Dialysis disequilibrium syndrome

• 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 ...

Science Photo Library / Getty Images Causes You would think that with dialysis being around for half a century, we would understand all its adverse effects by now. With dialysis disequilibrium though, that is not the case and the exact mechanism is still a matter of research. We do have some leads, though: • One of the theories that has been proposed is something called relative increase in the amount of water concentration in the blood.This water can then move into brain cells leading it to swell, causing something called cerebral edema.This swelling of the brain cells via this mechanism has been thought of as one of the possible reasons for the usual neurological problems associated with dialysis disequilibrium syndrome. • Decreased pH of the brain cells.In layman terms, this would mean that the brain cells have a higher level of "acid". This has been proposed as another possible cause. • Idiogenic osmoles produced in the brain (the details of numbers 2 and 3 are beyond the scope of this article). Prevention Since dialysis disequilibrium syndrome is thought to be related to rapid removal of toxins (urea) and fluid from the newly dialyzed patient, certain preventive measures might be helpful. Identifying the high-risk patient, as mentioned above, is the first step. Beyond that, there are certain strategies that might help: Treatment Treatment is mostly symptomatic. Nausea and vomiting can be treated medically using medications like ondansetron. If seizures ever happen, th...

Contents • 1 Background • 2 Clinical Features • 3 Differential Diagnosis • 3.1 Dialysis Complications • 4 Evaluation • 4.1 Workup • 4.2 Diagnosis • 5 Management • 5.1 Mild • 5.2 Severe • 6 Disposition • 7 Prevention • 8 See Also • 9 References Background • Abbreviation: DDS • A rare clinical syndrome occurring at end of dialysis or the beginning of continuous renal replacement therapy • Does not occur with • Occurs most commonly during initial hemodialysis or during hypercatabolic states • Tends to occur in patients who are initially started on dialysis, particularly with high initial BUN • Other risk factors: older or younger age, hyponatremia, pre-existing neurologic disease • Symptoms are thought to be secondary to the development of cerebral edema possibly due to urea removal during dialysis and from a decreased in pH in the cerebral intracelluar environment • Large and rapid solute clearance creates an osmotic gradient which can precipitate cerebral edema • Pre-dialysis urea in CSF lower than in blood • Post-dialysis urea in CSF higher, setting up osmotic gradient for water into CNS • More uremic patients pre-dialysis at higher risk Clinical Features Signs and symptoms develop during or after dialysis or during renal replacement therapy, usually self limited but can occasionally progress • • Disorientation • • Restlessness • • Asterixis • Muscle Cramps • Can progress to Differential Diagnosis • • • Nonketotic hyperosmolar • • Dialysis • Excessive ultrafiltration and •...

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A severe drop in blood pressure also increases the risk of blood clots. If left untreated, the formation of clots may require additional surgery to repair the access point and, in some cases, lead to stroke, seizures, and heart damage. Adhering to the recommended fluid restrictions can help. By limiting your fluid intake, the amount being extracted during dialysis will be decreased, and any drop in blood pressure will be minimized. • Centers for Disease Control and Prevention. • Morfin JA, Fluck RJ, Weinhandl ED, Kansal S, McCullough PA, Komenda P. Am J Kidney Dis. 2016;68(5S1):S43-S50. doi:10.1053/j.ajkd.2016.05.021 • National Heart, Lung, and Blood Institute. • Guttee V, Nie YX, Wang YM, Ding XQ. Open Access Libr J. 2017;4:e3623. doi:0.4236/oalib.1103623 • Elliott TL, Braun M. FP Essent. 2017;459:21-28. • Antlanger M, Hecking M, Haidinger M, et al. BMC Nephrol. 2013;14:266. doi:10.1186/1471-2369-14-266 • National Kidney Foundation. • Mistry K. Int J Nephrol Renovasc Dis. 2019;12:69-77. doi:10.2147/IJNRD.S165925