Synopsis
Recognise time-critical haemodialysis and peritoneal-dialysis complications, stabilise the patient and access, and activate the correct renal, vascular, infection or resuscitation pathway.
- Major haemorrhage from a fistula, graft, needle or disconnected circuit is immediately life-threatening: summon emergency help, stop the pump when relevant and apply firm direct pressure to the exact bleeding point.
- A previously functioning fistula with an absent or abruptly changed thrill may be thrombosed; protect the limb and contact the renal access team urgently because salvage becomes more difficult with delay.
- Fever, rigors or hypotension in a person with a dialysis catheter is catheter-related bloodstream infection until assessed, but chest, urine, skin, fistula and peritoneal sources must also be sought.
- Cold fingers, paraesthesia, hand weakness, rest pain or tissue loss distal to an access suggests steal syndrome; neurological deficit or threatened tissue requires urgent vascular review.
- Marked arm, neck or facial swelling on the access side suggests venous outflow obstruction or central venous stenosis rather than simple fluid overload.
- Aneurysmal access with shiny thinning skin, ulceration, scab, infection or rapid expansion has rupture potential and needs urgent specialist assessment; never cannulate through compromised skin.
- During haemodialysis, acute dyspnoea, chest or back pain, collapse or abnormal circuit blood may indicate air embolism, haemolysis, dialyser reaction, blood loss or acute coronary disease; secure the circuit and use ABCDE.
- Cloudy peritoneal dialysate warrants immediate PD-team contact, effluent sampling and prompt protocol treatment even without fever; fungal or refractory episodes may require catheter removal.
- Do not use a fistula or dialysis catheter for routine ward access, blood sampling or infusion without the renal team's authorisation and trained aseptic technique.
Key red flags
Uncontrolled access bleeding with shock requires emergency medical services, focused compression and resuscitation; do not release pressure repeatedly to inspect the wound.
Sudden absent fistula flow is a same-day renal access emergency, particularly when potassium or fluid control depends on imminent haemodialysis.
Fever with rigors, hypotension, altered consciousness or a dialysis catheter requires the sepsis pathway and urgent source-control discussion.
Severe hand rest pain, motor deficit or digital ulceration indicates threatened limb tissue and needs urgent vascular assessment.
Dark red or port-wine circuit blood with chest pain, dyspnoea or hyperkalaemia suggests haemolysis; stop treatment and do not retransfuse circuit contents.
Acute respiratory or neurological symptoms after suspected air entry require immediate circuit clamping and emergency resuscitation support.
Abdominal rigidity, shock or faeculent or fungal PD culture raises surgical or complex peritonitis and catheter-source-control concerns beyond routine outpatient therapy.
Investigation priorities
Distinguish bleeding, loss of flow, infection, aneurysm, outflow obstruction and distal ischaemia.
Management branches
A fistula, graft, needle site or dialysis circuit is bleeding heavily or the patient is haemodynamically unstable.
- Call emergency help, lie the patient safely, expose only what is needed and apply continuous firm direct pressure with a gloved hand and gauze to the precise bleeding point.
- If dialysis is running, trained staff stop the blood pump and clamp affected lines while maintaining pressure and preventing further air entry or blood loss.
- Follow major-haemorrhage ABCDE care with large-bore access away from the fistula limb, blood sampling and transfusion activation according to physiology.
- Obtain urgent renal and vascular surgical control; use any tourniquet or haemostatic adjunct only within emergency-service or local protocol because access and limb can be sacrificed.