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Complication of dialysis electrolytes imbalance

Electrolytes imbalance as one of dialysis complication might be slightly complicated


to discuss as it can also be the result of kidney failure itself (Krause & Schraga, 2015).
Generally, electrolytes abnormalities after dialysis arise due to the sudden electrolytes shift
during treatment.

The imbalances consist of hyperkalemia, hyponatremia, and

hypocalcemia. However, it is extremely important to noted that the listed abnormalities may
also being develop way before the dialysis treatment. Thats why most of the research done
on electrolyte imbalances as one of dialysis complication often measured pre and post
dialysis value (Kirschbaum, 2003; Abdul Majeed, 2011; Ciovicescu et al 2014).
The most common and clinically significant electrolyte abnormality is hyperkalemia.
By definition, hyperkalemia is the increment of potassium level in blood. This can be
dangerous and life-threatening as high potassium can affect the muscles of the body including
the heart; which could stop beating. Hyperkalemia lessens the resting membrane potential
time, slows the conduction velocity and increases the rate of repolarization of the heart
muscle. This phenomenon leads to arrhythmia and atrial fibrillation (Abdul Majeed, 2011).
Serum potassium will rise when the serum is acidemic; even total body potassium is
unchanged. Hyperkalemia is usually asymptomatic and should be treated empirically when
suspected. One of the useful diagnostic tools in detecting hyperkalemia is electrocardiography
(ECG) where severely peaked T waves will be observed. In addition, widening of the QRS
complex also illustrates severe hyperkalemia and must be treated immediately (Krause &
Schraga, 2015).
One of the article stated that this complication is uncommon for patient that comply
and adhered to the diet and treatment given to them.
hyperkalemia is a strict diet with low potassium content.

So, one of the management for

Foods Low in Potassium

Apples,

pears,

Foods High in Potassium

plums, Banana, dried fruit, prunes,

mandarins, grapes

apricot,

Kiwi, peach

Rhubarb

Cauliflower, peppers, carrots,


broccoli

Peas,

beans,

mushrooms,

spinach, beetroot

Cabbage, green beans, turnip Salt substitutes


Boiled/mashed potato, rice, Jacket/chipped/roast potato
pasta
Spirits, white wine, boiled Beer, stout, red wine, chocolate,
sweets

coffee

Table 1: Diet for hyperkalemia patient (courtesy of Beaumont Hospital Kidney


Centre)

By following the diet, potassium shift during dialysis might not give a big impact
towards patient. On the other hand, for emergency treatment, calcium salts are the most rapid
acting agents used to treat hyperkalemia. Calcium reversed the toxicity of potassium by
stabilizing the membrane from any unintended depolarization. This is usually the first line
treatment for severe hyperkalemia (Federer & Batuman, 2015). The effect is rapid but shortlived. This is due to the fact that calcium does not lower the potassium level in blood. Hence,
administration of calcium salt is always accompanied by other therapies that actually help
lower serum potassium levels.

Rapid correction of hyperkalemia also can be done by administering drugs that shift
potassium intracellularly such as insulin, dextrose, sodium bicarbonate, and albuterol. Their
mechanisms of action are described below (Lederer & Batuman, 2015):

Insulin and dextrose are administered accordingly. They works by facilitate the
uptake of glucose into muscle, and bring potassium with it. This caused a

downward shift in the serum potassium level.


Albuterol is a B-adrenergic agonists that stimulate the sodium-potassium
adenosine triphosphatase (Na+ -K+ -ATPase) pump, thereby shifting potassium

into the intracellular compartment.


Sodium bicarb acts as a buffer that breaks to water and carbon dioxide after
bind to free hydrogen ions. By increasing the pH, sodium bicarbonate
promotes a temporary potassium shift from the extracellular to the intracellular
environment.

Apart from that, cation-exchange resin named sodium polystyrene sulfonate is found to be
suitable for asymptomatic patient with mild to moderate hyperkalemia (Dipiro).
For other type of electrolytes imbalances such as hyponatremia, hypocalcemia, and
metabolic acidosis, the occurrence is rare. In fact, dialysis is listed as one of the emergency
treatment for metabolic acidosis (Dipiro) and had shown in a study that pre-dialysis metabolic
acidosis can be corrected by dialysis (Ciovicescu et al 2014).
As if occur, hyponatremia can be managed by introducing sodium solution by IV.
However, as most of dialysis patients are on fluid restriction, the amount infused need to be
included in their fluid calculation and need to be closely monitored. Uses of sodium retaining
medicine also can improve the hyponatremia situation (National Kidney Foundation, 2015).

For hypocalcemia, the event took place ranging from mild to moderate only. In
addition, patient with end stage renal failure (ESRD) often received oral calcium gluconate
and vitamin D supplementation in order to alleviate their ESRD complication. Uses of the
medication may help improved hypocalcemia complication of dialysis. Should this problem
still occur and emergency treatment is needed, magnesium and calcium (in their various
forms) are the only medications necessary to treat the condition (Suneja & Muster, 2015). As
for outpatient, endocrinologist will prescribe calcium and vitamin D supplementation; as had
been mentioned above.

References
1- Suneja, M. & Muster, H. A. (2015). Hypocalcemia Treatment &
Management. Retrieved from
http://emedicine.medscape.com/article/241893-treatment#d1
2- National Kidney Foundation (2015). Hyponatremia. Retrieved from
https://www.kidney.org/atoz/content/Hyponatremia
3- Lederer, E., (2015). Hyperkalemia medication. Retrieved from
http://emedicine.medscape.com/article/240903-medication#2
4- Simon, E. E., (2015). Hyponatremia treatment and management.
Retrieved from http://emedicine.medscape.com/article/242166treatment#d7
5- Krause, R. S. & Schraga, D. E., (2015). Dialysis complication of chronic
renal failure. Retrieved from
http://emedicine.medscape.com/article/1918879-overview#a2
6- Beaumont Hospital Kidney Centre (n.d). Haemodialysis complication.
Retrieved from http://www.beaumont.ie/kidneycentre-forpatientsaguidetodialysis-dialysis
7- Barry Kirschbaum (2003). The effect of hemodialysis on electrolytes and
acidbase parameters. Clinica Chimica Acta 336 (2003) 109113.
Retrieved from http://www.optimedical.com/pdf/articles/hemodialysiseffect-on-electrolytes.pdf
8- Ciovicescu F, Vesa C, Rdulescu D, Crian S, Duncea C. (2014),
Haemodialysis-induced electrolyte variation (serum calcium, magnesium
and bicarbonate) and intradialytic heart rhythm disorders. HVM Bioflux,
6(1):11-14. Retrieved from http://www.hvm.bioflux.com.ro/
9- Abdul-Majeed H. Al-Saffar (2011). Pre and post haemodialysis: the effect of
electrolyte imbalance on ECGs of patients with end stage renal disease.
Medical Journal of Babylon, 8(2):221-229.