Management of Temporary Altered Mental State Following Dialysis
The immediate priority is to recognize and treat dialysis disequilibrium syndrome (DDS) with hypertonic saline (3%) or mannitol, while simultaneously ruling out medication-induced causes, particularly pregabalin toxicity in patients taking this drug. 1, 2
Immediate Assessment and Acute Management
First-Line Interventions for Suspected DDS
Administer hypertonic saline (3%) or mannitol immediately if DDS is suspected, as this has demonstrated successful recovery without long-term neurologic sequelae in patients presenting with seizures and altered mental status during or after hemodialysis. 1
Stop or slow the dialysis session immediately if symptoms develop during treatment, as rapid urea removal is the primary pathophysiological mechanism causing cerebral edema. 3, 4
Monitor for progression of neurological symptoms including headache, nausea, confusion, seizures, and obtundation, as the prognosis is poor when serious manifestations occur without prompt intervention. 1, 5
Medication-Related Causes
Review pregabalin use urgently, as this drug causes mental status changes in up to 51% more dialysis patients compared to non-users, according to the American Journal of Kidney Diseases. 2
Monitor mental status closely until symptoms resolve in patients taking pregabalin, as recommended by the American Journal of Kidney Diseases, and consider this a medication side effect rather than automatically pursuing extensive neurological workup. 2
Perform thorough medication reconciliation to identify CNS depressants and other interacting drugs, as hospitalized dialysis patients are particularly vulnerable due to acute illness affecting drug metabolism. 6
Prevention Strategies for Future Sessions
Dialysis Prescription Modifications
Adjust hemodialysis parameters including duration, blood flow rate, and target urea reduction to prevent recurrence, as these modifications are key to avoiding seizures following hemodialysis. 3
Use gentler dialysis prescriptions in high-risk patients (extreme age, very high BUN, first dialysis session, preexisting neurological disease) to minimize rapid osmotic shifts. 4, 5
Avoid aggressive ultrafiltration rates that could compound cerebral edema risk through hypotension and reduced cerebral perfusion. 7
Medication Management
Consider alternative pain management strategies appropriate for dialysis patients when pregabalin is contraindicated or not tolerated, as recommended by the National Comprehensive Cancer Network. 2
Avoid increasing pregabalin doses too quickly before reaching steady state in patients with impaired elimination, per Mayo Clinic Proceedings recommendations. 2
Implement regular medication review by clinical pharmacists to reduce hospitalization rates and identify potential drug interactions. 6
Risk Stratification
High-Risk Features Requiring Modified Approach
Extreme age (very young or elderly patients have increased DDS susceptibility). 4
Markedly elevated BUN (rapid correction creates larger osmotic gradients). 3, 4
First dialysis session or sudden regimen changes (lack of adaptation to osmotic shifts). 4
Preexisting neurological conditions or increased blood-brain barrier permeability. 4
Concurrent use of CNS-active medications, particularly pregabalin, gabapentin, or other sedating agents. 2, 6
Non-Pharmacological Adjuncts
Consider music therapy, physical activity, and cognitive behavioral therapy as alternative approaches for symptom management in dialysis patients, which may reduce reliance on medications like pregabalin that increase altered mental state risk. 6, 7
Implement systematic symptom assessment protocols including symptom elicitation, evaluation, management, and clinician follow-up as outlined in KDIGO guidelines. 7
Critical Pitfalls to Avoid
Do not attribute altered mental status solely to "expected" post-dialysis fatigue without ruling out DDS or medication toxicity, as delayed recognition worsens outcomes. 1, 5
Do not continue aggressive dialysis in symptomatic patients hoping symptoms will resolve, as this can progress to seizures and obtundation. 1, 3
Do not overlook pregabalin as a reversible cause of mental status changes, as Critical Care guidelines specifically warn against missing this medication side effect. 2
Do not assume CRRT eliminates DDS risk, as this syndrome has been reported even with continuous modalities despite their slower solute clearance. 8