Complications of Long-Term Dialysis

Long-term dialysis sustains life but does not fully replace kidney function, and people on maintenance dialysis experience a high burden of complications. These span cardiovascular disease — the leading cause of death in this population — together with access-related problems, infections, mineral and bone disorders, anaemia, and modality-specific complications such as peritonitis and intradialytic events.

Definition

Complications of long-term dialysis are the cardiovascular, infectious, metabolic, mineral-bone, haematological, and access-related morbidities that accumulate in people maintained on chronic hemodialysis or peritoneal dialysis because dialysis only partially substitutes for kidney function.

Scope

This topic groups the major categories of complications encountered during maintenance dialysis: cardiovascular disease, vascular access and catheter complications, infection (including peritonitis in peritoneal dialysis), chronic kidney disease-mineral and bone disorder, anaemia, and intradialytic events. It is a reference overview that organises these problems conceptually rather than offering management instructions.

Core questions

• Why is cardiovascular disease so prevalent in people on dialysis?
• What complications arise specifically from vascular access and catheters?
• How do mineral-bone disorder and anaemia relate to dialysis?
• What complications are specific to each dialysis modality?

Key concepts

• Cardiovascular disease burden in kidney failure
• Vascular access stenosis, thrombosis, and infection
• Peritonitis (peritoneal dialysis)
• Chronic kidney disease-mineral and bone disorder (CKD-MBD)
• Anaemia of chronic kidney disease
• Intradialytic hypotension
• Catheter-related bloodstream infection

Mechanisms

Several complication categories share roots in incomplete replacement of kidney function. Cardiovascular disease reflects a combination of traditional risk factors and uraemia-related factors such as volume overload, hypertension, vascular calcification, and left ventricular hypertrophy, making it the dominant cause of death (Foley et al., 1998). Disordered mineral metabolism — retained phosphate, altered vitamin D and parathyroid hormone — drives bone disease and vascular calcification, while reduced erythropoietin underlies anaemia. Modality introduces its own hazards: hemodialysis is associated with intradialytic hypotension and access stenosis, thrombosis, and infection, whereas peritoneal dialysis is defined by the risk of peritonitis from breaching the peritoneal cavity (Li et al., 2022). Trials of higher dialysis dose did not abolish this residual morbidity, underscoring that complications are not explained by small-solute clearance alone (Eknoyan et al., 2002).

Clinical relevance

Recognising the spectrum of dialysis complications is essential to interpreting outcome data and the rationale for surveillance and preventive guidelines in kidney failure. This entry organises complication categories descriptively and is not a basis for diagnosing or managing complications in an individual patient.

Epidemiology

Mortality among people on maintenance dialysis is high relative to the general population, with cardiovascular disease the leading single cause (Foley et al., 1998). Infections, including catheter-related bloodstream infection and peritoneal dialysis peritonitis, are major causes of hospitalisation and a frequent reason for technique failure (Li et al., 2022).

Evidence & guidelines

The cardiovascular epidemiology of kidney failure was characterised in influential reviews (Foley et al., 1998), modality-specific infectious complications are addressed by dedicated recommendations such as the ISPD peritonitis guideline (Li et al., 2022), and trials such as HEMO inform how dialysis prescription relates to outcomes (Eknoyan et al., 2002). Mineral-bone and anaemia complications are covered by separate kidney guidelines summarised in related entries.

History

As dialysis transformed kidney failure into a chronic condition, attention shifted from acute survival to the long-term complications that limit life expectancy and quality of life. The recognition in the 1990s that cardiovascular disease dominates mortality in this population reframed dialysis care around cardiovascular and metabolic risk (Foley et al., 1998), and modality-specific complication prevention — vascular access surveillance and peritonitis prophylaxis — became central to long-term management.

Key figures

• Robert Foley
• Patrick Parfrey
• Mark Sarnak
• Philip Kam-Tao Li

Seminal works

• foley-1998
• li-2022-ispd

Frequently asked questions

What is the leading cause of death in people on long-term dialysis?

Cardiovascular disease is the leading cause of death among people on maintenance dialysis, reflecting both conventional risk factors and uraemia-related factors such as volume overload and vascular calcification.

Which complications are specific to each dialysis modality?

Hemodialysis is particularly associated with vascular access problems (stenosis, thrombosis, infection) and intradialytic hypotension, whereas peritoneal dialysis is characterised by the risk of peritonitis.