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Dialysis disequilibrium syndrome
From WikEM
Contents
Background
- Abbreviation: DDS
- A rare clinical syndrome occurring at end of dialysis or the beginning of continuous renal replacement therapy
- 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
- 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 [1]
- Pre-dialysis urea in CSF lower than in blood[2]
- 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
- Headache
- Disorientation
- Nausea and vomiting
- Restlessness
- Visual disturbances
- Asterixis
- Muscle Cramps
- Can progress to seizure, coma, and death[3]
Differential Diagnosis
- Subdural hematoma
- Uremia
- Nonketotic hyperosmolar coma
- Acute cerebrovascular event
- Dialysis dementia
- Excessive ultrafiltration and seizure
- Metabolic disturbances
- Meningitis
- Malignant hypertension[3][4]
- Hypocalcemia
- Intracranial Bleed
- Hypertensive Emergency
- Stroke
- Supratheurapeutic Medication Effects
- PRES
Dialysis Complications
- Dialysis-associated hypotension
- Dialysis disequilibrium syndrome
- Air embolism
- Missed dialysis (pulmonary edema)
Evaluation
Workup
- Bedside Glucose
- CBC
- Chem-10
- Liver Panel
- CT Brain
Diagnosis
- Is a clinical diagnosis, suggested by development of neurologic symptoms associated with dialysis
Management
Mild
- Symptomatic management for mild symptoms (nausea, headache, restlessness)
- Symptoms are self-limiting and typically resolve within several hours
Severe
- For severe symptoms, the mainstay of treatment is ICP reduction[3]
- Can give mannitol or hypertonic saline IV
- Can hyperventilate patient
Disposition
- Depends on severity
- Many cases can be discharged with followup
Prevention
- Response to treatment is typically poor, so preventive measures are important[3]
- Add an osmotic agent to mitigate the osmotic gradient
- Consider hemofiltration rather than hemodialysis[7]
See Also
References
- ↑ Silver SM. et al. Dialysis disequilibrium syndrome (DDS) in the rat: role of the "reverse urea effect". Kidney Int. 1992;42(1):161-6. Pubmed
- ↑ Zepeda-Orozco D and Quigley R. Dialysis disequilibrium syndrome. Pediatr Nephrol. 2012 Dec; 27(12): 2205–2211.
- ↑ 3.0 3.1 3.2 3.3 Zepeda-orozco D. et al. Dialysis disequilibrium syndrome. Pediatr Nephrol. 2012;27(12):2205-11.Pubmed
- ↑ Mahoney CA. et al. Uremic encephalopathies: clinical, biochemical, and experimental features. Am J Kidney Dis. 1982;2(3):324-36. Pubmed
- ↑ Port FK. et al. Prevention of dialysis disequilibrium syndrome by use of high sodium concentration in the dialysate. Kidney Int. 1973;3(5):327-33.Pubmed
- ↑ Rodrigo F. et al. Osmolality changes during hemodialysis. Natural history, clinical correlations, and influence of dialysate glucose and intravenous mannitol. Ann Intern Med. 1977;86(5):554-61. Pubmed
- ↑ Kishimoto T. et al. Superiority of hemofiltration to hemodialysis for treatment of chronic renal failure: comparative studies between hemofiltration and hemodialysis on dialysis disequilibrium syndrome. Artif Organs. 1980;4(2):86-93. Pubmed
Authors
Ross Donaldson, Robert Granata, Kevin Lu, Claire, Neil Young, Daniel Ostermayer
