Bored at Dialysis - Review

It’s a busy Monday at Downstate when EMS rolls in a 66 year old woman from her dialysis center. They tell you she was towards the end of her HD session when she became less responsive and vomited. Now she won’t answer your questions or follow commands but keeps saying “Oy, my head! Oy, I’m dizzy!” The dialysis center tells you this is her second dialysis session.

Vital signs: 140/90, 96, 22, 98% on RA, T 98.6. Notable on exam: AOx1, generalized weakness, sensation intact. And then she vomits…

What is your differential in this case?

CVA, subdural hematoma, meningitis, electrolyte abnormalities (hyponatremia, hypoglycemia), uremia, volume depletion, and… dialysis disequilibrium syndrome!

Dialysis disequilibrium syndrome occurs from cerebral edema, caused by osmotic shifts from significant urea removal in the blood, causing fluid to shift into brain cells. It may range from mild nausea and vomiting, to seizure, coma and death. Serious cases are rare, most often seen in new dialysis patients after a large removal of urea and other solutes. Treatment? First, rule out all other bad causes of altered mental status (like bleeds). Otherwise, symptomatic care and observation–symptoms should resolve within a few hours. For serious cases (seizures and comas), IV mannitol may be used to reduce ICP, however this is controversial.

What are some other common complications during dialysis?

Often patients can become hypotensive and “dizzy” during dialysis. The ddx for hypotension: excessive ultrafiltration causing hypovolemia, blood loss (maybe a leak in the machine), air embolism, or exacerbation of cardiac disease/ischemia/arrhythmias.

References

Uptodate.com – “Dialysis Disequilibrium Syndrome.” Lionel Mailloux

Tintinalli’s 7th Ed. Chapter 93. M. Spektor and R. Sinert

Cartoon: Peter Quaife, The Lighter side of dialysis

Special thanks to Dr. Willis!