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Kidney Week

Abstract: PO1192

The New Face of Dialysis Disequilibrium Syndrome: A Case Report, Systematic Literature Review, and Suggested Management Guidelines

Session Information

Category: Trainee Case Report

  • 701 Dialysis: Hemodialysis and Frequent Dialysis


  • Valliappan, Chidambaram Sunder, University of Virginia Medical Center, Charlottesville, Virginia, United States
  • Abdel-Rahman, Emaad M., University of Virginia Medical Center, Charlottesville, Virginia, United States

After implementation of standard protocols for new start dialysis, Dialysis Disequilibrium syndrome has become rare. Patients with preexisting neurologic damage, head trauma or stroke are more vulnerable to this complication. We present a case report of a patient who had a “near miss” safety event after starting intermittent hemodialysis in the setting of a traumatic brain injury (TBI). His deterioration on dialysis is not fully explained by the current leading theory on the pathogenesis of this syndrome (theory of “reverse urea effect”) implying that either a multifactorial etiology is implicated or that impaired cerebral autoregulation may play a more significant role than previously believed.

Case Description

A 70 year old male was hospitalized after being involved in a motor vehicle accident. He suffered multiple injuries including cardiac arrest from which he was revived, TBI and acute kidney injury (AKI) requiring initiation of hemodialysis using the new start protocol. Trends of intracranial pressure (ICP), cerebral perfusion pressure (CPP) and heart rate (HR) before, during and after intermittent hemodialysis showed clear worsening of these parameters after beginning dialysis with subsequent improvement after discontinuing dialysis (Figure).


This case points toward a change in the pattern of presentation of DDS, requiring new guidelines focusing on dialyzing vulnerable TBI patients. These guidelines include early initiation of dialysis, selection of CVVH as preferred modality given reduced dialysis dependency in AKI patients, adjusting dialysis settings to minimize urea clearance per unit time, utilizing ICP monitoring when available, using hypertonic saline to maintain serum sodium > 155 mmol/L and avoiding central lines on contralateral side to an internal jugular dialysis catheter to preserve cerebral venous return. The establishment of these guidelines may help reduce the risk of poor outcomes in this population.