Abstract
Dialysis disequilibrium syndrome (DDS) is a serious neurological complication of hemodialysis, and patients with acute brain injury are at increased risk. We report a case of DDS leading to intracranial hypertension in a patient with anoxic brain injury and discuss the subsequent dialysis strategy. A 13-year-old girl was admitted after prolonged resuscitation from cardiac arrest. Computed tomography (CT) revealed an inferior vena cava aneurysm and multiple pulmonary emboli as the likely cause. An intracranial pressure (ICP) monitor was inserted, and, on day 3, continuous renal replacement therapy (CRRT) was initiated due to acute kidney injury, during which the patient developed severe intracranial hypertension. CT of the brain showed diffuse cerebral edema. CRRT was discontinued, sedation was increased, and hypertonic saline was administered, upon which ICP normalized. Due to persistent hyperkalemia and overhydration, ultrafiltration and intermittent hemodialysis were performed separately on day 4 with a small dialyzer, low blood and dialysate flow, and high dialysate sodium content. During subsequent treatments, isolated ultrafiltration was well tolerated, whereas hemodialysis was associated with increased ICP necessitating frequent pauses or early cessation of dialysis. In patients at risk of DDS, hemodialysis should be performed with utmost care and continuous monitoring of ICP should be considered.
Highlights
Dialysis-requiring acute kidney injury (AKI) is a common occurrence in critically ill patients and is associated with increased mortality [1]
A rare but serious complication of dialysis is the so-called dialysis disequilibrium syndrome (DDS), defined as the occurrence of acute neurological symptoms attributed to cerebral edema and increased intracranial pressure (ICP) during or following dialysis [2]
Several of the mentioned risk factors were present in our patient, most notably anoxic brain injury due to prolonged cardiac arrest, which resulted in cerebral edema
Summary
Dialysis-requiring acute kidney injury (AKI) is a common occurrence in critically ill patients and is associated with increased mortality [1]. A rare but serious complication of dialysis is the so-called dialysis disequilibrium syndrome (DDS), defined as the occurrence of acute neurological symptoms attributed to cerebral edema and increased intracranial pressure (ICP) during or following dialysis [2]. Patients with acute brain injury are at increased risk of developing DDS and present a challenge when dialysis is indicated, as the need for acute dialysis must be balanced against the risk of neurological deterioration. We present a case of intracranial hypertension due to DDS in a patient with anoxic brain injury and discuss the management of hemodialysis in neurocritically ill patients
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