DIALYSIS DISEQUILIBRIUM SYNDROME WITH ACUTE PULMONARY EDEMA REQUIRING NONINVASIVE POSITIVE PRESSURE VENTILATION (NIPPV)

Abstract

SESSION TITLE: Critical Care 2 SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Dialysis Disequilibrium Syndrome (DDS) is an uncommon phenomenon. Complication involving the lungs as part of this disequilibrium syndrome is even a rarer entity. In this abstract we describe a case of pulmonary involvement in a patient who received her first dialysis session after missing many sessions and resulting in hypoxic respiratory failure from non-cardiogenic pulmonary edema post hemodialysis (HD) session. CASE PRESENTATION: 45 year old female with past medical history of Down's syndrome, hypothyroidism, insulin dependent diabetes and end stage renal disease requiring dialysis was brought to the hospital for vomiting after refusing 6 sessions of HD. Patient had mild hypoxemia from pulmonary edema (Fig. 1) requiring 2L/min of nasal cannula oxygen and serum BUN (167mg/dl) and creatinine (19.6mg/dl) were elevated. Since the patient deemed not to have capacity to refuse hemodialysis, a decision was made to treat her severe uremic complication with hemodialysis under moderate sedation after discussing with ethics consult and the family. After a 3 hours HD sessions of 1L fluid removal, patient developed acute change in mental status with obtundation and severe hypoxemia requiring NIPPV with 90% FiO2 with PaO2 54mmHg. Her BUN (69mg/dl) and creatinine (11.15mg/dl) were reduced significantly. Chest radiograph showed worsen bilateral pulmonary infiltrates (Fig. 1). The patient’s mental status improved and oxygen requirement went down with supportive management. DISCUSSION: Dialysis Disequilibrium syndrome is characterized by neurologic deterioration and cerebral edema which occurs after hemodialysis. It is a diagnosis of exclusion and is usually seen in initiation of HD and is very rare in patients that have already been on HD. Our patient had missed many sessions of HD due to her underlying disability and lack of capacity to refuse treatment. Pulmonary involvement of DDS is very rare and the pathophysiology is not well understood. Leading theories include 1) reverse osmotic shift due to rapid reduction of BUN in serum, which promotes water shift to interstitium producing pulmonary edema, 2) increased vascular permeability due to uremic toxins, 3) inflammatory milieu 4) transient leukocyte margination and pulmonary leukostasis with the use of previous bio-incompatible membranes.3 Treatment is supportive measures and avoidance of fast rates of HD is the best solution. CONCLUSIONS: DDS with Pulmonary involvement is a very rare phenomenon and clinicians should be aware of this process in patients with increasing pulmonary edema with hypoxic respiratory failure post HD sessions. In our patient, she continued to receive infrequent hemodialysis as needed (every 3-10 days) and her post HD mental status change and hypoxemia episode became lesser in significance. Reference #1: Arieff AI. Dialysis disequilibrium syndrome: current concepts on pathogenesis and prevention. Kidney Int 1994. 45: 629-635 Reference #2: Lopez-Almaraz, E. and Coreea-Rotter, R. Dialysis Disequilibrium Syndrome and other treatment complications of extreme uremia: A rare occurrence yet not vanished. Hemodialysis International, 12: 301–306. https://doi.org/10.1111/j.1542-4758.2008.00270.x Reference #3: Rousseau Y, Carreno MP, Poignet JL, et al. Dissociation between complement activation, integrin expression and neutropenia during hemodialysis. Biomaterials. 1999; 20:1959 DISCLOSURES: No relevant relationships by John Kileci, source=Web Response No relevant relationships by Young Im Lee, source=Web Response