Dialysis Disequilibrium Syndrome Research Articles

Dialysis disequilibrium syndrome: A case report

Dialysis disequilibrium syndrome (DDS) is a rare syndrome that can occur in patients with severe azotemia undergoing an initial hemodialysis (HD) session. DDS is associated with a more rapid decrease in urea concentration in the blood than in the brain during dialysis. Although severe DDS is less common, the milder forms of DDS may be missed by doctors. A 53-year-old male patient had the main complaint of severe dizziness in the last 10 months accompanied by a sensation of a wobbling head and tinnitus in his right ear. The patient had previously been diagnosed with polycystic kidney disease in 2018 and underwent regular hemodialysis two times a week since June 2019. In the patient's neurological status, cerebellar examination was positive for left dysmetria, left positive past pointing, Romberg test (open eye) fell to the right, and Romberg test (closed eye) fell to the right. There was no nystagmus on the patient's neuro-ophthalmological examination. Patients with kidney failure are at risk of developing DDS, so that appropriate precautions are needed. Due to the variability of symptoms, DDS often goes undiagnosed. Thus, it is important to be aware of the risk factors for DDS so that preventive steps can be taken appropriately. Continuous case reporting will raise awareness and the opportunity for further research to improve outcome in severe cases of DDS.
 Keywords: Dialysis; Disequilibrium; Dizziness; Polycystic Kidney.
 Citation: Yahya, Hidayati HB, Sugondo AT, Puspamaniar VA, Firdausa FS. Dialysis disequilibrium syndrome: A case report. Anaesth. pain intensive care 2024;28(1):191−195; DOI: 10.35975/apic.v28i1.2388
 Received: October 10, 2023; Reviewed: December 20, 2023; Accepted: January 02, 2024

Prevention of dialysis disequilibrium syndrome in children with advanced uremia with a structured hemodialysis protocol: A quality improvement initiative study.

Dialysis disequilibrium syndrome (DDS) is a rare but significant concern in adult and pediatric patients undergoing dialysis initiation with advanced uremia or if done after an interval. It is imperative to gain insights into the epidemiological patterns, pathophysiological mechanisms, and preventive strategies aimed at averting the onset of this ailment. Prospective observational quality improvement initiative cohort study. A prospective single-center study involving 50 pediatric patients under 18 years recently diagnosed with chronic kidney disease stage V with blood urea ≥200 mg/dL, admitted to our tertiary care center for dialysis initiation from January 2017 to October 2023. A standardized protocol was developed and followed for hemodialysis in pediatric patients with advanced uremia. This protocol included measures such as lower urea reduction ratios (targeted at 20%-30%) with shorter dialysis sessions and linear dialysate sodium profiling. Prophylactic administration of mannitol and 25% dextrose was also done to prevent the incidence of dialysis disequilibrium syndrome. Incidence of dialysis disequilibrium syndrome and severe dialysis disequilibrium syndrome, mortality, urea reduction ratios (URRs), neurological outcome at discharge, and development of complications such as infection and hypotension. Long-term outcomes were assessed at the 1-year follow-up including adherence to dialysis, renal transplantation, death, and loss to follow-up. The median serum creatinine and urea levels at presentation were 7.93 and 224 mg/dL, respectively. A total of 20% of patients had neurological symptoms attributable to advanced uremia at the time of presentation. The incidence of dialysis disequilibrium syndrome was 4% (n = 2) with severe dialysis disequilibrium syndrome only 2% (n = 1). Overall mortality was 8% (n = 4) but none of the deaths were attributed to dialysis disequilibrium syndrome. The mean urea reduction ratios for the first, second, and third dialysis sessions were 23.45%, 34.56%, and 33.50%, respectively. The patients with dialysis disequilibrium syndrome were discharged with normal neurological status. Long-term outcomes showed 88% adherence to dialysis and 38% renal transplantation. This study is characterized by a single-center design, nonrandomized approach, and limited sample size. Our structured protocol served as a framework for standardizing procedures contributing to low incidence rates of dialysis disequilibrium syndrome.

Dialysis disequilibrium syndrome in neurosurgery: literature review and illustrative case example.

The dialysis disequilibrium syndrome (DDS) is a complication in those undergoing dialysis for chronic kidney disease (CKD) or acute kidney injury (AKI), characterized by nonspecific symptoms that may progress to coma and death secondary to cerebral edema. This syndrome is associated with rapid change in electrolytes during dialysis with changes in intracranial pressure (ICP) and may have a higher incidence in the elderly neurosurgical patient population. Literature review and illustrative case example. A 62-year-old female presented with acute mental status change during hemodialysis (HD), with a history of a nonsurgical acute subdural hematoma (SDH) 10days prior. Imaging showed a conversion of the acute SDH to chronic SDH of 12.2mm in size with a 14.1 midline shift, for which she underwent a hemicraniectomy with SDH evacuation, with a gradual return to baseline. The literature review identified 5 publications meeting the inclusion criteria. Major theories of DDS include a reverse urea effect, intracerebral acidosis, idiogenic osmoles, and local inflammation. This complication may occur more frequently in the elderly neurosurgical patient population, likely due to age-related comorbidities, preexisting neurological insult, and increased permeability of the blood-brain barrier (BBB), leading to cerebral edema. DDS is a rare and potentially fatal complication of HD that may have a higher incidence in the elderly neurosurgical patient population, yet remains to be fully understood. Further study is recommended to characterize the pathophysiological mechanism and incidence of DDS in neurosurgical patients.

Dialysis disequilibrium syndrome in a child with uncal herniation: successful management.

Dialysis disequilibrium syndrome in a child with uncal herniation: successful management.

A Study to Assess the Risk Factors and Symptoms of DDS (Dialysis Disequilibrium Syndrome) Among Patient Undergoing Hemodialysis

Introduction:The dialysis disequilibrium syndrome is defined as a medical syndrome of neurologic deterioration that manifests in hemodialysis patients. It is much more likely to occur in patients during or immediately following their first treatment, but it can occur in any affected person who receives hemodialysis. Methods:For the study, a descriptive research design was used. The research was carried out at Saveetha Medical College Hospital in Chennai. The convenience sampling technique was used to select 60 samples that met the inclusion criteria. Dialysis Disequilibrium Syndrome (DDS) risk assessment was performed prior to hemodialysis imitation, and the client is continuously monitoring signs and symptoms of Dialysis Disequilibrium Syndrome (DDS) during intra dialysis and the first hour after dialysis. Descriptive and inferential statistics were used to analyse the data.Results: Intradialysis results Karl Pearson's correlation coefficient of 0.501 indicates a moderately positive correlation. Karl Pearson's Correlation value of r = 0.404 after dialysis indicates a mild positive correlation that was found to be statistically significant at the p0.001 level. Conclusion: This clearly implies that as the risk factor increases, so do the signs and symptoms. "As a result, early detection of DDS (Dialysis Disequilibrium Syndrome) is a very powerful action to reduce the severity of mortality."This descriptive study discusses the importance of demographic and clinical variables in the development of Dialysis Disequilibrium Syndrome (DDS).

Uremic Encephalopathy.

HomeRadiologyVol. 307, No. 1 PreviousNext Reviews and CommentaryFree AccessImages in RadiologyUremic EncephalopathyDavid A. Lizarazo , Jairo LizarazoDavid A. Lizarazo , Jairo LizarazoAuthor AffiliationsFrom the Department of Diagnostic Imaging, Fundación Santa Fe de Bogotá, Universidad El Bosque, Ave 116 No. 9-02, Bogotá 110246, Colombia (D.A.L.); and Department of Internal Medicine, Hospital Universitario Erasmo Meoz, Universidad de Pamplona, Cúcuta, Colombia (J.L.).Address correspondence to D.A.L. (email: [email protected]).David A. Lizarazo Jairo LizarazoPublished Online:Dec 20 2022https://doi.org/10.1148/radiol.221602MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In A 54-year-old man was admitted for a 3-day history of dysarthria, hand tremors, hypokinesia, and generalized muscle rigidity. His past medical history included diabetes mellitus and end-stage renal disease on hemodialysis. On admission, there were elevated blood urea nitrogen and creatinine levels with a metabolic acidosis. Axial CT scan of the brain showed symmetrical hypoattenuation of both basal ganglia (Figure). Noncontrast brain T2-weighted MRI demonstrated symmetrical high signal intensity in the basal ganglia surrounded by a more hyperintense rim delineating the lentiform nucleus (Figure). This is the lentiform fork sign, wherein the internal and external capsules and the medullary laminae become hyperintense with axial T2-weighted images (Figure). After correction of the metabolic acidosis with prompt dialysis and glycemic control, the neurologic examination returned to normal, and his symptoms completely resolved. A follow-up MRI examination was not performed.Images in a 54-year-old man who presented with a 3-day evolution of dysarthria, hand tremors, hypokinesia, and generalized muscle rigidity. He had diabetes mellitus and end-stage renal disease and was undergoing hemodialysis. Laboratory tests showed azotemia and metabolic acidosis. (A) Axial CT scan of brain shows symmetrical hypoattenuation in the bilateral basal ganglia. (B) Axial T2-weighted fluid-attenuated inversion recovery noncontrast brain MRI scan demonstrates bilateral symmetrical swollen lentiform nuclei with a hyperintense rim delineating the lentiform nucleus with a typical fork-like appearance representing the “lentiform fork sign.” (C) Schematic drawing shows the “lentiform fork sign.” At follow-up after correction of metabolic acidosis with prompt dialysis and glycaemic control, the neurologic examination was normal, and symptoms completely resolved. Follow-up scan was not performed. EC = external capsule, IC = internal capsule, LME = external medullary lamina, LMI = internal medullary lamina, TS = the stem.Download as PowerPointOpen in Image Viewer Uremic encephalopathy is a neurologic complication resulting from endogenous uremic toxins in patients with severe renal failure. The pathogenesis is complex and unclear (1). The lentiform fork sign (Figure) is attributed to metabolic acidosis in patients with diabetes and renal failure with a history of incomplete dialysis leading to reversible basal ganglia and adjacent white matter injury (2). The edematous external capsule represents the lateral arm of the fork, with both the external and internal capsule joining to build the stem of the fork. Edema of the medial lentiform margin forms the medial arm, which splits into two along the medullary laminae to envelop the globus pallidus (3). The lentiform fork sign is nonspecific for uremic encephalopathy. Differential diagnosis of pathologic conditions manifesting with this sign includes severe metabolic acidosis, ketoacidosis, dialysis disequilibrium syndrome, and intoxication (ie, methanol, ethylene glycol); this can also be drug induced (ie, metformin) (4).Disclosures of conflicts of interest: D.A.L. No relevant relationships. J.L. No relevant relationships.

Het dialyse-disequilibriumsyndroom: casusbespreking en literatuuroverzicht

Dialysis disequilibrium syndrome: a case report and review of the literature The dialysis disequilibrium syndrome (DDS) is a preventable, but potentially life-threatening complication of hemodialysis. Its incidence is low since the application of preventive measures, but its importance is not to be overlooked. The objective of this case report is to emphasize the importance of the prevention of DDS and to give an overview of the literature with a specific focus on prevention. A 62-year-old female patient presented to the emergency department with acute postrenal kidney injury due to a cervix carcinoma with invasion and obstruction of both ureters. Hemodialysis was deemed necessary because of hyperkalemia. By the end of this procedure, the patient suffered from severe neurological deterioration with stupor and myoclonus. She was urgently intubated, sedated and mechanically ventilated. The CT scan of the brain showed cerebral edema. DDS was suspected. The neurological symptoms improved during the following day. Bilateral nephrostomy catheters were placed, upon which the kidney injury resolved. This case report highlights the importance of risk stratification of patients at risk for DDS. In these patients, preventive measures are recommended, such as low-efficiency dialysis or treatment with osmotically active agents.

MO641: Hemodiafiltration with Intermittent Infusion Reduces the Incidence of Dialysis Disequilibrium Syndrome in Hemodialysis Patients in the Initiation Phase

Abstract BACKGROUND AND AIMS The dialysis disequilibrium syndrome (DDS) is a major complication in hemodialysis patients in the initiation phase. Since urea removal restriction is an effective method to prevent DDS, a reduced dialysis dose is used in the initiation phase in hemodialysis patients. However, despite this, some patients still develop DDS in the initiation phase. Hemodiafiltration with intermittent infusion (I-HDF) provides intermittent infusion during dialysis, which can reduce the imbalance between the intravascular and interstitial concentrations, thus maintaining a high plasma osmolarity and potentially high plasma osmolarity, lowering the incidence of DDS. The aim of the present study was to clarify whether starting the treatment with I-HDF is useful for preventing DDS in hemodialysis patients in the initiation phase. METHOD Since January 2021, we have used I-HDF at the start of the treatment in patients being initiated on hemodialysis at our hospital. We conducted a retrospective review to examine if there were any changes in the incidence of clinical symptoms such as DDS or the mean blood pressure during dialysis with this mode change. The participants in this study included 11 patients who were started on treatment with conventional low-dose hemodialysis (HD group) (10 males/1 female; 5 diabetic, 6 non-diabetic; mean age, 73.7 years; SD 8.3) and 14 patients who were started on treatment with I-HDF (I-HDF group) (12 males/2 females; 12 diabetic, 2 non-diabetic; mean age, 66.8 years; SD 16.1). We compared the prevalence of symptoms of DDS (headache, nausea, vomiting, leg cramps, fatigue and hypotension), the normalized dialysis dose (spKt/V), the urea nitrogen (UN), serum albumin (Alb), fluid removal rate and mean blood pressure in the HD and I-HDF groups at first treatment. The treatment conditions were FA-150F membrane for the HD group and FIX-170E membrane for the I-HDF group, with a blood flow rate of 150 mL/min, dialysate flow rate of 500 mL/min and treatment time of 3-h in both groups. I-HDF was carried out with five infusions of 150–200 mL/min for one minute by back filtration of the dialysate every 30 minutes. RESULTS A significantly lower incidence of DDS was noted in the I-HDF group, with 3 events in the I-HDF group as compared with 17 events in the HD group (P < .01, chi-squared test). There was no significant difference in the spKt/V, UN, Alb, or fluid removal rate between the two groups (P = .80, P = .28, P = .96 and P = .20, respectively). The mean blood pressure was significantly lower in the HD group than in the I-HDF group (P < .05, t-test). These results indicated that the incidence of DDS could be reduced by starting treatment with I-HDF in patients being initiated on hemodialysis, because the intentional loading of fluid by intermittent infusion may enhance plasma refilling and have a positive effect on suppressing any rapid changes in the plasma osmolality. CONCLUSION I-HDF was useful for maintaining the blood pressure and reducing the incidence of dialysis disequilibrium syndrome in the initiation phase in hemodialysis patients.

POS-525 INTEREST OF MANNITOL IN INTRACRANIAL HYPERTENSION DURING HEMODIALYSIS IN A PATIENT WITH ACUTE BRAIN INJURY: A CASE REPORT

Hemodialysis (HD) Patients with acute brain injury are at increased risk of dialysis disequilibrium syndrome (DDS). This is due to the added risk of increased intracranial pressure (ICP) during or following dialysis. We present here a case of severe intracranial hypertension due to post traumatic subdural hematoma in a long-term HD patient, improved by continuous mannitol infusions during HD sessions. A 37-year-old Caucasian woman, in HD during five years, had a car accident in january 2021 with initial loss of consciousness, vomiting, severe headache and a Glasgow score of 14/15. Cerebral CT showed frontal hemorrhagic contusions, a right temporal subdural hematoma, subarachnoid hemorrhage, a non-displaced fracture of the sagittal/frontal bones and severe cerebral edema (figure 1). The patient was transferred to the neurosurgical department for medical management and monitoring. No emergency surgery was needed. On day 4, during her first hemodialysis session post brain injury, the patient presented neurological deterioration, severe headache and vomiting. Her blood pressure was of 143/63, heart rate recorded at 76 and oxygen saturation was stable at 100%. On suspicion of cerebral edema, the session was stopped. CT revealed exacerbation of cerebral edema, with no change in lesions or hemorrhage. Similar problems were encountered on the following session. We tried a test dose of Mannitol 20%: 50ml over 5minutes after start of hemodialysis. Neurologic signs disappeared and the patient was stable. Slow Continous mannitol infusion at a dose of 0,2g/kg body weight was undergone during 3-hours HD session with blood pressure and heart rate monitoring. No complications and no clinical significant changes were observed, except a mild elevation of blood pressure(174/95) controlled by mannitol infusion rate reduction. On day 8, the patient received slower dose of Mannitol 20% : 0,2g/kg body weight over 3.5hours of hemodialysis with 50ml infused over 20min and the remaining 60ml over 3 hours. Repeated blood tests showed no hypernatremia. From day 10 and onwards, the patient was able to tolerate hemodialysis with similar settings. On day 20, a further CT scan showed improvement in cerebral edema and temporal hematoma. we began administrating smaller doses of Mannitol ( 0,1g/kg body weight). On day 28, Mannitol was discontinued, as neurological functions were stable and control cerebral CT showed almost total resorption of the hemmorage and a marked edema reduction (figure 2). This case highlights the inherent risks associated with hemodialysis in patients with acute brain injury. The patient in question was likely predisposed to DDS due to cerebral edema after traumatic subdural hemmorage. In high-risk patients, we suggest the infusion of hypertonic solutions such as mannitol during dialysis. It seems to be well tolerated and may allow correction of ICP and optimisation of hemodialysis sessions. However, the risk of hypertensive crisis and hypernatremia should be considered.

Case Report: A Case of Encephalopathy Presenting the Lentiform Fork Sign on MRI in a Diabetic Dialysis Patient

Basal ganglia lesions showing an expansile high signal intensity on T2-weighted MRI are termed the lentiform fork sign. This specific finding is mainly observed in diabetic patients with uremic encephalopathy with metabolic acidosis, although there are also reports in patients with ketoacidosis, dialysis disequilibrium syndrome, intoxication, and following drug treatment (e.g., metformin). A 57-year-old Japanese man on chronic hemodialysis for 4 years because of diabetic nephropathy was admitted to our hospital for relatively rapid-onset gait disturbance, severe dysarthria, and consciousness disturbance. Brain T2-weighted MRI showed the lentiform fork sign. Hemodialysis was performed the day before admission, and laboratory tests showed mild metabolic (lactic) acidosis, but no uremia. Surprisingly, metformin, which is contraindicated for patients with end-stage kidney disease, had been prescribed for 6 months in his medication record, and his sluggish speaking and dysarthria appeared gradually after metformin treatment was started. Thus, the encephalopathy was considered to be related to metformin treatment. He received hemodialysis treatment for 6 consecutive days, and his consciousness disturbance and dysarthria improved in 1 week. At the 8-month follow-up, the size of the hyperintensity area on MRI had decreased, while the mild gait disturbance remained. Considering the rapid onset of gait and consciousness disturbance immediately before admission, diabetic uremic syndrome may also have occurred with metformin-related encephalopathy, and resulted in the lentiform fork sign, despite the patient showing no evidence of severe uremia on laboratory data.

Case Report: A Case of Encephalopathy Presenting the Lentiform Fork Sign on MRI in a Diabetic Dialysis Patient

Basal ganglia lesions showing an expansile high signal intensity on T2-weighted MRI are termed the lentiform fork sign. This specific finding is mainly observed in diabetic patients with uremic encephalopathy with metabolic acidosis, although there are also reports in patients with ketoacidosis, dialysis disequilibrium syndrome, intoxication, and following drug treatment (e.g., metformin). A 57-year-old Japanese man on chronic hemodialysis for 4 years because of diabetic nephropathy was admitted to our hospital for relatively rapid-onset gait disturbance, severe dysarthria, and consciousness disturbance. Brain T2-weighted MRI showed the lentiform fork sign. Hemodialysis was performed the day before admission, and laboratory tests showed mild metabolic (lactic) acidosis, but no uremia. Surprisingly, metformin, which is contraindicated for patients with end-stage kidney disease, had been prescribed for 6 months in his medication record, and his sluggish speaking and dysarthria appeared gradually after metformin treatment was started. Thus, the encephalopathy was considered to be related to metformin treatment. He received hemodialysis treatment for 6 consecutive days, and his consciousness disturbance and dysarthria improved in 1 week. At the 8-month follow-up, the size of the hyperintensity area on MRI had decreased, while the mild gait disturbance remained. Considering the rapid onset of gait and consciousness disturbance immediately before admission, diabetic uremic syndrome may also have occurred with metformin-related encephalopathy, and resulted in the lentiform fork sign, despite the patient showing no evidence of severe uremia on laboratory data.

Dialysis disequilibrium syndrome (DDS) in pediatric patients on dialysis: systematic review and clinical practice recommendations.

Dialysis disequilibrium syndrome (DDS) is a rare neurological complication, most commonly affecting patients undergoing new initiation of hemodialysis (HD), but can also be seen in patients receiving chronic dialysis who miss regular treatments, patients having acute kidney injury (AKI), and in those treated with continuous kidney replacement therapy (CKRT) or peritoneal dialysis (PD). Although the pathogenesis is not well understood, DDS is likely a result of multiple physiological abnormalities. In this systematic review, we provide a synopsis of the data available on DDS that allow for a clear picture of its pathogenesis, preventive measures, and focus on effective management strategies. We conducted a literature search on PubMed/Medline and Embase from January 1960 to January 2021. Studies were included if the patient developed DDS irrespective of age and gender. A summary table was used to summarize the data from individual studies and included study type, population group, age group, sample size, patient characteristics, blood and dialysate flow rate, and overall outcome. A descriptive analysis calculating the frequency of population size, symptoms, and various treatments was performed using R software version 3.1.0. A total of 49 studies (321 samples) were identified and analyzed. Out of the included 49 studies, a total of 48 studies reported the presence of DSS among patients (1 study reported based on number of dialysis and therefore was not considered for analysis). Among these 48 studies, 74.3% (226/304) patients were reported to have DSS. The most common symptoms were nausea (25.2%), headache (24.8%), vomiting (23.9%), muscle cramps (18.1%), affected level of consciousness (8.8%), confusion (4.4%), and seizure (4.9%) among the 226 DDS patients. Furthermore, 12 studies decided to switch from HD to alternative dialysis modalities including continuous venovenous hemofiltration/hemodiafiltration (CVVH/CVVHDF) or PD which reported no DDS symptoms. Early recognition and timely prevention are crucial for DDS patients. We have provided comprehensive clinical practice points for pediatric, adolescent, and young adult populations. However, it is essential to recognize that DDS was reported more frequently in the early dialysis era, as there was a lack of advanced dialysis technology and limited resources.

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

ABSTRACTDialysis disequilibrium syndrome (DDS) is a rare complication of dialysis, especially with the general application of preventive strategies. Severe DDS with brain herniation is believed to be fatal. We present a patient presenting with bilateral uncal herniation after receiving two dialysis sessions with low-efficiency settings. Serial brain magnetic resonance imaging studies showed the temporal evolution of DDS-induced cerebral edema. With aggressive treatment of hypertonic saline and mannitol, the patient made a remarkable recovery. This case highlights that we should be cautious about this severe complication of dialysis even with preventive strategies, and recovery is possible with prompt recognition and treatment.

Review of Traditional Chinese Medicines for Common Complications Related to Hemodialysis: An Evidence-Based Perspective.

Renal replacement therapy is an important therapy for prolonging life in end-stage renal disease (ESRD) populations, and, in Taiwan, hemodialysis (HD) is the choice for most patients with ESRD. Although HD is effective for prolonging life, it is sometimes associated with complications that patients and doctors have to cope with every day, such as intradialytic hypotension, dialysis disequilibrium syndrome, and muscle cramps. Traditional Chinese medicine (TCM) is a complementary and alternative therapy that has been recognized for its efficacy in treating a variety of diseases by the World Health Organization. Nowadays, the clinical practice of TCM for HD-related complications has received attention for its effectiveness and safety. In this article, we summarize the TCM viewpoint and different TCM interventions for HD-related complications, such as Chinese herbal medicine, acupuncture, herbal acupoint therapy, auricular acupoints, and moxibustion. In the ESRD population, TCM is able to balance Yin and Yang, prevent cardiovascular accidents, control blood pressure, and relieve pain. More importantly, TCM may also improve common HD-related complications such as uremic symptoms, imbalance of electrolyte and fluid status, insomnia, and malnutrition. The mechanism of TCM is considered related to the regulation of autonomous functions and the activation of biologically active chemical substances. According to the studies noted in this review article, TCM has been proven effective for HD-related complications. However, more well-designed and rigorous research will be necessary to reveal the underlying mechanisms in the future.

Management of dysnatremias with continuous renal replacement therapy.

Disorders of serum sodium concentration are common in critically ill patients who may have concomitant acute kidney injury, chronic kidney disease, or end-stage kidney disease. Many of these patients may require customized serum sodium level management with dialysis which, if not strictly controlled, can lead to significant complications. Thus, controlled correction of the serum sodium level is necessary to avoid the development of osmotic demyelination syndrome in hyponatremic patients and dialysis disequilibrium syndrome in hypernatremic patients. Continuous renal replacement therapy offers unique benefits through the ability to slowly and safely correct dysnatremias that can be tailored to specific patient needs and should be considered in select patients.

Half the V by 120: A practical approach to the prevention of the dialysis disequilibrium syndrome.

The dialysis disequilibrium syndrome (DDS) results from osmotic shifts between the blood and the brain compartments. Patients at risk for DDS include those with very elevated blood urea nitrogen, concomitant hypernatremia, metabolic acidosis, and low total body water volumes. By understanding the underlying pathophysiology and applying urea kinetic modeling, it is possible to avoid the occurrence of this disorder. A urea reduction ratio (URR) of no more than 40%-45% over 2 h is recommended for the initial hemodialysis treatment. The relationship between the URR and Kt/V is useful when trying to model the dialysis treatment to a specific URR target. A simplified relationship between Kt/V and URR is provided by the equation: Kt/V=-ln (1 - URR). A URR of 40% is roughly equivalent to a Kt/V of 0.5. The required dialyzer urea clearance to achieve this goal URR in a 120-min treatment can simply be calculated by dividing half the patient's volume of distribution of urea by 120. The blood flow rate and dialyzer mass transfer coefficient (K0 A) required to achieve this clearance can then be plotted on a nomogram. Other methods to reduce the risk of DDS are reviewed, including the use of continuous renal replacement therapy.

Dialysis Disequilibrium Syndrome in a Patient With Acute Kidney Injury on Chronic Kidney Disease

Dialysis disequilibrium syndrome (DDS) is a neurological complication that has been known to occur after hemodialysis (HD). In recent years, the prevalence of DDS has been low as the symptoms are widely recognized; hence, preventive therapies, such as the slow and gentle procedure for HD, are often administered before starting dialysis. However, once DDS occurs, it may cause seizures, coma, and even death in severe cases. Since there has been no established treatment, recognizing risk factors and preventing the syndrome is important.A 76-year-old man was admitted to our hospital due to exacerbation of chronic heart failure. He also had a history of chronic kidney disease and had consulted with his home doctor about the preparation for HD a month before admission. After treatment with diuretics, the symptoms ameliorated, but he experienced presyncope and malaise. Laboratory tests revealed acute anemia and a decrease in renal function. Upper gastrointestinal endoscopy revealed active bleeding from a gastric ulcer, which was successfully stopped. However, his consciousness deteriorated because of uremia; hence, HD was initiated. We used a cellulose triacetate membrane with a surface area of 1.3 m2 and maintained a dialysate flow rate of 500 ml/min with a blood flow rate of 120 ml/min. Four hours after starting HD, he suddenly developed generalized tonic convulsions. The dialysis was immediately stopped, and the patient was transferred to an intensive care unit. A computed tomography scan of the head showed mild edematous change of the brain, and laboratory tests also revealed a rapid decrease of urea nitrogen. We rationalized that he might have developed DDS. After injection of levetiracetam for the treatment of seizures, we initiated continuous hemodiafiltration as renal replacement therapy. Fortunately, his consciousness gradually improved, and he was completely alert on day 18 after admission.With reference to our current report, DDS can occur even following acute kidney injury, as the progression rate of the injury and accumulation of blood urea may not correlate with the risk of the syndrome.

Pseudosubarachnoid hemorrhage: A systematic review of causes, diagnostic modalities, and outcomes in patients who present with pseudosubarachnoid hemorrhage.

Background: Patients with computed tomography (CT) findings consistent with subarachnoid hemorrhage without evidence of hemorrhage following autopsy or cerebrospinal fluid testing are termed to have pseudosubarachnoid hemorrhage (pSAH).Methods: A systematic review of literature was conducted based on the preferred reporting items for systematic reviews and meta-analysis statement. Studies were evaluated for associated cause of pSAH, imaging modality used in assessment, method of confirmatory testing, and clinical outcome.Results: Fifty studies were included in qualitative analysis including 197 cases of pSAH. Systematic review revealed 23 studies including 110 patients with pSAH attributed to hypoxic-ischemic brain injury following cardiac arrest. Three studies were included in meta-analysis that quantitatively analyzed differences in CT densities in patients with pSAH and true subarachnoid hemorrhage (true SAH). A random effects model meta-analysis showed a statistically significant decrease in densities in the Sylvian fissure in patients with pSAH compared to true SAH and a statistically significant decrease in densities in adjacent parenchyma in patients with pSAH compared to true SAH. Systematic review further revealed 32 patients with pSAH associated with spontaneous intracranial hypotension, 11 patients with pSAH related to infectious etiologies, 15 patients with pSAH associated with subdural hemorrhage, 20 cases of pSAH related to hyperhemoglobinemia, 2 cases related to valproate toxicity, and individual cases related to hyponatremia, diabetic ketoacidosis, sudden infant death syndrome, cerebellar infarction, and dialysis disequilibrium syndrome.Conclusion: This study is the first systematic review of causes, diagnostic modalities, and outcomes in patients who present with pSAH. A diagnosis of pSAH may be considered following assessment of CT densities following cardiac arrest.

EEG spectral changes induced by hemodialysis

ObjectiveTo investigate the EEG spectral changes induced during hemodialysis in patients with chronic kidney disease (CKD), and to identify the risk factors associated with changes in the Central Nervous System (CNS) during hemodialysis. Paradoxical neurological deterioration at the end of hemodialysis sessions, known as dialysis disequilibrium syndrome (DDS) has been described, but previous studies on EEG spectral changes during hemodialysis were controversial. MethodsWe performed quantitative EEG spectral analysis in 56 consecutive patients who underwent hemodialysis. We compared EEG at the start and at the end of the hemodialysis, and we correlated the spectral changes with the biochemical and clinical characteristics of the patients, using multivariate analysis. ResultsAt the end of hemodialysis sessions, we found a significant increase in total EEG power, relative power in delta frequency band and the ratio of delta-theta/alpha–beta power. EEG spectral changes were associated with younger age, recent start of hemodialysis therapy, level of uremia and lower level of glycaemia. ConclusionsQuantitative EEG spectral analysis showed that hemodialysis induced slowing of the EEG background activity. These changes were associated with risk factors of DDS. SignificanceEEG spectral changes are potential biomarkers for monitoring CNS function during hemodialysis.

Lentiform fork sign in a uremic patient with a high anion gap metabolic acidosis with seizures: a case report from North West of Ireland

BackgroundLentiform fork sign is a neuroradiological abnormality which is encountered in the clinical practice associated with uremic encephalopathy, dialysis disequilibrium syndrome and metabolic acidosis.Case presentationWe describe here a case of this neuro-radiological abnormality which was encountered in a patient with uraemia and high anion gap metabolic acidosis who presented with generalised convulsion and later had some tremor in her hands. In our patient, there were few predisposing factors which might have possibly resulted in this abnormality chronic kidney disease, diabetes mellitus, and metabolic acidosis.ConclusionThe Lentiform fork sign is a rare occurrence which can be related to a long list of toxic and metabolic causes but in conjunction with metabolic acidosis in chronic kidney disease patients, it can narrow down this list of alternate diagnosis.