"hemodialysis adequacy" AND "Kt/V"

"hemodialysis" AND "dialysis adequacy"

"muscle cramps" AND "hemodialysis"

PMID: 36691882

PMID: 40725745

mkdir -p /home/daytona/workspace/hd-complications-pdf && ls /home/daytona/worksp…

~/hd-complications-pdf/generate_pdf.py

from reportlab.lib.pagesizes import A4
from reportlab.lib import colors
from reportlab.lib.units import cm
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.enums import TA_LEFT, TA_CENTER, TA_JUSTIFY
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    HRFlowable, KeepTogether, PageBreak
)
from reportlab.platypus.flowables import HRFlowable
from reportlab.lib.colors import HexColor, white, black

OUTPUT = "/home/daytona/workspace/hd-complications-pdf/HD_Complications_Quick_Reference.pdf"

# ── Colour palette ──────────────────────────────────────────────────────────
NAVY      = HexColor("#1A3557")
TEAL      = HexColor("#1E7F8E")
LIGHT_BLU = HexColor("#D6EAF8")
LIGHT_GRN = HexColor("#D5F5E3")
LIGHT_YEL = HexColor("#FEF9E7")
LIGHT_RED = HexColor("#FDEDEC")
LIGHT_PUR = HexColor("#F4ECF7")
LIGHT_ORG = HexColor("#FDEBD0")
MID_TEAL  = HexColor("#A9CCE3")
ORANGE    = HexColor("#E67E22")
RED       = HexColor("#C0392B")
GREEN     = HexColor("#1E8449")
GREY_BG   = HexColor("#F2F3F4")
DARK_GREY = HexColor("#2C3E50")
MID_GREY  = HexColor("#5D6D7E")

# ── Document setup ───────────────────────────────────────────────────────────
doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A4,
    leftMargin=1.8*cm, rightMargin=1.8*cm,
    topMargin=2*cm, bottomMargin=2*cm,
    title="Hemodialysis Complications – Quick Reference",
    author="Orris Medical Reference"
)

W = A4[0] - 3.6*cm   # usable width

# ── Styles ───────────────────────────────────────────────────────────────────
base = getSampleStyleSheet()

def style(name, parent="Normal", **kw):
    s = ParagraphStyle(name, parent=base[parent])
    for k, v in kw.items():
        setattr(s, k, v)
    return s

S_COVER_TITLE = style("CoverTitle",
    fontSize=26, textColor=white, leading=32,
    alignment=TA_CENTER, fontName="Helvetica-Bold")
S_COVER_SUB = style("CoverSub",
    fontSize=13, textColor=HexColor("#D6EAF8"), leading=18,
    alignment=TA_CENTER, fontName="Helvetica")
S_COVER_DATE = style("CoverDate",
    fontSize=10, textColor=HexColor("#A9CCE3"), leading=14,
    alignment=TA_CENTER, fontName="Helvetica-Oblique")

S_SECTION = style("Section",
    fontSize=13, textColor=white, leading=17,
    fontName="Helvetica-Bold", alignment=TA_LEFT,
    leftIndent=6, spaceAfter=4)
S_SUBHEAD = style("Subhead",
    fontSize=10.5, textColor=NAVY, leading=14,
    fontName="Helvetica-Bold", spaceBefore=6, spaceAfter=2)
S_BODY = style("Body",
    fontSize=9, textColor=DARK_GREY, leading=13,
    fontName="Helvetica", spaceAfter=2)
S_BULLET = style("Bullet",
    fontSize=9, textColor=DARK_GREY, leading=13,
    fontName="Helvetica", leftIndent=14, spaceAfter=1,
    bulletIndent=5, bulletFontSize=9)
S_TABLE_HDR = style("TblHdr",
    fontSize=9, textColor=white, leading=12,
    fontName="Helvetica-Bold", alignment=TA_CENTER)
S_TABLE_CELL = style("TblCell",
    fontSize=8.5, textColor=DARK_GREY, leading=11,
    fontName="Helvetica")
S_TABLE_CELL_C = style("TblCellC",
    fontSize=8.5, textColor=DARK_GREY, leading=11,
    fontName="Helvetica", alignment=TA_CENTER)
S_FOOTER = style("Footer",
    fontSize=7.5, textColor=MID_GREY, alignment=TA_CENTER,
    fontName="Helvetica-Oblique")
S_CAPTION = style("Caption",
    fontSize=8, textColor=MID_GREY, leading=11,
    fontName="Helvetica-Oblique", alignment=TA_CENTER)
S_ALERT = style("Alert",
    fontSize=9, textColor=RED, leading=13,
    fontName="Helvetica-Bold", leftIndent=8)
S_NOTE = style("Note",
    fontSize=8.5, textColor=MID_GREY, leading=12,
    fontName="Helvetica-Oblique", leftIndent=8)

def b(text): return f"<b>{text}</b>"
def i(text): return f"<i>{text}</i>"
def colored(text, col): return f'<font color="{col}">{text}</font>'

# ── Helper builders ───────────────────────────────────────────────────────────
def section_header(title, color=TEAL):
    tbl = Table([[Paragraph(title, S_SECTION)]], colWidths=[W])
    tbl.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), color),
        ("ROUNDEDCORNERS", [4]),
        ("TOPPADDING", (0,0), (-1,-1), 5),
        ("BOTTOMPADDING", (0,0), (-1,-1), 5),
        ("LEFTPADDING", (0,0), (-1,-1), 10),
    ]))
    return tbl

def colored_box(content_rows, bg_color, border_color=None):
    """Wrap rows in a shaded box."""
    bc = border_color or bg_color
    tbl = Table(content_rows, colWidths=[W])
    tbl.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), bg_color),
        ("BOX", (0,0), (-1,-1), 0.5, bc),
        ("TOPPADDING", (0,0), (-1,-1), 4),
        ("BOTTOMPADDING", (0,0), (-1,-1), 4),
        ("LEFTPADDING", (0,0), (-1,-1), 10),
        ("RIGHTPADDING", (0,0), (-1,-1), 10),
    ]))
    return tbl

def two_col_table(headers, rows, col_widths, header_bg=NAVY):
    """Generic table with styled header."""
    data = [[Paragraph(h, S_TABLE_HDR) for h in headers]]
    for row in rows:
        data.append([Paragraph(str(c), S_TABLE_CELL) if i==0 else
                     Paragraph(str(c), S_TABLE_CELL) for i,c in enumerate(row)])
    tbl = Table(data, colWidths=col_widths, repeatRows=1)
    tbl.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,0), header_bg),
        ("ROWBACKGROUNDS", (0,1), (-1,-1), [white, GREY_BG]),
        ("GRID", (0,0), (-1,-1), 0.3, HexColor("#BDC3C7")),
        ("TOPPADDING", (0,0), (-1,-1), 4),
        ("BOTTOMPADDING", (0,0), (-1,-1), 4),
        ("LEFTPADDING", (0,0), (-1,-1), 6),
        ("RIGHTPADDING", (0,0), (-1,-1), 6),
        ("VALIGN", (0,0), (-1,-1), "TOP"),
    ]))
    return tbl

def bullet(text): return Paragraph(f"• {text}", S_BULLET)
def body(text):   return Paragraph(text, S_BODY)
def sp(h=4):      return Spacer(1, h)
def hr():         return HRFlowable(width="100%", thickness=0.5, color=HexColor("#BDC3C7"), spaceAfter=4, spaceBefore=4)

# ─────────────────────────────────────────────────────────────────────────────
# PAGE CALLBACKS (header / footer)
# ─────────────────────────────────────────────────────────────────────────────
def on_page(canvas, doc):
    canvas.saveState()
    # Top stripe
    canvas.setFillColor(NAVY)
    canvas.rect(0, A4[1]-1*cm, A4[0], 1*cm, fill=1, stroke=0)
    canvas.setFont("Helvetica-Bold", 8)
    canvas.setFillColor(white)
    canvas.drawString(1.8*cm, A4[1]-0.65*cm, "HD COMPLICATIONS – QUICK REFERENCE")
    canvas.setFont("Helvetica", 8)
    canvas.drawRightString(A4[0]-1.8*cm, A4[1]-0.65*cm, f"Page {doc.page}")
    # Bottom stripe
    canvas.setFillColor(GREY_BG)
    canvas.rect(0, 0, A4[0], 0.9*cm, fill=1, stroke=0)
    canvas.setFont("Helvetica-Oblique", 7)
    canvas.setFillColor(MID_GREY)
    canvas.drawCentredString(A4[0]/2, 0.32*cm,
        "For clinical reference only. Always consult institutional protocols and current guidelines.")
    canvas.restoreState()

def on_first_page(canvas, doc):
    # Full cover background
    canvas.setFillColor(NAVY)
    canvas.rect(0, 0, A4[0], A4[1], fill=1, stroke=0)
    # Decorative teal band
    canvas.setFillColor(TEAL)
    canvas.rect(0, A4[1]*0.38, A4[0], 4, fill=1, stroke=0)
    canvas.rect(0, A4[1]*0.35, A4[0], 4, fill=1, stroke=0)

# ─────────────────────────────────────────────────────────────────────────────
# CONTENT
# ─────────────────────────────────────────────────────────────────────────────
story = []

# ══════════════════════════════════════════════════════════
# COVER PAGE
# ══════════════════════════════════════════════════════════
story.append(Spacer(1, 5.5*cm))
story.append(Paragraph("HEMODIALYSIS COMPLICATIONS", S_COVER_TITLE))
story.append(Spacer(1, 0.3*cm))
story.append(Paragraph("Quick Reference Guide for Clinical Practice", S_COVER_SUB))
story.append(Spacer(1, 0.5*cm))
story.append(HRFlowable(width="60%", thickness=1, color=TEAL, spaceAfter=8, spaceBefore=4))
story.append(Spacer(1, 0.4*cm))
story.append(Paragraph(
    "Intradialytic &amp; Post-Dialytic Complications · Causes · Management Strategies",
    S_COVER_SUB))
story.append(Spacer(1, 4*cm))
story.append(Paragraph("Based on Brenner &amp; Rector's The Kidney · Harrison's PoIM 22E · "
                        "Comprehensive Clinical Nephrology 7E · Goldman-Cecil Medicine",
                        S_COVER_DATE))
story.append(Spacer(1, 0.3*cm))
story.append(Paragraph("July 2026", S_COVER_DATE))
story.append(PageBreak())

# ══════════════════════════════════════════════════════════
# PAGE 2 – OVERVIEW & QUICK TARGETS
# ══════════════════════════════════════════════════════════
story.append(section_header("OVERVIEW OF HEMODIALYSIS COMPLICATIONS"))
story.append(sp(6))
story.append(body(
    "Hemodialysis (HD) is a life-sustaining but physiologically demanding procedure. "
    "With over 400,000 patients receiving >60 million HD sessions/year in the US alone, "
    "complications—though infrequent per session—are clinically significant in aggregate. "
    "Complications are classified as <b>intradialytic</b> (occurring during the session) "
    "or <b>post-dialytic</b> (occurring after). Recognition and systematic management "
    "are essential to preserve patient safety and treatment adequacy."))
story.append(sp(8))

# Quick targets box
story.append(Paragraph("Key Adequacy Targets", S_SUBHEAD))
targets = [
    ["Parameter", "Target", "Notes"],
    ["spKt/V", "≥ 1.4 prescribed / ≥ 1.2 delivered", "Single-pool Kt/V per session"],
    ["eKt/V", "≥ 1.05", "Equilibrated (accounts for urea rebound)"],
    ["URR", "≥ 65%", "Urea Reduction Ratio per session"],
    ["Session duration", "≥ 4 h per session; ≥ 12 h/week", "Minimum; individualize upward"],
    ["Blood flow rate", "≥ 250 mL/min (250–450)", "Limited by access function"],
    ["Dialysate flow rate", "500–800 mL/min (countercurrent)", "Higher rates have diminishing returns"],
    ["UF rate", "< 10–13 mL/kg/h", "Higher rates ↑ cardiovascular risk"],
    ["Dialyzer", "High-flux synthetic membrane", "Polysulfone preferred"],
    ["Dialysate Na", "Match patient's serum Na (~138–140 mEq/L)", "Avoid fixed high Na"],
    ["Dialysate K", "2 mEq/L (standard)", "Adjust for pre-HD K level"],
    ["Serum phosphate", "< 5.5 mg/dL", "Longer sessions improve removal"],
]
col_w = [W*0.22, W*0.38, W*0.40]
tbl_data = [[Paragraph(h, S_TABLE_HDR) for h in targets[0]]]
for row in targets[1:]:
    tbl_data.append([Paragraph(row[0], S_TABLE_CELL),
                     Paragraph(row[1], S_TABLE_CELL),
                     Paragraph(row[2], S_TABLE_CELL)])
t = Table(tbl_data, colWidths=col_w, repeatRows=1)
t.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), NAVY),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [white, LIGHT_BLU]),
    ("GRID", (0,0), (-1,-1), 0.3, HexColor("#BDC3C7")),
    ("TOPPADDING", (0,0), (-1,-1), 4), ("BOTTOMPADDING", (0,0), (-1,-1), 4),
    ("LEFTPADDING", (0,0), (-1,-1), 6), ("RIGHTPADDING", (0,0), (-1,-1), 6),
    ("VALIGN", (0,0), (-1,-1), "MIDDLE"),
]))
story.append(t)
story.append(PageBreak())

# ══════════════════════════════════════════════════════════
# PAGE 3 – INTRADIALYTIC HYPOTENSION
# ══════════════════════════════════════════════════════════
story.append(section_header("1. INTRADIALYTIC HYPOTENSION (IDH)", NAVY))
story.append(sp(5))

# Definition box
story.append(colored_box([
    [Paragraph("<b>Definition (KDOQI):</b> Decrease in systolic BP ≥ 20 mmHg "
               "<i>or</i> decrease in MAP ≥ 10 mmHg associated with clinical symptoms requiring intervention.", S_BODY)]
], LIGHT_BLU, MID_TEAL))
story.append(sp(6))
story.append(body(f"<b>Frequency:</b> Occurs in 15–30% of all HD sessions; >50% of sessions in susceptible patients. "
                  "Strongly associated with large interdialytic weight gains, female sex, diabetes, older age, longer vintage, and underlying cardiac disease."))
story.append(sp(8))

idh_data = [
    [Paragraph("CAUSES", S_TABLE_HDR), Paragraph("PREVENTION", S_TABLE_HDR), Paragraph("ACUTE MANAGEMENT", S_TABLE_HDR)],
    [
        Paragraph("• Excessive/rapid UF (>10–13 mL/kg/h)\n• Impaired vascular refilling\n• Reduced cardiac reserve\n"
                  "• Heat transfer from dialysate → vasodilation\n• ↓ plasma osmolality (solute removal)\n"
                  "• Antihypertensive medications\n• Food intake during dialysis\n• Low dialysate Ca or Mg\n• Acetate-based dialysate", S_TABLE_CELL),
        Paragraph("• Reassess dry weight\n• ↓ interdialytic sodium/fluid intake\n• Individualize dialysate Na ≈ serum Na\n"
                  "• Cool dialysate (35–36.5°C)\n• Dialysate Ca 2.25–2.5 mEq/L\n• Avoid antihypertensives pre-HD\n"
                  "• No food during HD (esp. diabetics)\n• UF modeling / sequential UF\n• Extend session or ↑ frequency\n"
                  "• Midodrine 2.5–10 mg, 15–30 min pre-HD (refractory cases)\n• Bicarbonate (not acetate) dialysate", S_TABLE_CELL),
        Paragraph("• ↓ UF rate or pause UF\n• Supine / Trendelenburg position\n• Normal saline 100–250 mL bolus\n"
                  "• ↓ blood flow rate\n• O₂ supplementation\n• If no reversal: discontinue HD\n"
                  "• Rule out myocardial ischemia, pericardial effusion", S_TABLE_CELL),
    ]
]
idh_tbl = Table(idh_data, colWidths=[W*0.33, W*0.34, W*0.33], repeatRows=1)
idh_tbl.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), TEAL),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [LIGHT_BLU]),
    ("GRID", (0,0), (-1,-1), 0.3, HexColor("#BDC3C7")),
    ("TOPPADDING", (0,0), (-1,-1), 5), ("BOTTOMPADDING", (0,0), (-1,-1), 5),
    ("LEFTPADDING", (0,0), (-1,-1), 6), ("RIGHTPADDING", (0,0), (-1,-1), 6),
    ("VALIGN", (0,0), (-1,-1), "TOP"),
]))
story.append(idh_tbl)
story.append(sp(8))
story.append(Paragraph(
    "<i>Note: High UF rates (>10–13 mL/kg/h) are independently associated with increased cardiovascular morbidity and mortality. "
    "Midodrine side effects include supine hypertension, urinary retention, and pilomotor reactions.</i>", S_NOTE))
story.append(PageBreak())

# ══════════════════════════════════════════════════════════
# PAGE 4 – MUSCLE CRAMPS
# ══════════════════════════════════════════════════════════
story.append(section_header("2. MUSCLE CRAMPS", NAVY))
story.append(sp(5))
story.append(colored_box([
    [Paragraph("<b>Frequency:</b> Occur during/after ~60% of HD sessions (Brenner &amp; Rector). "
               "Account for <b>15% of premature session discontinuations</b>. "
               "Predominantly affect legs; onset typically late in the session.", S_BODY)]
], LIGHT_RED, RED))
story.append(sp(6))

cramp_patho = [
    [Paragraph("PATHOGENESIS", S_TABLE_HDR), Paragraph("MECHANISM", S_TABLE_HDR)],
    [Paragraph("Volume contraction + hypotension", S_TABLE_CELL),
     Paragraph("Vasoconstriction → impaired O₂ delivery to muscle; occurs with excessive UF or over-reaching dry weight", S_TABLE_CELL)],
    [Paragraph("Plasma hypoosmolality", S_TABLE_CELL),
     Paragraph("Solute diffusion ↓ plasma osmolality → osmotic fluid shift into muscle cells → altered intracellular ion concentrations → spontaneous contraction", S_TABLE_CELL)],
    [Paragraph("Hypomagnesemia", S_TABLE_CELL),
     Paragraph("Mg²⁺ is lost during dialysis; critical for neuromuscular stability. Dialysate Mg typically 0.5–1 mEq/L", S_TABLE_CELL)],
    [Paragraph("L-Carnitine deficiency", S_TABLE_CELL),
     Paragraph("Carnitine is freely dialyzable; deficiency impairs muscle fatty acid oxidation → fatigue + cramping", S_TABLE_CELL)],
    [Paragraph("Uremic toxin accumulation", S_TABLE_CELL),
     Paragraph("Unidentified uremic solutes accumulating between sessions may increase muscle irritability", S_TABLE_CELL)],
    [Paragraph("Nutritional deficiencies", S_TABLE_CELL),
     Paragraph("Vitamin E deficiency may lower cramp threshold", S_TABLE_CELL)],
]
cramp_tbl = Table(cramp_patho, colWidths=[W*0.35, W*0.65], repeatRows=1)
cramp_tbl.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), NAVY),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [white, LIGHT_RED]),
    ("GRID", (0,0), (-1,-1), 0.3, HexColor("#BDC3C7")),
    ("TOPPADDING", (0,0), (-1,-1), 4), ("BOTTOMPADDING", (0,0), (-1,-1), 4),
    ("LEFTPADDING", (0,0), (-1,-1), 6), ("RIGHTPADDING", (0,0), (-1,-1), 6),
    ("VALIGN", (0,0), (-1,-1), "TOP"),
]))
story.append(cramp_tbl)
story.append(sp(8))

# Acute management
story.append(Paragraph("Acute Management – Raise Plasma Osmolality", S_SUBHEAD))
acute_cramp = [
    [Paragraph("Agent", S_TABLE_HDR), Paragraph("Dose", S_TABLE_HDR), Paragraph("Notes", S_TABLE_HDR)],
    [Paragraph("50% Dextrose (D50W)", S_TABLE_CELL), Paragraph("25–50 mL IV", S_TABLE_CELL),
     Paragraph("Preferred (non-diabetics); no thirst or significant fluid gain", S_TABLE_CELL)],
    [Paragraph("23–23.5% Hypertonic saline", S_TABLE_CELL), Paragraph("15–20 mL IV", S_TABLE_CELL),
     Paragraph("Effective; causes post-dialytic thirst and ↑ IDWG", S_TABLE_CELL)],
    [Paragraph("25% Mannitol", S_TABLE_CELL), Paragraph("50–100 mL IV", S_TABLE_CELL),
     Paragraph("Effective; repeated use → thirst, fluid overload", S_TABLE_CELL)],
    [Paragraph("Normal saline + pause UF", S_TABLE_CELL), Paragraph("100–200 mL IV", S_TABLE_CELL),
     Paragraph("When cramps accompany hypotension", S_TABLE_CELL)],
]
act = Table(acute_cramp, colWidths=[W*0.28, W*0.20, W*0.52], repeatRows=1)
act.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), TEAL),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [white, GREY_BG]),
    ("GRID", (0,0), (-1,-1), 0.3, HexColor("#BDC3C7")),
    ("TOPPADDING", (0,0), (-1,-1), 4), ("BOTTOMPADDING", (0,0), (-1,-1), 4),
    ("LEFTPADDING", (0,0), (-1,-1), 6), ("RIGHTPADDING", (0,0), (-1,-1), 6),
    ("VALIGN", (0,0), (-1,-1), "TOP"),
]))
story.append(act)
story.append(sp(8))

story.append(Paragraph("Prevention Strategies", S_SUBHEAD))
prev_cramp = [
    [Paragraph("Strategy", S_TABLE_HDR), Paragraph("Details", S_TABLE_HDR)],
    [Paragraph("Prescription adjustment", S_TABLE_CELL),
     Paragraph("↑ dry weight by 0.5 kg if no fluid overload; extend session; ↑ frequency; ↓ UF rate", S_TABLE_CELL)],
    [Paragraph("Dietary counselling", S_TABLE_CELL),
     Paragraph("Reduce Na intake → ↓ IDWG → lower required UF rate per session", S_TABLE_CELL)],
    [Paragraph("Sodium modeling", S_TABLE_CELL),
     Paragraph("Start dialysate Na 145–155 mEq/L; linear taper to 135–140 mEq/L by end of session", S_TABLE_CELL)],
    [Paragraph("Vitamin E", S_TABLE_CELL),
     Paragraph("Taken before bedtime; small RCTs suggest benefit; safe and well-tolerated", S_TABLE_CELL)],
    [Paragraph("Quinine sulfate 250–300 mg", S_TABLE_CELL),
     Paragraph("⚠ FDA BLACK BOX WARNING: risk of TMA, QT prolongation, hypersensitivity. Largely abandoned in the US.", S_TABLE_CELL)],
    [Paragraph("Oxazepam 5–10 mg", S_TABLE_CELL),
     Paragraph("Given 2 h pre-dialysis; some evidence of benefit", S_TABLE_CELL)],
    [Paragraph("L-Carnitine 20 mg/kg/session", S_TABLE_CELL),
     Paragraph("IV post-dialysis; meta-analysis results inconsistent for cramps specifically", S_TABLE_CELL)],
    [Paragraph("Magnesium supplementation", S_TABLE_CELL),
     Paragraph("If hypomagnesemia documented; also stretching, creatine monohydrate 12 mg pre-HD", S_TABLE_CELL)],
    [Paragraph("Blood volume biofeedback", S_TABLE_CELL),
     Paragraph("Automated UF adjustment guided by continuous relative blood volume monitoring", S_TABLE_CELL)],
    [Paragraph("Non-pharmacological", S_TABLE_CELL),
     Paragraph("Exercise, aromatherapy, reflexology, massage, acupressure (meta-analysis of 14 RCTs supports efficacy)", S_TABLE_CELL)],
]
prev = Table(prev_cramp, colWidths=[W*0.30, W*0.70], repeatRows=1)
prev.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), NAVY),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [white, LIGHT_YEL]),
    ("GRID", (0,0), (-1,-1), 0.3, HexColor("#BDC3C7")),
    ("TOPPADDING", (0,0), (-1,-1), 4), ("BOTTOMPADDING", (0,0), (-1,-1), 4),
    ("LEFTPADDING", (0,0), (-1,-1), 6), ("RIGHTPADDING", (0,0), (-1,-1), 6),
    ("VALIGN", (0,0), (-1,-1), "TOP"),
    # Highlight quinine row in red
    ("BACKGROUND", (0,5), (-1,5), LIGHT_RED),
    ("TEXTCOLOR", (0,5), (0,5), RED),
]))
story.append(prev)
story.append(PageBreak())

# ══════════════════════════════════════════════════════════
# PAGE 5 – CARDIOVASCULAR & ARRHYTHMIAS + DISEQUILIBRIUM
# ══════════════════════════════════════════════════════════
story.append(section_header("3. CARDIOVASCULAR COMPLICATIONS", NAVY))
story.append(sp(5))

cv_data = [
    [Paragraph("COMPLICATION", S_TABLE_HDR), Paragraph("CAUSES / RISK FACTORS", S_TABLE_HDR), Paragraph("MANAGEMENT", S_TABLE_HDR)],
    [Paragraph("Myocardial stunning / LV dysfunction", S_TABLE_CELL),
     Paragraph("• Rapid UF → ↓ preload\n• Sympathetic activation\n• Heat transfer from dialysate\n• Dialysis-induced regional wall motion abnormalities", S_TABLE_CELL),
     Paragraph("• Cool dialysate (35–36.5°C)\n• ↓ UF rate; extend session\n• Avoid food during HD\n• Echocardiography if recurrent IDH", S_TABLE_CELL)],
    [Paragraph("Cardiac arrhythmias", S_TABLE_CELL),
     Paragraph("• Electrolyte shifts (K⁺, Ca²⁺, Mg²⁺)\n• Low dialysate Ca\n• Pre-existing LVH, IHD\n• Autonomic dysregulation", S_TABLE_CELL),
     Paragraph("• Individualize dialysate K (min 2 mEq/L)\n• Dialysate Ca 2.25–2.5 mEq/L\n• Avoid rapid K removal\n• Cardiac monitoring in high-risk patients", S_TABLE_CELL)],
    [Paragraph("Hypertension (post-HD)", S_TABLE_CELL),
     Paragraph("• Fluid overload / inadequate UF\n• RAAS activation\n• Sympathetic overactivity\n• Endothelial dysfunction", S_TABLE_CELL),
     Paragraph("• Achieve dry weight\n• Restrict dietary Na\n• More frequent/longer HD\n• Antihypertensives after HD session", S_TABLE_CELL)],
    [Paragraph("Increased mortality risk\n(long interdialytic interval)", S_TABLE_CELL),
     Paragraph("• Extended Saturday-to-Monday gap\n• Fluid/solute accumulation\n• Cardiovascular stress", S_TABLE_CELL),
     Paragraph("• Minimise long interval\n• Consider 6×/week HD for high-risk patients\n• Monitor for post-weekend presentations", S_TABLE_CELL)],
]
cv = Table(cv_data, colWidths=[W*0.22, W*0.38, W*0.40], repeatRows=1)
cv.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), TEAL),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [white, LIGHT_BLU]),
    ("GRID", (0,0), (-1,-1), 0.3, HexColor("#BDC3C7")),
    ("TOPPADDING", (0,0), (-1,-1), 5), ("BOTTOMPADDING", (0,0), (-1,-1), 5),
    ("LEFTPADDING", (0,0), (-1,-1), 6), ("RIGHTPADDING", (0,0), (-1,-1), 6),
    ("VALIGN", (0,0), (-1,-1), "TOP"),
]))
story.append(cv)
story.append(sp(10))

# Disequilibrium syndrome
story.append(section_header("4. DIALYSIS DISEQUILIBRIUM SYNDROME (DDS)", NAVY))
story.append(sp(5))
dds_data = [
    [Paragraph("FEATURE", S_TABLE_HDR), Paragraph("DETAILS", S_TABLE_HDR)],
    [Paragraph("Definition", S_TABLE_CELL),
     Paragraph("Neurological syndrome resulting from rapid solute removal in severely uremic patients, especially at dialysis initiation", S_TABLE_CELL)],
    [Paragraph("Mechanism", S_TABLE_CELL),
     Paragraph("Rapid ↓ plasma osmolality → osmotic gradient → cerebral oedema. Brain retains 'idiogenic osmoles' when plasma urea falls faster than CNS equilibration.", S_TABLE_CELL)],
    [Paragraph("Symptoms (mild)", S_TABLE_CELL),
     Paragraph("Nausea, vomiting, headache, restlessness, blurred vision", S_TABLE_CELL)],
    [Paragraph("Symptoms (severe)", S_TABLE_CELL),
     Paragraph("Seizures, obtundation, coma (rare but life-threatening)", S_TABLE_CELL)],
    [Paragraph("Risk factors", S_TABLE_CELL),
     Paragraph("Very high BUN pre-dialysis, first HD session, rapid solute removal, paediatric patients, pre-existing neurological disease", S_TABLE_CELL)],
    [Paragraph("Prevention", S_TABLE_CELL),
     Paragraph("Use low-efficiency dialyzer initially; short first sessions (2 h); slow blood flow rate (150–200 mL/min); target BUN reduction ≤30–40% in first session", S_TABLE_CELL)],
    [Paragraph("Management", S_TABLE_CELL),
     Paragraph("Stop or slow HD; IV mannitol (1 g/kg) or hypertonic saline; seizure management (benzodiazepines); supportive care", S_TABLE_CELL)],
]
dds = Table(dds_data, colWidths=[W*0.25, W*0.75], repeatRows=1)
dds.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), NAVY),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [white, LIGHT_PUR]),
    ("GRID", (0,0), (-1,-1), 0.3, HexColor("#BDC3C7")),
    ("TOPPADDING", (0,0), (-1,-1), 4), ("BOTTOMPADDING", (0,0), (-1,-1), 4),
    ("LEFTPADDING", (0,0), (-1,-1), 6), ("RIGHTPADDING", (0,0), (-1,-1), 6),
    ("VALIGN", (0,0), (-1,-1), "TOP"),
]))
story.append(dds)
story.append(PageBreak())

# ══════════════════════════════════════════════════════════
# PAGE 6 – ACCESS & INFECTIOUS COMPLICATIONS
# ══════════════════════════════════════════════════════════
story.append(section_header("5. VASCULAR ACCESS COMPLICATIONS", NAVY))
story.append(sp(5))
access_data = [
    [Paragraph("COMPLICATION", S_TABLE_HDR), Paragraph("CAUSES", S_TABLE_HDR), Paragraph("MANAGEMENT", S_TABLE_HDR)],
    [Paragraph("AV fistula / graft thrombosis", S_TABLE_CELL),
     Paragraph("• Stenosis (intimal hyperplasia)\n• Hypotension\n• External compression\n• Hypercoagulability", S_TABLE_CELL),
     Paragraph("• Fistulogram\n• Thrombolysis or thrombectomy\n• Angioplasty / stent for stenosis\n• Anticoagulation if indicated", S_TABLE_CELL)],
    [Paragraph("Stenosis", S_TABLE_CELL),
     Paragraph("• Venous outflow stenosis\n• Subclavian stenosis (tunneled catheter history)\n• Neointimal hyperplasia", S_TABLE_CELL),
     Paragraph("• Surveillance with access flow measurement\n• Angioplasty (PTA) ± stenting\n• Surgical revision if refractory", S_TABLE_CELL)],
    [Paragraph("Access recirculation", S_TABLE_CELL),
     Paragraph("• Stenosis reducing forward flow\n• Reversed needle placement\n• Low blood flow", S_TABLE_CELL),
     Paragraph("• Measure recirculation (urea method or ultrasound dilution)\n• Treat underlying stenosis\n• Reduces delivered Kt/V", S_TABLE_CELL)],
    [Paragraph("Catheter infection / bacteraemia", S_TABLE_CELL),
     Paragraph("• Biofilm formation\n• Hub contamination\n• Femoral > IJ > subclavian (infection risk)", S_TABLE_CELL),
     Paragraph("• Blood cultures × 2\n• Empiric broad-spectrum antibiotics (Staph + GNR coverage)\n• Catheter removal after 48 h of negative cultures\n• Antibiotics ≥ 2–3 weeks for bacteraemia", S_TABLE_CELL)],
    [Paragraph("Steal syndrome", S_TABLE_CELL),
     Paragraph("• High-flow AV access diverts blood from distal limb\n• Large calibre graft / fistula", S_TABLE_CELL),
     Paragraph("• Banding\n• DRIL procedure (Distal Revascularisation Interval Ligation)\n• Access revision or ligation if severe", S_TABLE_CELL)],
]
acc = Table(access_data, colWidths=[W*0.22, W*0.37, W*0.41], repeatRows=1)
acc.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), TEAL),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [white, LIGHT_GRN]),
    ("GRID", (0,0), (-1,-1), 0.3, HexColor("#BDC3C7")),
    ("TOPPADDING", (0,0), (-1,-1), 5), ("BOTTOMPADDING", (0,0), (-1,-1), 5),
    ("LEFTPADDING", (0,0), (-1,-1), 6), ("RIGHTPADDING", (0,0), (-1,-1), 6),
    ("VALIGN", (0,0), (-1,-1), "TOP"),
]))
story.append(acc)
story.append(sp(8))

story.append(colored_box([
    [Paragraph("<b>Access Hierarchy:</b> AV Fistula (gold standard) > AV Graft > Tunneled Catheter (last resort). "
               "Catheters carry the highest infection risk and lowest flow rates, limiting delivered Kt/V.", S_BODY)]
], LIGHT_GRN, GREEN))
story.append(PageBreak())

# ══════════════════════════════════════════════════════════
# PAGE 7 – METABOLIC & OTHER COMPLICATIONS
# ══════════════════════════════════════════════════════════
story.append(section_header("6. METABOLIC & ELECTROLYTE COMPLICATIONS", NAVY))
story.append(sp(5))

meta_data = [
    [Paragraph("COMPLICATION", S_TABLE_HDR), Paragraph("CAUSE", S_TABLE_HDR), Paragraph("MANAGEMENT", S_TABLE_HDR)],
    [Paragraph("Hyperkalemia (pre-HD)", S_TABLE_CELL),
     Paragraph("Dietary excess, metabolic acidosis, tissue catabolism, missed sessions", S_TABLE_CELL),
     Paragraph("Dietary K restriction; standard dialysate K 2 mEq/L; correct acidosis; avoid rapid K removal (arrhythmia risk)", S_TABLE_CELL)],
    [Paragraph("Hyperphosphatemia", S_TABLE_CELL),
     Paragraph("Poor dietary control; predominantly intracellular → slow equilibration; inadequate dialysis time", S_TABLE_CELL),
     Paragraph("Phosphate binders (Ca-based, non-Ca-based, sevelamer); longer HD sessions; dietary counselling; target PO₄ <5.5 mg/dL", S_TABLE_CELL)],
    [Paragraph("Metabolic acidosis", S_TABLE_CELL),
     Paragraph("Loss of buffering capacity; urea generation; inadequate dialysate bicarbonate", S_TABLE_CELL),
     Paragraph("Dialysate HCO₃ 35 mEq/L (standard); target pre-HD HCO₃ 22–26 mEq/L; adequate Kt/V", S_TABLE_CELL)],
    [Paragraph("Hyponatremia (post-HD)", S_TABLE_CELL),
     Paragraph("Low dialysate Na relative to plasma; excessive water gain", S_TABLE_CELL),
     Paragraph("Individualise dialysate Na; restrict free water intake; avoid fixed low dialysate Na", S_TABLE_CELL)],
    [Paragraph("Hypocalcemia / Hypercalcemia", S_TABLE_CELL),
     Paragraph("Low dialysate Ca; over-correction with Ca supplements; hyperparathyroidism", S_TABLE_CELL),
     Paragraph("Dialysate Ca 2.25–2.5 mEq/L; cinacalcet; vitamin D analogues; parathyroidectomy for severe HPT", S_TABLE_CELL)],
    [Paragraph("Hypomagnesemia", S_TABLE_CELL),
     Paragraph("Inadequate dialysate Mg; poor dietary intake; diuretic use", S_TABLE_CELL),
     Paragraph("Dialysate Mg 0.5–1 mEq/L; oral Mg supplementation if symptomatic", S_TABLE_CELL)],
]
meta = Table(meta_data, colWidths=[W*0.22, W*0.38, W*0.40], repeatRows=1)
meta.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), TEAL),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [white, LIGHT_ORG]),
    ("GRID", (0,0), (-1,-1), 0.3, HexColor("#BDC3C7")),
    ("TOPPADDING", (0,0), (-1,-1), 5), ("BOTTOMPADDING", (0,0), (-1,-1), 5),
    ("LEFTPADDING", (0,0), (-1,-1), 6), ("RIGHTPADDING", (0,0), (-1,-1), 6),
    ("VALIGN", (0,0), (-1,-1), "TOP"),
]))
story.append(meta)
story.append(sp(10))

story.append(section_header("7. DIALYSATE & WATER-RELATED COMPLICATIONS", NAVY))
story.append(sp(5))
water_data = [
    [Paragraph("PROBLEM", S_TABLE_HDR), Paragraph("CAUSE / MECHANISM", S_TABLE_HDR), Paragraph("PREVENTION / MANAGEMENT", S_TABLE_HDR)],
    [Paragraph("Bacterial contamination / pyrogenic reactions", S_TABLE_CELL),
     Paragraph("Gram-negative bacteria in water system; biofilm formation; endotoxin passage across membranes", S_TABLE_CELL),
     Paragraph("Monthly cultures of source water, product water, dialysate; LAL assay for endotoxin; ultrapure dialysate for HDF; prompt culture & antibiotics", S_TABLE_CELL)],
    [Paragraph("Chloramine toxicity", S_TABLE_CELL),
     Paragraph("Inadequate dechlorination; causes haemolytic anaemia and methaemoglobinaemia", S_TABLE_CELL),
     Paragraph("Activated carbon filtration; regular monitoring of water treatment system", S_TABLE_CELL)],
    [Paragraph("Aluminium toxicity", S_TABLE_CELL),
     Paragraph("Aluminium-contaminated water or phosphate binders; causes dialysis encephalopathy, adynamic bone disease, anaemia", S_TABLE_CELL),
     Paragraph("Reverse osmosis + deionisation; monitor water Al levels; avoid Al-based binders; deferoxamine chelation for toxicity", S_TABLE_CELL)],
    [Paragraph("Fluoride toxicity", S_TABLE_CELL),
     Paragraph("High fluoride in source water; inadequate removal", S_TABLE_CELL),
     Paragraph("Reverse osmosis; periodic water analysis; AAMI standards compliance", S_TABLE_CELL)],
]
water = Table(water_data, colWidths=[W*0.22, W*0.38, W*0.40], repeatRows=1)
water.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), NAVY),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [white, LIGHT_BLU]),
    ("GRID", (0,0), (-1,-1), 0.3, HexColor("#BDC3C7")),
    ("TOPPADDING", (0,0), (-1,-1), 5), ("BOTTOMPADDING", (0,0), (-1,-1), 5),
    ("LEFTPADDING", (0,0), (-1,-1), 6), ("RIGHTPADDING", (0,0), (-1,-1), 6),
    ("VALIGN", (0,0), (-1,-1), "TOP"),
]))
story.append(water)
story.append(PageBreak())

# ══════════════════════════════════════════════════════════
# PAGE 8 – ANTICOAGULATION & BLEEDING + ANEMIA
# ══════════════════════════════════════════════════════════
story.append(section_header("8. ANTICOAGULATION, BLEEDING & CLOTTING", NAVY))
story.append(sp(5))
anticoag_data = [
    [Paragraph("SCENARIO", S_TABLE_HDR), Paragraph("APPROACH", S_TABLE_HDR)],
    [Paragraph("Standard anticoagulation", S_TABLE_CELL),
     Paragraph("Unfractionated heparin (UFH): bolus 1,000–5,000 U pre-HD + infusion 500–1,500 U/h. Target aPTT 1.5–2× baseline. Stop 30–60 min before session ends.", S_TABLE_CELL)],
    [Paragraph("HIT (Heparin-Induced Thrombocytopenia)", S_TABLE_CELL),
     Paragraph("Substitute argatroban or bivalirudin; avoid all heparin products including heparin flushes", S_TABLE_CELL)],
    [Paragraph("Active bleeding / high risk", S_TABLE_CELL),
     Paragraph("Heparin-free HD: frequent saline flushes (100 mL q15–30 min); citrate anticoagulation; or regional heparin with protamine reversal", S_TABLE_CELL)],
    [Paragraph("Dialyzer clotting", S_TABLE_CELL),
     Paragraph("Fibrin deposition in hollow fibres → ↓ effective membrane area → ↓ Kt/V. Risk with low blood flow, high haematocrit, inadequate heparin.", S_TABLE_CELL)],
    [Paragraph("Uremic bleeding", S_TABLE_CELL),
     Paragraph("Platelet dysfunction (↓ GP Ib, ↓ ADP/TXA₂). Treat with: dialysis (reversal), dDAVP 0.3 mcg/kg IV, conjugated oestrogens, cryoprecipitate. Correct anaemia (target Hgb ≥10 g/dL).", S_TABLE_CELL)],
]
ac = Table(anticoag_data, colWidths=[W*0.30, W*0.70], repeatRows=1)
ac.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), TEAL),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [white, LIGHT_YEL]),
    ("GRID", (0,0), (-1,-1), 0.3, HexColor("#BDC3C7")),
    ("TOPPADDING", (0,0), (-1,-1), 5), ("BOTTOMPADDING", (0,0), (-1,-1), 5),
    ("LEFTPADDING", (0,0), (-1,-1), 6), ("RIGHTPADDING", (0,0), (-1,-1), 6),
    ("VALIGN", (0,0), (-1,-1), "TOP"),
]))
story.append(ac)
story.append(sp(10))

story.append(section_header("9. ANAEMIA MANAGEMENT IN HD", NAVY))
story.append(sp(5))
anaemia_data = [
    [Paragraph("PARAMETER", S_TABLE_HDR), Paragraph("TARGET / APPROACH", S_TABLE_HDR)],
    [Paragraph("Target Haemoglobin", S_TABLE_CELL), Paragraph("10–11.5 g/dL (KDIGO); avoid >13 g/dL (↑ thrombosis risk)", S_TABLE_CELL)],
    [Paragraph("ESA therapy", S_TABLE_CELL), Paragraph("Erythropoietin alfa, darbepoetin alfa; IV preferred in HD patients; dose adjust for Hgb response", S_TABLE_CELL)],
    [Paragraph("Iron targets", S_TABLE_CELL), Paragraph("Serum ferritin >200 µg/L; TSAT >20%; IV iron preferred (ferric carboxymaltose, ferric gluconate, iron sucrose)", S_TABLE_CELL)],
    [Paragraph("ESA hypo-response", S_TABLE_CELL), Paragraph("Evaluate: iron deficiency, infection/inflammation (↑CRP), hyperparathyroidism, haemolysis, malnutrition, inadequate dialysis", S_TABLE_CELL)],
    [Paragraph("L-Carnitine", S_TABLE_CELL), Paragraph("May reduce ESA requirements in carnitine-deficient patients; evidence inconsistent (2025 review)", S_TABLE_CELL)],
]
an = Table(anaemia_data, colWidths=[W*0.30, W*0.70], repeatRows=1)
an.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), NAVY),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [white, LIGHT_PUR]),
    ("GRID", (0,0), (-1,-1), 0.3, HexColor("#BDC3C7")),
    ("TOPPADDING", (0,0), (-1,-1), 4), ("BOTTOMPADDING", (0,0), (-1,-1), 4),
    ("LEFTPADDING", (0,0), (-1,-1), 6), ("RIGHTPADDING", (0,0), (-1,-1), 6),
    ("VALIGN", (0,0), (-1,-1), "TOP"),
]))
story.append(an)
story.append(PageBreak())

# ══════════════════════════════════════════════════════════
# PAGE 9 – TROUBLESHOOTING INADEQUATE DIALYSIS + SUMMARY
# ══════════════════════════════════════════════════════════
story.append(section_header("10. TROUBLESHOOTING INADEQUATE DIALYSIS DOSE", NAVY))
story.append(sp(5))
story.append(body("When URR <65% or delivered Kt/V <1.2, investigate systematically:"))
story.append(sp(4))

trouble_data = [
    [Paragraph("STEP", S_TABLE_HDR), Paragraph("CHECK", S_TABLE_HDR), Paragraph("ACTION", S_TABLE_HDR)],
    [Paragraph("1", S_TABLE_CELL), Paragraph("Session representativeness", S_TABLE_CELL),
     Paragraph("Was the session shortened, interrupted, or otherwise unusual? Repeat measurement before changing prescription.", S_TABLE_CELL)],
    [Paragraph("2", S_TABLE_CELL), Paragraph("Vascular access recirculation", S_TABLE_CELL),
     Paragraph("Most common cause. Measure recirculation by urea or ultrasound dilution method. Treat underlying stenosis.", S_TABLE_CELL)],
    [Paragraph("3", S_TABLE_CELL), Paragraph("Blood sampling errors", S_TABLE_CELL),
     Paragraph("Post-HD blood drawn too late → falsely low Kt/V. Pre-HD sample from access line → falsely low pre-HD BUN. Follow sampling protocol strictly.", S_TABLE_CELL)],
    [Paragraph("4", S_TABLE_CELL), Paragraph("Treatment time", S_TABLE_CELL),
     Paragraph("Increase session duration – most effective single intervention. Document actual 'time on dialysis' vs. prescribed time.", S_TABLE_CELL)],
    [Paragraph("5", S_TABLE_CELL), Paragraph("Dialyzer efficiency", S_TABLE_CELL),
     Paragraph("Switch to higher KoA dialyzer. Check for membrane clotting (reduced effective surface area).", S_TABLE_CELL)],
    [Paragraph("6", S_TABLE_CELL), Paragraph("Blood / dialysate flow rates", S_TABLE_CELL),
     Paragraph("Increase Qb (if access allows) and/or Qd. Verify countercurrent flow configuration.", S_TABLE_CELL)],
    [Paragraph("7", S_TABLE_CELL), Paragraph("Vascular access type", S_TABLE_CELL),
     Paragraph("Transition from catheter to permanent AV access if feasible – higher flows, lower recirculation.", S_TABLE_CELL)],
    [Paragraph("8", S_TABLE_CELL), Paragraph("Body size / V estimation", S_TABLE_CELL),
     Paragraph("If lean body mass has increased, V is larger → same Kt gives lower Kt/V. Adjust prescription to ideal V, not current V.", S_TABLE_CELL)],
]
tr = Table(trouble_data, colWidths=[W*0.07, W*0.27, W*0.66], repeatRows=1)
tr.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), TEAL),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [white, GREY_BG]),
    ("GRID", (0,0), (-1,-1), 0.3, HexColor("#BDC3C7")),
    ("TOPPADDING", (0,0), (-1,-1), 4), ("BOTTOMPADDING", (0,0), (-1,-1), 4),
    ("LEFTPADDING", (0,0), (-1,-1), 6), ("RIGHTPADDING", (0,0), (-1,-1), 6),
    ("VALIGN", (0,0), (-1,-1), "TOP"),
    ("ALIGN", (0,0), (0,-1), "CENTER"),
]))
story.append(tr)
story.append(sp(10))

# Summary
story.append(section_header("QUICK REFERENCE SUMMARY", ORANGE))
story.append(sp(5))

summary_data = [
    [Paragraph("COMPLICATION", S_TABLE_HDR), Paragraph("KEY CAUSE", S_TABLE_HDR), Paragraph("FIRST-LINE RESPONSE", S_TABLE_HDR)],
    [Paragraph("Intradialytic Hypotension", S_TABLE_CELL), Paragraph("Excessive UF rate", S_TABLE_CELL), Paragraph("↓ UF + supine + 100–250 mL saline", S_TABLE_CELL)],
    [Paragraph("Muscle Cramps", S_TABLE_CELL), Paragraph("Hypovolaemia + hypoosmolality", S_TABLE_CELL), Paragraph("D50W 25–50 mL IV; reassess dry weight", S_TABLE_CELL)],
    [Paragraph("Disequilibrium Syndrome", S_TABLE_CELL), Paragraph("Rapid urea removal → cerebral oedema", S_TABLE_CELL), Paragraph("Slow/stop HD; mannitol 1 g/kg IV", S_TABLE_CELL)],
    [Paragraph("Access Thrombosis", S_TABLE_CELL), Paragraph("Stenosis / hypotension", S_TABLE_CELL), Paragraph("Thrombolysis / thrombectomy + fistulogram", S_TABLE_CELL)],
    [Paragraph("Catheter Bacteraemia", S_TABLE_CELL), Paragraph("Biofilm / hub contamination", S_TABLE_CELL), Paragraph("Blood cultures + empiric antibiotics + catheter removal", S_TABLE_CELL)],
    [Paragraph("Inadequate Kt/V", S_TABLE_CELL), Paragraph("Access recirculation / short time", S_TABLE_CELL), Paragraph("Check recirculation; ↑ session time; ↑ flows", S_TABLE_CELL)],
    [Paragraph("Hyperphosphataemia", S_TABLE_CELL), Paragraph("Diet + intracellular shift", S_TABLE_CELL), Paragraph("Binders + longer sessions", S_TABLE_CELL)],
    [Paragraph("Arrhythmia", S_TABLE_CELL), Paragraph("Rapid K/Ca shifts", S_TABLE_CELL), Paragraph("Individualise dialysate K/Ca; cardiac monitoring", S_TABLE_CELL)],
    [Paragraph("Uremic Bleeding", S_TABLE_CELL), Paragraph("Platelet dysfunction", S_TABLE_CELL), Paragraph("Adequate dialysis + dDAVP + correct anaemia", S_TABLE_CELL)],
]
sm = Table(summary_data, colWidths=[W*0.27, W*0.33, W*0.40], repeatRows=1)
sm.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), ORANGE),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [white, LIGHT_YEL]),
    ("GRID", (0,0), (-1,-1), 0.3, HexColor("#BDC3C7")),
    ("TOPPADDING", (0,0), (-1,-1), 4), ("BOTTOMPADDING", (0,0), (-1,-1), 4),
    ("LEFTPADDING", (0,0), (-1,-1), 6), ("RIGHTPADDING", (0,0), (-1,-1), 6),
    ("VALIGN", (0,0), (-1,-1), "TOP"),
]))
story.append(sm)
story.append(sp(8))

story.append(colored_box([
    [Paragraph(
        "<b>Sources:</b> Brenner &amp; Rector's The Kidney (10th Ed.) · Harrison's Principles of Internal Medicine 22E (2025) · "
        "Comprehensive Clinical Nephrology 7th Ed. · Goldman-Cecil Medicine · Washington Manual of Medical Therapeutics · "
        "Kesik G &amp; Altinok Ersoy N, Ther Apher Dial 2023 (PMID 36691882) · Kljajić M et al., J Clin Med 2025 (PMID 40725745)",
        S_NOTE)]
], GREY_BG, HexColor("#BDC3C7")))

# ─────────────────────────────────────────────────────────────────────────────
# BUILD
# ─────────────────────────────────────────────────────────────────────────────
doc.build(story,
          onFirstPage=on_first_page,
          onLaterPages=on_page)
print("PDF generated:", OUTPUT)

cd /home/daytona/workspace/hd-complications-pdf && python generate_pdf.py 2>&1

ls -lh /home/daytona/workspace/hd-complications-pdf/HD_Complications_Quick_Refer…