Dialysis disequilibrium syndrome: an underdiagnosed condition? Results from a monocentric observational study

Dialysis disequilibrium syndrome (DDS) is a neurological complication occurring during hemodialysis initiation whose pathogenesis remains incompletely understood. Limited prospective adult data exists on DDS incidence and risk factors.

We conducted a prospective observational study (February 2021-February 2022) including 48 patients initiating hemodialysis. DDS was assessed using a standardized severity score (0-3) before and after each of the first four sessions, defined as any increase in post-session score (Δ Score ≥ 1). Univariate and multivariate logistic regression identified risk factors.

Among 48 patients (70.8% male, median age 67 years), 22.9% developed DDS with two patients experiencing multiple episodes. Univariate analysis identified centrally acting agent use (45.5% vs. 8.1%, P = .01), fluid overload (45.4% vs. 13.5%, P = .03), lower pre-dialysis pH (7.28 vs. 7.37, P = .04), and higher chloride (100 vs. 94 mmol/l, P = .01) as significant associations. Pre-dialysis urea was not associated with DDS (P = .15). Multivariate analysis identified intradialytic hypertension as an independent risk factor (Odds ratio = 4.43, 95% confidence interval: 1.38-18.15, P = .01) occurring in 78.6% of DDS sessions versus 40.0% of non-DDS sessions.

DDS is a common complication (22.9% incidence) with intradialytic hypertension as the key independent predictor. Pre-dialysis urea concentration was not predictive. These findings suggest a pathophysiological model involving acid-base dynamics and intracranial pressure regulation rather than solute gradients alone. Future multicenter studies are needed to validate these findings and optimize dialysis initiation strategies.