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
Initial Management
- Initiate renal replacement therapy promptly when uremic encephalopathy is present, as this is the primary intervention that addresses the underlying cause - accumulation of uremic toxins 1, 2
- CRRT is recommended over intermittent hemodialysis for patients who have or are at risk for cerebral edema, according to the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines 1
- For hemodynamically unstable patients, CRRT provides advantages due to greater improvement in hemodynamic stability, better control of azotemia and fluid overload, and improved nutritional support 1, 3
Indications for Immediate Renal Replacement Therapy
- Overt uremic symptoms including encephalopathy 1, 3
- Persistent hyperkalemia 3
- Severe metabolic acidosis 3
- Volume overload unresponsive to diuretic therapy 3
Management of Precipitating Factors
Identifying and managing precipitating factors is crucial in treating uremic encephalopathy:
- Gastrointestinal bleeding: Perform endoscopy, complete blood count, and stool blood tests; treat with transfusion, endoscopic intervention, or vasoactive drugs 4
- Infection: Check complete blood count, C-reactive protein, cultures; treat with appropriate antibiotics 4
- Dehydration: Assess skin elasticity, blood pressure, pulse rate; stop or reduce diuretics, provide fluid therapy (e.g., intravenous albumin infusion) 4
- Electrolyte disturbances: Monitor serum electrolytes closely, as both the underlying condition and treatments can affect electrolyte balance 4, 3
Management of Seizures
- For active seizures, administer anticonvulsants such as diazepam, phenytoin, or barbiturates 1
- Consider levetiracetam (10 mg/kg, maximum 500 mg per dose every 12 hours) as it is generally well-tolerated with minimal drug interactions 1
- EEG monitoring may be beneficial to detect epileptic activity and guide treatment in patients with seizures 1
Monitoring and Follow-up
- Check electrolyte levels regularly during treatment 1, 3
- Neurological symptoms that do not improve after improvement in clearance should prompt a search for other explanations 2
- Monitor for dialysis-related complications such as dialysis disequilibrium syndrome, which consists of headache, nausea, muscle cramps, obtundation, and seizures 5, 6
Special Considerations
- Hybrid therapy (sequential HD followed by CRRT) may be beneficial for patients who require rapid reduction of toxins, prevention of rebound effect, or have moderate or severe encephalopathy 1
- Avoid aluminum-containing phosphate binders when possible, especially in combination with citrate salts which enhance aluminum absorption, to prevent dialysis dementia 1, 6
- Consider antioxidant therapy as an adjuvant treatment, as oxidative stress has been identified as a contributing factor to uremic encephalopathy 7
Prognosis
- Many neurological complications of uremia may fail to fully respond to dialysis, and some may be elicited or aggravated by dialysis or renal transplantation 7
- The diagnosis of uremic encephalopathy is often made retrospectively when symptoms improve after dialysis or transplantation 2
- Neurological symptoms that persist despite adequate clearance should prompt investigation for other causes 2