this study, four patients during 6 months period experienced the upper GI bleeding. International data is also documenting the low incidence of haematemesis as the complication of maintenance haemodialysis9.

               

The cardiovascular complications, like hypertension, arrythmias have also been observed, hypokalamia being the cause of arrythmia. It requires termination of dialysis until and unless the management of hypokalamia. Hypokalamia., hypertension and air embolism were observed in 24%, 7%, and 5%  respectively.

               

It has been suggested that hypotension and associated symptoms may be related to the biochemical changes caused by cellulosic membranes or due to hypovolemia or excessive ultra filtration of water at the time of dialysis10. The ultrafilteration depends upon the condition of the patient, if hypotention and hypovolumia is evident, then no ultrafilteration is advised.

               

Cardiac arrhythmias are frequently associated with haemodialysis and have been reported to be seen in some series among 76% of the patients11. These appeared to occur mostly after the first three hours of dialysis. Various risk factors predisposing dialysis patients to arrhythmias have been identified including rapid electrolyte and fluid shifts, acid base alterations, alteration in parathyroid and calcium metabolism, reduced oxygen saturation levels and changes in erythocytes potassium levels12.

               

Hypertension is a major problem among patients with end-stage renal disease. Hypertension in most dialysis patients is mainly dependent on salt and water retention. Restricting fluid and salt intake and removing fluid during dialysis are effective in about 80% of cases. Anti-hypertensive treatment promotes dialysis hypotension and prevents adequate fluid removal during dialysis8.

               

Headache, fits, disequilibrium and dementia were the neurological complications observed in 6%, 5%, 4% and 3% respectively. These complications in this study also reflect low frequency in contrast to other international studies13,14. This contrast is due to the short duration of maintenance dialysis in this study (mean 18 months) as compared to international data in which patients were on maintenance haemodialysis for the period of more than 5 years.

               

The shivering, fever and itching were the other common recorded complications of haemodialysis. These were observed in 45%, 42% and 22% respectively. These results are comparable with other studies15,16.

 

CONCLUSION

 

The results of this study  revealed a very high frequency of the complications associated with maintenance haemodialysis. The psychological complications like depressive illness and impotence were at the top with frequency of 61.1% and 17.8% respectively. The miscellaneous complications like fever, shivering and itching followed the psychological complication in order of frequency. The other major proportion of complications was GIT related complications, these were vomiting, abdominal pain and nausea. The lowest frequency were cardiovascular and neurological complications.

               

The proper work-up of the patients prior to institution of maintenance haemodialysis and appropriate pre-medicine may prevent or decrease the frequency of these complications, which require another study for pathogenesis of these complications.

 

REFERENCE

 

 

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17. Gruppo. Emodialisie Patologic Cardiovasculari: Multicentre, cross sectional study of ventricular arrhythmias in chronically haemodialyzed patients. Lancet 1988; 6: 305-9.

18. Weise F. London GM: Effect of haemodialysis on cardiovascular rhythms in end stage renal failure. Kidney Int 1995; 47: 1443-52.

19. Bates N. Aluminium encephalopathy. Contrib Nephrol 1985; 45: 29-41.

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