Case 5: Dialysis Disequilibrium Syndrome

 Lets slow things down! A patient at risk of dialysis disequilibrium syndrome

58 year old Caucasian female with history of systemic lupus erythematosus, hypertension, stroke, alcoholic cirrhosis and chronic kidney stage 5 is being initiated on hemodialysis for worsening uremic symptoms (worsening nausea, vomiting and headaches over the past couple of months) via a left arm brachiocephalic AV fistula. Her predialysis laboratory data is as follows: BUN- 140mg/dl; creatinine- 8.0; Serum K- 5.2meq/l; serum bicarbonate-12meq/l. Serum Na-135meq/l. Choose the best dialysis Rx for this patient for his first hemodialysis treatment.
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You have selected the best dialysis Rx for this patient
Qb = 200ml/min
Qd = 300ml/min
KoA = 600
Time = 2hours or 120min

Patient is at a risk of dialysis disequilibrium syndrome given this is her first dialysis treatment and she has a high BUN, chronic uremic symptoms, severe metabolic acidosis and a history of stroke and alcohol liver disease. The rapidity and magnitude of osmotic shifts associated with dialysis can lead to cerebral swelling and neurologic compromise. The goal here is to avoid abruptly high urea clearance with the first few hemodialysis treatments. Using a low blood flow, low dialysate flow, a small dialyzer with a low KoA, and short treatment duration will avoid high urea clearances. Qb and treatment time can be increased in a step wise manner over the next 3-4 daily treatments.

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