Dialysis disequilibrium syndrome leading to sudden brain death in a chronic hemodialysis patient

Dialysis disequilibrium syndrome (DDS) is a rare central nervous system (CNS) disease which develops in patients receiving hemodialysis (HD). Although it has been reported in patients receiving chronic HD, DDS is more common during or immediately after the first HD treatment. The exact incidence of DDS is unknown. Death in DDS is an extremely rare phenomenon and to the best of our knowledge only 9 cases have been reported showing this association. We present a unique case of a 42‐year‐old female on chronic HD, and no prior history of CNS disease, who developed brain death in the setting of DDS 2 hours into the dialysis treatment. A literature review of all previously reported cases was performed.