Disequilibrium Syndrome

This is a central nervous system disorder that is seen in patients on hemodialysis.

It is most commonly seen in patients who are new to HD. Other patients at greater risk include the elderly and pediatric patients as well as those with pre-existing CNS disease.

It is thought to be primarily related to cerebral edema.  The pathogenesis is unclear but is thought to be related to osmotic fluid shifts into the brain when cerebral urea levels remain high and plasma urea levels are rapidly dropped during HD.

Manifestations:

·         Headache

·         Nausea/vomiting

·         Disorientation

·         Restlessness

·         Blurred vision

·         Confusion

·         Seizures

·         Coma

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Treatment

The mainstay of treatment is in prevention during the HD session by adjusting flow rates and filtration amounts of the solutes.

If you think your patient has symptoms of this in presentation to the ED shortly after HD, you should alert the HD facility as they may need to change the settings of the patients dialysis. 

For patients who are critically ill with mental status changes, seizures etc, the goal is to raise the plasma osmolality with either hypertonic saline or mannitol.  Of course, other etiologies of change in mental status (hypoglycemia, intracranial bleed, ischemic stroke….to name a few) should be ruled out.

Linda Regan, MD FACEP

Program Director, Emergency Medicine Residency

Johns Hopkins Medical Institutions