Abstract
OBJECTIVE: To describe a case of delayed dialysis disequilibrium syndrome resulting in acute fatal cerebral edema.
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: 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: 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: 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.
Disclosure: Dr. Stroup has nothing to disclose. Dr. Nouh has nothing to disclose. Dr. Wichter has nothing to disclose.
Wednesday, March 20 2013, 2:00 pm-7:00 pm
- Copyright © 2013 by AAN Enterprises, Inc.
Disputes & Debates: Rapid online correspondence
NOTE: All authors' disclosures must be entered and current in our database before comments can be posted. Enter and update disclosures at http://submit.neurology.org. Exception: replies to comments concerning an article you originally authored do not require updated disclosures.
- Stay timely. Submit only on articles published within 6 months of issue date.
- Do not be redundant. Read any comments already posted on the article prior to submission.
- 200 words maximum.
- 5 references maximum. Reference 1 must be the article on which you are commenting.
- 5 authors maximum. Exception: replies can include all original authors of the article.
- Submitted comments are subject to editing and editor review prior to posting.