What Are the Complications of Dialysis? Short- and Long-Term Problems and Their Treatment

Why Does Dialysis Cause Complications?

Dialysis replaces only part of kidney function — mainly removal of small-molecule wastes and fluid. It cannot fully replicate the kidney's endocrine roles (making red cells, activating vitamin D), its continuous 24-hour fine-tuning, or clearance of middle and large molecules. And dialysis itself is an intervention on the body. Complications therefore fall into two groups:

• Acute problems during treatment (can occur at any session)
• Chronic problems that accumulate (emerge gradually over years)

Part 1: Acute Complications During Dialysis

1. Intradialytic hypotension

The most common, occurring in about 10–30% of hemodialysis sessions.

• Causes: fluid removed too fast or too much, dry weight set too low, blood-pressure medication before dialysis, autonomic neuropathy, poor cardiac function, eating during treatment
• Symptoms: dizziness, nausea, yawning, blurred vision, cramps, altered consciousness
• Management: slow or pause ultrafiltration, raise the legs, give saline
• Prevention: limit interdialytic weight gain (< 3–5% of dry weight), reassess dry weight, adjust timing of BP medication, cool the dialysate, lengthen sessions, avoid eating during treatment

2. Muscle cramps

• Causes: rapid fluid removal, going below dry weight, electrolyte imbalance (sodium, calcium, magnesium)
• Management: slow ultrafiltration, give saline or hypertonic solution, stretch
• Prevention: as for hypotension; the physician may adjust dialysate sodium or prescribe medication

3. Dialysis disequilibrium syndrome

• Mostly in new patients with very high urea levels
• Cause: blood urea falls rapidly, brain urea lags behind, water shifts into brain cells causing cerebral edema
• Symptoms: headache, nausea, restlessness; in severe cases seizures or coma
• Prevention: start with short, low-blood-flow, low-efficiency sessions and build up gradually

4. Others

• Nausea and vomiting: often linked to hypotension
• Headache: disequilibrium, caffeine withdrawal, hypertension
• Chest pain / arrhythmia: rapid electrolyte shifts, coronary disease
• Allergic reactions: to membrane material, sterilants or heparin (rare but serious)
• Air embolism, blood leak: machine safety systems make these extremely rare

Part 2: Vascular Access Complications

Daily self-checks of the fistula (look, listen, feel for the thrill) are the patient's most important self-care task.

Part 3: Complications Specific to Peritoneal Dialysis

Peritonitis

• Symptoms: cloudy effluent, abdominal pain, fever
• Causes: contamination during exchanges (most common), spread from exit-site infection, migration of gut bacteria
• Management: seek care immediately, send effluent for culture, intraperitoneal antibiotics usually for 2–3 weeks
• Prevention: strict sterile technique, exit-site care, periodic retraining
• Recurrent or severe peritonitis can destroy membrane function and force a switch to HD

Others

• Exit-site / tunnel infection
• Hernia: from raised abdominal pressure; needs surgical repair
• Dialysate leak: early catheter use or weak abdominal wall
• Ultrafiltration failure: membrane loses its ability to remove fluid after long exposure to high-glucose solutions
• Encapsulating peritoneal sclerosis (EPS): rare but serious late complication where the fibrosed peritoneum encases the bowel

Part 4: Long-Term Chronic Complications

1. Cardiovascular disease (the leading cause of death)

Dialysis patients face a 10–30-fold higher risk of cardiovascular death than the general population, accounting for about half of all deaths.

• Drivers: hypertension, fluid overload, vascular calcification (calcium–phosphate imbalance), anemia, inflammation, uremic toxins, diabetes
• Manifestations: left ventricular hypertrophy, heart failure, coronary disease, arrhythmia, sudden death
• Management: strict fluid and BP control, calcium–phosphate control, correct anemia, stop smoking, exercise, treat lipids

2. CKD–Mineral and Bone Disorder (CKD-MBD)

The kidneys can no longer excrete phosphate or activate vitamin D → phosphate rises, calcium falls → parathyroid hormone (PTH) climbs in compensation → calcium is leached from bone and deposited in vessels and soft tissue.

• Manifestations: bone pain, fractures, itching, vascular calcification, calciphylaxis (rare but deadly)
• Management:
  • Dietary phosphate restriction; avoid phosphate additives
  • Phosphate binders (calcium carbonate, calcium acetate, lanthanum, sevelamer, ferric citrate, etc.) taken with meals
  • Active vitamin D (calcitriol, paricalcitol)
  • Calcimimetics (cinacalcet, etelcalcetide) to lower PTH
  • Parathyroidectomy when medication fails
  • Targets individualized by the physician per KDIGO CKD-MBD guidelines

3. Renal anemia

Insufficient erythropoietin (EPO) from the kidneys, compounded by iron deficiency, inflammation and blood loss during dialysis.

• Symptoms: fatigue, breathlessness, dizziness, poor exercise tolerance, increased cardiac strain
• Management:
  • Erythropoiesis-stimulating agents (ESAs): injectable EPO analogues
  • Iron: mainly intravenous
  • HIF-PH inhibitors: newer oral agents (roxadustat, daprodustat)
  • Target hemoglobin usually 10–11.5 g/dL (KDIGO); higher targets increase cardiovascular risk

4. Infection

Immune function is impaired; infection is the second leading cause of death.

• Access infections, pneumonia, hepatitis B/C (cross-infection risk in dialysis units — greatly reduced in Taiwan)
• Prevention: vaccination (influenza, pneumococcus, hepatitis B, COVID-19, shingles), access care, hand hygiene

5. Malnutrition and protein-energy wasting (PEW)

• Causes: poor appetite, dietary restrictions, loss of protein and amino acids into dialysate, chronic inflammation, metabolic acidosis
• Impact: muscle loss, weakened immunity, higher mortality
• Management: protein needs increase to 1.0–1.2 g/kg/day on dialysis; adequate calories; correct acidosis; regular dietitian review; oral supplements when needed

6. Hyperkalemia

• Potassium accumulates between sessions; severe cases cause arrhythmia and cardiac arrest
• Management: dietary potassium restriction, potassium binders (newer agents patiromer, sodium zirconium cyclosilicate), never skip sessions, review medications

7. Dialysis-related amyloidosis

• After long-term dialysis (usually > 10 years), β2-microglobulin deposits in joints and bone
• Manifestations: carpal tunnel syndrome, shoulder pain, bone cysts
• Prevention: high-flux dialyzers, hemodiafiltration (HDF)

8. Other long-term issues

• Pruritus (itching): high phosphate, PTH, uremic toxins, dry skin; the new drug difelikefalin is now available
• Sleep disorders and restless legs syndrome
• Sexual dysfunction and fertility problems
• Depression and anxiety: prevalence around 20–30%, often under-recognized
• Cognitive decline
• Acquired kidney cysts and increased renal cell carcinoma risk: periodic imaging is recommended for long-term patients

Part 5: Advances in Dialysis Prescription That Reduce Complications

• Hemodiafiltration (HDF): combines diffusion and convection to clear more middle molecules. The CONVINCE trial (2023) showed high-volume HDF reduces all-cause mortality
• Longer or more frequent dialysis: nocturnal extended sessions, or 5–6 short sessions a week, give better fluid and BP control
• Individualized dialysate: tailored sodium, potassium, calcium and bicarbonate
• Cool dialysate: reduces intradialytic hypotension

Key Takeaways

1. Dialysis replaces only part of kidney function; complications arise from both "incomplete replacement" and "the treatment itself"
2. Acute problems (hypotension, cramps) are mostly about fluid management — limiting interdialytic weight gain is the patient's most powerful tool
3. Chronically, cardiovascular disease leads; mineral-bone disorder, anemia, infection and nutrition are the four pillars of management
4. Every complication has matching monitoring and treatment; regular labs, taking medication as prescribed, and access self-checks are the foundation
5. Dialysis technology keeps advancing (HDF, new drugs) — discuss the most suitable prescription with your team

References

• KDIGO. 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of CKD-MBD. Kidney Int Suppl. 2017.
• KDIGO. Clinical Practice Guideline for Anemia in Chronic Kidney Disease. 2012.
• National Kidney Foundation. KDOQI Clinical Practice Guideline for Hemodialysis Adequacy: 2015 Update.
• National Kidney Foundation. KDOQI Clinical Practice Guideline for Nutrition in CKD: 2020 Update. Am J Kidney Dis. 2020.
• ISPD. Peritonitis guideline recommendations: 2022 update. Perit Dial Int. 2022.
• Blankestijn PJ, et al. Effect of Hemodiafiltration or Hemodialysis on Mortality in Kidney Failure (CONVINCE). N Engl J Med. 2023.
• NIDDK. Hemodialysis: Possible complications.
• Taiwan Society of Nephrology. Dialysis patient care guidelines.

This article summarizes publicly available medical information for educational purposes only and is not medical advice. For any questions about your health, illness or physical care, please seek help through professional medical channels and consult your physician.