Dialysis line infections

Quick tip; fever without obvious source in a patient who dialyses via a tunnelled dialysis line is treated as line sepsis until proven otherwise.

Quick tip: a patient’s dialysis line is their lifeline. It should never be used for blood tests or intravenous treatments unless there is an extreme emergency.

Many people have a permanent line to receive their dialysis, which is tunnelled under the skin to decrease infection risk. These work well for dialysis but commonly become infected - about 1 bacteraemia for every 1000 days of use. Line related infection has a mortality rate of up to 25%.

Bacteraemia often presents with fevers or rigors when the line is used for dialysis, but it can also present with vague symptoms - nausea, vomiting, confusion, or malaise.
On examination the line may have an erythematous exit site or pain, redness, swelling or pus over the tunnel. However, the line can look externally normal and still be internally infected and seeding bacteria.
Take routine bloods and blood cultures peripherally, and blood cultures from the line. Safely taking line cultures is vital, and you may need to ask the dialysis nurses or ICU nursing team for help in accessing the line in a sterile manner (and locking it with heparin again afterwards). If safely taking line cultures is impossible, then just take peripheral blood cultures.
70% of line-associated bacteraemias are caused by S. aureus or S. epidermidis. Though true bacteraemia due to S. epidermis may be rare in the general population (and its presence in a peripheral blood culture is often put down to contamination), it should be considered more likely to be genuine in dialysis patients.
Treatment: each trust will have its own antibiotic guidelines.
The line may need to be removed, especially if S. aureus or Pseudomonas infection, or if there is evidence of tunnel infection. The line should be removed urgently if there is life threatening sepsis.

Exit site infection in the systemically well patient

An alternative clinical scenario is the well patient who has developed redness or purulent discharge localised to the line exit site. Management will depend upon the appearance of the line but a rule of thumb is;

if the exit site is red but dry, take swab and await result
if exit site oedematous or cellulitic, swab and prescribe PO antibiotics (usually flucloxacillin)
If erythema or tenderness is >2cm from exit site this is called a ‘tunnel infection’ rather than an ‘exit site infection’, and requires more aggressive management (almost always removal of the dialysis catheter)

References

Steddon S, Chesser A, Cunningham J, Ashman N. Oxford handbook of nephrology and hypertension. Oxford University Press; 2014.
Li PK, Szeto CC, Piraino B, de Arteaga J, Fan S, Figueiredo AE, Fish DN, Goffin E, Kim YL, Salzer W, Struijk DG. ISPD peritonitis recommendations: 2016 update on prevention and treatment. Peritoneal Dialysis International. 2016 Sep 1;36(5):481-508.
Ashby D, Borman N, Burton J, Corbett R, Davenport A, Farrington K, Flowers K, Fotheringham J, Fox A, Franklin G, Gardiner C. Clinical Practice Guideline Haemodialysis.
https://www.rcr.ac.uk/system/files/publication/field_publication_files/bfcr193-gadolinium-based-contrast-agent-adult-patients.pdf

Post-dialysis hypotension

Post dialysis hypotension

During dialysis most patients have a certain amount of fluid removed from their body, aiming to leave them at their “target weight” or “dry weight”. Sometimes if they have too much fluid removed too quickly, or if their target weight is set inappropriately low, their blood pressure drops. This is often exacerbated by antihypertensive medications, autonomic dysfunction or limited cardiac reserve. Hypotension often happens during or immediately after dialysis, but sometimes occurs later, when ambulating after returning home.

Presents commonly with postural symptoms and dizziness, but can also cause cramps, abdominal pain or a collapse / blackout episode
If a patient presents to ED with ongoing symptomatic hypotension you can give a small amount of fluid (e.g. 250ml IV fluid), and reassess. Let the renal team know if they require emergency review due to post-dialysis hypotension, as they can then alter dialysis parameters for future sessions to avoid recurrence
Usual management is to ensure they are not on inappropriate antihypertensives and reviewing their target weight.
Remember causes of collapse other than excess fluid removal are also common in dialysis patients and should be considered as they would be in non-dialysis patients presenting with hypotension, for example;
Cardiac ischaemia
Arrhythmia
Sepsis
Haemorrhage
Pulmonary embolism
Pericardial effusion and tamponade

References

Steddon S, Chesser A, Cunningham J, Ashman N. Oxford handbook of nephrology and hypertension. Oxford University Press; 2014.
Li PK, Szeto CC, Piraino B, de Arteaga J, Fan S, Figueiredo AE, Fish DN, Goffin E, Kim YL, Salzer W, Struijk DG. ISPD peritonitis recommendations: 2016 update on prevention and treatment. Peritoneal Dialysis International. 2016 Sep 1;36(5):481-508.
Ashby D, Borman N, Burton J, Corbett R, Davenport A, Farrington K, Flowers K, Fotheringham J, Fox A, Franklin G, Gardiner C. Clinical Practice Guideline Haemodialysis.
https://www.rcr.ac.uk/system/files/publication/field_publication_files/bfcr193-gadolinium-based-contrast-agent-adult-patients.pdf

AV fistula complications

AV fistula complications

Many people receive dialysis via a fistula in their arm - a connection between a vein and an artery, with high blood flows that can be accessed for dialysis.

A common complication of fistulas is that they can thrombose - if this happens it is either picked up at a dialysis session, or the patient might notice their fistula has lost its ‘buzz’ upon palpation and self-present
Fistula thrombosis needs to be referred urgently to the renal team on-call or the access surgeons (vascular or transplant depending on the hospital) to attempt salvage. Do FBC, U+Es and clotting on arrival as they may need urgent surgery ± dialysis
Fistulae can become infected, and there may be evidence of cellulitis of the overlying soft tissues. If it looks infected take swabs, bloods and blood cultures, and treat with antibiotics covering gram positive and gram negative organisms
Rarely fistulas can bleed or rupture and this must be discussed with the emergency vascular surgeons on call. Apply pressure to the site, elevate the arm and manage resuscitation as per any major haemorrhage.

References

Steddon S, Chesser A, Cunningham J, Ashman N. Oxford handbook of nephrology and hypertension. Oxford University Press; 2014.
Li PK, Szeto CC, Piraino B, de Arteaga J, Fan S, Figueiredo AE, Fish DN, Goffin E, Kim YL, Salzer W, Struijk DG. ISPD peritonitis recommendations: 2016 update on prevention and treatment. Peritoneal Dialysis International. 2016 Sep 1;36(5):481-508.
Ashby D, Borman N, Burton J, Corbett R, Davenport A, Farrington K, Flowers K, Fotheringham J, Fox A, Franklin G, Gardiner C. Clinical Practice Guideline Haemodialysis.
https://www.rcr.ac.uk/system/files/publication/field_publication_files/bfcr193-gadolinium-based-contrast-agent-adult-patients.pdf

PD peritonitis

Quick tip - All Peritoneal dialysis patients admitted to hospital must be discussed with their local Nephrology unit, regardless of their cause of admission as they will need specialist input to enable them to continue to dialyse, either on a nephrology ward, or on a ward with a Nephrology unit on-site.

Some patients are on peritoneal dialysis - they have a tube (PD catheter) in their peritoneal space which allows their peritoneum to be instilled with dialysis fluid. This slowly removes waste products and fluid from the body, using the peritoneal membrane as the filter. This process is usually completed several times per day, or overnight, using an automated PD machine. The catheter exit site is kept sterile and patients are very careful with hand hygiene when connecting and disconnecting themselves. However, despite best practise, microbes can infect the peritoneal space and cause PD peritonitis:

Usually presents with abdominal pain and cloudy dialysis fluid upon draining. Other possible symptoms include fever, vomiting, malaise, diarrhoea and systemic sepsis.
Commonly the abdomen is soft and diffusely tender, though the patient can be painfree. The PD catheter exit site and tunnel should be examined for evidence of infection.
If the patient has brought in their bag of PD fluid, take a look at it - does it look clear or cloudy? Test this by putting printed text under the bag and seeing if you can read it through the fluid (you would normally be able to).
A sample of freshly drained PD fluid should always be sent to the lab for white cell count and culture if there is any concern regarding peritonitis. The highest yield is if fluid is sent in blood culture bottles, but different hospitals have different protocols. Only a trained member of staff can access the patient’s PD catheter in a sterile fashion, so it is important to liaise with the local renal team early.
Remember that patients on PD who develop abdominal pain can still have other conditions (appendicitis, perforated viscus, etc), so consideration should be given to surgical review or CT imaging if there is concern the history is inconsistent with ‘typical’ PD peritonitis

The patient will need to start antibiotics. Ideally these are given intraperitoneally (IP), as this route can help them remain outpatient if they are well enough.

If the patient is unstable/septic or there is likely to be significant delay in administering IP antibiotics, then broad-spectrum IV antibiotics should be given.
PD peritonitis should be discussed with the local renal team or PD team early, as investigation, transfer and management can be a logistical challenge.

References

Steddon S, Chesser A, Cunningham J, Ashman N. Oxford handbook of nephrology and hypertension. Oxford University Press; 2014.
Li PK, Szeto CC, Piraino B, de Arteaga J, Fan S, Figueiredo AE, Fish DN, Goffin E, Kim YL, Salzer W, Struijk DG. ISPD peritonitis recommendations: 2016 update on prevention and treatment. Peritoneal Dialysis International. 2016 Sep 1;36(5):481-508.
Ashby D, Borman N, Burton J, Corbett R, Davenport A, Farrington K, Flowers K, Fotheringham J, Fox A, Franklin G, Gardiner C. Clinical Practice Guideline Haemodialysis.
https://www.rcr.ac.uk/system/files/publication/field_publication_files/bfcr193-gadolinium-based-contrast-agent-adult-patients.pdf

Dialysis patient pitfalls

Pitfalls of managing dialysis patients

Ideally all dialysis patients would be looked after in a location where they could be managed by both the specialist team they require and the renal MDT. Occasionally this is not possible - either because they have presented to ED, or are admitted in a hospital that does not have renal on site and they must be under a different team for a specific reason e.g. the stroke or orthopaedics teams.

Missed dialysis

Usually haemodialysis patients have outpatient dialysis 3 times a week on a Monday/Wednesday/Friday or a Tuesday/Thursday/Saturday schedule. Where possible they should stick to their usual schedule while in hospital, though it may need to be rearranged to accommodate investigations or procedures. Upon admission to hospital, the dialysis unit and/or the renal registrar on call should be informed.

If they can’t be accommodated in their outpatient usual slot (e.g. if too unwell) they will need daily potassium and volume status monitoring. All dialysis patients on admission should be maintained on their usual low potassium diet and fluid restriction if the reason for admission does not requre fluid resuscitation.
If their potassium is high, unless they can receive immediate dialysis, this will need to be managed medically - see hyperkalemia section
If they are too unwell to transfer or dialyse in an outpatient setting they may need to go to ICU for monitored dialysis

Peritoneal dialysis patients may tolerate missing dialysis for 24-48 hours. However, they too will need daily potassium and volume status monitoring and early contact with the local renal team is advised.

IV Contrast for CT and MRI imaging

It is agreed that dialysis patients do not require dialysis after an IV iodinated contrast CT scan to “remove the contrast”.

Gadolinium (MRI contrast) is associated with nephrogenic systemic fibrosis (NSF) in patients either on dialysis, with AKI or with CKD stage 5. NSF is a very rare but debilitating condition resembling scleroderma in the skin, which can also affect internal organs and become life-threatening. This is rarer with newer generation gadolinium agents.

Whether or not the patient should have gadolinium contrast depends upon the risk:benefit of having the scan, and how effective alternate imaging techniques would be at answering the clinical question.
It is not recommended that patients who are not yet on dialysis initiate dialysis solely for gadolinium removal.
For patients already on haemodialysis the Royal College of Radiologists recommend dialysis is arranged post-gadolinium administration within a maximum time of 24 hours, though the evidence base for this recommendation is weak and nephrology practise will vary from centre to centre.

Fluids

In general dialysis patients need to keep to a strict fluid intake limit - about 800-1000mls a day.
If they are an inpatient they should not have routine ‘maintenance fluid’.
If they are unwell or septic and require IV fluids it is fine to give them - we would recommend smaller boluses (250ml) and more frequent re-assessment of observations and fluid status, and a lower threshold for senior input.
Emergencies such as diabetic ketoacidosis, which usually requires large volume fluid resuscitation, can be complex to manage in dialysis patients and early involvement of the local renal team is advised.

Anaemia

Anaemia is common in dialysis patients, and they often receive IV iron and synthetic erythropoietin (EPO) on haemodialysis, aiming to keep the haemoglobin between 100-120g/L.
Both IV iron and EPO act relatively slowly to increase the haemoglobin, and often work poorly in the setting of inflammation (for example when patients are in hospital due to sepsis or surgical problems).
Blood transfusion is avoided if possible in patients who are transplant candidates as it may sensitise patients to non-self antigens and make it harder for them to get a transplant in future, however do give blood transfusion if required e.g. for acute bleeding or symptomatic anaemia.
A blood transfusion results in a volume and potassium load and monitoring of volume status and electrolytes is required.
Discuss anaemia with the on-call renal team if you are concerned, and to coordinate giving blood transfusions while on dialysis if possible.

Top tips for managing dialysis patients on non-renal wards

The average dialysis patient will have more frequent and longer hospital admissions compared to the general population, and can come to harm if being looked after by non-specialist teams, whether due to incorrect drug dosing, lack of attention to fluid balance or other causes.

Keep in touch with the on-call renal team and we can help you and your patient with anaemia management, electrolyte disturbances, drug prescribing issues, fluid balance and dialysis coordination.
Remember that the outpatient dialysis unit is not the safest place for the unwell patient, especially with high early warning scores, hypotension or high oxygen requirements.
Do not take blood from the patient’s dialysis line or fistula, and do not place a cannula or measure blood pressure on the same arm as the fistula.
Try to arrange investigations or procedures around patient's dialysis schedules, but if in an emergency or an intervention must be at a specific time then let the renal team know to rearrange dialysis.
Often dialysis nurses send a ‘post-dialysis’ set of U+Es to ensure good clearance, on which the potassium and phosphate may appear low. However both electrolytes almost always rapidly rebound to normal levels, so do not prescribe replacement based on post-dialysis U+Es as it is rarely required.
The Edinburgh Renal Unit have a fantastic website which is well worth a look - for example their section on electrolyte replacement in dialysis patients http://edren.org/ren/handbook/unithdbk/fluid-and-electrolyte-replacement-in-renal-failure/
Between haemodialysis sessions serum creatinine and urea will accumulate - it is normal for creatinine to rise by well over 100μmol per day after a dialysis session. This is not the same as AKI and does not require action, especially not IV fluids.
For drug dosing do not use the eGFR report from a post-haemodialysis blood sample, which will be falsely high. Instead always use the renal drug handbook and dose for dialysis patients.
Inform the renal team if concern about bleeding, or if awaiting an investigation to investigate potential bleeding (e.g. CT head after a fall), or being considered for surgery or an invasive procedure as otherwise the patient will receive heparin while on dialysis.
The dialysis nurses can take whatever blood tests or blood cultures are needed whilst the patient is on dialysis. Let them know and save the patient an extra venepuncture.
Preserve the veins of patients on dialysis (or with CKD), as they may need them for fistulas in the future. Where possible take bloods and place venflons in the hands, and avoid the non-dominant arm.
Ensure the patient is on an appropriate renal diet and fluid restriction while on non-specialist inpatient wards.
Maintain caution with IV fluids.
If the patient is missing physiotherapy sessions due to their dialysis schedule (eg. if missing Mon/Wed/Fri physio due being away at haemodialysis), discuss altering the schedule with the renal team.

References

Steddon S, Chesser A, Cunningham J, Ashman N. Oxford handbook of nephrology and hypertension. Oxford University Press; 2014.
Li PK, Szeto CC, Piraino B, de Arteaga J, Fan S, Figueiredo AE, Fish DN, Goffin E, Kim YL, Salzer W, Struijk DG. ISPD peritonitis recommendations: 2016 update on prevention and treatment. Peritoneal Dialysis International. 2016 Sep 1;36(5):481-508.
Ashby D, Borman N, Burton J, Corbett R, Davenport A, Farrington K, Flowers K, Fotheringham J, Fox A, Franklin G, Gardiner C. Clinical Practice Guideline Haemodialysis.
https://www.rcr.ac.uk/system/files/publication/field_publication_files/bfcr193-gadolinium-based-contrast-agent-adult-patients.pdf

The contents of these pages were created with great care. For the accuracy, completeness and timeliness of content, we can not take any responsibility. As a service provider we are responsible according §7 1 TMG for own contents on these pages under the general laws. According to §8 to 10 TMG we are not obligated as a service provider to monitor transmitted or stored information, or to investigate circumstances that indicate illegal activity. Obligations to remove or block the use of information under the general laws remain unaffected. However, a relevant liability is only possible from the date of knowledge of a specific infringement. Upon notification of such violations, we will remove the content immediately.

Privacy Policy of Buku Haematology

This Application collects some Personal Data from its Users.

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Owner and Data Controller

Buku Haematology - Newcastle - United Kingdom

Owner contact email: bukuhaem@gmail.com

Types of Data collected

Buku Haematology (The Owner) records no personally identifiable data. The following usage data are collected by default by the host of our App, AppYourself GmbH. This data is then managed as per their privacy policy below.

System Version
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Opening of each module together with the time of the action
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Buku Haematology (owned by Buku Tech Ltd) retain none of this data. We can see our user traffic, country of access and modules accessed. Unique identifiers are generated for each user by the AppYourself system to show the number of times the App is accessed and which modules are viewed by individuals. No further information about the individual is given.

AppYourself privacy policy

We (Buku Haematology) have removed those elements that we have chosen not to include in the App (such as Facebook integration for example). Please contact privacy@appyourself.net if you have any questions about personal data storage.

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Detailed information on the processing of Personal Data

Key facts about data control by AppYourself;

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Further information about Personal Data

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Additional information about Data collection and processing

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To determine whether any of the third-party services it uses honor the “Do Not Track” requests, please read their privacy policies.

Changes to this privacy policy

The Owner reserves the right to make changes to this privacy policy at any time by notifying its Users on this page and possibly within this Application and/or - as far as technically and legally feasible - sending a notice to Users via any contact information available to the Owner. It is strongly recommended to check this page often, referring to the date of the last modification listed at the bottom.

Should the changes affect processing activities performed on the basis of the User’s consent, the Owner shall collect new consent from the User, where required.

Definitions and legal references

Personal Data (or Data)

Any information that directly, indirectly, or in connection with other information — including a personal identification number — allows for the identification or identifiability of a natural person.

Usage Data

Information collected automatically through this Application (or third-party services employed in this Application), which can include: the IP addresses or domain names of the computers utilized by the Users who use this Application, the URI addresses (Uniform Resource Identifier), the time of the request, the method utilized to submit the request to the server, the size of the file received in response, the numerical code indicating the status of the server's answer (successful outcome, error, etc.), the country of origin, the features of the browser and the operating system utilized by the User, the various time details per visit (e.g., the time spent on each page within the Application) and the details about the path followed within the Application with special reference to the sequence of pages visited, and other parameters about the device operating system and/or the User's IT environment.

User

The individual using this Application who, unless otherwise specified, coincides with the Data Subject.

Data Subject

The natural person to whom the Personal Data refers.

Data Processor (or Data Supervisor)

The natural or legal person, public authority, agency or other body which processes Personal Data on behalf of the Controller, as described in this privacy policy.

Data Controller (or Owner)

The natural or legal person, public authority, agency or other body which, alone or jointly with others, determines the purposes and means of the processing of Personal Data, including the security measures concerning the operation and use of this Application. The Data Controller, unless otherwise specified, is the Owner of this Application.

This Application

The means by which the Personal Data of the User is collected and processed.

Service

The service provided by this Application as described in the relative terms (if available) and on this site/application.

European Union (or EU)

Unless otherwise specified, all references made within this document to the European Union include all current member states to the European Union and the European Economic Area.

Cookies

Small sets of data stored in the User's device.

Legal information

This privacy statement has been prepared based on provisions of multiple legislations, including Art. 13/14 of Regulation (EU) 2016/679 (General Data Protection Regulation).

This privacy policy relates solely to this Application, if not stated otherwise within this document.

Latest update: May 17, 2018

Cookie Policy of Buku Haematology

Cookies and other Identifiers consist of portions of code placed on the User’s device that assist the Owner in providing the Service according to the purposes described.

Some of the purposes for which Identifiers are used may also require the User's consent. Whenever consent is given, it can be freely withdrawn at any time following the instructions provided in this document.

Activities strictly necessary for the operation of this Application and delivery of the Service

This Application uses Cookies or other Identifiers to carry out activities that are strictly necessary for the operation or delivery of the Service and, therefore, do not require Users to consent. Users can disable such Identifiers by modifying their browser or device settings as described in more detail within this document, but this may affect core operational functions or result in the unavailability of the Service.

Other activities

Experience enhancement

This Application uses Cookies or other Identifiers to provide a personalized user experience by improving the quality of preference management options, and by enabling interaction with external networks and platforms.

Measurement

This Application uses Cookies or other Identifiers to measure traffic and analyze User behavior with the goal of improving the Service.

Analytics

The services contained in this section enable the Owner to monitor and analyze web traffic and can be used to keep track of User behavior.

Google Analytics for Firebase (Google LLC)

Google Analytics for Firebase or Firebase Analytics is an analytics service provided by Google LLC.

In order to understand Google's use of Data, consult Google's partner policy.

This Application uses identifiers for mobile devices and technologies similar to cookies to run the Firebase Analytics service.

Personal Data processed: Cookies, unique device identifiers for advertising (Google Advertiser ID or IDFA, for example) and Usage Data.

Place of processing: United States – Privacy Policy. Privacy Shield participant.

How to provide or withdraw consent

Users can provide or withdraw consent to the use of Cookies and other Identifiers by setting their preferences within the cookie notice or by updating such preferences via the relevant consent-preferences widget accordingly, if available.

Additionally, Users can manage preferences regarding Identifiers directly from within their own device settings and prevent – for example – the storing of third-party Identifiers. It is also possible, via relevant browser or device features, to delete previously stored Identifiers, including those used to remember the User’s initial consent. Users can, for example, find information about how to manage Identifiers in the most commonly used browsers at the following addresses: Google Chrome, Mozilla Firefox, Apple Safari and Microsoft Internet Explorer.

With regard to any Identifiers stored by third parties, Users can manage their preferences and withdraw their consent by clicking the related opt-out link (where provided), by using the means indicated in the third party's privacy policy, or by contacting the third party.

Notwithstanding the above, Users are hereby informed that they may follow the instructions provided by YourOnlineChoices (EU), the Network Advertising Initiative (US) and the Digital Advertising Alliance (US), DAAC (Canada), DDAI (Japan) or other similar services. Such initiatives allow Users to select their tracking preferences for most of the advertising tools. The Owner thus recommends that Users make use of these resources in addition to the information provided in this document.

Owner and Data Controller

Buku Haematology - Newcastle - United Kingdom

Owner contact email: bukuhaem@gmail.com

Since the storing of third-party Cookies and other Identifiers through the services used within this Application cannot be technically controlled by the Owner, any specific references to Identifiers stored by third parties are to be considered indicative. In order to obtain complete information, the User is kindly requested to consult the privacy policies of the respective third-party services listed in this document.

Given the objective complexity surrounding technologies related to Cookies and other Identifiers, Users are encouraged to contact the Owner should they wish to receive any further information on the use of such Identifiers by this Application.

Definitions and legal references

Personal Data (or Data)

Usage Data

User

The individual using this Application who, unless otherwise specified, coincides with the Data Subject.

Data Subject

The natural person to whom the Personal Data refers.

Data Processor (or Data Supervisor)

The natural or legal person, public authority, agency or other body which processes Personal Data on behalf of the Controller, as described in this privacy policy.

Data Controller (or Owner)

This Application

The means by which the Personal Data of the User is collected and processed.

Service

The service provided by this Application as described in the relative terms (if available) and on this site/application.

European Union (or EU)

Unless otherwise specified, all references made within this document to the European Union include all current member states to the European Union and the European Economic Area.

Cookie

Cookies are Identifiers consisting of small sets of data stored in the User's browser.

Identifier

Any technology - including Cookies - that allows for the storing of information, or the accessing of already-stored information, on the User’s device.

Legal information

This privacy statement has been prepared based on provisions of multiple legislations, including Art. 13/14 of Regulation (EU) 2016/679 (General Data Protection Regulation).

This privacy policy relates solely to this Application, if not stated otherwise within this document.

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