Ver el código de «Dialysis disequilibrium syndrome»

==Background==
*Abbreviation: DDS
*A rare clinical syndrome occurring at end of dialysis or the beginning of continuous renal replacement therapy
**Does not occur with [[peritoneal dialysis]]<ref>Wolfson AB. Renal failure. In: Walls RM, Hockberger RS, Gausche-Hill M, et al., eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed. Elsevier; 2018:(Ch) 87.</ref>
**Occurs most commonly during initial hemodialysis or during hypercatabolic states
**Tends to occur in patients who are initially started on dialysis, particularly with high initial BUN
**Other risk factors: older or younger age, hyponatremia, pre-existing neurologic disease
**Symptoms are thought to be secondary to the development of cerebral edema possibly due to urea removal during dialysis and from a decreased in pH in the cerebral intracelluar environment
*Large and rapid solute clearance creates an osmotic gradient which can precipitate cerebral edema <ref>Silver SM. et al. Dialysis disequilibrium syndrome (DDS) in the rat: role of the "reverse urea effect". Kidney Int. 1992;42(1):161-6. [http://www.ncbi.nlm.nih.gov/pubmed?term=1635345 Pubmed]</ref>
**Pre-dialysis urea in CSF lower than in blood<ref>Zepeda-Orozco D and Quigley R. Dialysis disequilibrium syndrome. Pediatr Nephrol. 2012 Dec; 27(12): 2205–2211.</ref>
**Post-dialysis urea in CSF higher, setting up osmotic gradient for water into CNS
**More uremic patients pre-dialysis at higher risk

==Clinical Features==
''Signs and symptoms develop during or after dialysis or during renal replacement therapy, usually self limited but can occasionally progress''
*[[Headache]]
*Disorientation
*[[Nausea and vomiting]]
*Restlessness
*[[Visual disturbances]]
*Asterixis
*Muscle Cramps
*Can progress to [[seizure]], [[coma]], and [[death]]<ref name="DDS">Zepeda-orozco D. et al. Dialysis disequilibrium syndrome. Pediatr Nephrol. 2012;27(12):2205-11.[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3491204/ Pubmed]</ref>

==Differential Diagnosis==
*[[Subdural hematoma]]
*[[Uremia]]
*Nonketotic hyperosmolar [[coma]]
*[[Acute cerebrovascular event]]
*Dialysis [[dementia]]
*Excessive ultrafiltration and [[seizure]]
*Metabolic disturbances
**[[Hypoglycemia]]
**[[Hyponatremia]]
*[[Meningitis]]
*[[Malignant hypertension]]<ref name="DDS"></ref><ref>Mahoney CA. et al. Uremic encephalopathies: clinical, biochemical, and experimental features. Am J Kidney Dis. 1982;2(3):324-36. [http://www.ncbi.nlm.nih.gov/pubmed/6756130 Pubmed]</ref>
*[[Hypocalcemia]]
*[[ICH|Intracranial Bleed]]
*[[Hypertensive Emergency]]
*[[Stroke]]
*Supratheurapeutic Medication Effects
*[[PRES]]

{{Dialysis complications DDX}}

==Evaluation==
===Workup===
*Bedside Glucose
*CBC
*Chem-10
*[[LFTs]]
*[[head CT|CT Brain]]

===Diagnosis===
*Is a clinical diagnosis, suggested by development of neurologic symptoms associated with dialysis
**However, must first exclude more serious diagnoses (rule out [[SDH]], [[CVA]]).

==Management==
===Mild===
*Symptomatic management for mild symptoms (nausea, headache, restlessness)
**Symptoms are self-limiting and typically resolve within several hours

===Severe===
*For severe symptoms, the mainstay of treatment is ICP reduction<ref name="DDS"></ref>
**Can give [[mannitol]] or [[hypertonic saline]] IV
**Can hyperventilate patient

==Disposition==
*Depends on severity
**Many cases can be discharged with followup 

==Prevention==
*Response to treatment is typically poor, so preventive measures are important<ref name="DDS"></ref>
*Add an osmotic agent to mitigate the osmotic gradient
**Elevate the sodium concentration in the diasylate<ref> Port FK. et al. Prevention of dialysis disequilibrium syndrome by use of high sodium concentration in the dialysate. Kidney Int. 1973;3(5):327-33.[http://www.ncbi.nlm.nih.gov/pubmed/4792047/ Pubmed]</ref>
**Elevate the glucose concentration in the diasylate (717 mg/dl) or add IV mannitol (1g/kg)<ref>Rodrigo F. et al. Osmolality changes during hemodialysis. Natural history, clinical correlations, and influence of dialysate glucose and intravenous mannitol. Ann Intern Med. 1977;86(5):554-61. [http://www.ncbi.nlm.nih.gov/pubmed/851303/ Pubmed]</ref>
*Consider hemofiltration rather than hemodialysis<ref>Kishimoto T. et al. Superiority of hemofiltration to hemodialysis for treatment of chronic renal failure: comparative studies between hemofiltration and hemodialysis on dialysis disequilibrium syndrome. Artif Organs. 1980;4(2):86-93. [http://www.ncbi.nlm.nih.gov/pubmed/7396769/ Pubmed]</ref>

==See Also==
*[[Dialysis complications]]

==References==
<references/>

[[Category:Renal]]
[[Category:Neurology]]