Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Seizures in patients undergoing hemodialysis

Kathryn A Davis, MD, MSTR
Iheanyichukwu Ogu, MD
Thomas A Golper, MD
Section Editor
Jeffrey S Berns, MD
Deputy Editor
Alice M Sheridan, MD


Seizures are not uncommon among hemodialysis patients [1].

There are many potential causes of seizures among hemodialysis patients. In most circumstances, seizure activity occurs during or shortly after the hemodialysis procedure because of the hemodynamic and biochemical changes associated with the process [1].

This topic reviews the causes and treatment of seizures in hemodialysis patients. The management of seizures in patients without renal failure is presented elsewhere. (See "Overview of the management of epilepsy in adults".)

A review of other acute complications that may occur during dialysis are presented separately. (See "Acute complications during hemodialysis".)


Causes — The evaluation of a new-onset seizure is similar to that of nondialysis patients. The following causes are due to either end-stage renal disease (ESRD) or treatment with hemodialysis: uremic encephalopathy, dialysis dysequilibrium syndrome (DDS), intradialytic hemodynamic instability, aluminum-associated dialysis dementia, air embolism, hypoglycemia, hypocalcemia, and hyponatremia.

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Apr 24, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Glenn CM, Astley SJ, Watkins SL. Dialysis-associated seizures in children and adolescents. Pediatr Nephrol 1992; 6:182.
  2. Arieff AI. Dialysis disequilibrium syndrome: current concepts on pathogenesis and prevention. Kidney Int 1994; 45:629.
  3. Rostand SG, Brunzell JD, Cannon RO 3rd, Victor RG. Cardiovascular complications in renal failure. J Am Soc Nephrol 1991; 2:1053.
  4. Rodrigo F, Shideman J, McHugh R, et al. Osmolality changes during hemodialysis. Natural history, clinical correlations, and influence of dialysate glucose and intravenous mannitol. Ann Intern Med 1977; 86:554.
  5. Zepeda-Orozco D, Quigley R. Dialysis disequilibrium syndrome. Pediatr Nephrol 2012; 27:2205.
  6. Patel N, Dalal P, Panesar M. Dialysis disequilibrium syndrome: a narrative review. Semin Dial 2008; 21:493.
  7. Bagshaw SM, Peets AD, Hameed M, et al. Dialysis Disequilibrium Syndrome: brain death following hemodialysis for metabolic acidosis and acute renal failure--a case report. BMC Nephrol 2004; 5:9.
  8. Marshall MR, Golper TA. Low-efficiency acute renal replacement therapy: role in acute kidney injury. Semin Dial 2011; 24:142.
  9. Beccari M. Seizures in dialysis patients treated with recombinant erythropoietin. Review of the literature and guidelines for prevention. Int J Artif Organs 1994; 17:5.
  10. Edmunds ME, Walls J, Tucker B, et al. Seizures in haemodialysis patients treated with recombinant human erythropoietin. Nephrol Dial Transplant 1989; 4:1065.
  11. Strippoli GF, Craig JC, Manno C, Schena FP. Hemoglobin targets for the anemia of chronic kidney disease: a meta-analysis of randomized, controlled trials. J Am Soc Nephrol 2004; 15:3154.
  12. Lin CS, Cheng CJ, Chou CH, Lin SH. Piperacillin/tazobactam-induced seizure rapidly reversed by high flux hemodialysis in a patient on peritoneal dialysis. Am J Med Sci 2007; 333:181.
  13. Ferrara N, Abete P, Giordano M, et al. Neurotoxicity induced by Cefepime in a very old hemodialysis patient. Clin Nephrol 2003; 59:388.
  14. Hassan H, Bastani B, Gellens M. Successful treatment of normeperidine neurotoxicity by hemodialysis. Am J Kidney Dis 2000; 35:146.
  15. Davenport A, Goel S, Mackenzie JC. Neurotoxicity of acyclovir in patients with end-stage renal failure treated with continuous ambulatory peritoneal dialysis. Am J Kidney Dis 1992; 20:647.
  16. Almond MK, Fan S, Dhillon S, et al. Avoiding acyclovir neurotoxicity in patients with chronic renal failure undergoing haemodialysis. Nephron 1995; 69:428.
  17. Helldén A, Odar-Cederlöf I, Diener P, et al. High serum concentrations of the acyclovir main metabolite 9-carboxymethoxymethylguanine in renal failure patients with acyclovir-related neuropsychiatric side effects: an observational study. Nephrol Dial Transplant 2003; 18:1135.
  18. Schuerer DJ, Brophy PD, Maxvold NJ, et al. High-efficiency dialysis for carbamazepine overdose. J Toxicol Clin Toxicol 2000; 38:321.
  19. Seto AH, Song JC, Guest SS. Ertapenem-associated seizures in a peritoneal dialysis patient. Ann Pharmacother 2005; 39:352.
  20. Muruve DA, Steinman TI. Contrast-induced encephalopathy and seizures in a patient with chronic renal insufficiency. Clin Nephrol 1996; 45:406.
  21. Chang JM, Hwang SJ, Kuo HT, et al. Fatal outcome after ingestion of star fruit (Averrhoa carambola) in uremic patients. Am J Kidney Dis 2000; 35:189.
  22. Neto MM, da Costa JA, Garcia-Cairasco N, et al. Intoxication by star fruit (Averrhoa carambola) in 32 uraemic patients: treatment and outcome. Nephrol Dial Transplant 2003; 18:120.
  23. Alfrey AC, LeGendre GR, Kaehny WD. The dialysis encephalopathy syndrome. Possible aluminum intoxication. N Engl J Med 1976; 294:184.
  24. Mahoney CA, Arieff AI. Uremic encephalopathies: clinical, biochemical, and experimental features. Am J Kidney Dis 1982; 2:324.
  25. Reidenberg MM. The binding of drugs to plasma proteins and the interpretation of measurements of plasma concentrations of drugs in patients with poor renal function. Am J Med 1977; 62:466.
  26. Israni RK, Kasbekar N, Haynes K, Berns JS. Use of antiepileptic drugs in patients with kidney disease. Semin Dial 2006; 19:408.
  27. Depner TA, Gulyassy PF. Plasma protein binding in uremia: extraction and characterization of an inhibitor. Kidney Int 1980; 18:86.
  28. Reynolds F, Ziroyanis PN, Jones NF, Smith SE. Salivary phenytoin concentrations in epilepsy and in chronic renal failure. Lancet 1976; 2:384.
  29. Faridi MM, Aggarwal A. Phenytoin induced vitamin D deficiency presenting as proximal muscle weakness. Indian Pediatr 2010; 47:624.
  30. Lee RH, Lyles KW, Colón-Emeric C. A review of the effect of anticonvulsant medications on bone mineral density and fracture risk. Am J Geriatr Pharmacother 2010; 8:34.
  31. Bansal AD, Hill CE, Berns JS. Use of Antiepileptic Drugs in Patients with Chronic Kidney Disease and End Stage Renal Disease. Semin Dial 2015; 28:404.
  32. Porto I, John EG, Heilliczer J. Removal of phenobarbital during continuous cycling peritoneal dialysis in a child. Pharmacotherapy 1997; 17:832.
  33. Kandrotas RJ, Love JM, Gal P, Oles KS. The effect of hemodialysis and hemoperfusion on serum valproic acid concentration. Neurology 1990; 40:1456.
  34. Kandrotas RJ, Oles KS, Gal P, Love JM. Carbamazepine clearance in hemodialysis and hemoperfusion. DICP 1989; 23:137.