Dialysis Disequilibrium Syndrome: A Severe Case with Neurologic Recovery - A Case Report.

INTRODUCTION: Dialysis disequilibrium syndrome is a serious complication occurring during hemodialysis initiation and after a break from hemodialysis, with a myriad of neurological symptoms. CASE PRESENTATION: We report a case of a 68-year-old woman with a history of hypertension, type 2 diabetes mellitus, and recently diagnosed end-stage kidney disease. She presented to the emergency room with disorientation and hypertensive urgency and had started hemodialysis 3 months prior but declined further treatment. Laboratory data revealed blood urea nitrogen of 151 mg/dL, creatinine of 18 mg/dL, bicarbonate level of 5 mEq/L, and potassium of 6.6 mEq/L. A temporary hemodialysis catheter was inserted, and dialysis was initiated with a blood flow rate of 300 mL/min and a dialysate flow rate of 600 mL/min, using an Optiflux 180NRe dialyzer (surface area 1.7 m2) for a duration of 3 h. The patient developed seizure activity after 2 h and 55 min, described as tonic-clonic seizure lasting 5 min. The urea reduction ratio was 57.6%, and the bicarbonate level increased from 5 to 16 mEq/L. She remained in a stuporous state, with no response to stimuli. She was transferred to the intensive care unit and received 20% mannitol 0.5 g/kg (40 g), followed by 3% hypertonic saline (30 mL bolus, then 50 mL/h infusion), with the aim of maintaining a serum sodium concentration between 145 and 155 mEq/L. Forty-eight hours later, she began to open her eyes to voice and consistently followed commands. CONCLUSION: Our patient's dialysis disequilibrium syndrome severity correlated with the urea reduction ratio and severe metabolic acidosis, highlighting the importance of achieving a low urea reduction ratio (<40%) and a targeted rise in bicarbonate levels, both of which are risk factors for dialysis disequilibrium syndrome. In addition, the use of 3% saline and mannitol is an important preventive and rescue strategy.