Abstract Details

Title Dialysis Disequilibrium Syndrome with Fatal Cerebral Edema

Topic Critical Care/Emergency Neurology/Trauma

Presentation(s) P05 - (-)

Poster/Presentation
Number 210

Objective

Background BACKGROUND: Dialysis disequilibrium is a rare phenomenon, which occurs more commonly in younger patients who are relatively new to dialysis. Manifestations range from headache, muscle cramps, and nausea, to seizures, altered sensorium and rarely coma or death. The pathogenesis is not fully understood, but proposed mechanisms include reverse urea effect, ideogenic osmoles, and paradoxical cerebral acidemia.

Design/Methods DESIGN/METHODS: We report the case of a 21-year-old Hispanic male with end-stage renal disease on hemodialysis for the past month due to IgA nephropathy who presented with 2 reported seizures after a routine dialysis session. In the emergency department, the patient was unresponsive, intubated, with decerebrate posturing and intact brainstem reflexes. Stat imaging of the brain and intracranial vasculature including MRI was negative for ischemia, mass lesion or hydrocephalus. Cortical changes on flair were noted that were suggestive of early encephalitis. He was started on antiepileptics, broad-spectrum antibiotics, acyclovir and a lumbar puncture was performed. Cerebrospinal fluid was acellular with elevated protein at 257 mg/dL and normal opening pressure.

Results RESULTS: Exam was stable overnight. The patient was dialyzed the following morning for severe hyperkalemia. Approximately 3 hours into dialysis, he developed absent brainstem reflexes. Stat imaging revealed massive diffuse cerebral edema. Despite all measures, he continued to deteriorate and died 4 days later.

Conclusions CONCLUSIONS: Although described in the literature, acute fatal cerebral edema following dialysis is not commonly seen. We hypothesize that the patient suffered acute cerebral edema due to dialysis disequilibrium syndrome. The rapid deterioration after the second dialysis session supports this hypothesis.

Authors/Disclosures
Tiffani S. Franada, DO, FAAN (OSF Healthcare Illinois Neurological Institute) PRESENTER	Dr. Franada has nothing to disclose.
Amre Nouh, MD, FAAN (Cleveland Clinic)	Dr. Nouh has stock in Openwater.
Douglas L. Arnold, MD, FAAN (Montreal Neurological Institute, McGill Univ)	Dr. Arnold has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Biogen. Dr. Arnold has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for BMS. Dr. Arnold has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Frequency Therapeutics. Dr. Arnold has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Merck. Dr. Arnold has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Novartis. Dr. Arnold has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Roche. Dr. Arnold has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Sanofi. Dr. Arnold has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Shionogi. Dr. Arnold has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Xfacto communications. Dr. Arnold has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Eli Lilly. Dr. Arnold has received personal compensation in the range of $500-$4,999 for serving as a Consultant for EMD Serono. Dr. Arnold has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Biohaven. Dr. Arnold has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Find therapeutics. Dr. Arnold has received personal compensation in the range of $500-$4,999 for serving as a Consultant for GSK. Dr. Arnold has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Idorsia. Dr. Arnold has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Kiniksa. Dr. Arnold has received personal compensation in the range of $100,000-$499,999 for serving as a Consultant for Clario.
Melvin D. Wichter, MD	No disclosure on file

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