Kakajiwala Aadil, Weiss Scott, Lopez Sonya, Palmer Joann, Baluarte Hobart Jorge
Division of Nephrology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States.
Division of Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States.
J Pediatr Intensive Care. 2017 Jun;6(2):123-126. doi: 10.1055/s-0036-1584682. Epub 2016 Jun 20.
Dialysis disequilibrium syndrome (DDS) is characterized by acute neurological manifestations in patients undergoing first dialysis treatment. The mechanisms for the development of DDS include the reverse urea effect, transient intracranial acidosis, and idiogenic osmoles which can increase intracellular osmolality and promote water movement into the brain. We present a case of a 4-year-old child with chronic kidney disease who underwent a preemptive living unrelated donor kidney transplant. He had a 24 mEq/L drop in his sodium concentration, 92% reduction in blood urea nitrogen (BUN) concentration, and a 67 mOsm/kg drop in serum osmolality within 18 hours after transplant, with concurrent development of symptomatic and radiologic cerebral edema, similar to that described in DDS. Mental status rapidly returned to baseline after administration of 3% hypertonic saline. This case highlights the risk of cerebral edema in patients who have a high pretransplant BUN. It emphasizes the need for close monitoring of vital signs, mental status, and electrolytes in children undergoing renal transplant. Hypertonic solutions can be used to prevent or manage cerebral edema in these patients when serum osmolality decreases rapidly. Pretransplant dialysis is another consideration to proactively reduce serum hyperosmolality.
透析失衡综合征（DDS）的特征是首次接受透析治疗的患者出现急性神经学表现。DDS发生的机制包括尿素逆向效应、短暂性颅内酸中毒和内生性渗透分子，这些因素可增加细胞内渗透压并促使水分进入大脑。我们报告一例4岁慢性肾病患儿，其接受了非亲属活体供肾的先发制肾移植。移植后18小时内，他的血钠浓度下降了24 mEq/L，血尿素氮（BUN）浓度降低了92%，血清渗透压下降了67 mOsm/kg，同时出现了有症状的放射性脑水肿，与DDS中描述的情况相似。给予3%高渗盐水后，精神状态迅速恢复至基线水平。该病例突出了移植前BUN水平高的患者发生脑水肿的风险。它强调了对接受肾移植的儿童密切监测生命体征、精神状态和电解质的必要性。当血清渗透压迅速下降时，高渗溶液可用于预防或处理这些患者的脑水肿。移植前透析是另一个可主动降低血清高渗状态的考虑因素。
