Papilledema in a Patient on Hemodialysis

Introduction: About 68% of people with end-stage kidney disease (ESKD) in the United States are on hemodialysis (HD). About 80% of these patients start HD using a catheter. Central venous obstruction is a common complication in patients with HD catheters which can result in increased morbidity and mortality including pain and swelling in the affected limb, superior vena cava syndrome and neurological symptoms including vision loss. We present an ESKD patient who developed papilledema and eventually permanent partial vision loss after placement of HD catheter. Case Description: A 47-year-old man with EKSD on hemodialysis via a right internal jugular (RIJ) catheter for three months presented with intermittent headaches, progressive blurred vision in the right eye with reports of tinnitus during dialysis. Dilated fundoscopic exam was significant for bilateral papilledema, right (4+) greater than left (1+). Further workup revealed no evidence of retrobulbar optic nerve enhancement on MRI, an increased opening pressure (OP) of 31 cm H2O on lumbar puncture (LP) with mild pleocytosis and mildly increased protein levels of cerebrospinal fluid (CSF). We diagnosed him with papilledema due to increased intracranial pressure (ICP). Non-arteritic anterior ischemic optic neuropathy was considered as well as an infectious cause given CSF findings and history of Mycobacterium avium-cellulare skin infection. He was discharged home but returned 1 week later with new onset diplopia and cranial nerve VI palsy. Repeat LP showed an elevated OP of 27 cm H2O. Subsequently a lumbar drain was placed with subjective improvement in visual symptoms. Central venous stenosis was ruled out with a CT venogram. RIJ vein HD catheter was removed and lumbar drain clamped for over 48 hours with continued stability to mild improvement in both subjective symptoms and objective vision testing. The patient was discharged with a new right femoral vein HD catheter with continued improvement in visual symptoms and papilledema. Discussion: There are multiple possible causes of papilledema in ESKD patients including central venous obstruction due to catheter-induced vein injury, thrombus, and extrinsic compression, hypervolemia and anemia as some of the more common causes. It is likely underrecognized necessitating a high index of suspicion, prompt evaluation and intervention to prevent permanent vision loss.