Managing Dialysis Side Effects: How to Stay Comfortable and in Control

At Florida Kidney Physicians, we understand that starting dialysis is a significant life change. Even after learning how treatment works, many people still wonder how they will feel during or after treatment.

Dialysis-related symptoms may include fatigue, nausea, headaches, muscle cramps, blood pressure changes, abdominal fullness, or discomfort near the dialysis access. Some symptoms improve when the treatment prescription is adjusted. Others may indicate an infection, access problem, fluid imbalance, medication effect, or another medical condition that needs evaluation.

People often describe all of these experiences as dialysis side effects, but they are not all the same:

• Treatment-related symptoms can occur because of changes in fluid volume, blood pressure, or blood chemistry.
• Medical complications include peritonitis, access infection, access dysfunction, sepsis, and uncontrolled bleeding.

Recognizing this difference is important. An infection or access problem should never be normalized as an expected side effect of dialysis.

Why Dialysis-Related Symptoms Can Happen

Dialysis replaces part, but not all, of the work normally performed by healthy kidneys. It removes waste products and extra fluid and helps regulate minerals and electrolytes in the blood.

During hemodialysis, fluid is removed from the bloodstream through a process called ultrafiltration. If fluid is removed faster than the body can comfortably replace it from surrounding tissues, circulating blood volume may decrease. This can contribute to low blood pressure, dizziness, nausea, weakness, headaches, or muscle cramps.

Peritoneal dialysis uses dialysis solution inside the abdomen. The solution may cause temporary fullness or pressure. Constipation, catheter position, drainage problems, trapped air, or infection may cause additional symptoms.

Not every symptom is caused by dialysis itself. Fatigue, nausea, pain, headaches, or weakness may also be related to anemia, medications, infection, nutrition, heart disease, sleep problems, or another medical condition.

Common Hemodialysis Symptoms and How to Respond

Low Blood Pressure During Hemodialysis

Low blood pressure during treatment is called intradialytic hypotension.

Why It Happens

When fluid is removed faster than the circulation can adjust, blood volume may decrease and blood pressure may fall.

The risk may also be affected by:

• Heart function
• Blood pressure medications
• Illness
• Eating during treatment
• Treatment duration
• The amount of fluid gained between sessions
• The prescribed post-dialysis target weight—the weight your care team aims for after removing the appropriate amount of extra fluid

KDOQI guidance supports individualizing fluid removal so that the treatment achieves appropriate fluid balance while reducing blood pressure and circulation problems during dialysis.

What You May Feel

• Dizziness or lightheadedness
• Nausea
• Blurred vision
• Sweating
• Weakness
• Muscle cramps
• Feeling as though you may faint

What to Do

• Tell the dialysis staff as soon as symptoms begin.
• Follow the sodium, fluid, and weight-gain goals established by your care team.
• Follow your dialysis center’s instructions about eating before or during treatment.
• Change position slowly after the session.
• Do not drink extra fluid or change blood pressure medications on your own.

Your care team may review the fluid-removal rate, treatment time, post-dialysis target weight, dialysis fluid settings, medication schedule, or other clinical factors.

Muscle Cramps

Muscle cramps commonly affect the legs and may occur toward the end of a hemodialysis session.

Why They Happen

Cramps may be associated with:

• Rapid fluid removal
• Falling blood pressure
• Reduced circulation to the muscles
• Changes in electrolyte concentrations during treatment

NIDDK identifies removing too much fluid too quickly as one possible cause of painful muscle cramps during hemodialysis.

What to Do

• Tell the dialysis staff immediately.
• Stretch gently only if the staff says it is safe.
• Stay within the individualized weight-gain goal between treatments established by your care team.
• Follow your individualized sodium and fluid plan.
• Ask whether your post-dialysis target weight, treatment time, fluid-removal rate, or dialysis prescription should be reviewed.

Do not use quinine, tonic water, electrolyte supplements, magnesium products, or over-the-counter medications as treatments for dialysis cramps unless your clinician specifically approves them.

Quinine is not approved by the FDA for preventing or treating leg cramps. Its use for cramps has been associated with serious blood disorders, bleeding complications, and dangerous heart-rhythm problems.

Fatigue

Fatigue during or after dialysis is common, but persistent or severe exhaustion deserves evaluation.

Why It Happens

Dialysis-related fatigue may have several contributing factors:

• Blood pressure or fluid-volume changes
• Anemia
• Poor sleep
• Inadequate calorie or protein intake
• Medication effects
• Emotional stress
• Other medical conditions
• A dialysis prescription that needs review

Anemia related to kidney disease may cause fatigue, weakness, dizziness, headaches, shortness of breath, or difficulty concentrating.

What May Help

• Maintain a consistent sleep schedule.
• Plan a period of rest after treatment when needed.
• Include gentle activity, such as walking, when approved by your clinician.
• Follow the nutrition plan developed with your renal dietitian.
• Attend the full dialysis treatment prescribed for you.
• Tell your care team if fatigue is worsening or interfering with work, mobility, self-care, or daily activities.

Do not assume that severe fatigue will disappear simply because your body is getting used to dialysis. Your team may need to review anemia treatment, dialysis adequacy, nutrition, medications, blood pressure, sleep, or other possible causes.

Nausea and Headaches

The timing of nausea or headaches can help your care team evaluate their possible cause.

Nausea or Headaches During Hemodialysis

Symptoms that begin during treatment may be associated with:

• A sudden decrease in blood pressure
• Rapid fluid removal
• Changes in blood chemistry
• Medication effects
• Food intake during treatment
• High blood pressure

Tell the dialysis staff when the symptom begins so they can check your blood pressure and assess the treatment.

Nausea Between Treatments

Persistent nausea, vomiting, poor appetite, headaches, or difficulty concentrating outside the dialysis session may have several causes.

These may include:

• Medication effects
• Infection
• Gastrointestinal illness
• Ongoing uremic symptoms
• A dialysis prescription that needs review
• Another medical condition

Uremic symptoms may include nausea, vomiting, poor appetite, reduced alertness, and low energy. However, these symptoms are not specific enough for a patient to diagnose inadequate dialysis without a clinical evaluation.

When a Headache Is an Emergency

A sudden or severe headache accompanied by new confusion, difficulty speaking, one-sided weakness, unusual drowsiness, fainting, vision loss, or a seizure is not a routine dialysis symptom.

Tell the dialysis staff immediately or call 911.

Medication Safety

• Take anti-nausea or pain medication only when prescribed or approved by your clinician.
• Do not self-treat with over-the-counter NSAIDs such as ibuprofen, naproxen, or similar anti-inflammatory medicines.
• NSAIDs may affect blood pressure, fluid balance, bleeding risk, cardiovascular health, and any remaining kidney function.
• At recommended doses, acetaminophen is generally considered safer for the kidneys than NSAIDs. However, it is not risk-free and should be checked with your clinician.
• Ask before taking acetaminophen if you have liver disease, regularly use alcohol, or take other medicines containing acetaminophen.
• Check cold, flu, and combination pain products because they may already contain acetaminophen.
• Do not stop prescribed low-dose aspirin or another blood-thinning medication because of this NSAID warning. Ask the prescribing clinician before making any change.

The National Kidney Foundation advises people with kidney disease not to self-treat with NSAIDs and notes that acetaminophen should still be used at recommended doses and reviewed with a healthcare professional. It also distinguishes prescribed low-dose aspirin from higher aspirin doses that act more like other NSAIDs.

Fluid Safety

Do not drink additional fluid to treat a headache unless your dialysis team instructs you to do so.

Extra fluid may contribute to:

• Swelling
• High blood pressure
• Shortness of breath
• Greater fluid removal during the next treatment

Dialysis Access Pain, Discomfort, and Warning Signs

Pain around one type of dialysis access does not always mean the same thing as pain around another.

Fistula or Graft Needle Discomfort

Brief discomfort during needle insertion may occur.

However, pain that persists, increases, begins between treatments, or occurs with swelling, warmth, redness, drainage, numbness, coldness, or weakness should be evaluated.

Ask your dialysis team whether an approved numbing cream or spray may be appropriate before needle insertion.

Catheter Pain or Tenderness

A hemodialysis catheter does not require needle insertion during each treatment. Therefore, new pain or tenderness near a catheter should not be dismissed as routine needle discomfort.

Contact your dialysis team immediately for:

• New or increasing catheter pain
• Tenderness along the catheter tunnel
• Redness or warmth
• Swelling
• Pus or unusual drainage
• A wet, loose, or damaged dressing
• Fever or chills
• A visible catheter cuff
• Bleeding from the catheter site or tubing

The CDC recommends checking the dialysis access for redness, pus, unusual drainage, and swelling and reporting these signs promptly.

What Is a Thrill?

The thrill is the buzzing or vibrating sensation you can feel over a working fistula or graft. Your dialysis team should teach you where and how to check it.

Contact your dialysis team immediately if the thrill:

• Disappears
• Becomes much weaker
• Feels clearly different from usual

What Is a Bruit?

The bruit is the whooshing sound created by blood flowing through the access. It is usually checked by a clinician using a stethoscope.

The National Kidney Foundation identifies an absent or changed thrill or bruit as a warning sign that a fistula or graft may not be working properly.

Protecting a Fistula or Graft

• Check the thrill as instructed.
• Keep the access area clean.
• Do not allow blood pressure measurements on the access arm.
• Do not allow unapproved blood draws or IV placement in the access arm.
• Avoid tight clothing, jewelry, heavy pressure, or sleeping on the access arm.
• Do not apply unapproved creams, powders, ointments, or topical medications.
• Report persistent bleeding, swelling, redness, warmth, drainage, numbness, coldness, or weakness.

Review our complete guide to Dialysis Access Care for more information about protecting a fistula, graft, hemodialysis catheter, or PD catheter.

Common Peritoneal Dialysis Symptoms and Complications

Abdominal Fullness or Pressure

Why It Happens

Peritoneal dialysis solution occupies space inside the abdomen. This may create pressure or fullness, particularly when beginning treatment or changing position.

What May Help

• Perform exchanges in the position taught during training.
• Wear clothing that does not press on the abdomen or catheter.
• Report pain, difficulty breathing, poor appetite, leakage, swelling, or fullness that does not improve.

Do not reduce the fill volume, change the solution concentration, shorten dwell times, or skip exchanges on your own. These are parts of the dialysis prescription and must be adjusted by the PD team.

Shoulder Pain

Why It Can Happen

Air may occasionally enter the abdomen during a PD exchange. Trapped air or pressure beneath the diaphragm can irritate tissues connected to the phrenic nerve.

Because nerve signals from the diaphragm and shoulder share related pathways, the brain may interpret irritation near the diaphragm as shoulder pain. This is called referred pain. Shoulder pain associated with air in the abdomen has been described as a mechanical complication of peritoneal dialysis.

What to Do

• Prime the tubing and perform each connection exactly as taught.
• Do not make unapproved changes to the exchange procedure.
• Report repeated, severe, or persistent shoulder pain to the PD team.
• Call 911 if the pain occurs with chest pain, severe shortness of breath, fainting, or rapidly worsening symptoms.

Not every episode of shoulder pain is caused by trapped air. Musculoskeletal, heart, lung, and abdominal conditions may also cause shoulder discomfort.

Constipation and Drainage Problems

Why They Are Connected

Constipation can change the position of the PD catheter or place pressure around it. This may slow or prevent complete drainage.

What You May Notice

• Slow drainage
• Incomplete drainage
• Abdominal pressure or swelling
• Catheter discomfort
• Repeated cycler alarms

What May Help

• Follow the fiber recommendations provided by your renal dietitian.
• Stay physically active within your clinician’s recommendations.
• Consume only the amount of fluid included in your individualized plan.
• Use stool softeners or laxatives only when approved by your nephrologist or PD team.

Contact the PD team if constipation continues or interferes with drainage.

Cloudy Fluid or Abdominal Pain

Cloudy drained dialysis fluid is considered possible peritonitis until proven otherwise, even when abdominal pain is mild or absent.

Abdominal pain also requires evaluation when the drained fluid appears clear.

ISPD guidance states that people using PD who develop cloudy drained fluid should be presumed to have peritonitis until the diagnosis is confirmed or excluded.

Other Possible Symptoms

• Fever
• Chills
• Nausea or vomiting
• Abdominal tenderness
• Abdominal swelling
• Poor appetite
• Unusual weakness
• Feeling generally unwell

What to Do Immediately

• Contact your PD team immediately.
• Do not wait until the next day or the next routine appointment.
• Keep the drained dialysis bag.
• Follow your program’s instructions for bringing the bag or obtaining a sample.
• Do not discard the cloudy fluid unless instructed.
• Do not take leftover antibiotics.
• Do not change the exchange schedule or dialysis solution on your own.
• Use the after-hours contact instructions provided by your dialysis program.

The clinical team may collect fluid for testing and begin antibiotic treatment before final test results are available. The patient should not start an antibiotic protocol independently.

Learn more about how both forms of dialysis work in Dialysis Process Explained and Hemodialysis vs. Peritoneal Dialysis.

Strategies for Reducing Dialysis Discomfort Safely

Report Symptoms Early

Do not wait until a symptom becomes severe. Early reporting allows the team to check:

• Blood pressure
• Fluid removal
• Access function
• Medications
• Positioning
• Dialysis fluid settings
• Other possible causes

Track When Symptoms Occur

Keep brief notes about:

• Whether the symptom begins before, during, or after treatment
• How long it lasts
• Your weight before and after treatment
• What you ate or drank beforehand
• Medication changes
• Whether the symptom occurs during every treatment
• Fever, swelling, breathing difficulty, or access changes

These patterns can help your team distinguish a treatment-related symptom from another medical problem.

Follow Your Individualized Nutrition and Fluid Plan

Sodium, potassium, phosphorus, protein, calorie, and fluid needs vary according to:

• Dialysis modality
• Laboratory results
• Remaining kidney function
• Blood pressure
• Medications
• Nutritional status
• Other medical conditions

Do not follow broad dietary restrictions or increase fluid intake based only on general internet advice.

Read more about individualized planning in Dialysis Diet and Fluid Management.

Complete the Prescribed Treatment

Do not shorten or skip dialysis because of discomfort without speaking with the dialysis team.

Repeated symptoms usually require evaluation and treatment adjustment rather than less dialysis.

Use Relaxation Techniques as Supportive Measures

Deep breathing, meditation, reading, guided relaxation, or listening to music may reduce stress during treatment.

These methods may support comfort, but they should not replace evaluation of pain, dizziness, breathing difficulty, or other physical symptoms.

Include Gentle Activity

Walking or gentle stretching between treatments may support circulation, sleep, energy, and mood when approved by your clinician.

For additional support, review Emotional Well-Being During Dialysis.

When to Contact Your Dialysis Team Immediately

Contact your dialysis team immediately for:

• Cloudy peritoneal dialysis fluid
• New or worsening abdominal pain
• Fever or chills
• Redness, warmth, swelling, tenderness, or drainage near an access or catheter
• New catheter pain or tenderness
• A missing or clearly changed thrill
• Persistent vomiting
• Repeated episodes of low blood pressure
• Severe or persistent muscle cramps
• Sudden weight gain or increasing swelling
• New or gradually worsening shortness of breath
• Persistent access pain
• Bleeding that takes longer than usual to stop
• PD drainage problems or repeated cycler alarms
• Fatigue, nausea, or headaches that are persistent or worsening
• Any symptom that is new or significantly different from your usual experience

Follow the contact and after-hours instructions provided by your dialysis program.

When to Call 911

Call 911 for:

• Chest pain
• Sudden or severe shortness of breath
• Shortness of breath at rest
• Difficulty breathing that prevents normal speech
• Blue or gray lips
• Fainting or inability to wake normally
• Severe confusion
• A seizure
• Sudden facial drooping
• Sudden one-sided weakness
• New difficulty speaking
• A sudden severe headache with neurological symptoms
• A very fast or irregular heartbeat accompanied by severe symptoms
• Heavy bleeding that soaks through the dressing
• Bleeding that continues despite firm direct pressure
• Any rapidly worsening or life-threatening symptom

If a fistula or graft is bleeding heavily, apply firm direct pressure with clean gauze while emergency help is on the way. Do not delay the 911 call while trying to stop significant bleeding, and do not drive yourself.

Contact your dialysis team promptly for new or gradually worsening shortness of breath. Call 911 if it is sudden, severe, occurs at rest, or is accompanied by chest pain, fainting, blue or gray lips, or an inability to speak normally.

Contact your dialysis team immediately for fever or chills. Call 911 if they occur with severe confusion, fainting, severe shortness of breath, extreme weakness, clammy skin, or rapidly worsening symptoms.

Frequently Asked Questions

Are dialysis side effects normal?

Some symptoms can occur during or after dialysis, but they should not automatically be considered normal. Report symptoms that are new, persistent, severe, or worsening.

Why do I feel nauseated during dialysis?

Nausea during hemodialysis may accompany low blood pressure, rapid fluid removal, changes in blood chemistry, medications, or eating during treatment. Tell the staff as soon as it begins.

What does nausea between treatments mean?

Persistent nausea between treatments may have several causes, including medications, infection, gastrointestinal illness, ongoing uremic symptoms, or a dialysis prescription that needs review.

Can I take ibuprofen for a dialysis headache?

Do not take ibuprofen, naproxen, or another NSAID unless your nephrologist explicitly approves it. Acetaminophen may be safer for the kidneys at recommended doses, but it should also be approved for your situation.

How can I reduce low blood pressure during dialysis?

Follow your individualized sodium, fluid, and weight-gain goals and report dizziness, nausea, weakness, or cramping immediately. Your team may need to adjust fluid removal, treatment time, target weight, medications, or the dialysis prescription.

What are the thrill and bruit?

The thrill is the buzzing vibration you feel over a fistula or graft. The bruit is the whooshing sound a clinician hears with a stethoscope. A missing or clearly changed thrill requires immediate contact with the dialysis team.

Should I change my PD fill volume if I feel too full?

No. Do not change fill volume, dwell time, solution concentration, or the number of exchanges without instructions from your PD team.

Can cloudy PD fluid wait until the next morning?

No. Cloudy drainage is considered possible peritonitis until proven otherwise. Contact your PD team immediately and follow its instructions for saving and testing the drained fluid.

Is a severe headache during dialysis an emergency?

A sudden or severe headache with confusion, weakness, difficulty speaking, fainting, unusual drowsiness, vision loss, or a seizure requires emergency care. Tell dialysis staff immediately or call 911.

What should I do if my fistula or graft will not stop bleeding?

Apply firm direct pressure with clean gauze and call 911 if the bleeding is heavy, soaks through the dressing, or continues despite pressure. Do not drive yourself.