Dialysis Disequilibrium Syndrome: A Severe Case with Neurologic Recovery - A Case Report

Dialysis disequilibrium syndrome is a serious complication occurring during hemodialysis initiation and after a break from hemodialysis, with a myriad of neurological symptoms.

We report a case of a 68-year-old woman with a history of hypertension, type 2 diabetes mellitus, and recently diagnosed end-stage kidney disease. She presented to the emergency room with disorientation and hypertensive urgency and had started hemodialysis 3 months prior but declined further treatment. Laboratory data revealed blood urea nitrogen of 151 mg/dL, creatinine of 18 mg/dL, bicarbonate level of 5 mEq/L, and potassium of 6.6 mEq/L. A temporary hemodialysis catheter was inserted, and dialysis was initiated with a blood flow rate of 300 mL/min and a dialysate flow rate of 600 mL/min, using an Optiflux 180NRe dialyzer (surface area 1.7 m²) for a duration of 3 h. The patient developed seizure activity after 2 h and 55 min, described as tonic-clonic seizure lasting 5 min. The urea reduction ratio was 57.6%, and the bicarbonate level increased from 5 to 16 mEq/L. She remained in a stuporous state, with no response to stimuli. She was transferred to the intensive care unit and received 20% mannitol 0.5 g/kg (40 g), followed by 3% hypertonic saline (30 mL bolus, then 50 mL/h infusion), with the aim of maintaining a serum sodium concentration between 145 and 155 mEq/L. Forty-eight hours later, she began to open her eyes to voice and consistently followed commands.

Our patient's dialysis disequilibrium syndrome severity correlated with the urea reduction ratio and severe metabolic acidosis, highlighting the importance of achieving a low urea reduction ratio (<40%) and a targeted rise in bicarbonate levels, both of which are risk factors for dialysis disequilibrium syndrome. In addition, the use of 3% saline and mannitol is an important preventive and rescue strategy.