Dialysis Disequilibrium Syndrome and Cerebellar Herniation with Successful Reversal Using Mannitol

Abstract

Dialysis disequilibrium syndrome (DDS) is a morbid but rare complication of dialysis. Feared sequalae of this diagnosis are brain herniation and death. This report presents a patient who was diagnosed with DDS with subsequent tonsillar herniation shown on imaging with complete resolution of clinical signs and symptoms, as well as imaging findings of herniation after prompt initiation of intravenous mannitol. This is the first known case of reversal and survival of DDS-induced tonsillar herniation using mannitol.

Dialysis Disequilibrium Syndrome: A Red Flag to Check Post Hemodialysis

“…Lastly, the idiogenic osmol theory suggests that after a rapid correction of hypernatremia or hyperglycemia, idiogenic osmoles are created as an adaptive reflex from the cerebral cortex. These osmoles create the osmotic gradient that leads to cerebral edema and the development of DDS [ 6 , 7 ].…”

Dialysis Disequilibrium Syndrome Induced Seizure Following Hemodialysis

“…The idiogenic osmole theory defines the production of idiogenic osmoles as an adaptive response from the cerebral cortex in 48 hours that occurs when there is a rapid correction of hyperglycemia or hypernatremia. Idiogenic osmoles mediate the gradient osmotic, which favors water movement intracellularly and causes cerebral edema [4,[7][8][9].…”

“…Although there is no certainty about hemodialysis prescription, many experts suggest having two hours of hemodialysis and a slower blood flow rate (150-250 mL/min) with up to 40% reduction in blood urea as target dialysis. Hemodialysis should be stopped immediately with the notice of any signs of DDS [4,[6][7][8]11].…”

“…The risk factors of DDS are first dialysis treatment, older age, hypertension, CKD, hyperglycemia, hypernatremia, hyperuricemia, metabolic acidosis, pre-existing cerebral edema, and neurological abnormalities, and any conditions that can increase the permeability of the blood-brain barrier, such as infection (meningitis, vasculitis), tumors of CNS, hemolytic uremic syndrome, and thrombotic thrombocytopenic purpura. The symptoms of DDS relate to osmotic fluid shift, which can be affected by urea and dialysis [ 4 , 7 ]. Although the pathogenesis of DDS is unknown, there are three theories that can explain the syndrome: reserve osmotic shift, intracerebral acidosis, and idiogenic osmole.…”

Recovery of severe dialysis disequilibrium syndrome with uncal herniation following therapy with mannitol, hyperventilation and hypertonic saline

“…To our knowledge, this is the second report in the literature of a patient with DDS-induced brain herniation who survived and recovered [ 5 ] and the first case with brain imaging to document the temporal evolution of the DDS. Although previous literature reported that most treatments of DDS were futile, we believe that these patients should receive timely treatment since the build-up of osmotic gradient in the CNS system is transient and self-limiting once the dialysis is discontinued.…”