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Raina R, Davenport A, Warady B, Vasistha P, Sethi SK, Chakraborty R, Khooblall P, Agarwal N, Vij M, Schaefer F, Malhotra K, Misra M. Dialysis disequilibrium syndrome (DDS) in pediatric patients on dialysis: systematic review and clinical practice recommendations. Pediatr Nephrol 2022; 37:263-274. [PMID: 34609583 DOI: 10.1007/s00467-021-05242-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/12/2021] [Accepted: 07/13/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVES Dialysis disequilibrium syndrome (DDS) is a rare neurological complication, most commonly affecting patients undergoing new initiation of hemodialysis (HD), but can also be seen in patients receiving chronic dialysis who miss regular treatments, patients having acute kidney injury (AKI), and in those treated with continuous kidney replacement therapy (CKRT) or peritoneal dialysis (PD). Although the pathogenesis is not well understood, DDS is likely a result of multiple physiological abnormalities. In this systematic review, we provide a synopsis of the data available on DDS that allow for a clear picture of its pathogenesis, preventive measures, and focus on effective management strategies. METHODS We conducted a literature search on PubMed/Medline and Embase from January 1960 to January 2021. Studies were included if the patient developed DDS irrespective of age and gender. A summary table was used to summarize the data from individual studies and included study type, population group, age group, sample size, patient characteristics, blood and dialysate flow rate, and overall outcome. A descriptive analysis calculating the frequency of population size, symptoms, and various treatments was performed using R software version 3.1.0. RESULTS A total of 49 studies (321 samples) were identified and analyzed. Out of the included 49 studies, a total of 48 studies reported the presence of DSS among patients (1 study reported based on number of dialysis and therefore was not considered for analysis). Among these 48 studies, 74.3% (226/304) patients were reported to have DSS. The most common symptoms were nausea (25.2%), headache (24.8%), vomiting (23.9%), muscle cramps (18.1%), affected level of consciousness (8.8%), confusion (4.4%), and seizure (4.9%) among the 226 DDS patients. Furthermore, 12 studies decided to switch from HD to alternative dialysis modalities including continuous venovenous hemofiltration/hemodiafiltration (CVVH/CVVHDF) or PD which reported no DDS symptoms. CONCLUSION Early recognition and timely prevention are crucial for DDS patients. We have provided comprehensive clinical practice points for pediatric, adolescent, and young adult populations. However, it is essential to recognize that DDS was reported more frequently in the early dialysis era, as there was a lack of advanced dialysis technology and limited resources.
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Affiliation(s)
- Rupesh Raina
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA. .,Department of Nephrology, Akron Children's Hospital, Akron, OH, USA. .,School of Medicine Cleveland Ohio, Case Western Reserve University, Cleveland, OH, USA.
| | - Andrew Davenport
- University College London Centre for Nephrology, Division of Medicine, University College London Medical School, Royal Free Hospital, London, UK
| | - Bradley Warady
- Division of Nephrology, University of Missouri-Kansas City School of Medicine, Children's Mercy, Kansas City, MO, USA
| | - Prabhav Vasistha
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Sidharth Kumar Sethi
- Pediatric Nephrology & Pediatric Kidney Transplantation, Kidney and Urology Institute, MedantaThe Medicity Hospital, Gurgaon, India
| | - Ronith Chakraborty
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA.,Department of Nephrology, Akron Children's Hospital, Akron, OH, USA
| | - Prajit Khooblall
- Department of Internal Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Nirav Agarwal
- Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Manan Vij
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Franz Schaefer
- Department of Pediatric Nephrology, University Children's Hospital Heidelberg, Heidelberg, Germany
| | - Kunal Malhotra
- Division of Nephrology, University of Missouri School of Medicine, Columbia, MO, USA
| | - Madhukar Misra
- Division of Nephrology, University of Missouri School of Medicine, Columbia, MO, USA
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A case report with a literature review: cerebral meningioma diagnosed by convulsion and consciousness disorder on initiating hemodialysis. RENAL REPLACEMENT THERAPY 2020. [DOI: 10.1186/s41100-020-0257-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Neurological symptoms sometimes occur in hemodialysis patients, with causes including cerebral infarction, cerebral hemorrhaging, meningitis, and encephalitis. Dialysis disequilibrium syndrome (DDS) is widely known as a complication of hemodialysis and is typically encountered in severe uremic patients newly started on hemodialysis. The pathogenesis of DDS is thought to be brain edema that manifests as neurological symptoms, including headache, nausea, confusion, seizures, and coma. However, the relationship between brain tumors and neurological manifestations during hemodialysis is poorly understood.
Case presentation
The patient was a 55-year-old man with severe renal dysfunction and uremia symptoms. Blood chemistry showed severe azotemia and acidosis. The patient was placed on short-duration hemodialysis (2 h) with a relatively small surface area, low blood flow (100 mL/min), and intradialytic glycerol infusion to prevent DDS. However, after his first hemodialysis treatment, he complained of disturbed consciousness. We diagnosed his neurological condition as DDS and observed the progress carefully. The next morning, his symptoms had completely resolved, so the patient was started on his second hemodialysis session with the same conditions. However, 2 h after starting the second hemodialysis session, he suffered convulsions accompanied by impaired consciousness. Brain computed tomography (CT) revealed a convexity meningioma and cerebral edema with a midline shift. Before starting the hemodialysis, he had shown no history of seizures, morning headache, or other neurological symptoms. In this case, meningioma was diagnosed based on an increase in the intracranial pressure which occurred after the initiation of hemodialysis.
Conclusion
We report this suggestive case to prompt physicians to consider the potential effect of hemodialysis introduction on the brain pressure.
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O'Sullivan P, Sajjad J, Abrar S, Marks C. Headache during haemodialysis in a patient with shunt: a cause for concern? BMJ Case Rep 2015; 2015:bcr-2014-208887. [PMID: 25819823 DOI: 10.1136/bcr-2014-208887] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
A 20-year-old woman with a functioning ventriculoperitoneal (VP) shunt consistently reported unbearable vertex headaches and nausea during the last hour of her haemodialysis (HD) sessions. After one particularly severe episode, which was associated with vomiting, restlessness and blurred vision, her team suspected that she was developing dialysis disequilibrium syndrome. She improved fully on cessation of HD, requiring simple analgaesia only, and continued dialysis three times per week. Several more distressing episodes of nausea and headaches compelled us to give intravenous mannitol during HD, resulting in temporary improvement. Subsequently, shorter and more frequent dialysis sessions along with intravenous mannitol resulted in satisfactory clinical response.
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Affiliation(s)
| | - Jahangir Sajjad
- Department of Neurosurgery, Cork University Hospital, Cork, Ireland
| | - Sahibzada Abrar
- Department of Neurosurgery, Cork University Hospital, Cork, Ireland
| | - Charles Marks
- Department of Neurosurgery, Cork University Hospital, Cork, Ireland
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Puma N, Biassoni V, Gandola L, Pecori E, Ardissino G, Paglialonga F, Indini A, Antonelli M, Massimino M. Medulloblastoma treatment in a child on dialysis. CNS Oncol 2014; 3:31-6. [DOI: 10.2217/cns.13.62] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Managing patients who suffer from both cancer and end-stage renal disease is challenging because there is a paucity of data, especially for children. There are no published reports of adjuvant chemotherapy for medulloblastoma being used in children on dialysis. In this article we describe the case of an Italian 5-year-old boy on hemodialysis for chronic renal failure who presented with a desmoplastic medulloblastoma with extensive nodularity and nuclear β-catenin expression. The patient was treated with craniospinal irradiation after complete surgical resection, followed by six cycles of cyclophosphamide and vincristine. Vincristine was administered at the usual dosage for children with normal kidney function, cyclophosphamide was delivered after dialysis and over the course of the following day, starting with 50% of the commonly used dosage. This is the first case report of chemotherapy given during hemodialysis in a child with medulloblastoma. This treatment proved easy to administer despite the child’s kidney disease and it maintained disease remission with no additional toxicity.
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Affiliation(s)
- Nadia Puma
- Pediatrics Unit, Fondazione IRCCS, Istituto Nazionale Tumori, Via Giacomo Venezian 1, 20133 Milan, Italy
| | - Veronica Biassoni
- Pediatrics Unit, Fondazione IRCCS, Istituto Nazionale Tumori, Via Giacomo Venezian 1, 20133 Milan, Italy
| | - Lorenza Gandola
- Pediatric Radiotherapy Unit, Fondazione IRCCS, Istituto Nazionale Tumori, Milan, Italy
| | - Emilia Pecori
- Pediatric Radiotherapy Unit, Fondazione IRCCS, Istituto Nazionale Tumori, Milan, Italy
| | - Gianluigi Ardissino
- Pediatric Nephrology & Dialysis Unit, Fondazione IRCCS, Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabio Paglialonga
- Pediatric Nephrology & Dialysis Unit, Fondazione IRCCS, Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alice Indini
- Pediatrics Unit, Fondazione IRCCS, Istituto Nazionale Tumori, Via Giacomo Venezian 1, 20133 Milan, Italy
| | - Manila Antonelli
- Department of Radiological, Pathological & Oncological Sciences, Sapienza University, Rome, Italy
| | - Maura Massimino
- Pediatrics Unit, Fondazione IRCCS, Istituto Nazionale Tumori, Via Giacomo Venezian 1, 20133 Milan, Italy
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Tsuchida Y, Takata T, Ikarashi T, Iino N, Kazama JJ, Narita I. Dialysis disequilibrium syndrome induced by neoplastic meningitis in a patient receiving maintenance hemodialysis. BMC Nephrol 2013; 14:255. [PMID: 24238645 PMCID: PMC3840624 DOI: 10.1186/1471-2369-14-255] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Accepted: 11/14/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Dialysis disequilibrium syndrome is characterized by neurological symptoms resulting from cerebral edema, which occurs as a consequence of hemodialysis. Dialysis disequilibrium syndrome most often occurs in patients who have just started hemodialysis, during hemodialysis, or soon after hemodialysis; although it may also occur in patients who are under maintenance hemodialysis with pre-existing neurological disease. CASE PRESENTATION A 70-year-old woman, who had been receiving maintenance hemodialysis for one year, was diagnosed with ovarian cancer by ascites cytological examination. Two years later, she reported severe headache and nausea during hemodialysis and was diagnosed with dialysis disequilibrium syndrome. Although brain images revealed mild hydrocephalus without any mass lesions, poorly differentiated adenocarcinoma cells were detected in her cerebrospinal fluid. These findings indicated that DDS was induced by neoplastic meningitis due to ovarian cancer metastasis. CONCLUSION Neoplastic meningitis should be considered and excluded in hemodialysis patients with dialysis disequilibrium syndrome and malignancy by cytological examination of the cerebrospinal fluid even if cerebral imaging shows no obvious lesions. This is the first reported case of dialysis disequilibrium syndrome induced by neoplastic meningitis in a patient receiving maintenance hemodialysis.
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Affiliation(s)
| | | | | | - Noriaki Iino
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-dori, Niigata, Niigata 951-8510, Japan.
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