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%.
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;
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.
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.
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:
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.
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.
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.
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.
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.