Seizures in a Patient With New Hemodialysis

Case Study

A rapid response event was initiated for a patient in the dialysis unit. On arrival of first responders, the patient was non-arousable and having generalized shaking of extremities. Per the dialysis nurse, the patient started having seizure-like activity 3 min prior. He was also reporting nausea and headache earlier. On chart review, the patient was a 58-year-old male with a past medical history of diabetes mellitus-2, hypertension, and recently diagnosed end-stage renal disease. The patient was admitted 2 h prior for altered mental status and was found to be uremic, for which he was receiving urgent hemodialysis. This was his first hemodialysis session. Two hours into the dialysis session, he had sudden onset of seizure-like activity. Due to this, his dialysis session was stopped, and a rapid response was called.

Vital Signs

Temperature: 100.7 °F, axillary
Blood Pressure: 139/96 mmHg
Heart Rate: 96 beats per min (bpm), sinus rhythm on telemetry
Respiratory Rate: 17 breaths per min
Pulse Oximetry: 96% oxygen saturation on room air

Focused Physical Examination

A quick exam revealed a middle-aged male lying in bed with generalized tonic-clonic movements. He was unresponsive to stimuli and did not withdraw from a painful stimulus. An arteriovenous fistula was visible in the antecubital fossa of his left arm. His cardiac and respiratory exams were not performed because of active seizures.

Interventions

After securing the airway by placing an oral airway, the patient was turned to his lateral side (to prevent aspiration), and pulse oximetry was placed to monitor oxygen saturation. Capillary blood glucose was checked to rule out hypoglycemia, which revealed a glucose level of 108 mg/dL. A basal metabolic panel (BMP) was drawn to rule out electrolyte abnormalities. The patient was given a dose of lorazepam (4 mg IV), which broke his seizure episode. Due to seizure-like activity lasting almost 5 min, in the setting of uremia and first-time hemodialysis, with no prior history of seizures, the most likely diagnosis was dialysis disequilibrium syndrome (DDS). Nephrology attending was present at the bedside, and further dialysis was stopped. The patient was transferred to the intensive care unit for closer monitoring.

Final Diagnosis

Seizures in the setting of dialysis disequilibrium syndrome (DDS).

Dialysis Disequilibrium Syndrome

N

eurologic symptoms ranging from confusion to coma, which are mostly seen in patients on first-time hemodialysis or non-adherence to HD.

Risk factors for DDS included BUN >175, older age, previous head trauma, seizure disorder, stroke, conditions that increase blood-brain barrier permeability, and conditions associated with cerebral edema. While poorly understood, it is thought to be caused by the presence of increased urea which quickly declines from the bloodstream during hemodialysis resulting in an osmotic shift toward the urea that has built up into tissues, which results in cerebral edema.

Patients can present with a wide variety of symptomatology. Mild symptoms include nausea, headache, confusion, and disorientation. Severe symptoms include seizures, coma, and death. DDS remains a clinical diagnosis based on symptoms and typical history. While most of the mild symptoms usually self-resolve, for severe symptoms, the diagnosis will be one of exclusion and will require workup of alternate causes of altered mental status. Various causes of seizures and altered mental status in a patient on hemodialysis are discussed in Table 47.1 .

Table 47.1

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