Dialysis disequilibrium on CKRT: avoiding the steep slippery slope

Area of Science:

• Nephrology
• Critical Care Medicine

Background:

• Current guidelines lack specific recommendations for initiating kidney replacement therapy (KRT) prescription parameters and monitoring.
• Acute kidney injury (AKI) management guidelines do not adequately address the risk of dialysis disequilibrium syndrome (DDS).

Observation:

• A 16-year-old patient with severe kidney failure initiated continuous kidney replacement therapy (CKRT).
• The patient developed generalized seizure activity and diffuse encephalopathy 31 hours into therapy, despite a significant BUN reduction.
• CT and EEG findings were negative for acute intracranial processes, suggesting a metabolic cause.

Findings:

• The patient's presentation with encephalopathy and seizures during CKRT suggests a potential case of dialysis disequilibrium syndrome (DDS).
• A decreased clearance rate during KRT should be considered in patients with risk factors for DDS.
• Frequent monitoring of BUN and serum osmolality is vital for adjusting KRT prescriptions.

Implications:

• The potential for DDS exists beyond intermittent hemodialysis and can occur later in the course of KRT.
• More specific guidelines are needed for DDS risk assessment, timing, and therapeutic goals in early KRT.
• Enhanced guidelines for DDS would provide critical support for nephrologists managing acute kidney injury.