How should uremic encephalopathy be managed in an older adult with end‑stage chronic kidney disease or acute kidney injury requiring dialysis?

Management of Uremic Encephalopathy in Older Adults

Initiate hemodialysis immediately when uremic encephalopathy is diagnosed in an older adult with end-stage chronic kidney disease or acute kidney injury, as renal replacement therapy is the definitive treatment and cognitive symptoms improve after dialysis. 1, 2, 3

Primary Treatment: Renal Replacement Therapy

Modality Selection Based on Clinical Stability

For hemodynamically stable older adults, initiate intermittent hemodialysis (IHD) rather than continuous renal replacement therapy (CRRT), as IHD provides superior efficiency for rapid removal of uremic toxins. 2, 4

• IHD offers rapid clearance of uremic toxins and electrolytes, which is critical for reversing encephalopathy 2, 4
• Frequent (daily) dialysis sessions may be needed initially given the continuous release of uremic metabolites 2, 4

For hemodynamically unstable older adults or those with cerebral edema, CRRT is preferred over intermittent hemodialysis. 5, 1, 2

• CRRT provides greater hemodynamic stability, better control of azotemia and fluid overload, and improved nutritional support 5, 1
• The gradual solute removal with CRRT reduces the risk of dialysis disequilibrium syndrome, which older adults are particularly vulnerable to 1

Hybrid Therapy Consideration

Sequential hemodialysis followed by CRRT may be beneficial for older adults with moderate to severe encephalopathy who require rapid toxin reduction while preventing rebound effects. 1

Management of Seizures (If Present)

For active seizures complicating uremic encephalopathy, administer anticonvulsants immediately. 1

• Levetiracetam (10 mg/kg, maximum 500 mg per dose every 12 hours) is preferred as it is generally well-tolerated with minimal drug interactions 1
• Alternative agents include diazepam, phenytoin, or barbiturates 1
• Consider EEG monitoring to detect subclinical epileptic activity and guide treatment 1

Addressing Precipitating Factors

Identify and treat precipitating factors that may worsen encephalopathy, including gastrointestinal bleeding, infection, dehydration, and electrolyte disturbances. 1

• Perform endoscopy, complete blood count, and stool blood tests if gastrointestinal bleeding is suspected; treat with transfusion, endoscopic intervention, or vasoactive drugs as needed 1
• Check complete blood count, C-reactive protein, and cultures to identify infection 1
• Assess skin elasticity, blood pressure, and pulse rate to evaluate hydration status 1
• Monitor serum electrolytes closely and correct abnormalities 1

Electrolyte Management

Check electrolyte levels regularly during dialysis initiation, as older adults are at higher risk for rapid shifts. 1

• Hyperkalemia (>5.0 mEq/L) in the setting of uremic symptoms requires urgent dialysis 2, 4
• Severe hyperphosphatemia (>6 mg/dL) warrants prophylactic dialysis before overt symptoms develop 4
• Avoid aluminum-containing phosphate binders, especially in combination with citrate salts which enhance aluminum absorption and can worsen encephalopathy 1

Special Considerations for Older Adults

Goals of Care Discussion

Patient wishes regarding dialysis and mechanical ventilation should be discussed before initiating renal replacement therapy, as older adults with uremic encephalopathy requiring dialysis face high in-hospital mortality. 5

• The decision to initiate permanent dialysis depends on multiple factors including underlying renal function, associated morbidity, and quality of life considerations 5
• Advance care planning preferences should be periodically reviewed if extended dialysis duration is expected 5

Nutritional Support

For older adults with chronic kidney disease and encephalopathy who cannot achieve adequate oral intake, consider overnight tube feeding to optimize nutrient intake while awaiting dialysis. 5

• Energy intake of 35 kcal/kg/day is recommended in stable CKD patients 5
• Use disease-specific formulae (protein-restricted with reduced electrolyte content) for enteral nutrition lasting more than 5 days 5

Common Pitfalls to Avoid

Do not delay dialysis initiation while attempting conservative management, as uremic encephalopathy represents advanced uremic toxicity that will not respond to conservative measures alone. 2, 6

Do not routinely treat hypocalcemia that commonly accompanies hyperphosphatemia with calcium supplementation, as this can worsen calcium-phosphate precipitation in tissues. 4

• Only symptomatic hypocalcemia (tetany, seizures) requires cautious calcium gluconate administration 4

If neurological symptoms do not improve after dialysis adequately improves clearance, promptly search for other explanations beyond uremia. 3, 6

• Many confounding conditions overlap with uremic encephalopathy in older adults with kidney disease 3
• The diagnosis is often made retrospectively when symptoms improve after dialysis 3, 6

Monitoring and Prognosis

Cognitive impairment may improve after kidney transplantation, suggesting that brain damage from uremic toxins is at least partially reversible. 7

• Uremic toxins disrupt the blood-brain barrier and damage brain cells 7
• Improvement in cognitive performance markers and structural brain abnormalities has been observed post-transplantation 7