DIALYSIS DISEQUILIBRIUM SYNDROME: A RARE COMPLICATION OF HEMODIALYSIS

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Dialysis disequilibrium syndrome (DDS) is a rare but potentially fatal complication of hemodialysis. Incidence DDS has not been clearly defined only 37 cases have reported in literature. Manifestations vary severity from mild to severe. Severe manifestations (altered mental status, seizures, and coma) are rarely seen clinical practice. The pathogenesis involves the development cerebral edema, however, exact mechanism poorly understood. proposed for edema rapid decline extracellular urea osmolality leading osmosis into intracellular space. CASE PRESENTATION: 57-year-old female with chronic kidney disease stage V right brachiocephalic arteriovenous fistula delayed hemodialysis (HD) initiation against her nephrologist's recommendation, presents hospital after syncopal event. Initial workup revealed serum BUN >110 mg/dL Creatinine 15 severe metabolic acidosis hyperkalemia. She was temporarily stabilized insulin, sodium bicarbonate, calcium chloride sent urgent HD. Prior HD, patient awake, oriented, without any neurological deficits. Approximately 1 hour finishing became lethargic unable follow commands signs focal An brain Computed-Tomography (CT) scan showed sulcal effacement poor gray-white matter differentiation frontal parietal lobes, suggestive diffuse edema. administered 5 mL 23% hypertonic saline solution due concern DDS. A up Magnetic Resonance Imaging demonstrated bilateral symmetric acute leukoencephalopathy. following day, patient's status returned baseline repeat CT improvement DISCUSSION: Changes shortly HD should raise suspicion order prevent complications such as herniation death. can aid diagnosis delay treatment. Current recommendations restrict clearance 40% initial levels offer shorter dialysis sessions lower dialysate blood flow rates, or hemofiltration high risk patients. This be difficult apply population higher prescription needed correct emergent indications like hyperkalemia acidemia. Treatment directed at decreasing intracranial pressure. CONCLUSIONS: In our case, used. fatal, prompt recognition symptoms reversal therapy lead complete recovery. Emphasis on education about will result early timely intervention. REFERENCE #1: Bhandari B, Komanduri S. Disequilibrium Syndrome. StatPearls Publishing; 2020. Accessed February 6, 2021. http://www.ncbi.nlm.nih.gov/pubmed/32644444 #2: Arieff AI. syndrome: concepts prevention. Kidney Int. 1994;45(3):629-635. doi:10.1038/ki.1994.84 #3: Adapa S, Konala V, Aeddula N, et al. (June 25, 2019) Syndrome: Rare Serious Complication Hemodialysis Effective Management. Cureus 11(6): e5000. doi:10.7759/cureus.5000 DISCLOSURES: No relevant relationships by Yoosif Abdalla, source=Web Response Sheyla Gonzalez, Javas Gupta, Jose Lopez, Richard Medina-Perez,