Idiogenic osmoles may be generated in brain during acute azotemia as an adaptive response to increased plasma BUN to prevent brain cell shrinkage ( 15) but are probably not generated during rapid HD ( 9). Moreover, the content of brain organic osmolytes (myoinosotol, glutamine, and taurine, etc.) did not increase in rapidly dialyzing animals ( 9, 13, 14). ( 13) reported that retained urea in brain was sufficient to cause a change in brain water content in rapidly dialyzing animals. ( 12) suggested that generation of new solutes (“idiogenic osmoles”) in brain tissue accounted for brain edema during rapid HD. In animal models of uremia, the alteration in brain urea and other electrolytes concentrations does not completely account for the increase in brain osmolality during rapid HD ( 12). The CSF-to-plasma BUN ratio was 0.91 predialysis, 1.99 immediately after dialysis, and back to baseline 24 hours later. They obtained concurrent plasma and cerebrospinal fluid (CSF) samples before dialysis, immediately after dialysis, and 24 hours after dialysis. ( 11) studied 10 patients with AKI (baseline BUN concentrations of 210–460 mg/dl) undergoing their initial HD session. This lag (reverse urea effect) creates an osmotic gradient that promotes net water shift from the blood into the brain, leading to cerebral edema and its associated manifestations ( 9, 10). DDS is attributed to the faster decline of urea concentration in the blood than in the brain during the dialysis session. It is characterized by nausea, vomiting, headache, encephalopathy, and seizures ( 7, 8). Intradialytic hypotension, a relatively common complication during dialysis, is also beyond the scope of this review but has been the subject of some recent comprehensive papers ( 3– 6).ĭialysis disequilibrium syndrome (DDS) is a rare syndrome occurring in patients with severe azotemia undergoing their initial HD session. Complications related to more frequent HD are not addressed in this review. We have provided case reports to illustrate these emergencies in Supplemental Appendix. This review highlights major emergencies that may occur during HD treatments ( Table 1), measures to minimize them, and specific interventions to prevent catastrophic consequences on the rare occasions when such complications arise. Ongoing dialysis staff training is essential to both prevent human error as well as ensure prompt and effective interventions when complications happen. A smaller number are due to rare idiosyncratic reactions. Most HD emergencies can be attributed to human error. The low rate of major complications can be attributed to numerous safety features in modern dialysis machines meticulous treatment and testing of the dialysate solution to prevent exposure to trace elements, toxins, and pathogens adherence to detailed treatment protocols and extensive training of dialysis staff to handle medical emergencies. For example, a cardiac arrest occurs only seven times per 100,000 HD sessions ( 2). Given the high comorbidity in patients on HD and the complexity of the dialysis treatment, it is remarkable how rarely a life-threatening complication occurs during dialysis. Each one receives dialysis at least thrice weekly (156 times per year) for a total of over 62 million dialysis sessions annually. There are currently approximately 400,000 patients with ESRD on maintenance hemodialysis (HD) in the United States ( 1). Finally, we describe root cause analysis after a dialysis emergency has occurred to prevent a future recurrence. These emergencies include dialysis disequilibrium syndrome, venous air embolism, hemolysis, venous needle dislodgement, vascular access hemorrhage, major allergic reactions to the dialyzer or treatment medications, and disruption or contamination of the dialysis water system. In this review, we highlight major emergencies that may occur during hemodialysis treatments, describe their pathogenesis, offer measures to minimize them, and provide specific interventions to prevent catastrophic consequences on the rare occasions when such emergencies arise. Most hemodialysis emergencies can be attributed to human error. The low rate of dialysis emergencies can be attributed to numerous safety features in modern dialysis machines meticulous treatment and testing of the dialysate solution to prevent exposure to trace elements, toxins, and pathogens adherence to detailed treatment protocols and extensive training of dialysis staff to handle medical emergencies. Given the high comorbidity in patients on hemodialysis and the complexity of the dialysis treatment, it is remarkable how rarely a life-threatening complication occurs during dialysis.
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