Should Dialysis Be Resumed After a Brief Seizure of Unknown Etiology?
Dialysis should be immediately discontinued when a seizure occurs, the patient should be stabilized and evaluated for the underlying cause, and dialysis should NOT be resumed during the same session. 1
Immediate Management During the Seizure
Stop dialysis immediately when seizure activity begins, as the NKF-K/DOQI guidelines explicitly recognize that clinical complications during hemodialysis sessions—including seizures—constitute interruptions that reduce actual dialysis time and require treatment discontinuation. 1
Ensure airway protection, administer oxygen, and obtain intravenous access if not already present for emergency medication administration. 2, 3
Do not attempt to continue or resume dialysis during active seizure activity or the immediate post-ictal period, as patient safety takes absolute priority over completing the prescribed dialysis session. 1
Post-Seizure Evaluation Before Any Consideration of Resumption
Immediate Diagnostic Priorities
Measure finger-stick glucose immediately to rule out hypoglycemia, which is among the most common reversible causes of altered mental status in dialysis patients. 4
Check vital signs including blood pressure, as intradialytic hypotension can cause cerebral hypoperfusion and neurological complications. 4
Obtain urgent electrolyte panel measuring sodium, calcium, magnesium, potassium, and phosphate, as hyponatremia and other electrolyte disturbances are common seizure triggers in kidney disease patients. 5, 6
Review all medications, particularly pregabalin (associated with 51% higher incidence of altered mental status in dialysis patients), antibiotics, and any renally-cleared antiepileptic drugs that may have accumulated. 4, 7
Assess for Dialysis Disequilibrium Syndrome (DDS)
DDS is a critical consideration if this was an early dialysis session (especially first or second treatment), if aggressive ultrafiltration was used, or if pre-dialysis BUN was markedly elevated. 2, 3, 6
DDS presents with seizures occurring during or within 4 hours after hemodialysis initiation, caused by cerebral edema from rapid osmotic shifts. 2, 3
If DDS is suspected based on timing and rapid BUN reduction, obtain head CT to evaluate for cerebral edema. 2
Neurological Assessment
Obtain EEG if altered mental status persists after the seizure to exclude non-convulsive status epilepticus, which is a treatable condition that can be overlooked. 1, 4
Assess for uremic encephalopathy if pre-dialysis BUN was severely elevated, as uremia itself causes seizures independent of dialysis. 2, 6
Decision Algorithm: Should Dialysis Be Resumed?
DO NOT resume dialysis in the same session if:
The seizure occurred during the first 2 hours of dialysis (high suspicion for DDS). 2, 3
Patient remains post-ictal or has altered mental status. 4
Intradialytic hypotension was documented before the seizure. 4, 8
Electrolyte abnormalities are identified that require correction. 5, 6
The cause of the seizure remains unidentified after initial evaluation. 6
Plan for subsequent dialysis sessions:
If DDS is confirmed or suspected, switch to continuous renal replacement therapy (CRRT) or continuous hemodiafiltration rather than intermittent hemodialysis for the next 24-72 hours, as this provides gentler, slower solute removal. 2
When resuming intermittent hemodialysis after DDS, use conservative parameters: reduce blood flow rate to 100-150 mL/min, limit initial session to 2 hours, use smaller dialyzer surface area (1.0-1.3 m²), and target only 30-40% BUN reduction in first session. 2, 3
Reduce dialysate temperature to 35-36°C to minimize hypotensive episodes in future sessions. 8
Correct any identified electrolyte abnormalities (particularly hypomagnesemia, which occurs in 60-65% of critically ill dialysis patients) before the next dialysis session. 5
Antiepileptic Management Considerations
If seizure treatment is required, levetiracetam is preferred in dialysis patients as it has predictable renal clearance, but recognize that it is extensively removed by hemodialysis and supplemental dosing (250-500 mg) is required after each dialysis session. 2, 7
Avoid valproate in patients with hepatic dysfunction, but it is less affected by renal impairment than other options. 7
Monitor free drug concentrations rather than total levels for highly protein-bound antiepileptic drugs, as uremia causes hypoalbuminemia. 7
Documentation Requirements
Document the interruption time precisely in the dialysis record, as NKF-K/DOQI guidelines emphasize that failure to account for interruptions due to clinical complications results in inaccurate assessment of delivered dialysis dose. 1
Record the exact time dialysis was stopped, duration of seizure, interventions performed, and reason dialysis was not resumed. 1
This interruption must be factored into calculations of Kt/V and URR for adequacy assessment. 1
Critical Pitfall to Avoid
Do not attribute the seizure solely to "uremia" and simply resume dialysis without investigating reversible causes such as medication accumulation (especially pregabalin), dialysis disequilibrium, hypoglycemia, or electrolyte disturbances—each requires specific management beyond just continuing dialysis. 4, 6