Dialysis disequilibrium syndrome: Difference between revisions

(Text replacement - "HTN" to "hypertension")
(Expanded differential, workup and management sections, minor additions and formatting changes to background and clinical features, added references)
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==Background==
==Background==
*Clinical syndrome occurring at end of dialysis
*Dialysis Disequilibrium Syndrome (DDS) is a rare clinical syndrome occurring at end of dialysis or the beginning of continuous renal replacement therapy
**Occurs most commonly during initial dialysis or during hypercatabolic states
**Occurs most commonly during initial hemodialysis or during hypercatabolic states
**Large solute clearances -> cerebral edema
*Large and rapid solute clearance creates an osmotic gradient which can precipitate cerebral edema <ref>Silver SM. et al. Dialysis disequilibrium syndrome (DDS) in the rat: role of the "reverse urea effect". Kidney Int. 1992;42(1):161-6. [http://www.ncbi.nlm.nih.gov/pubmed?term=1635345 Pubmed]</ref>


==Clinical Features==
==Clinical Features==
*nausea and vomiting, hypertension; can progress to seizure, coma, death
*Headache
*Disorientation
*Nausea and vomiting
*Restlessness
*Can progress to seizure, coma & death <ref name="DDS">Zepeda-orozco D. et al. Dialysis disequilibrium syndrome. Pediatr Nephrol. 2012;27(12):2205-11.[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3491204/ Pubmed]</ref>


==Differential Diagnosis==
==Differential Diagnosis==
*[[Subdural hematoma]]
*[[Uremia]]
*Nonketotic hyperosmolar [[coma]]
*[[Acute cerebrovascular event]]
*Dialysis dementia
*Excessive ultrafiltration and seizure
*Metabolic disturbances
**[[Hypoglycemia]]
**[[Hyponatremia]]
*[[Meningitis]]
*[[Malignant hypertension]]<ref name="DDS"></ref><ref>Mahoney CA. et al. Uremic encephalopathies: clinical, biochemical, and experimental features. Am J Kidney Dis. 1982;2(3):324-36. [http://www.ncbi.nlm.nih.gov/pubmed/6756130 Pubmed]</ref>
{{Dialysis complications DDX}}
{{Dialysis complications DDX}}


==Workup==
==Workup==
*Diagnosis of exclusion (rule out SDH, CVA)
*Diagnosis suggested by development of neurologic symptoms associated with dialysis, however DDS is a diagnosis of exclusion (rule out [[SDH]], [[CVA]]).


==Management==
==Management==
*Treat with mannitol
===Prevention===
*Response to treatment is typically poor, so preventive measures are important<ref name="DDS"></ref>
*Add an osmotic agent to mitigate the osmotic gradient
**Elevate the sodium concentration in the diasylate<ref> 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.[http://www.ncbi.nlm.nih.gov/pubmed/4792047/ Pubmed]</ref>
**Elevate the glucose concentration in the diasylate (717 mg/dl) or add IV mannitol (1g/kg)<ref>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. [http://www.ncbi.nlm.nih.gov/pubmed/851303/ Pubmed]</ref>
*Consider hemofiltration rather than hemodialysis<ref>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. [http://www.ncbi.nlm.nih.gov/pubmed/7396769/ Pubmed]</ref>


==Disposition==
===Treatment===
*The mainstay of treatment is ICP reduction<ref name="DDS"></ref>
**Can give mannitol or hypertonic saline IV
**Can hyperventilate patient
*Symptomatic management for mild symptoms (nausea, headache, restlessness)
*Symptoms are self-limiting and typically resolve within several hours


==See Also==
==See Also==
*[[Dialysis complications]]
*[[Dialysis complications]]
==External Links==


==References==
==References==

Revision as of 01:53, 1 August 2016

Background

  • Dialysis Disequilibrium Syndrome (DDS) is 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
  • Large and rapid solute clearance creates an osmotic gradient which can precipitate cerebral edema [1]

Clinical Features

  • Headache
  • Disorientation
  • Nausea and vomiting
  • Restlessness
  • Can progress to seizure, coma & death [2]

Differential Diagnosis

Dialysis Complications

Workup

  • Diagnosis suggested by development of neurologic symptoms associated with dialysis, however DDS is a diagnosis of exclusion (rule out SDH, CVA).

Management

Prevention

  • Response to treatment is typically poor, so preventive measures are important[2]
  • Add an osmotic agent to mitigate the osmotic gradient
    • Elevate the sodium concentration in the diasylate[4]
    • Elevate the glucose concentration in the diasylate (717 mg/dl) or add IV mannitol (1g/kg)[5]
  • Consider hemofiltration rather than hemodialysis[6]

Treatment

  • The mainstay of treatment is ICP reduction[2]
    • Can give mannitol or hypertonic saline IV
    • Can hyperventilate patient
  • Symptomatic management for mild symptoms (nausea, headache, restlessness)
  • Symptoms are self-limiting and typically resolve within several hours

See Also

References

  1. ↑ 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
  2. ↑ 2.0 2.1 2.2 2.3 Zepeda-orozco D. et al. Dialysis disequilibrium syndrome. Pediatr Nephrol. 2012;27(12):2205-11.Pubmed
  3. ↑ Mahoney CA. et al. Uremic encephalopathies: clinical, biochemical, and experimental features. Am J Kidney Dis. 1982;2(3):324-36. Pubmed
  4. ↑ 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
  5. ↑ 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
  6. ↑ 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
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