Dialysis disequilibrium syndrome - Revision history

Elcatracho: /* Background */

2021-01-19T00:15:40Z

Background

← Older revision		Revision as of 00:15, 19 January 2021
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	*Abbreviation: DDS		*Abbreviation: DDS
	*A rare clinical syndrome occurring at end of dialysis or the beginning of continuous renal replacement therapy		*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		**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		**Tends to occur in patients who are initially started on dialysis, particularly with high initial BUN

ClaireLewis at 02:09, 3 October 2019

2019-10-03T02:09:08Z

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	*Nonketotic hyperosmolar [[coma]]		*Nonketotic hyperosmolar [[coma]]
	*[[Acute cerebrovascular event]]		*[[Acute cerebrovascular event]]
	*Dialysis dementia		*Dialysis [[dementia]]
	*Excessive ultrafiltration and seizure		*Excessive ultrafiltration and [[seizure]]
	*Metabolic disturbances		*Metabolic disturbances
	**[[Hypoglycemia]]		**[[Hypoglycemia]]
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	*[[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>		*[[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]]		*[[Hypocalcemia]]
	*Intracranial Bleed		*[[ICH\|Intracranial Bleed]]
	*[[Hypertensive Emergency]]		*[[Hypertensive Emergency]]
	*[[Stroke]]		*[[Stroke]]
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	*CBC		*CBC
	*Chem-10		*Chem-10
	*~~Liver Panel~~		*[[LFTs]]
	*CT Brain		*[[head CT\|CT Brain]]

	===Diagnosis===		===Diagnosis===

DrKarb: /* Background */

2018-02-21T16:18:31Z

Background

← Older revision		Revision as of 16:18, 21 February 2018
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	**Occurs most commonly during initial hemodialysis or during hypercatabolic states		**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		**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		**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>		*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>

Rossdonaldson1: /* Management */

2017-04-27T11:19:25Z

Management

← Older revision		Revision as of 11:19, 27 April 2017
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	==Management==		==Management==
			===Mild===
	*Symptomatic management for mild symptoms (nausea, headache, restlessness)		*Symptomatic management for mild symptoms (nausea, headache, restlessness)
	**Symptoms are self-limiting and typically resolve within several hours		**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>		*For severe symptoms, the mainstay of treatment is ICP reduction<ref name="DDS"></ref>
	**Can give [[mannitol]] or [[hypertonic saline]] IV		**Can give [[mannitol]] or [[hypertonic saline]] IV

Rossdonaldson1 at 10:18, 27 April 2017

2017-04-27T10:18:35Z

← Older revision		Revision as of 10:18, 27 April 2017
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	==Evaluation==		==Evaluation==
	*Clinical Diagonosis		===Workup===
	*Bedside Glucose		*Bedside Glucose
	*CBC		*CBC
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	*CT Brain		*CT Brain

	==~~Workup~~==		===Diagnosis===
	*~~Diagnosis~~ suggested by development of neurologic symptoms associated with dialysis, ~~however DDS is a diagnosis of exclusion~~ (rule out [[SDH]], [[CVA]]).		*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==
			*Symptomatic management for mild symptoms (nausea, headache, restlessness)
			**Symptoms are self-limiting and typically resolve within several hours
			*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

	~~==Management==~~		==Prevention==
	===Prevention===
	*Response to treatment is typically poor, so preventive measures are important<ref name="DDS"></ref>		*Response to treatment is typically poor, so preventive measures are important<ref name="DDS"></ref>
	*Add an osmotic agent to mitigate the osmotic gradient		*Add an osmotic agent to mitigate the osmotic gradient
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	**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>		**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>		*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>

	~~===Treatment===~~
	*The mainstay of treatment is ICP reduction<ref name="DDS"></ref>
	**Can give [[mannitol]] or [[hypertonic saline]] IV
	**Can hyperventilate patient
	*Symptomatic management for mild symptoms (nausea, headache, restlessness)
	*Symptoms are self-limiting and typically resolve within several hours


	~~==Management==~~
	*Supportive in most cases
	*Limit the rate of urea removal during first few session of dialysis to prevent dysequilibrium syndrome
	*For severe symptoms such as seizure, consider stopping dialysis

	~~==Disposition==~~
	*Most cases can be discharged with followup

	==See Also==		==See Also==

Rossdonaldson1: /* Background */

2017-04-27T10:06:42Z

Background

← Older revision		Revision as of 10:06, 27 April 2017
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	==Background==		==Background==
			*Abbreviation: DDS
	*A rare clinical syndrome occurring at end of dialysis or the beginning of continuous renal replacement therapy		*A rare clinical syndrome occurring at end of dialysis or the beginning of continuous renal replacement therapy
	**Occurs most commonly during initial hemodialysis or during hypercatabolic states		**Occurs most commonly during initial hemodialysis or during hypercatabolic states

Rossdonaldson1: /* Differential Diagnosis */

2017-04-27T10:06:17Z

Differential Diagnosis

← Older revision		Revision as of 10:06, 27 April 2017
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	*[[Meningitis]]		*[[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>		*[[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>
	~~{{Dialysis complications DDX}}~~


	~~===Other===~~
	*[[Hypoglycemia]]
	*[[Hyponatremia]]
	*[[Hypocalcemia]]		*[[Hypocalcemia]]
	*[[Uremia]]
	*Intracranial Bleed		*Intracranial Bleed
	*[[Hypertensive Emergency]]		*[[Hypertensive Emergency]]
	*[[Stroke]]		*[[Stroke]]
	*Supratheurapeutic Medication Effects		*Supratheurapeutic Medication Effects
	*PRES		*[[PRES]]

			{{Dialysis complications DDX}}

	==Evaluation==		==Evaluation==

Rossdonaldson1 at 10:03, 27 April 2017

2017-04-27T10:03:40Z

← Older revision		Revision as of 10:03, 27 April 2017
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	==Background==		==Background==
	*~~Dialysis Disequilibrium Syndrome (DDS) is a~~ rare clinical syndrome occurring at end of dialysis or the beginning of continuous renal replacement therapy		*A rare clinical syndrome occurring at end of dialysis or the beginning of continuous renal replacement therapy
	**Occurs most commonly during initial hemodialysis or during hypercatabolic states		**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
			**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>		*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>		**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		**Post-dialysis urea in CSF higher, setting up osmotic gradient for water into CNS
	**More uremic patients pre-dialysis at higher risk		**More uremic patients pre-dialysis at higher risk


	*Characterized by neurological symptoms that is thought to be secondary to cerebral edema affecting dialysis patients
	*Tends to occur in patients who are initially started on dialysis, particularly with high initial BUN
	*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

	==Clinical Features==		==Clinical Features==
	*Headache		''Signs and symptoms develop during or after dialysis or during renal replacement therapy, usually self limited but can occasionally progress''
			*[[Headache]]
	*Disorientation		*Disorientation
	*Nausea and vomiting		*[[Nausea and vomiting]]
	*Restlessness		*Restlessness
	*~~Can progress to seizure, coma & 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>~~		*[[Visual disturbances]]



	*Signs and symptoms develop during or after dialysis or during renal replacement therapy, usually self limited but can occasionally progress
	*Headache
	*Nausea
	*Visual disturbances
	*Asterixis		*Asterixis
	*Altered mental staus
	*Seizures
	*Coma
	*Muscle Cramps		*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==		==Differential Diagnosis==

Rossdonaldson1 at 10:01, 27 April 2017

2017-04-27T10:01:09Z

@@ Line 6: / Line 6: @@
 **Post-dialysis urea in CSF higher, setting up osmotic gradient for water into CNS
 **More uremic patients pre-dialysis at higher risk
 ==Clinical Features==
@@ Line 13: / Line 18: @@
 *Restlessness
 *Can progress to seizure, coma & 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==
@@ Line 27: / Line 44: @@
 *[[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>
 {{Dialysis complications DDX}}
 ==Workup==
 *Diagnosis suggested by development of neurologic symptoms associated with dialysis, however DDS is a diagnosis of exclusion (rule out [[SDH]], [[CVA]]).
 ==Management==
@@ Line 46: / Line 84: @@
 *Symptoms are self-limiting and typically resolve within several hours
 ==Management==
@@ Line 96: / Line 92: @@
 ==Disposition==
 *Most cases can be discharged with followup
 ==References==
 <references/>
 [[Category:Renal]]
 [[Category:Neurology]]

Rossdonaldson1 at 09:58, 27 April 2017

2017-04-27T09:58:43Z

← Older revision		Revision as of 09:58, 27 April 2017
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	[[Category:Renal]]		[[Category:Renal]]

			==Background==
			*Characterized by neurological symptoms that is thought to be secondary to cerebral edema affecting dialysis patients
			*Tends to occur in patients who are initially started on dialysis, particularly with high initial BUN
			*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

			==Clinical Features==
			*Signs and symptoms develop during or after dialysis or during renal replacement therapy, usually self limited but can occasionally progress
			*Headache
			*Nausea
			*Visual disturbances
			*Asterixis
			*Altered mental staus
			*Seizures
			*Coma
			*Muscle Cramps

			==Differential Diagonsis==
			*[[Hypoglycemia]]
			*[[Hyponatremia]]
			*[[Hypocalcemia]]
			*[[Uremia]]
			*Intracranial Bleed
			*[[Hypertensive Emergency]]
			*[[Stroke]]
			*Supratheurapeutic Medication Effects
			*PRES

			==Evaluation==
			*Clinical Diagonosis
			*Bedside Glucose
			*CBC
			*Chem-10
			*Liver Panel
			*CT Brain

			==Management==
			*Supportive in most cases
			*Limit the rate of urea removal during first few session of dialysis to prevent dysequilibrium syndrome
			*For severe symptoms such as seizure, consider stopping dialysis

			==Disposition==
			*Most cases can be discharged with followup

			==References==
			<references/>
			*Mailloux L, et al. Dialysis Dysequilibrium Syndrome. UpToDate. Waltham, Mass.: UpToDate; 2017. www.uptodate.com. Accessed April 13, 2017.

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