What to do now

• Contact the nephrologist/dialysis center immediately and go for evaluation before the next dialysis session.
• Check temperature, pulse and blood pressure. If BP is low, patient is confused/drowsy, has breathing difficulty, persistent rigors, chest pain, vomiting, or temperature ≥39°C, go to ER now.
• Tell the treating team: onset after dialysis, access is AVF, prior HCV, all drug allergies, and whether other dialysis patients had similar symptoms. A pyrogenic reaction from the dialysis system is possible, but infection must be ruled out first.

Fever medicine while going to hospital

• Paracetamol 500 mg once now, then every 6 to 8 hours only if needed.
• Indian examples: Dolo 500, Crocin 500, Calpol 500.
• Keep total ≤3,000 mg/day. If there is cirrhosis, active significant liver dysfunction, regular alcohol intake, or low body weight, keep total ≤2,000 mg/day unless their doctor advises otherwise.
• Do not take ibuprofen, diclofenac, nimesulide, ketorolac, or combination “cold/fever” tablets without nephrologist advice. Avoid duplicate paracetamol from combination products.

Investigations to request urgently

1. Blood cultures: two sets from separate peripheral venipuncture sites.
   • If any dialysis catheter is present in addition to AVF, take paired cultures from catheter and peripheral blood.
2. CBC with differential, platelet count.
3. CRP and/or procalcitonin.
4. Serum electrolytes: potassium, sodium, bicarbonate, calcium; also urea, creatinine, glucose.
5. Liver function tests: bilirubin, AST/ALT, albumin, INR if clinically indicated, given HCV history.
6. Serum lactate and blood gas if fever is high, BP low, rapid breathing, confusion, or suspected sepsis.
7. Urine routine and culture only if patient still passes urine or has urinary symptoms.
8. Chest X-ray if cough, breathlessness, low oxygen, or unclear source.
9. AV fistula assessment: inspect for pain, warmth, redness, swelling, discharge, bleeding, aneurysm; check thrill/bruit. Ask for Doppler ultrasound of AVF if local signs, pain, swelling, altered thrill, suspected collection/thrombosis, or persistent bacteremia.
10. If blood cultures grow Staphylococcus aureus, persistent fever, new murmur, back/joint pain, or embolic features: discuss echocardiography and evaluation for metastatic infection.

Most likely causes

1. AV fistula cannulation-site infection or occult AVF infection
   • May have pain, warmth, redness, swelling, discharge, bleeding, or aneurysm.
   • Important: local signs can be absent despite bacteremia.
2. Bacteremia from another source
   • Staphylococcus aureus is an important organism in dialysis-access infections.
   • Also consider gram-negative infection, pneumonia, UTI if residual urine output, infected diabetic foot/skin lesion, dental infection.
3. Dialysis-related pyrogenic reaction
   • Consider if fever/rigors began during or shortly after dialysis and especially if another patient had similar symptoms or there is a water/dialysate problem.
   • But a reaction lasting into the next day makes infection more concerning. Check the machine, dialysate batch, RO-water log, disinfection records, endotoxin/microbial testing according to your unit protocol.
4. Viral illness, including COVID-19/influenza/dengue depending on local outbreak and symptoms.
   • HCV itself does not usually explain a sudden fever and chills occurring after dialysis.

Immediate technician actions

• Record and repeat: temperature, BP, pulse, respiratory rate, SpO₂, mental status.
• Examine and document AVF: warmth, erythema, tenderness, induration, swelling, discharge, bleeding, aneurysm/pseudoaneurysm, and presence/quality of thrill and bruit.
• Notify nephrologist/physician urgently.
• If hypotension, SpO₂ <94%, altered sensorium, persistent rigors, tachypnea, chest pain, or severe weakness: shift to emergency department now.
• Do not cannulate a visibly inflamed/purulent AVF site. Use the unit’s alternate-access and infection-control protocol under nephrologist direction.
• Check whether other patients from the same shift developed fever/chills, and preserve relevant machine/dialysate records for investigation.

Investigations to send today

Essential

1. Two sets of blood cultures, from two separate venipuncture sites.
   • If there is any central catheter, send paired cultures from catheter/bloodline and peripheral sample as per local protocol.
2. CBC with differential and platelet count
3. CRP and preferably procalcitonin
4. Serum electrolytes, calcium, bicarbonate, glucose, urea/creatinine
5. LFT, bilirubin, albumin, and PT/INR if clinically indicated because of HCV history
6. Serum lactate if unwell, hypotensive, tachypneic, or suspected sepsis
7. Urine routine and culture if patient makes urine or has dysuria
8. Chest X-ray if cough, breathlessness, hypoxia, or no source is evident
9. AVF Doppler ultrasound if local tenderness/swelling, altered thrill, suspected pseudoaneurysm, thrombosis, or collection
10. Rapid COVID-19/flu testing if respiratory symptoms or local circulation
11. Region and symptom dependent: malaria test, dengue NS1/IgM, etc.

Medicine

Safe fever control only, pending doctor review

• Paracetamol 500 mg orally, every 6-8 hours only if needed.
  • Examples: Dolo 500, Crocin 500, Calpol 500.
  • Maximum usually 3 g in 24 hours. Keep maximum 2 g/day if cirrhosis, significant liver dysfunction, low body weight, or regular alcohol intake, unless the treating doctor advises otherwise.

Avoid

• Ibuprofen, diclofenac, aceclofenac, nimesulide, ketorolac, and OTC cold-combination tablets.
• Do not give oral antibiotics such as azithromycin, cefixime, ciprofloxacin, amoxicillin-clavulanate, etc. empirically.

Antibiotics