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Dialysis Disequilibrium Syndrome: brain death following hemodialysis for metabolic acidosis and acute renal failure--a case report Bagshaw SM; Peets AD; Hameed M; Boiteau PJ; Laupland KB; Doig CJBMC Nephrol 2004[Aug]; 5 (ä): 9BACKGROUND: 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. CASE PRESENTATION: 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.|*Brain Death[MESH]|Acidosis/etiology/*therapy[MESH]|Acute Kidney Injury/etiology/*therapy[MESH]|Adult[MESH]|Bacteremia/complications[MESH]|Brain Edema/*etiology/physiopathology[MESH]|Escherichia coli Infections/complications[MESH]|Extracellular Fluid/chemistry[MESH]|Humans[MESH]|Hydronephrosis/*complications[MESH]|Intracellular Fluid/chemistry[MESH]|Male[MESH]|Models, Biological[MESH]|Multiple Organ Failure/etiology[MESH]|Osmolar Concentration[MESH]|Pneumonia/complications[MESH]|Pyuria/complications[MESH]|Renal Dialysis/*adverse effects[MESH]|Staphylococcal Infections/complications[MESH]|Streptococcal Infections/complications[MESH]|Streptococcus agalactiae[MESH]|Substance Abuse, Intravenous/complications[MESH]|Syndrome[MESH]|Systemic Inflammatory Response Syndrome/*complications[MESH] |
