CHSU Discovery

Abstract:

Introduction: Dialysis disequilibrium syndrome is a rare neurologic constellation of symptoms that shortly follow starting dialysis, especially if the patient is dialysis-naive. It occurs due to the rapid correction of electrolytes and removal of urea, which alters the osmotic gradient, leading to cerebral edema and neurologic manifestations. Our case report describes a patient who required first-time dialysis due to acute renal failure. He subsequently developed fixed, dilated pupils and absent gag reflex within 2 hours of initiating dialysis. He was treated supportively in the ICU with IV Mannitol and was able to make a full neurologic recovery.

Discussion and limitation: Due to how rarely Dialysis Disequilibrium (DDS) Syndrome is reported, it is not well-discussed in the literature and fewer reports of successful treatment of severe DDS exist. In our patient with acute renal failure, he required emergent dialysis in the hospital. However, he developed DDS, so dialysis had to be stopped. We treated his suspected DDS with IV Mannitol, since there have been a few reported cases of this successfully reversing DDS. Despite an initially worrisome neurologic exam, with an absent gag reflex and fixed, dilated pupils, our patient was able to make a full neurologic recovery. It is theorized that Mannitol acts as an osmolyte in the plasma, which can stop water from going through the aquaporins into the astrocytes as a result of the rapid removal of urea. This is a temporizing measure, which allows the body time to shift urea out of the astrocytes. Nevertheless, it is difficult to say with certainty whether the IV Mannitol was responsible for his full neurologic recovery or whether the cessation of SLED was sufficient. Since DDS is a spectrum of neurologic symptoms, further investigation of the role of IV Mannitol in both mild and severe cases of DDS will need to be done to determine its utility and role.