Approach Considerations
The presence of uremic encephalopathy in a patient with either acute kidney injury or chronic kidney disease is an indication for the initiation of dialytic therapy (ie, hemodialysis, peritoneal dialysis, continuous renal replacement therapy). Yanai et al reported three cases of uremic encephalopathy that developed in anuric patients receiving peritoneal dialysis; all cases resolved with institution of hemodialysis. [18]
After beginning dialysis, patients generally show clinical improvement, although electroencephalographic (EEG) findings may not improve immediately. In patients with end-stage renal disease (ESRD), EEG abnormalities generally improve after several months but may not completely normalize.
Address the following factors when treating uremic encephalopathy, which are also included in the standard care of any patient with ESRD:
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Adequacy of dialysis
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Correction of anemia
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Regulation of calcium and phosphate metabolism
Administer medications (eg, iron, erythropoietin, phosphate binders, vitamin D analogues) for patients with ESRD to optimize their quality of life. Sedatives should be avoided.
Consultations
Consult a neurologist if symptoms do not improve upon initiation of dialysis. Consult a vascular surgeon for placement of vascular access in patients with ESRD. Refer patients with ESRD to a dietitian familiar with renal diseases. Refer patients with chronic kidney disease to a nephrologist for regular monitoring of estimated glomerular filtration rate (eGFR), so that dialysis may be initiated before encephalopathy develops.
Diet
To avoid malnutrition in patients with ESRD, maintain adequate protein intake (1.2 g/kg/d) and initiate dialysis (despite the presence of encephalopathy).
Long-Term Monitoring
Schedule maintenance hemodialysis for patients who have ESRD.
Mental status should be carefully monitored.
