Dialysis Disequilibrium Syndrome With Cerebral Edema in an Adult Patient Following the Initial Dialysis Session

Abstract

Dialysis is a common treatment for removing toxins, electrolytes, and excess fluids due to impaired kidney function. A rare but life-threatening complication that can arise is dialysis disequilibrium syndrome (DDS) with cerebral edema. DDS is characterized by a range of neurological symptoms that may occur following dialysis. Its incidence is not well-established because it often presents with nonspecific symptoms, making diagnosis challenging. Here, we present a case of a 64-year-old female with a history of hypertension and chronic kidney disease stage 5, who sought evaluation for nausea and vomiting with coffee-ground emesis that began three weeks prior. Despite an initial blood transfusion stabilizing her hemoglobin with no further hematemesis, she developed DDS with cerebral edema after her first dialysis session. The condition was managed with 3% hypertonic saline, which quickly resolved both her cerebral edema and neurological symptoms. She tolerated subsequent dialysis sessions without complications and was discharged with a follow-up arranged with nephrology and an outpatient dialysis chair. This case report reviews the clinical features, risk factors, pathophysiology, management, and treatment goals for DDS. In patients commencing dialysis, particular attention should be given to preventing DDS, especially in those with elevated blood urea nitrogen levels above 100 mg/dL. Prompt recognition and treatment are crucial to balance the osmotic gradient and prevent severe outcomes, such as cerebral edema and death.

Keywords: chronic kidney disease (ckd); dialysis; dialysis disequilibrium syndrome; diffuse cerebral edema; reverse urea effect.

Figure 1. Abdominal ultrasound

The abdominal ultrasound revealed a hyperechoic right kidney.

Figure 2. Retroperitoneal kidney ultrasound

The retroperitoneal kidney ultrasound showed no signs of hydronephrosis.

Figure 3. CT scan of the brain

CT of the brain shows diffuse loss of CSF spaces along the cerebral convexities and blurring of the gray-white matter junction, indicating cerebral edema.