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Dialysis disequilibrium syndrome (DDS) in pediatric patients on dialysis: systematic review and clinical practice recommendations

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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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Data availability

All data used for analysis is available online.

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Acknowledgements

We would like to thank Dr. Abhishek Tibrewal for his aid with statistical analysis.

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Authors and Affiliations

  1. Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA

    Rupesh Raina, Prabhav Vasistha, Ronith Chakraborty & Manan Vij

  2. Department of Nephrology, Akron Children’s Hospital, Akron, OH, USA

    Rupesh Raina & Ronith Chakraborty

  3. School of Medicine Cleveland Ohio, Case Western Reserve University, Cleveland, OH, USA

    Rupesh Raina

  4. University College London Centre for Nephrology, Division of Medicine, University College London Medical School, Royal Free Hospital, London, UK

    Andrew Davenport

  5. Division of Nephrology, University of Missouri-Kansas City School of Medicine, Children’s Mercy, Kansas City, MO, USA

    Bradley Warady

  6. Pediatric Nephrology & Pediatric Kidney Transplantation, Kidney and Urology Institute, MedantaThe Medicity Hospital, Gurgaon, India

    Sidharth Kumar Sethi

  7. Department of Internal Medicine, Northeast Ohio Medical University, Rootstown, OH, USA

    Prajit Khooblall

  8. Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA

    Nirav Agarwal

  9. Department of Pediatric Nephrology, University Children’s Hospital Heidelberg, Heidelberg, Germany

    Franz Schaefer

  10. Division of Nephrology, University of Missouri School of Medicine, Columbia, MO, USA

    Kunal Malhotra & Madhukar Misra

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  1. Rupesh Raina
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Raina, R., Davenport, A., Warady, B. et al. Dialysis disequilibrium syndrome (DDS) in pediatric patients on dialysis: systematic review and clinical practice recommendations. Pediatr Nephrol 37, 263–274 (2022). https://doi.org/10.1007/s00467-021-05242-1

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