Overview of Hemodialysis Complications

Complications of hemodialysis (HD) access create significant problems for renal practitioners, the healthcare system and especially for individuals living with end stage renal disease. Chronic HD access complications include thrombosis, infection, ischemic steal syndrome, aneurysms, venous hypertension, hematomas, heart failure, and prolonged bleeding and result in frequent interventions and increased morbidity and mortality1. In addition, access interventions are often costly, challenging and may require specialized surgical expertise.

Thrombosis and infection are the among the most common vascular access dysfunctions1 and thrombosis is the most common cause of vascular access loss2. Thrombosis and infection occur more frequently in arteriovenous grafts (AVG) and dialysis catheters than in arteriovenous fistulae (AVF). The Dialysis Outcomes and Practice Patterns Study (DOPPS) reports that AVG are 3.8 times more likely to require thrombectomy and 3.0 times more likely to require access intervention than AVF3. AVF thrombosis rates remain in the range of 0.2 to 0.8 per patient year and AVG thrombosis rates are typically in the range of 0.6 to 1.2 per patient year4.  Although, the United States Renal Data System (USRDS) data confirm that AVF have the lowest complication rates of any available vascular access with 0.64 procedures per patient year versus 1.61 for AVG5; once a primary fistula is established, thrombosis is the leading cause of failure in approximately 40% of cases6.

Infectious complications of vascular access are a major source of morbidity and mortality among HD patients. Previous studies have reported infection as a common cause of death; accounting for 9.5 to 36% of deaths in HD patients7. Vascular access infections (most commonly found in patients utilizing dialysis catheters) are reported to be the source in up to 48 to 73% of all bacteremias in HD patients8. The risk of bacteremia with tunnel cuffed catheters averages 2.3 per 1000 catheter days.  This translates into an approximate 20 to 25% bacteremia risk over the average duration of use1.

Ischemic steal syndrome secondary to a HD arteriovenous access occurs in approximately 5 to 10% of cases9. 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 outflow9. 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) 9 and the endoluminal-assisted revision (MILLER) procedures10.

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.

Venous hypertension occurs in approximately 3% of fistulas and grafts and is usually related to central vein stenosis (CVS)1. Percutaneous transluminal angioplasty of a CVS, supplemented by stent placement as needed, is effective and considered the primary treatment for such lesions due to the lack of viable and safe surgical options11.

Hematomas result from needle infiltration. Needle infiltration of new fistulae is a relatively frequent complication, which occurs most commonly in older patients14. If the access has been assessed as mature for venipuncture, poor cannulation skills are often the root cause of infiltrations.

High-output heart failure from fistula placement occurs if fistula flow exceeds 20% of cardiac output12. This complication is a rare complication that is usually under-diagnosed in the dialysis population13.

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 atrophy15. Clinical examination of the site should be performed, and previous static or dynamic venous pressure measurements should be reviewed.

Vascular access management has improved dramatically over the past decades4.  Promising new therapies including catheter lock solutions, biological tissue engineering and the merging of current access conduits into a singular device are currently under development and evaluation. It is hoped that these and other new technologies may decrease the future incidence of vascular access complications.


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  13. Khreiss M, Haddad FF, Musallam KM, Medawar W, Daouk M, Khalil I. High-output cardiac failure secondary to a large arteriovenous fistula: A persistent threat to the dialysis and kidney transplant patient. NDT Plus. 2009;2(2):147-148. Available from: /pmc/articles/PMC4421340/.

P/N 101051-01 Rev A 03/2021