Early-Onset Dialysis Disequilibrium Syndrome Presenting With Hypoxia and Subtle Neurological Signs During Initial Hemodialysis.

Dialysis disequilibrium syndrome (DDS) is a rare but serious neurological complication seen in patients with severe uremia during initiation of hemodialysis. Early recognition is essential to prevent morbidity. We report a 35-year-old male with obstructive uropathy presenting with severe azotemia (urea = 316 mg/dL, creatinine = 24 mg/dL). He underwent his first hemodialysis session, which was conducted over 2.5 hours using a low-efficiency approach. Within 15-30 minutes of initiation, he developed vomiting, decreased responsiveness, and staring spells without overt seizures. Oxygen saturation dropped to 80%, requiring supplemental oxygen. Due to an altered mental status, subjective symptoms could not be assessed at presentation. A clinical diagnosis of DDS was strongly considered based on temporal association and risk profile. The patient improved within 12 hours with supportive care. Subsequent dialysis sessions were modified to a low-efficiency strategy and were well tolerated. This case highlights the importance of recognizing atypical neurological presentations of DDS, particularly in patients with impaired communication, and emphasizes preventive dialysis strategies.