Nephrology Hypertension

Hemodialysis: Acute Complications - Dialysis Disequilibrium Syndrome

Does this patient have dialysis disequilibrium syndrome?

Symptoms

Symptoms result from brain edema, varying from mild to severe:

  • Headache

  • Nausea with or without vomiting

  • Dizziness

  • Muscle cramp

  • Blurred vision

  • Tremors

  • Restlessness

  • Agitation

  • Alteration of consciousness

  • Seizure

  • Coma

  • Sudden cardiac arrest

Syndrome is usually mild, transient, and self-limited

Symptoms develop during dialysis, immediately post-dialysis or within 24 hours after completion of dialysis

Risk factors

  • High serum urea nitrogen level

  • Aggressive urea removal during the first hemodialysis treatment (decline by more tha 30%)

  • Children

  • Pre-existing neurological impairment

  • Metabolic acidosis

Differential diagnosis

  • Acute hyponatremia

  • Acute hypoglycemia

  • Acute hypercalcemia

  • Acute hypocalcemia

  • Uremic encephalopathy

  • Cerebrovascular accident (ischemic or hemorrhage)

  • Acute subdural hematoma

  • Malignant hypertension

What tests to perform?

This is a clinical diagnosis.

No gold standard for definitive diagnosis, thus mostly diagnosed by exclusion

Laboratory tests and imaging studies should be ordered to identify other potential causes:

  • Blood glucose (to exclude hypoglycemia)

  • Serum calcium (to exclude hypocalcemia or hypercalcemia)

  • Serum sodium (to exclude hyponatremia)

  • Head CT scan or brain MRI (to exclude a cerebrovascular accident or subdural hematoma; dialysis disequilibrium syndrome is characterized by diffuse cerebral edema)

How should patients with dialysis disequilibrium syndrome be managed?

Slow, gentle initial hemodialysis session (aim for an, initial urea reduction ratio goal of 30%, which is equivalent to a single pool Kt/V of 0.6):

Dialysis time - 2 hours

Blood flow rate - 200 mL/min

Small surface area (low efficiency) dialyzer

Gradual increase in dialysis efficiency until conventional goal achieved (urea reduction ratio of 65% or single pool Kt/V of 1.2)

High sodium dialysate/sodium profiling

An increase in serum sodium level of 2 mEq/L yields an osmotic force equivalent to a serum urea nitrogen level of approximately 11 mg/dL.

Consider using a fixed dialysate sodium level of 143-146 mEq/L for the initial hemodialysis treatment in high-risk patients

Bicarbonate dialysate (30 mEq/L)

Intra-dialytic administration of osmoticallly active substances

Intravenous 50% dextrose in water (50 mL)

Intravenous mannitol (1gm/kg) (optional)

What happens to patients with dialysis disequilibrium syndrome?

Need for hospitalization

Risk of neurological permanent damage (demyelination of the pontine and extrapontine areas, rare)

Death (in severe form, rare)

How to utilize team care?

1. Specialty consultations – neurologist

2. Nursing - Close monitoring of high-risk patients

Are there clinical practice guidelines to inform decision making?

Applications- No

Limitations - absence of systematic reviews or meta-analyses on this topic

Other considerations

ICD-10-CM diagnosis code E87.8: Other disorders of electrolyte and fluid balance, not elsewhere classified

What is the evidence?

Patel, N, Dalal, P, Panesar, M. "Dialysis disequilibrium syndrome: a narrative review". Semin Dial. vol. 21. 2008. pp. 493-8.

Zepeda-Orozco, D, Quigley, R. "Dialysis disequilibrium syndrome". Pediatr Nephrol. vol. 27. 2012 Dec. pp. 2205-11.

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