Hemodialysis: Acute Complications – Seizure

Does this patient have seizure?

Focal or generalized seizure






Uremic encephalopathy

Dialysis disequilibrium syndrome

Hard water syndrome (high calcium or magnesium in dialysate)

Cerebrovascular accident (ischemic or hemorrhage)

Subdural hematoma

Malignant hypertension (hypertensive encephalopathy)

Cerebral anoxia due to sustained hypotension

Suboptimal anti-convulsant plasma level (removed during dialysis)

Acute aluminum intoxication

Drug-induced neurotoxicity (theophylline, meperidine, and anti-microbial agents [e.g., penicillin, cefepime, imipenem

Alcohol withdrawal

What tests to perform?

Clinical diagnosis:

Laboratory tests should be ordered to identify causes

Blood glucose to exclude hypoglycemia

Serum sodium to exclude hyponatremia

Serum calcium to exclude hypocalcemia or hypercalcemia

Serum magnesium to exclude hypomagnesemia

Neuro-imaging study (CT scan or MRI) should be obtained to exclude intracranial pathology especially in the setting of focal or refractory seizures

Electroencephalography and lumbar puncture may be required

How should patients with seizure be managed?

Stop dialysis

Maintain airway patency and protection (in case of prolonged postictal state)

Intravenous benzodiazepine such as lorazepam (first choice), diazepam, and midazolam

Intravenous phenytoin if uncontrolled by benzodiazepine

Intravenous 50% dextrose in water if hypoglycemia is suspected

Identify causes and correct causes

What happens to patients with seizure?

Need for hospitalization

Risk of aspiration pneumonitis

Risk of permanent neurological damage (especially in status epilepticus)

Death (rare)

How to utilize team care?

1. Specialty consultations – Neurologist

2. Nursing – Close monitoring of high-risk patients with frequent neurological assessment

Are there clinical practice guidelines to inform decision making?

2013 updated evidence review of antiepileptic drug efficacy and effectiveness as initial monotherapy for epileptic seizures and syndromes (Published by The International League Against Epilepsy, ILAE)

Limitations: Focused on long-term efficacy as initial monotherapy for patients with newly diagnosed or untreated epilepsy (not dialysis patients).

Other considerations

ICD-10-CM diagnosis code R56.9: Unspecified convulsion

What is the evidence?

Glauser, T, Ben-Menachem, E, Bourgeois, B, Cnaan, A, Guerreiro, C, Kälviäinen, R, Mattson, R, French, JA, Perucca, E, Tomson, T. “ILAE Subcommission on AED Guidelines. Updated ILAE evidence review of antiepileptic drug efficacy and effectiveness as initial monotherapy for epileptic seizures and syndromes”. Epilepsia. vol. 54. 2013. pp. 551-63.