E:\IBUK\NERS DESEMBER 2021\18--
378 Jurnal Ners dan Kebidanan, Volume 8, Issue 3, December 2021, page 378–385
Intradialytic Complication and Associated Factors Among
Patients Undergoing Hemodialysis
Yeni Kartika Sari1, Ning Arti Wulandari2, Sandi Alfa Wiga Arsa3, Iwit Ratna Ari Dewi4
1,2,3Nursing Department, STIKes Patria Husada Blitar, Indonesia
4Nursing Practitioner, RSK Budi Rahayu Blitar, Indonesia
JURNAL NERS DAN KEBIDANAN
(JOURNAL OF NERS AND MIDWIFERY)
http://jnk.phb.ac.id/index.php/jnk
JNK
History Article:
Received, 24/11/2021
Accepted, 23/12/2021
Published, 26/12/2021
Keywords:
CKD, Intradialytic Complication,
Hemodialysis
Article Information Abstract
Hemodialysis is one of the vital management options for end-stage renal
disease (ERDS) patients. Adequate hemodialysis can make a good quality of
patient life. Hemodialysis patient commonly has experienced intradialytic
complications, and it can be life-threatening. ESRD patients who are not
compliant with fluid and dietary restrictions raised Intradialytic weight gain
(IDWG), and blood pressure leads to intradialytic complications. This study
aimed to determine factors associated with intradialytic complications among
undergoing hemodialytic patients in Blitar. The data analysis used Multiple
linear regression analysis to ascertain the possible factors that influence
intradialytic complications. The sample was 55 hemodialysis patients with
intradialytic complications. Based on this study, the Spearman Rank correla-
tion test results, the factor that correlated with intradialytic complications
was patient compliance with a Sig (2-tailed) value of 0.016 with a correlation
coefficient value of -0.26. The correlation coefficient in the results above
was negative, namely -0.263 so that the correlation between the two vari-
ables was not unidirectional. The higher compliance showed, the lower the
intradialytic complications. The odds ratio (OR) value between adherence
and the occurrence of intradialytic complications was 3,229. That value meant
that patients with kidney failure who do not comply with the diet will have a
3-fold risk of intradialytic complications compared to patients with renal
failure who comply. This result emphasizes the need for constant motivation
and education at frequent intervals to ensure better adherence.
© 2021 Journal of Ners and Midwifery
378
Correspondence Address:
STIKes Patria Husada Blitar – East Java, Indonesia P-ISSN : 2355-052X
Email: ulfamaria845@gmail.com E-ISSN : 2548-3811
DOI: 10.26699/jnk.v8i3.ART.p378–385
This is an Open Access article under the CC BY-SA license (http://creativecommons.org/licenses/by-sa/4.0/)
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379Sari, Wulandari, Arsa, Dewi, Intradialytic Complication and Associated Factors Among ...
INTRODUCTION
Chronic Kidney Disease (CKD) is one of the
health problems in Indonesian society, which has
an increased incidece of kidney failure with an un-
favorable prognosis and high cost. Chronic Kidney
Failure (CKD) in Indonesia ranks second in terms
of financing after heart disease Hemodialysis is one
of the actions for CKD patients with ERDS (End-
Stage Renal Disease). Hemodialysis measures are
increasing from year to year. In 2017 there was a
drastic increase in line with the rise in population
participating in the BPJS Health or JKN program
so that they had full access and financing for he-
modialysis. According to the Indonesian Renal Reg-
istry, in 2017, there were 77,892 people currently
living on regular hemodialysis, while in 2018, HD
procedures in Indonesia reached 132,142 active
patients (Increased 70%).
One of the big problems that contribute to fail-
ure in the hemodialysis process is the problem of
non-compliance. Patients should follow dietary rules,
change lifestyles, take medicines recommended by
health care providers and regularly perform hemo-
dialysis therapy. The Patient’s non-compliance
harms the patient’s health (Nita Samsyah, 2011).
The study results Marfuah, n.d, ( 2018.) show that
compliance with fluid intake restrictions in hemodi-
alysis patients in the non-adherent category was
43.9% in the obedient class, 19.3%, and the less
compliant 36.8%. The impact of non-adherence to
fluid restriction is weight gain.
Bodyweight is the most critical indicator in pa-
tients undergoing hemodialysis. Significant weight
gain in the span of a few days indicates excess
fluid in the Patient’s body. A study from Astuti and
Endang in 2018 showed that excess fluid could lead
to intradialytic complications, which is intradialytic
hypertension. Intradialytic hypertension is associ-
ated with significant interdialytic fluid overload. It
is also related to high ultrafiltration during dialysis
sessions. Sever a l r epor ts ha ve shown tha t
intradialytic hypertension is related to hyperactivity
of the sympathetic nervous system, impaired en-
dothelial function, and increased cardiac output due
to fluid expenditure (ultrafiltration) (Wibowo, 2020).
Another study shows that during 4 hours of hemo-
dialysis, all respondents reported one or more
intradialytic complications. The most common com-
plications were hypertension (85.7%), muscle
cra mps (55. 4%), na usea (51. 8%), hea da che
(46.4%), chest pain (12.5%), fever (8.9%), and
hypotension (5.4%), (Suparti, 2019).
According to Daugirdas, J. T., Blake, P. G., &
Ing (2015), complications of hemodialysis include
imbalance syndrome, dialysis reactions, hemolysis,
air embolism, arrhythmias, cardiac tamponade, sei-
zures, and intr acerebr al hemorr hage. (Yunie
Armiyati, 2009) at PKU Muhammadiyah Hospital
Yogyakarta from fifty hemodialysis patients showed
that 96% of patients experienced intradialytic com-
plications in the form of hypertension (70%), head-
ache (40%), hypotension (26%), muscle cramps
(18%), arrhythmia (12%), nausea and vomiting
(10%), shortness of breath (10%), fever and chills
(2%). The IRR.tim (2018)IRR in 2018, with a total
number of 30554 patients, noted that the most fre-
quent complications during hemodialysis were hy-
pertension (38%), followed by hypotension (15%).
The etiology of the two complications above was
closely related to the amount of ultrafiltration
According to Landry, observations during data
collection showed that most patients had excess
predialysis fluid with an increase in body weight of
3-5 kg. Excess predialysis fluid will increase vas-
cular resistance and cardiac pumping. Patients with
intradialytic hypertension experienced a significant
increase in peripheral vascular resistance in the fi-
nal hours of dialysis(Ferdinan et al., 2019).
In addition to intradialytic hypertension, other
intradialytic complications are nausea and vomit-
ing; the incidence of nausea and vomiting during
hemodialysis is a gastrointestinal symptom com-
monly experienced by clients and an adaptation to
clients who have just undergone hemodialysis. Many
clients experience nausea and vomiting due to
changes in blood pressure, UFR that is too fast,
anxiety, and overeating during hemodialysis. Nau-
sea and vomiting may occur in patients with
intradialytic hypotension. The most frequent com-
plication of hemodialysis is Intradialytic hypoten-
sion, accounting for 20-30% of hemodialysis com-
plications. Intradialytic hypotension was a signifi-
cant clinical problem disturbing the quality of he-
modialysis patients because of the symptoms of
nausea and cramps (Chaidir & Putri, 2014). Hy-
potension in diabetic nephropathy patients and the
elderly are often dangerous because it can trigger
ischemic heart disease and heart rhythm disorders
(Chaidir & Putri, 2014).
380 Jurnal Ners dan Kebidanan, Volume 8, Issue 3, December 2021, page 378–385
Complications of intradialytic hypotension lead
to obstruction of the adequate dose of dialysis (ad-
equate dose of dialysis), where episodes of hypoten-
sion cause compartmental effects and produce sub-
optimal Kt/Vera. In episodes of intradialytic hy-
potension, ultrafiltration should discontinue to pre-
vent further blood volume reduction and facilitate
refilling blood volume from the interstitial compart-
ment. We treat dialytic hypotension by resetting the
dialytic machine by slowing the blood flow rate
(Chaidir & Putri, 2014). In addition, according to
Kobrin, S.M. & Berns, J.S (2007), high ultrafiltra-
tion withdrawals can cause cramping. The incidence
of muscle cramps at around 24-86%, especially in
the first year of hemodialysis. Cramping is mainly
seen in the lower extremities and rarely occurs in
the abdomen, arms, and hands (Nasution et al.,
2014). Low blood volume due to the withdrawal of
large amounts of fluid during dialysis, changes in
osmolarity, high ultrafiltration, and intracellular or
extracellular potassium and calcium balance led to
muscle cramps during dialysis (Marcel Brass,
Perrine Ruby, 2009). Muscle cramps can occur near
the end of a dialysis session. An uncontrollable in-
crease in the speed of contraction or thinning of the
muscle causes muscle cramps and occurs within
seconds to minutes, causing pain. Intradialytic
muscle cramping usually occurs in the lower ex-
tremities (Padoli & Ayunda Bella, 2017).
Based on the results of observations in July
2020 in the Hemodialysis Room of the Budi Rahayu
Catholic Hospital (RSK) and the Mardi Waluya
Blitar General Hospital (RSU) it was obtained that
from 40 hemodialysis patients who did not obey to
diet and fluid restriction were 25 patients or about
60%, and they often come with shortness of breath
(due to excess body fluid volume, namely weight
gain exceeding 5% of the Patient’s dry body weight
and uremic symptoms (nausea, vomiting, and anor-
exia). Moreover, as a result, these patients experi-
ence complications, which often occur, namely hy-
potension and hypertension.
Fluid restriction and dietary regulation are some
of the programs applied to patients with chronic kid-
ney failure to maintain a nutritional state so that the
quality of life and rehabilitation to achieve as much
as possible, prevent and reduce uremic syndrome,
and reduce the risk of diminishing kidney function.
After running hemodialysis therapy, the patient is
given medication by the doctor. Adherence to treat-
ment adherence is the success factor. The success
of treatment lies in the facilities or facilities in the
hospital, medical personnel skills, and the patient’s
lifestyle and medication adherence. The results of
therapy will not be optimal without the awareness
of the Patientpatient to maintain his life, and can
also cause therapy failure or complications that are
detrimental and fatal (Rahma, 2017).
Non-adherence to patients with chronic kid-
ney failure caused by the thirst felt by the patient,
and the patient admitted that he did not comply with
the diet recommended by health workers. Dietary
non-compliance includes fluid and nutritional intake
because of boredom with the menu. The family has
warned about the diet, but the patient is not obedi-
ent to the diet. In addition, patients also do not main-
tain nutrition and fluid intake shortly after hemodi-
alysis because they feel refreshed after eating and
drinking (Firmansyah, 2016).
METHOD
This research was a correlation study with a
cross-sectional approach where the dependent and
independent variables was observed at one time.
The dependent variable in this study was intradialytic
complications. At the same time, the independent
var iables wer e IDWG, Blood Pr essur e, and
Intradialysis Patient Compliance. This research was
conducted in the Hemodialysis Room at two Blitar
City Hospitals, namely RSK Budi Rahayu and
RSUD Mardi Waluyo. The population in this study
was hemodialysis patients in both hospitals, as many
as 90 patients. The sample was part of the popula-
tion which met the inclusion criteria of 83 patients.
The criteria set was patients who could read and
write, patients who routinely did hemodialysis twice
a week, and patients who were not in critical con-
dition or had decreased consciousness. The instru-
ment used in this study was a hemodialysis patient
compliance questionnaire and observation sheets
regarding intradialytic complications, blood pressure,
and patient weight. The collected data will be ana-
lyzed using Spearman Rank correlation analysis with
a significance value of 0.05.
RESULT
Information obtained that from a total of 83
respondents, most of them aged > 50 years (63.9%),
female was 51.8%, high school education/equiva-
lent was 38.6% and 56.6% did not work.
381Sari, Wulandari, Arsa, Dewi, Intradialytic Complication and Associated Factors Among ...
No Charactheristic f %
1 Age
< 35 years 4 4,8
35 - 50 years 26 31,3
> 50 years 53 63,9
2 Genders
Male 40 48,2
Female 43 51,8
3 Education
Elementary 7 8,4
Junior High 16 19,3
Senior High 32 38,6
Diploma 7 8,4
Bachelor 21 25,3
5 Work
Working 36 43,4
Employe 47 56,6
Table 1 The Charactheristic of Respondents
No Complaint F %
1 No 16 19,3
2 Dypsnea 15 18,1
3 Nausea 8 9,6
5 Headache 15 18,1
6 Oedem 22 26,5
7 Chest pain 7 8,4
Table 2 The Respondent’s Complaint before Dialysis
25 February – 12 Marc 2021
Based on Table 2, information is obtained that
the most common complaint experienced by respon-
dents is oedem (26.5%)
Table 3 Correlation between Adherence and Intradyalitic Complications
Intradialytic Complications
Total
0,05
Spearman rho
p = 0,016
rs= -0,263
or: 3,229
Present No
Table 4 Correlation between IDWG and Intradialytic Complications
Normal f 11 15 26
IDWG % 13 18 31
Abnormal f 17 40 57
% 20 48 69
Total f 28 57 83
% 33 67 100,0
Intradialytic Complications
Total
0,05
Spearman rho
p = 0,265
Present Not Present
Obey f 24 20 44
Adherence % 54,5 45,5 100,0
Not Obey f 31 8 39
% 79,5 20,5 100,0
Total f 55 28 83
% 66,3 33,7 100,0
382 Jurnal Ners dan Kebidanan, Volume 8, Issue 3, December 2021, page 378–385
DISCUSSION
Hemodialysis is a vital management option for
end-stage renal disease (ERDS) patients (IRR.tim,
2018), patient can have a good quality of life with
adequate hemodialysis. However, complications
during dialysis can be life-threatening (Alfikrie et
al., 2020).
Hemodialysis can prevent death but cannot
cure the disease or restore the Patient’spatient’s
condition to its original state, causing the Patient
patient to adhere to hemodialysis therapy. Adher-
ence is crucial in the management of ESRD pa-
tients. WHO describes adherence as the extent to
which a person’s behavior (taking medications, fol-
lowing a recommended diet, and executing lifestyle
changes) correspondents with the agreed recom-
mendations of health care providers (WHO, 2003).
IDWG and adherence to dietary and fluid restric-
tions are determinants of intradialytic complications
among undergoing hemodialysis patients
Based on this study, the Rank Spearman cor-
relation test showed that a factor correlated with
intradialytic complications was patient compliance
with a Sig (2-tailed) value of 0.016 with a correla-
tion coefficient value of -0.26. The correlation co-
efficient in the results above is negative, namely -
0.263 so that the correlation between the two vari-
ables is not unidirectional, meaning that the higher
the compliance, the lower the intradialytic compli-
cations. At the same time, the OR value between
compliance with the occurrence of intradialytic com-
plications is 3.229, which means that patients with
kidney failure who are not compliant with the diet
will have a 3-fold risk of intradialytic complications
compared to patients with renal failure who are
obedient. Meanwhile, blood pressure and IDWG
did not correlate with intradialytic complications,
with a sig (2-tailed) value > 0.05. The most com-
mon intradialytic complications were time limitation
in dealing with excessive dialytic weight gain and
achieving a dry weight target on a three-times-
weekly schedule, supported by age. Elderly CKD
patients accompanied by the comorbid disease will
increase the risk of dialysis complications (Andrew
Davenport, 2006).
This study’s results follow the theory that pa-
tients with chronic kidney disease (CKD) in main-
taining their quality of life must comply with hemo-
dialysis therapy and its recommendation to limit fluid
intake. However, in subsequent hemodialysis
therapy, patients often complain of shortness of
breath due to increased volume. body fluids (Bare,
2002). Compliance with therapy in hemodialysis
patients is an important thing to note because if the
Patientpatient does not comply, there will be a
buildup of harmful substances from the body due to
metabolism in the blood. So that the Patientpatient
feels pain throughout the body and if this is allowed
to cause death (Patimah et al., 2015). Non-adher-
ence of hemodialysis patients to therapy (diet, fluid
restriction, medication, and hemodialysis) is com-
mon in patients with end-stage renal disease (ESRD)
undergoing hemodialysis. The patient must adapt
to dietary and fluid restrictions, medications, and
renal replacement therapy as routinely administered.
The fact shows that the respondents who ex-
perienced an increase in body weight between two
hemodialysis sessions (IDWG) abormal were 17
respondents (20%). Of this number of respondents
who did not comply, as many as 11 people (13%).
According to the theory (Wahyuni et al., 2014) re-
garding the compliance of chronic renal failure pa-
tients in maintaining body weight between two di-
alysis times which states that IDWG that exceeds
Table 5 Correlation between blood pressure and Intradialytic Complications
Normal f 12 27 39
TD % 14,4 32,6 47
HT f 16 28 44
% 19,2 33,8 53
Total f 28 55 83
% 33,6 66,4 100
Intradialytic Complications
Total
0,05
Spearman rho
p = 0,591
Present Not Present
383Sari, Wulandari, Arsa, Dewi, Intradialytic Complication and Associated Factors Among ...
5% of dry body weight can cause shortness of
breath, pulmonary edema, and peripheral edema.
Interdialysis weight gain in patients occurs due to
non-adherence to therapy and reasonable control
of fluid intake.
This study on IDWG shows a positive coeffi-
cient value caused by poor volume control and can
harm the cardiovascular system. The initial risk is
due to excessive sodium and water content (Lolyta
et al., 2012). Based on field observations, research-
ers saw that patients who came with Mild and
Moderate IDWG could undergo HD safely and
comfortably without experiencing complications. On
the other hand, in patients with moderate to severe
IDWG, the majority experienced complications, ei-
ther showing clinical manifestations or not.
The study results obtained pre-hypertensive
blood pressure before HD as many as 27 people
(32.5%). From this result, 15 respondents obeyed
(18.1%). PUDIASTUTI (2011) revealed that an
increase in diastolic blood pressure was a more criti-
cal factor than an increase in systolic, but now it is
known that systolic hypertension in people over 50
years of age represents a greater risk. From this
study, the results of pre-HD blood pressure for sys-
tolic pressure: 120 - 139 and diastolic pressure: 80 -
89 as many as 27 people or 32.5%. According to
the Joint National Committee on Prevention, De-
tection, Evaluation, and Treatment on High Blood
Pressure (JNC VII), classification is included in
prehypertension. According to the researchers, be-
cause patients routinely take hypertension medica-
tion, systolic and diastolic blood pressure tends to
be stable.
The results showed that from 66.3% (55 re-
spondents) who had complications, 39.8% (33 re-
spondents) experienced an increase in weight (In-
tra Dialytic Weight Gain-IDWG) >3. The most com-
mon complications are cramps, hypotension, and
hypertension. (Kamil et al., 2018). Mustikasari &
Noorratri, Erika Dewi (2017) from the Center for
Kidney Disease Research in California found that
86% of hemodialysis patients had an interdialytic
weight of more than than one 1.5 kg. The addition
of IDWG values that are too high can cause harm-
ful effects on the body, including hypotension, muscle
cramps, shortness of breath, nausea, and vomiting
(Ulrich Moissl, Marta Arias-Guilent,Petter Wabel,
Nestor Fontsere, Montserrat Carrera, José Maria
Campistol, 2013). A high IDWG will lead to high
ultrafiltration as well.
Cramps and hypotension are the most com-
mon complications. Complications of cramps as
many as 28 people (33.7%), while for hypotension
complications, as many as 20 people (24.1%). Sev-
eral theories state that intradialytic hypotension is
the most common complication and complication
exper ienced by clients dur ing hemodia lysis
(Daugirdas et al., 2015). The primary factor caus-
ing intradialytic hypotension is a decrease in blood
volume. They are beginning hemodialysis, a sud-
den decrease in blood volume because of blood
movement from the intravascular into the dialyzer.
The decrease in blood volume triggers the ac-
tivation of the cardiopressure reflex, causing an in-
crease in parasympathetic nerve activity, decreas-
ing cardiac output and blood pressure. While muscle
cramps during hemodialysis because of the low
blood volume due to the withdrawal of large amounts
of fluid during dialysis, changes in osmolarity, high
ultrafiltration, and changes in the balance of potas-
sium and calcium intracellular or extracellularly
(Ferdinan, D., Suwito, J., 2019). According to re-
searchers, the incidence of hypotension and cramps
in this study led by the majority of respondents with
fluid withdrawal (UFG) > 3 liters or > 10 ml/kg BW/
hour due to weight gain between two HD sessions
as well as high > 3 kg. If the ultrafiltration is too
high even though it is not following the increase in
body weight (increase in body fluids in liters), then
the Patient will experience symptoms of intradialytic
hypotension, cold sweats, dizziness, and yawning,
BP can drop to < 90/60 mmHg and can cause
muscle cramps. Due to a decrease in fluid volume,
especially intravenous fluids that are too fast, which
will cause a decrease in cardiac output, even though
the dialysis time has not been over. To prevent hy-
potension/ intradialytic cramps, recommended for
clients to consume healthy foods and an appropri-
ate diet outside of dialysis time.
CONCLUSION
Based on the study, the Rank Spearman cor-
relation test showed that the adherence correlated
with intradialytic complications with a Sig (2-tailed)
value of 0.016 with a correlation coefficient value
of -0.26. The correlation coefficient in the results
above was negative, namely -0.263 so that the cor-
relation between the two variables was not unidi-
rectional, meaning that the higher the compliance,
the lower the intradialytic complications. Meanwhile,
the OR value between adherence and the occur-
384 Jurnal Ners dan Kebidanan, Volume 8, Issue 3, December 2021, page 378–385
rence of intradialytic complications was 3,229, which
meant that patients with kidney failure who did not
comply with the diet had a 3-fold risk of intradialytic
complications compared to patients with renal fail-
ure who comply.
SUGGESTION
Patients need constant motivation and educa-
tion at frequent intervals to ensure better adher-
ence.
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