Uremic Encephalopathy

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Practice Essentials

Uremic encephalopathy is an organic brain disorder. It develops in patients with acute or chronic renal failure, usually when the estimated glomerular filtration rate (eGFR) falls and remains below 15 mL/min.[1, 2, 3, 4]

Manifestations of this syndrome vary from mild symptoms (eg, lassitude, fatigue) to severe signs (eg, seizures, coma). Severity and progression depend on the rate of decline in renal function; thus, symptoms are usually worse in patients with acute kidney injury. Prompt identification of uremia as the cause of encephalopathy is essential because symptoms are readily reversible following initiation of dialysis.[5, 6]

See also Neurological Manifestations of Uremic Encephalopathy.

Pathophysiology

Uremic encephalopathy has a complex pathophysiology, and many toxins that accumulate in kidney failure may be contributive. Uremic encephalopathy may occur in a patient with acute kidney injury or chronic kidney failure of any etiology.

One contributing factor to uremic encephalopathy may involve imbalances of neurotransmitter amino acids within the brain. During the early phase of uremic encephalopathy, plasma and cerebrospinal fluid (CSF) determinations indicate that levels of glycine increase and levels of glutamine and gamma-aminobutyric acid (GABA) decrease. As uremia progresses, it has been proposed that the accumulation of guanidino compounds results in activation of excitatory N-methyl-D-aspartate (NMDA) receptors and inhibition of inhibitory GABA receptors, which may cause myoclonus and seizures.[5, 7, 8] In addition, alterations occur in metabolism of dopamine and serotonin in the brain, which may lead to early symptoms (eg, sensorial clouding).

Parathyroid hormone (PTH) likely contributes to uremic encephalopathy.[9]  Secondary hyperparathyroidism, which occurs in kidney failure, causes an increase in calcium content in the cerebral cortex. In animal models with uremia, electroencephalographic (EEG) changes were typical of those observed in patients with renal failure. In uremic patients with secondary hyperparathyroidism, EEG changes have been shown to improve after medical suppression of PTH or parathyroidectomy.

The specific mechanism by which PTH causes disturbance in brain function is unclear, but it may involve increases in intracellular concentration of calcium in brain cells. However, since the encephalopathy improves with dialysis, which does not have a marked effect on PTH levels, hyperparathyroidism is not thought to be the main cause.

A study of acute kidney injury in mice found evidence of a blood-brain barrier disruption from such injury, with increased neuronal pyknosis and microgliosis. In addition, proinflammatory chemokines were increased in brain tissue.[10]

Numerous other uremic toxins may contribute to uremic encephalopathy, but there has been a notable lack of research in this area. Although the encephalopathy correlates roughly with blood urea nitrogen (BUN) level, urea is not itself thought to be causative.

Epidemiology

Frequency

United States

Most patients with an eGFR of less than 10 mL/min develop some degree of encephalopathy; however, they may not be clearly symptomatic. In one pediatric study, encephalopathy occurred in 40% of the children with a BUN level greater than 90 mg/dL. As the BUN level increased, the likelihood of these children developing convulsions increased.[11]

Mortality/Morbidity

Symptoms include somnolence and decreased mentation. Asterixis may be present. These findings are reversible following initiation of dialysis and recovery of renal function in patients with acute kidney injury. Symptoms are also reversible following the institution of dialysis or renal transplantation in patients with end-stage renal disease (ESRD). The severe complications (ie, seizures, coma) can lead to death. Early recognition of encephalopathy in the setting of decreased renal function is crucial to prevent morbidity or mortality. With prompt dialytic therapy, the mortality rate is low.

Race-, Sex-, and Age-related Demographics

No racial predilection exists. No significant association between sex and incidence exists. Uremic encephalopathy may develop at any age.

History

Early symptoms of uremic encephalopathy include the following:

More severe signs and symptoms of uremic encephalopathy include the following:

Physical

Physical examination findings may include the following:

Laboratory Studies

Obtain the following laboratory studies:

Determine drug levels because medications (eg, digoxin, lithium) may accumulate in patients with kidney failure and contribute to encephalopathy. However, some medications that are excreted by the kidney cannot be detected. These may also accumulate in patients with kidney failure, resulting in encephalopathy (eg, penicillin, cimetidine, meperidine, baclofen).

Imaging Studies

Obtain a magnetic resonance imaging (MRI) or computed tomography (CT) scan of the head  for a uremic patient who presents with severe neurologic symptoms, to rule out structural abnormalities (eg, cerebrovascular accident, intracranial mass, subdural hematoma).

Typical MRI findings in patients with uremic encephalopathy include increased signal intensity (lentiform fork sign) in either the cerebral cortex or the basal ganglia.[13, 14] A CT scan may show bilateral hypodensities involving the basal ganglia, midbrain, or thalamus.[15]

 

Encephalography

An electroencephalograpm (EEG) is commonly performed on patients with metabolic encephalopathy. Findings typically include the following:

Reduction in frequency of EEG waves correlates with the decrease in renal function and the alterations in cerebral function. After the initial period of dialysis, clinical stabilization may occur while the EEG findings do not improve. Eventually, EEG results move toward normal.

Aside from the routine EEG, evoked potentials (EPs) (ie, EEG signals that occur at a reproducible time after the brain receives a sensory stimulus [eg, visual, auditory, somatosensory]) may be helpful in evaluating uremic encephalopathy. Chronic renal failure prolongs latency of the cortical visual-evoked response. Auditory-evoked responses are generally not altered in uremia, but delays in the cortical potential of the somatosensory-evoked response do occur.

Cognitive Function Tests

 Several cognitive function tests are used to evaluate uremic encephalopathy, including the following:

Alterations in choice reaction time appear to correlate best with renal failure.

Procedures

Lumbar puncture is not routinely performed; however, it may be indicated to find other causes of encephalopathy if a patient's mental status does not improve after initiation of dialysis. No specific CSF finding indicates uremic encephalopathy.

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.[16]

After beginning dialysis, the patient generally improves clinically, 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:

Consultations

See the list below:

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).

Further Outpatient Care

See the list below:

Inpatient & Outpatient Medications

See the list below:

Deterrence/Prevention

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.

Complications

Complications of uremic encephalopathy include the following:

Author

James W Lohr, MD, Professor, Department of Internal Medicine, Division of Nephrology, Fellowship Program Director, University of Buffalo State University of New York School of Medicine and Biomedical Sciences

Disclosure: Received research grant from: GSK<br/>Partner received salary from Alexion for employment.

Specialty Editors

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Ajay K Singh, MB, MRCP, MBA, Associate Professor of Medicine, Harvard Medical School; Director of Dialysis, Renal Division, Brigham and Women's Hospital; Director, Brigham/Falkner Dialysis Unit, Faulkner Hospital

Disclosure: Nothing to disclose.

Chief Editor

Vecihi Batuman, MD, FASN, Huberwald Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Renal Section, Southeast Louisiana Veterans Health Care System

Disclosure: Nothing to disclose.

Acknowledgements

Donald A Feinfeld, MD, FACP, FASN Consulting Staff, Division of Nephrology and Hypertension, Beth Israel Medical Center

Disclosure: Nothing to disclose.

References

  1. Bolton CF, Young GB. Encephalopathy of chronic renal failure. Neurological Complications of Renal Disease. 1990. 49-74.
  2. Brouns R, De Deyn PP. Neurological complications in renal failure: a review. Clin Neurol Neurosurg. 2004 Dec. 107(1):1-16. [View Abstract]
  3. Lien Y-HH. Nervous system manifestations of renal failure. In: Coffman TM, Falk RJ, Molitoris BA, Neilson EG, Schrier RW, eds. Schrier's Diseases of the Kidney. 9th ed. Philadelphia PA: Lippincott/Wolters Kluwer; 2013. 2277-96.
  4. Seifter JL, Samuels MA. Uremic encephalopathy and other brain disorders associated with renal failure. Semin Neurol. 2011 Apr. 31(2):139-43. [View Abstract]
  5. Biasioli S, D'Andrea G, Feriani M, Chiaramonte S, Fabris A, Ronco C, et al. Uremic encephalopathy: an updating. Clin Nephrol. 1986 Feb. 25(2):57-63. [View Abstract]
  6. Biasioli S. Neurologic aspects of dialysis. Nissenson A, Fine R, eds. Clinical Dialysis. 2005. 855-876.
  7. Deguchi T, Isozaki K, Yousuke K, Terasaki T, Otagiri M. Involvement of organic anion transporters in the efflux of uremic toxins across the blood-brain barrier. J Neurochem. 2006 Feb. 96(4):1051-9. [View Abstract]
  8. De Deyn PP, Vanholder R, Eloot S, et al. Guanidino compounds as uremic (neuro)toxins. Semin Dial. 2009 Jul-Aug. 22(4):340-5. [View Abstract]
  9. Moe SM, Sprague SM. Uremic encephalopathy. Clin Nephrol. 1994 Oct. 42(4):251-6. [View Abstract]
  10. Liu M, Liang Y, Chigurupati S, Lathia JD, Pletnikov M, Sun Z, et al. Acute kidney injury leads to inflammation and functional changes in the brain. J Am Soc Nephrol. 2008 Jul. 19(7):1360-70. [View Abstract]
  11. Nomoto K, Scurlock C, Bronster D. Dexmedetomidine controls twitch-convulsive syndrome in the course of uremic encephalopathy. J Clin Anesth. 2011 Dec. 23(8):646-8. [View Abstract]
  12. Yamamoto T, Satomura K, Okada S, et al. Risk factors for neurological complications in complete hemolytic uremic syndrome caused by Escherichia coli O157. Pediatr Int. 2009 Apr. 51(2):216-9. [View Abstract]
  13. Schmidt M, Sitter T, Lederer SR, Held E, Schiffl H. Reversible MRI changes in a patient with uremic encephalopathy. J Nephrol. 2001 Sep-Oct. 14(5):424-7. [View Abstract]
  14. Kim DM, Lee IH, Song CJ. Uremic Encephalopathy: MR Imaging Findings and Clinical Correlation. AJNR Am J Neuroradiol. 2016 Sep. 37 (9):1604-9. [View Abstract]
  15. Kumar G, Goyal MK. Lentiform Fork sign: a unique MRI picture. Is metabolic acidosis responsible?. Clin Neurol Neurosurg. 2010 Nov. 112 (9):805-12. [View Abstract]
  16. Yanai A, Uchiyama K, Ishibashi Y. Uremic encephalopathy in patients undergoing assisted peritoneal dialysis: a case series and literature review. CEN Case Rep. 2019 Nov. 8 (4):271-279. [View Abstract]