Dialysis Disequilibrium Syndrome: brain death following hemodialysis for metabolic acidosis and acute renal failure--a case report.
BACKGROUND
Dialysis disequilibrium syndrome (DDS) is the clinical phenomenon of acute neurologic symptoms attributed to cerebral edema that occurs during or following intermittent hemodialysis (HD). We describe a case of DDS-induced cerebral edema that resulted in irreversible brain injury and death following acute HD and review the relevant literature of the association of DDS and HD.


METHODS
A 22-year-old male with obstructive uropathy presented to hospital with severe sepsis syndrome secondary to pneumonia. Laboratory investigations included a pH of 6.95, PaCO2 10 mmHg, HCO3 2 mmol/L, serum sodium 132 mmol/L, serum osmolality 330 mosmol/kg, and urea 130 mg/dL (46.7 mmol/L). Diagnostic imaging demonstrated multifocal pneumonia, bilateral hydronephrosis and bladder wall thickening. During HD the patient became progressively obtunded. Repeat laboratory investigations showed pH 7.36, HCO3 19 mmol/L, potassium 1.8 mmol/L, and urea 38.4 mg/dL (13.7 mmol/L) (urea-reduction-ratio 71%). Following HD, spontaneous movements were absent with no pupillary or brainstem reflexes. Head CT-scan showed diffuse cerebral edema with effacement of basal cisterns and generalized loss of gray-white differentiation. Brain death was declared.


CONCLUSIONS
Death is a rare consequence of DDS in adults following HD. Several features may have predisposed this patient to DDS including: central nervous system adaptations from chronic kidney disease with efficient serum urea removal and correction of serum hyperosmolality; severe cerebral intracellular acidosis; relative hypercapnea; and post-HD hemodynamic instability with compounded cerebral ischemia.
Bagshaw
Sean M
SM
Department of Critical Care Medicine, Calgary Health Region, University of Calgary, Calgary, Alberta, Canada. smbagsha@ucalgary.ca
Peets
Adam D
AD
Hameed
Morad
M
Boiteau
Paul J E
PJ
Laupland
Kevin B
KB
Doig
Christopher J
CJ
D000138:Acidosis / Q000209:etiology / Q000628:therapy*; D058186:Acute Kidney Injury / Q000209:etiology / Q000628:therapy*; D000328:Adult; D016470:Bacteremia / Q000150:complications; D001926:Brain Death; D001929:Brain Edema / Q000209:etiology* / Q000503:physiopathology; D004927:Escherichia coli Infections / Q000150:complications; D045604:Extracellular Fluid / Q000737:chemistry; D006801:Humans; D006869:Hydronephrosis / Q000150:complications*; D007424:Intracellular Fluid / Q000737:chemistry; D008297:Male; D008954:Models, Biological; D009102:Multiple Organ Failure / Q000209:etiology; D009994:Osmolar Concentration; D011014:Pneumonia / Q000150:complications; D011776:Pyuria / Q000150:complications; D006435:Renal Dialysis / Q000009:adverse effects*; D013203:Staphylococcal Infections / Q000150:complications; D013290:Streptococcal Infections / Q000150:complications; D013292:Streptococcus agalactiae; D015819:Substance Abuse, Intravenous / Q000150:complications; D013577:Syndrome; D018746:Systemic Inflammatory Response Syndrome / Q000150:complications*