Dysequilibrium syndrome

Background

• Characterized by neurological symptoms that is thought to be secondary to cerebral edema affecting dialysis patients
• 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

Clinical Features

• Signs and symptoms develop during or after dialysis or during renal replacement therapy, usually self limited but can occasionally progress
• Headache
• Nausea
• Visual disturbances
• Asterixis
• Altered mental staus
• Seizures
• Coma
• Muscle Cramps

Differential Diagonsis

• Hypoglycemia
• Hyponatremia
• Hypocalcemia
• Uremia
• Intracranial Bleed
• Hypertensive Emergency
• Stroke
• Supratheurapeutic Medication Effects
• PRES

Evaluation

• Clinical Diagonosis
• Bedside Glucose
• CBC
• Chem-10
• Liver Panel
• CT Brain

Management

• Supportive in most cases
• Limit the rate of urea removal during first few session of dialysis to prevent dysequilibrium syndrome
• For severe symptoms such as seizure, consider stopping dialysis

Disposition

• Most cases can be discharged with followup

References

• Mailloux L, et al. Dialysis Dysequilibrium Syndrome. UpToDate. Waltham, Mass.: UpToDate; 2017. www.uptodate.com. Accessed April 13, 2017.