Dialysis disequilibrium syndrome: An overview of the current neurosurgical state

Dialysis disequilibrium syndrome (DDS) is a rare but serious neurologic complication of hemodialysis caused by rapid osmotic shifts leading to cerebral edema. Although well recognized in nephrology, DDS is underappreciated in neurosurgical practice, where it often presents only after significant intracranial hypertension has developed. As dialysis use expands, early neurosurgical awareness is increasingly important.

This narrative review synthesizes current evidence on DDS pathophysiology, clinical features, diagnostic considerations, and management, with a specific focus on neurosurgical implications. Data from case reports, pooled analyses, and neurocritical care studies were examined to characterize intracranial pressure (ICP) changes associated with renal replacement therapy and to identify points for multidisciplinary intervention.

DDS most frequently occurs during early or rapid hemodialysis in patients with markedly elevated urea levels. A pooled analysis shows ICP elevation in up to 73% of neurosurgical patients receiving intermittent hemodialysis versus 38% treated with continuous modalities. Despite these risks, standardized neurosurgical protocols for prevention or monitoring remain lacking. Evidence supports gradual urea clearance, early use of continuous therapies, and timely hyperosmolar treatment when cerebral edema develops. However, delayed recognition and limited cross-disciplinary coordination continue to hinder effective management.

DDS is a preventable neurocritical complication that requires stronger integration into neurosurgical practice. Improved interdisciplinary communication, structured monitoring strategies, and incorporation of DDS into neurocritical care training could support earlier recognition and safer dialysis initiation. Reframing DDS as a shared neurosurgical-nephrology responsibility is essential to moving from reactive treatment toward prevention and improving neurologic outcomes.