<p>Dialysis disequilibrium syndrome prevention and management</p>

Abstract

The dialysis disequilibrium syndrome (DDS) is a clinical constellation of neurologic symptoms and signs occurring during or shortly following dialysis, especially when dialysis is first initiated. It is a diagnosis of exclusion occurring in those that are uremic and hyperosmolar, in whom rapid correction with renal replacement therapy leads to cerebral edema and raised intracranial pressure with resultant clinical neurologic manifestations. DDS is most commonly described in association with hemodialysis but can occur in patients with acute kidney injury requiring continuous renal replacement therapy (CRRT). To date, it has not been described in association with peritoneal dialysis. The syndrome is uncommon and becoming rarer, so performing randomized controlled trials to evaluate the effectiveness of potential therapies is almost impossible. This also makes studying the pathophysiology in humans challenging. It is associated with mortality but is also preventable, so identification of patients at risk, preventive measures, early recognition and prompt management of DDS will minimize morbidity and mortality associated with this syndrome. While the focus of this review is the prevention and management of DDS, there will be an emphasis on what is known about the pathophysiology because it strongly impacts the prevention and management strategies.

Dialysis Disequilibrium Syndrome and Cerebellar Herniation with Successful Reversal Using Mannitol

“…This can be achieved by utilizing low-flux dialysis membranes, setting low flow rates (Qd of 300 and Qb 250, respectively), modulating the dialysate sodium and glucose concentrations, and shortening the duration of therapy. Additional methods, including prophylactic mannitol administration, have been suggested [ 2 , 7 , 8 ].…”

Use of non-invasive intracranial pressure pulse waveform to monitor patients with End-Stage Renal Disease (ESRD) Intracranial pressure in patients with ESRD

“…Intradialytic hypotension is the commonest complication among HD patients [16–20] and may precede DDS. The symptoms like headache, nausea, and muscle cramps experienced by some patients of the current study during follow-up may represent a milder but not diagnosed spectrum of DDS [5]. Our understanding of the pathophysiology of DDS has improved since its initial description and it is now evident from animal and human studies that DDS is associated with the development of cerebral edema and increased ICP [21,22].…”

“…However, HD is associated with frequent complications, including hypotension and muscle cramps, in addition to postdialysis complaints of headache, fatigue, and inability to concentrate, which may significantly affect patients’ quality of life [4]. Mild signs and symptoms like headache, nausea, and muscle cramps are often attributed to volume depletion due to excessive ultrafiltration, but may represent a milder but not diagnosed form of dialysis disequilibrium syndrome (DDS) [5].…”

A mathematical approach to severe hyponatremia and hypernatremia in renal replacement therapies

“…DDS is unlikely to result solely from rapid correction of hypernatremia 8 . It is conceivable that rapid correction of azotemia is more likely to result in DDS, especially if another cause of hyperosmolality, such as hyperglycemia or hypernatremia, is rapidly corrected at the same time 9 …”