What is the treatment for uremic encephalopathy?

Treatment of Uremic Encephalopathy

Renal replacement therapy, specifically hemodialysis, is the definitive treatment for uremic encephalopathy, with continuous renal replacement therapy (CRRT) being preferred in hemodynamically unstable patients or those with cerebral edema. 1

Clinical Presentation and Diagnosis

• Uremic encephalopathy presents with a spectrum of neurological manifestations ranging from mild confusion to deep coma, often accompanied by movement disorders such as asterixis, tremor, multifocal myoclonus, and seizures 2, 3
• The diagnosis is often made retrospectively when symptoms improve after dialysis or transplantation, as there are no specific clinical, laboratory, or imaging findings 2
• Symptoms typically correlate with the progression of renal failure and accumulation of uremic toxins 4

Initial Management

• Initiate renal replacement therapy promptly when severe encephalopathy is present 1
• Indications for immediate renal replacement therapy include:
  • Overt uremic symptoms including severe encephalopathy 1
  • Persistent hyperkalemia and severe metabolic acidosis 1
  • Volume overload unresponsive to diuretic therapy 1

Selection of Renal Replacement Modality

Continuous Renal Replacement Therapy (CRRT)

• CRRT is recommended over intermittent hemodialysis for patients who have or are at risk for cerebral edema 1
• CRRT provides advantages in hemodynamically unstable patients due to:
  • Greater improvement in hemodynamic stability 1
  • Better control of azotemia and fluid overload 1
  • Improved nutritional support 1
  • Less risk of dialysis disequilibrium syndrome 5

Intermittent Hemodialysis

• Can be used in hemodynamically stable patients 1
• Consider shorter, more frequent dialysis sessions rather than fewer longer sessions to reduce risk of dialysis disequilibrium syndrome 6
• Initial dialysis should be gentle with gradual increase in intensity to avoid rapid shifts in solutes that may worsen neurological symptoms 5

Management of Seizures Associated with Uremic Encephalopathy

• For active seizures, administer anticonvulsants such as diazepam, phenytoin, or barbiturates 6
• Consider levetiracetam (10 mg/kg, maximum 500 mg per dose every 12 hours) as it is generally well-tolerated with minimal drug interactions 6
• Monitor for respiratory depression and have airway management equipment readily available 6

Monitoring and Follow-up

• Check electrolyte levels (particularly sodium, potassium, calcium, phosphate) regularly 6
• Consider EEG monitoring to detect epileptic activity and guide treatment in patients with seizures 6
• Regular neurological assessment during subsequent dialysis sessions 6
• Neurological symptoms that do not improve after improvement in clearance should prompt a search for other explanations 2

Special Considerations

• Arteriovenous fistula dysfunction can contribute to inadequate dialysis and persistent uremic encephalopathy 7
• Aluminum toxicity can cause acute neurotoxicity with symptoms including agitation, confusion, myoclonic jerks, and seizures; consider measuring plasma aluminum levels if suspected 6
• Avoid aluminum-containing phosphate binders when possible, especially in combination with citrate salts which enhance aluminum absorption 6

Common Pitfalls and Caveats

• Failure to recognize vascular access recirculation can lead to inadequate dialysis and persistent uremic symptoms 7
• Dialysis disequilibrium syndrome (headache, nausea, muscle cramps, obtundation, seizures) can occur with the initiation of dialysis therapy, especially if performed too rapidly 5
• Neurological symptoms in dialysis patients may be due to other causes including subdural hematoma, electrolyte disorders, vitamin deficiencies, drug intoxication, or hypertensive encephalopathy 5