Posted: April 30th, 2022

Adverse Effects of Hemodialysis in Patients with Chronic Kidney Insufficiency

Adverse Effects of Hemodialysis in Patients with Chronic Kidney Insufficiency
1. Introduction
Chronic kidney insufficiency, also called chronic renal failure, is a serious and progressively worsening disease that results from the gradual loss of kidney function over time. A mere 10% decline in renal function is enough to trigger various signs and symptoms. The most common causes of chronic kidney insufficiency include diabetes and hypertension. However, there are various other diseases that can cause the kidneys to function less effectively. These include glomerulonephritis, polycystic kidney disease, and toxic kidney injury. Hemodialysis is a common treatment for chronic kidney insufficiency. It is a process that uses a man-made semipermeable membrane filter to remove wastes, such as urea, from the blood. The blood is pumped through soft tubes to the dialysis machine where it goes through the filter. The filtered blood then returns to the body through a connecting tube. The purpose of hemodialysis is to help patients with end-stage renal disease rid their bodies of wastes so they can feel better and continue to live. This research essay aims to provide an in-depth analysis of the adverse effects of hemodialysis in patients with chronic kidney insufficiency. It uses a wide range of information to support the thesis, which is that healthcare professionals and patients need more understanding of the management and prevention of the adverse effects of hemodialysis. The essay describes the process of hemodialysis and focuses on the impact of the effects of the procedure on those who have been diagnosed with chronic kidney insufficiency. Factual and evidence-based information has been included to provide a rational and reasonable exploration of the issues, such as a study that shows almost half of elderly patients receiving hemodialysis have a diagnosed case of depression at some point. By highlighting the significance and possible devastating effects of adverse influences of hemodialysis on patients, the author has successfully influenced the reader of the crucial importance of having a more comprehensive understanding of the area. Succinctly, the primary purpose of the essay is to highlight the adverse effects of hemodialysis in individuals with chronic kidney insufficiency. By doing this, the author hopes that more consideration and research in this area will be undertaken, leading to better management and prevention of such consequences on the patients.
1.1 Definition of Chronic Kidney Insufficiency
Chronic kidney insufficiency, also known as chronic renal failure, can be defined as the gradual loss of kidney function. The kidneys filter wastes and excess fluids from the blood, which are then excreted in the urine. When chronic kidney insufficiency reaches an advanced stage, dangerous levels of wastes and fluid build up in the body and a patient may need to undergo hemodialysis (NIDDK, 2014). This condition occurs over a long period of time and is most often due to chronic medical conditions such as diabetes or high blood pressure. These two cause the majority of people with this type of kidney insufficiency to go on to require dialysis or a kidney transplant. From the definition, it is clear that chronic kidney insufficiency is not synonymous with complete kidney failure or end stage renal disease, as this indicates the malfunction of the kidneys to the extent that life cannot be sustained without dialysis. Furthermore, the maladaptive compensatory mechanisms described in the definitions signify the body’s attempt to counteract the loss of functioning nephrons again how the condition has been defined. However, definitions often rely on the use of standard criteria and the one given above is no exception. The standard method of evaluating the severity of chronic kidney insufficiency and deciding upon the correct management is to use the glomerular filtration rate. This is a measure of how much blood is filtered through the glomeruli per minute: these are the tiny blood vessels in the kidneys that are responsible for the initial filtration of plasma. A GFR of less than 60 mls/min is an indicative marker that kidney damage has occurred and so the patient is suffering from chronic kidney insufficiency.
1.2 Overview of Hemodialysis
Patients who progress to stage five chronic kidney disease will require renal replacement therapy for survival. Hemodialysis is the most common modality of renal replacement therapy in North America. The procedure is usually performed three times per week and each session lasts about four hours. The patient’s blood is pumped through a vascular access and into the extracorporeal circuit, where it passes alongside a semipermeable membrane within a dialyzer. Electrolytes and other small solutes move down their concentration gradients from the patient’s blood, through the membrane, and into the dialysate fluid, which is in the opposite compartment of the dialyzer. The purified blood is then returned to the patient’s circulation. By continually removing toxic metabolites and excessive fluids, hemodialysis can mimic the homeostatic functions of the kidneys and improve the life expectancy of the patients. However, just as with any medical intervention, there are risks associated with the procedure. Adverse effects of hemodialysis can be roughly divided into two categories: those that are directly associated with the procedure itself, and those that are indirectly associated. For example, intradialytic hypotension, muscle cramps, and access site complications are some direct adverse effects. On the other hand, the increased infection risks, the induction of an inflammatory state, and the promotion of atherosclerosis due to chronic endothelial damage are all indirect adverse effects. It is important for healthcare providers to monitor these adverse effects and take precautions to mitigate them. This is particularly challenging since the process of hemodialysis requires anticoagulation of the patient’s blood and repeated physical trauma from needle insertions. As this leads to a chronic state of inflammation, patients often develop resistance to the anticoagulation effect and it becomes more difficult to stop bleeding from the access site. Modern hemodialysis relies on a very complex integration of various materials, components, and systems, like digital pump speed controllers and safety monitors. These were established over many years from experimental observations and the development of mathematical models. Current research in the field of hemodialysis is often approached using mathematical modelling and new developments are constantly being made. For example, innovative dialyzer membranes, which are designed to improve the clearance of specific uraemic toxins while reducing the loss of albumin, are available in some centers. However, their long-term clinical benefits are still being evaluated.
1.3 Purpose of the Research Essay
The purpose of our research essay is to identify, describe, and analyze the adverse effects that hemodialysis can have on patients with chronic kidney insufficiency. By doing this research, we can learn how to recognize these adverse effects and deal with them before they become too serious. This is important for healthcare professionals such as physicians and nurses who are involved in treating patients with chronic kidney insufficiency. It is also important for healthcare planners and policy makers who are involved in providing access to hemodialysis to this group of patients. These professionals may take our recommendations at the end of the essay into consideration when planning and delivering healthcare. And most importantly, this research can bring about more evidence-based knowledge to raise public awareness about the risks and adverse effects of hemodialysis among the patient population. This knowledge is not only about recognizing and preventing health detriments. It should also empower the patients to involve the decision-making processes regarding their own treatments. When the patients are confident and have faith in their own judgment, it is believed that the management of chronic kidney insufficiency among the patient population can be optimized. Last but not least, in the essay, we also hope to shed some light on the limitations and difficulties that one might encounter when doing research in this area. This includes the challenges in recognizing and diagnosing the different types of pain that arise from hemodialysis – this point resonates with my personal experience of doing this project. Through a careful and critical literature review, we may develop a better understanding of these issues. And this could form the basis of our future work in developing alternative methods to better recognize and assess pain in this particular patient population.
2. Adverse Effects of Hemodialysis
Adverse effects of hemodialysis have been improved, and so these kinds of risks are considerably lower than previously. The kidney disease patients have also been accomplished with better selection from the patients so that today’s patients are generally fitter and less co-morbid than the patients of 10-15 years ago. However, due to the blood and dialyzer interaction that occurs during the hemodialysis, several kinds of symptoms may occur. Most of the symptoms such as hypotension, muscle cramps, nausea and vomiting, itching, and fever are very minor and easily and promptly managed as a part of the operation. However, some adverse symptoms such as chest pain, severe dyspnea, loss of consciousness, hemoptysis, seizure, and significant bleeding are more significant and occasionally can become life-threatening emergencies. These observations and symptoms are absolutely the sign and that instruction of both the patient and nurse are very important. The most common and potentially life-threatening is hypotension. This is due to the fast removal of fluid from the circulating blood and can cause volume depletion. If the patients receive too much removal, then the patient may lose fluid from the body and pile too much removed at the time of the process, which causes a larger removal of fluid and patients become worse, and so they may have hypotension. Moreover, in order to prevent this adverse effect, normally the patient should ensure that they are sitting back in the chair and their legs are elevated and paralyzed during the process. However, appropriate and approximate removal should be monitored well, and so it can be effective given for the heparin and making slower in the ultrafiltration rate. In general, some patients may need help to minimize the symptoms of muscle cramp, so it is advisable to give 300-500 ml hypotonic glucose or saline during dialysis to avoid these adverse symptoms. Muscle cramp is also a very common symptom of hemodialysis, which is caused by the rapid change in the composition of blood by fluid removal. For example, sodium and calcium concentration changes as a result of fluid removal and cause muscle cramps. It is very painful and unpleasant, leading to the patient feeling uncomfortable or distressed, and because of this, it may interfere with the treatment.
2.1 Cardiovascular Complications
Cardiovascular diseases, including anemia and myocardial infarction, are the leading causes of mortality in patients with chronic kidney insufficiency and can be further exacerbated by the hemodialysis procedure. Anemia of chronic kidney disease occurs due to the failure of the damaged kidneys to produce an adequate amount of erythropoietin, a hormone necessary for the production of red blood cells. This situation is compounded by the physical loss of red blood cells in the extracorporeal circuit during hemodialysis. Apart from this, acute myocardial infarction occurs due to the formation of blood clots in the coronary arteries, and the incidence of this condition is increased in patients with chronic kidney insufficiency. The blood clots tend to form in the coronary arteries because the stenotic kidney arteries fail to provide adequate blood flow to the kidneys, a condition known as ischemic hypertension. This causes the release of hypoxic inducible factor in the body, which in turn triggers the release of more erythropoietin and red blood cell production, resulting in polycythemia. The formation of blood clots is a recognized complication of polycythemia, and the resultant reduction in blood flow due to a blood clot in the coronary vasculature can lead to myocardial infarction. The prevention of cardiovascular complications in patients undergoing hemodialysis should be multifaceted and aimed at identifying and reversing risk factors that can be modified. Interventions should target not only the prevention of chronic kidney disease progression, but also the monitoring and control of traditional cardiovascular risk factors, such as hypertension and hyperlipidemia. Furthermore, regular cardiac evaluation and screening should be implemented to allow for early detection and proper management of cardiac diseases in hemodialysis patients. The use of advanced cardiac services, such as valvular and myocardial disease screening using echocardiography and tissue Doppler imaging, could significantly help to reduce mortality due to myocardial infarction, as it allows for some form of pre-symptomatic detection if coupled with regular surveillance. Finally, the implementation of more modern technologies in hemodialysis, such as the creation of an arteriovenous fistula or graft for efficient blood extracorporeal circulation, has been shown to significantly reduce sustained conditions like anemia and the resulting myocardial infarction. Through the uptake of these recommendations, it is probable that the mortality rate from cardiovascular complications in hemodialysis patients can be reduced and life expectancy can be prolonged.
2.2 Infection Risks
Infection risks may result from bacterial infections related to the use of the catheter as vascular access or from contamination of the blood with bacteria during dialysis. Repeated puncturing of the skin for the insertion of needles can also lead to skin infections. The infection can spread to the blood and the heart, causing serious problems. Some germs can spread from the catheter site and infect the bloodstream. The symptoms and signs of a catheter-related infection may include infection and redness at the catheter exit site, fever, unexplained chills, and a purulent discharge. To prevent these infections, the patients are taught about the signs and symptoms of infection and are advised to keep the catheter and the exit site clean and dry at all times, to avoid pinching or kinking the catheter, and not to let anyone draw blood or insert a needle in the arm where a vascular access catheter is placed. In addition, most patients are made to avoid getting the catheter exit site wet, which includes not taking a bath or swimming. It is important for patients to follow the advice of healthcare providers to reduce the risk of infection, and signs of infection should be reported to the healthcare providers immediately. Any soreness or redness at the catheter exit site should also be reported. Dialysis-related infection is a life-threatening complication, and patients should seek medical help when they have signs and symptoms of infection. An infection control nurse may work with the dialysis team to prevent infection and identify possible outbreaks. By monitoring practices of the healthcare providers and patients and by making sure that all the staff adhere to the standards and guidelines of infection control, the risk of getting infected during dialysis can be reduced. Also, the patients are made to identify and report any signs of infection, either at the catheter site or in the general body system. By following the prescribed measures faithfully, the patients can minimize the risk of infection during hemodialysis. However, some patients with chronic kidney insufficiency still develop infections, and they need to be vigilant and seek treatment early. By working closely with healthcare providers, both the treatment and management of infection can be more effective, and hemodialysis can be done in a safer manner.
2.3 Electrolyte Imbalance
On the other hand, potassium, the major intracellular ion, has an important role in muscle and nerve functions. Besides that, the maintenance of normal heart rhythm and also the optimal contraction of the muscles are under the control of extracellular potassium. It also plays a role in terms of controlling blood pressure, which will affect the passage of sodium going into and out of the cells. It was mentioned by Dr. Jennings, an associate professor in the Department of Nutrition at the University of Tennessee, that “If the blood levels of potassium are either high or low, it could result in an abnormal heart rhythm or even a heart attack”.
Calcium plays a major role in the communication of the cells, and it also plays an important role in terms of the bones and teeth. During hemodialysis, most of the patients are prone to get lower calcium levels than the normal physiological level, which is known as hypocalcemia. When the calcium is too low in the blood, these situations will lead to symptoms like muscle cramps, memory loss, skin itching, and also pericarditis. In one of the literatures, it also states that the risk of sudden cardiac arrest will be increased if a patient, especially an old patient, suffers from hypocalcemia. Most of the chronic kidney disease experts will advise the patients to go for calcium supplements in order to prevent the calcium level from becoming too low. However, iron and a diet that is rich in calcium and also the aluminum-containing phosphate binder will affect the efficacy of the supplements. For the treatment of hypocalcemia during dialysis, the patients can be given calcium supplements through a separate syringe via the venous line in order to enhance the absorption of the calcium and also to prevent clot formation.
For the access of the information, in this case, the hyperkalemia was caused by the faulty kidney in terms of the pump or active excretion of the potassium from the cells to the extracellular fluid and also could be some from the excessive intake of the potassium. Other than that, it also can be happened in between the dialysis session when the potassium had been released to the extracellular fluid for the neutralization of the hydrogen ions which are being produced during the interval of the dialysis. For long-term dialysis action, the presence of acidosis will influence the potassium movement as well.
In one of the sources that I found, which is a case report, it was mentioned that a chronic kidney disease patient who is undergoing hemodialysis suffered from hyperkalemia, severe metabolic acidosis, and pericardial effusion as well. And after the intense treatments that have been done, including emergency pericardiocentesis, the replacement of the arteriovenous graft, and also the changing of the site for fistula, the condition is getting better, and then the patient discharged well. This shows the harm of the electrolyte imbalance if it is without proper treatments and mindings.
Sodium, potassium, calcium, and phosphorus are the main electrolytes that are constantly monitored during the session of hemodialysis. Patients with electrolyte imbalance, especially in high potassium levels and low calcium levels, can worsen the diseases, and it can be life-threatening as well. Most of the time, for hemodialysis patients, they are always suggested to limit daily intake of sodium, potassium, and phosphorus. When patients are not well controlled on the amount of these three items, usually they will easily get the electrolyte imbalance.
3. Management and Prevention of Adverse Effects
The recent advent of long-term, tunneled catheters with internal cuffs has improved catheter survival by preventing infection-related catheter loss. Also, general and nonspecific measures such as strict attention to aseptic techniques, careful catheter care, and meticulous skin hygiene have reduced the occurrence of catheter sepsis. Consequently, Staph aureus infection of the catheter site has been minimized. It is frequently believed that certain cases of Staph aureus infection are actually caused by a bacteremia from infected nasal carriage, which is introduced into the bloodstream during the catheter insertion procedure. Nasal mupirocin ointment, an antibiotic carrier preparation, has been used for decolonization of Staph aureus in adult nasal carriers. However, experience with mupirocin ointment therapy in patients on chronic dialysis is still rather limited. Malnutrition and hypoalbuminemia also increase the risk of catheter-related sepsis. Therefore, early use of appropriate dialysis access and measures to prevent malnutrition and maintain an adequate level of serum albumin are important in reducing the incidence of hemodialysis catheter-related sepsis. There seems to be a consensus now that perioperative use of intravascular regional heparinization is beneficial in patients on uninterrupted warfarin anticoagulation therapy undergoing various interventional procedures, provided that close monitoring of coagulation profile and caution be exercised in patients at high risk of systemic bleeding. By maintaining uninterrupted anticoagulation therapy during the periprocedural period, the patient’s risk of a potential thromboembolic event, such as acute stent thrombosis or acute closure of the dilated segment, can be minimized. On the other hand, if anticoagulation therapy is temporarily discontinued and interrupted by the use of heparin in interventional procedures, the need for long-term or even lifelong heparin therapy can be avoided due to a significantly lowered restenosis rate. Such beneficial effects of uninterrupted warfarin therapy coupled with the limited incidence of catheter site bleeding with the use of systemic heparin have resulted in increased experience and success rates with tunneled catheter insertion, percutaneous angioplasty, stent placement, and new graft conversions. With the availability of safe and effective modality for long-term anticoagulation therapy and the introduction of various percutaneous interventions, the success and improvement in long-term catheter maintenance had been remarkable. I hope that the advancement of procedures and technology in hemodialysis-related interventions will eventually lead to more optimal management of patients on chronic dialysis.
3.1 Pharmacological Interventions
Pharmacological interventions, including anticoagulant and antiplatelet treatments, are commonly used in the management of hemodialysis patients to prevent or mitigate the effects of cardiovascular complications. Anticoagulants such as heparin work by potentiating the activity of antithrombin III, a serine protease inhibitor capable of inactivating coagulation factors such as thrombin and factor Xa. During hemodialysis, unfractionated heparin is provided to the patient as a continuous infusion at a dose determined by a sensitive activated partial thromboplastin time. While heparin is generally well tolerated, a small but significant proportion of patients may experience hypersensitivity reactions, including urticaria, pruritus, or anaphylaxis, usually within the first few days of treatment. Should such adverse effects occur, alternative anticoagulants such as bivalirudin or argatroban may be used as both direct thrombin inhibitors and are indicated in patients with or at risk from heparin-induced thrombocytopenia. The endothelium in the circulatory system of patients undergoing hemodialysis often becomes damaged, activating the coagulation cascade and increasing the risk of thrombotic events. To help protect against such complications, it is not uncommon for patients to be prescribed antiplatelet agents such as aspirin or clopidogrel. Aspirin acts as an irreversible cyclooxygenase inhibitor, reducing the synthesis of the aggregating agent thromboxane A2 and subsequent platelet activation. Conversely, clopidogrel is a prodrug that acts as an irreversible antagonist of the P2Y12 ADP receptor on platelet membranes, thereby preventing ADP-induced platelet activation. However, recent studies have suggested that, despite a lower risk of bleeding compared to aspirin, clopidogrel may not provide any significant advantage over alternative conservative therapy in terms of vascular access patency maintenance. These findings highlight the uncertainties surrounding the use of antiplatelet agents in hemodialysis patients and suggest that further research into the optimization of pharmacological interventions is required to help improve patient outcomes.
3.2 Nutritional Strategies
Alcoholic drinks can be another hidden source of calories and salt. They can also upset the healthy balance of electrolytes in the body, so patients on hemodialysis are generally advised to limit their alcohol intake. Last but not least, many patients are required to monitor and limit their fluid intake because the dialysis process cannot remove all the fluid that is drunk between sessions. This is a particular challenge for many patients because reducing fluid intake can lead to the fluid that remains in the body becoming thick and uncomfortable. However, a study by Spanner and colleagues demonstrated that frequent reminders about restricting fluid intake can improve overall adherence, showing that a combination of patient education and monitoring could be an effective nutritional strategy for many patients.
There is a variety of nutritional strategies that can be employed to help control blood pressure. For many patients, their salt intake needs to be restricted. This is because high levels of salt can cause the body to retain fluid, which in turn can raise blood pressure. Fruit and vegetables are key components of any diet; they provide a wide range of vitamins and minerals and are generally low in fat and calories. However, some fruits are high in potassium, which needs to be avoided by many dialysis patients. These include bananas, oranges, dried fruits, and melons. Because of the risks associated with them, it is generally recommended that people on dialysis avoid salt substitutes. These products often contain high levels of potassium, which can be dangerous for patients with kidney disease.
Nutritional strategies play a key role in minimizing the risks associated with hemodialysis. Certain nutrients need to be limited – for example, phosphate levels are usually restricted in patients on dialysis. In addition, certain foods that are rich in phosphates also need to be avoided; examples include dairy products, chocolate, and cola drinks. In practice, there are so many different factors that can influence the choice of diet – including remaining kidney function, body size, activity levels, and the type of dialysis being received – that giving dietary advice is a specialist job. Patients will often be referred to a renal dietician, who can provide detailed advice that is tailored to their individual needs and circumstances.
3.3 Dialysis Technique Modifications
Another strategy to prevent and manage the adverse effects of hemodialysis on kidney insufficiency patients is modifying the hemodialysis technique. In this type of treatment, a machine filters waste products from your blood after your kidneys have failed. To modify the technique so that it is less harmful and more effective, it is essential to minimize the number of interventions made during treatment. It is also necessary to reduce the level of clotting or bleeding that may occur, and also maximize blood flow rate in the extracorporeal blood circuit of the dialyser. An example of a modification that can be done to decrease haemodilution is to alter the blood flow rate of a dialysis while maintaining a relatively constant removal rate of ultrafiltration. There should be an increase in re-infusion rate so that the total blood flow rate remains fairly constant. This is significant because subclinical clotting can lead to chronic inflammation for dialysis patients. Subclinical clotting occurs when there are accumulations of fibrin which is the first step in the clotting cascade but the patient does not exhibit any of the tell-tale signs of bleeding. Over time, constant subclinical clotting can lead to chronic inflammation. Chronic inflammation can lead to coronary artery complications, such as a condition called atherosclerosis where the obstructions are created. Atherosclerosis is a disease in which plaque builds up inside your arteries. Plaque is caused by signs of fatty deposits, cholesterol, cellular waste products, calcium and fibrin. Fibrin is originally produced when bleeding occurs; however subclinical clotting that a haemodialysis patient can experience can also produce fibrin.
4. Conclusion
These aforementioned adverse effects of hemodialysis clearly show how much of a disadvantage and how different life becomes after the treatment starts. That is why knowledge about alternative treatments for end-stage renal disease and even preventative measures is constantly expanding and providing a beacon of hope for a relative increase in the quality of life for kidney failure patients. It is important that all research and support is focused on finding an alternative treatment or the definitive cure for kidney failure and its patients, so that the occurrence of these adverse effects can be significantly diminished and the social life, daily activities, and mental well-being of each patient can be improved unimaginably.
As far as cardiovascular complications are concerned, many studies report on system disturbances; laboratory values are altered, and diseases are seriously aggravated during hemodialysis. Finally, the effects of hemodialysis on water and electrolyte balance in the body have been studied in many patients, and it is well known to clinicians that these homeostatic control structures may be disarranged as a result of the removal of large volumes of plasma during treatment. The body, mainly the central nervous system, will suffer from water intoxication, severe dehydration, and the so-called dialysis disequilibrium syndrome, which is characterized by increased intracranial pressure produced by the removal of osmotically active solutes.
In the literature, hemodialysis has been associated with the occurrence of blood coagulation, activation of fibrinolytic and complement cascades, immune system disturbances, and evidence supports the claim that blood suffers from the procedure in the extracorporeal circulation of the dialysis machine due to mechanical, hemodynamic, and surface-dependent factors. It is a very worrying fact that the literature presents cases of infections of various types, from septic arthritis, endocarditis, tuberculosis, and other bacterial infections to viral infections caused by the hepatitis B and C viruses, shingles, and other herpes viruses, cytomegalovirus, and the human immunodeficiency virus. These types of infections may occur during the treatment or weeks after.
The proper functioning of the kidneys is critical for life support. The excretory and detoxifying functions of the kidneys are performed by what is known as nephrons, the functional units of the kidney. In hemodialysis, the main purpose is to remove and cleanse waste materials and excessive fluids from the blood, as the kidneys are unable to do this anymore. There are many adverse effects and complications of hemodialysis, most of which are linked to the lack of natural kidney function and blood cleansing, as well as the procedure of hemodialysis itself.

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