eMedicine Specialties > Neurology > Behavioral Neurology and Dementia

Uremic Encephalopathy: Treatment & Medication

Author: Gabriel Bucurescu, MD, MS, Staff Neurologist, Neurology Service, Philadelphia Veterans Affairs Medical Center
Contributor Information and Disclosures

Updated: Dec 9, 2008

Treatment

Medical Care

The medical care of uremic encephalopathy (UE) includes correcting the metabolic disturbance, which usually requires dialysis (hemodialysis or peritoneal dialysis) or renal transplantation. Symptoms improve as renal function improves.

  • Seizures may be treated with anticonvulsants.
    • These drugs should be administered at lower-than-usual doses to accommodate the low albumin levels observed in chronic renal failure (RF). These low albumin levels can lead to higher levels of unbound anticonvulsant.
    • The unbound drug is the therapeutically active fraction.
  • Emergency treatment of subdural hematoma or intracranial hemorrhage is addressed in other articles.
  • Cerebrovascular disease is a significant cause of morbidity and mortality in patients with chronic renal failure. The main causes of ischemic stroke are atherosclerosis and thromboembolic or intradialytic hypotension. Patients with chronic renal failure have a high prevalence of hyperhomocysteinemia, an independent risk factor for atherosclerosis. Most hemodialysis and renal transplant patients are partially refractory to treatment intended to reduce homocysteine levels. Dialysis itself appears to promote the development of arterial disease, perhaps due to oxidative stress. The progression of atherosclerosis is further speculated to be influenced by the use of immunosuppresive agents. Thromboembolic ischemic cerebrovascular accidents may result from cardiac disease (dilated cardiomyopathy, arrhythmia) or artery-to-artery embolism due to severe atherosclerosis.
  • Ultrafiltration-related arterial hypotension is a common complication in hemodialysis, especially in older patients with anemia. Severe arterial hypotension can cause cerebral hypoperfusion leading to ischemic stroke in the boundary zones between vascular territories. Treatment consists of fluid repletion.
  • Caution must be exercised in administering drugs whose metabolism is affected by impaired renal function because their levels can rise to toxic levels.
  • Hypertension and diabetes mellitus can both exacerbate the encephalopathic symptoms. Hypertensive encephalopathy is thought to be caused by vasogenic edema due to impaired cerebrovascular autoregulation, endothelial injury, and elevated plasma concentrations of natriuretic peptides. Hypertensive encephalopathy is thought to occur in 5% of uremic patients. Recombinant human erythropoietin for correction of renal anemia can cause hypertension in up to 35% of patients. Patients with diabetes tend to do worse.
  • Infections need to be treated appropriately.

Surgical Care

The role of surgery in managing UE is limited to cases involving renal transplantation, neurosurgical care for subdural hematoma or intracranial hemorrhage, and vascular access.

Consultations

  • Specialist in critical care medicine
  • Nephrologist
  • Vascular surgeon
  • Neurosurgeon
  • Infectious disease specialist: Bacterial meningitis remains a high cause of mortality in hemodialyzed patients, often because of delay in treatment.5

Diet

Patients must maintain a low-salt, low-protein (ie, renal) diet.

Activity

in general, patients with UE are ill, and in the acute phase, their activity is limited to bed rest.

More on Uremic Encephalopathy

Overview: Uremic Encephalopathy
Differential Diagnoses & Workup: Uremic Encephalopathy
Treatment & Medication: Uremic Encephalopathy
Follow-up: Uremic Encephalopathy
Multimedia: Uremic Encephalopathy
References
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References

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Further Reading

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Keywords

encephalopathy, renal failure, wernicke encephalopathy, hepatic encephalopathy, uremic state, uremia, uremic coma, uremic dementia, dialysis encephalopathy, uremic encephalopathy, UE, dialysis dementia, dialysis disequilibrium syndrome, RF, end-stage renal disease, ESRD, progressive renal insufficiency, multiorgan failure

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Contributor Information and Disclosures

Author

Gabriel Bucurescu, MD, MS, Staff Neurologist, Neurology Service, Philadelphia Veterans Affairs Medical Center
Gabriel Bucurescu, MD, MS is a member of the following medical societies: American Academy of Neurology, American Clinical Neurophysiology Society, and American Epilepsy Society
Disclosure: Nothing to disclose.

Medical Editor

J Stephen Huff, MD, Associate Professor, Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia Health Sciences Center
J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Richard J Caselli, MD, Professor, Department of Neurology, Mayo Medical School, Rochester, MN; Chair, Department of Neurology, Mayo Clinic of Scottsdale
Richard J Caselli, MD is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, American Neurological Association, and Sigma Xi
Disclosure: Nothing to disclose.

CME Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Howard A Crystal, MD, Professor, Departments of Neurology and Pathology, State University of New York Downstate; Consulting Staff, Department of Neurology, University Hospital and Kings County Hospital Center
Howard A Crystal, MD is a member of the following medical societies: American Academy of Neurology and American Neurological Association
Disclosure: Pfizer Honoraria Speaking and teaching; Myriad Honoraria Consulting

 
 
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