Encephalopathy dialysis

Uremic and dialysis encephalopathies. Patients with renal failure continue to manifest neuropsychiatric symptoms despite significant advances in therapeutics and management. Patients with renal failure who are not yet on dialysis develop an array of symptoms, including clouding of consciousness, disturbed sleep patterns, tremor and asterixis that may progress to coma and death. 

AD is a primary degenerative dementia affecting humans as young as in their forties. The German physician Alois Alzheimer first described the disease in 1906. It is characterized by senile plaques and paired helical filaments (PHFs), and the severity of the condition directly parallels their number.63 The involvement of aluminum in this and related dementias (dialysis encephalopathy and amyotrophic lateral sclerosis — Parkinson dementia in Guam) is currently a highly contested issue in neurological research. 

The major population at risk for aluminum loading and toxicity consists of individuals with renal failure. In a study by Alfrey (1980), 82% of nondialyzed uremic patients and 100% of dialyzed uremic patients had an increased body burden of aluminum. The decreased renal function and loss of the ability to excrete aluminum, ingestion of aluminum compounds to lessen gastrointestinal absorption of phosphate, the aluminum present in the water used for dialysate, and the possible increase in gastrointestinal absorption of aluminum in uremic patients can result in elevated aluminum body burdens. The increased body burdens in uremic patients has been associated with dialysis encephalopathy (also referred to as dialysis dementia), skeletal toxicity (osteomalacia, bone pain, pathological fractures, and proximal myopathy), and hematopoietic toxicity (microcytic, hypochromic anemia). Pre-term infants may also be particularly sensitive to the toxicity of aluminum due to reduced renal capacity (Tsou et al. 1991)... 

Alfrey AC, LeGendre GR, Kaehny WD. 1976. The dialysis encephalopathy syndrome Possible aluminum intoxication. N Engl J Med 294 184-188. 

McDermott JR, Smith AI, Ward MK, et al. 1978. Brain-aluminum concentration in dialysis encephalopathy. Lancet 1 901-904. 

Nathan E, Pedersen SE. 1980. Dialysis encephalopathy in a non-dialysed uraemic boy treated with aluminum hydroxide orally. Acta Paediatr Scand 69 793-796. 

Parkinson IS, Ward MK, Feest TG, et al. 1979. Fractioning dialysis osteodystrophy and dialysis encephalopathy An epidemiological survey. Lancet 1 406-409. 

In the past several clinical patterns have been described. The most important recognized clinical patterns or types of Al toxicity include two types of encephalopathy. Firstly, the classical dialysis dementia sometimes referred to as dialysis encephalopathy syndrome (DES) or dementia dialytica [24, 28, 37, 42, 70-74] and secondly, the acute or subacute Al encephalopathy [41]. There are also two types of bone disease - either osteomalacia with bone fractures and proximal myopathy or aplastic bone disease [41, 75, 76]. There is quite some confusion in the definitions of Al toxicity in the literature. Because there seems to be an obligatory lag phase of at least several days to weeks for symptoms to occur, acute Al encephalopathy, defined as a direct result of a single overdose, probably does not exist. Because of the long lag phase of several months to years necessary to develop the chronic dialysis encephalopathy and also because acute Al encephalopathy has an abrupt, sudden onset of symptoms one can understand why the term acute is used instead of the more descriptive subacute . The descriptions dialysis dementia [37, 42, 46, 73, 74] and dialysis encephalopathy [33-36, 38, 40, 41, 78] are also unfortunate because true dementia is rare in Al encephalopathy [73] and non-dialyzed patients can also develop these symptoms [78]. There are also many dialysis-related encephalopathy syndromes unrelated to Al. As an example,... 

Myocardial dysfunction may arise from Al loading, but this is not substantiated as yet. Al levels have been found markedly increased in the heart in patients with chronic dialysis encephalopathy [15]. It is presumed that sudden cardiac death may practically be due to Al cardiotoxicity [27, 106]. At pathology evaluation patients Nos. 7-9 showed signs of pulmonary edema. 

Elevated aluminum levels have been implicated as the cause of dialysis encephalopathy or dementia in renal failure patients undergoing long-term hemodialysis [85]. Some patients used aluminum-containing medications. Moreover, patients with renal failure cannot remove aluminum from the blood. Dialysis dementia can arise after three to seven years of hemodialysis treatment. Speech disorders precede dementia and convulsions. Since many hemodialysis units rely on systems to purify fluoridated tap water, it is likely that many patients are being exposed inadvertently to increased concentrations of fluoride and aluminum. Increased serum fluoride concentration and fluoride intoxication have been also observed in chronic hemodialysis patients. Arnow et al. [96] reported that 12 of 15 patients receiving dialysis treatment in one room became acutely ill, with multiple non-specific symptoms and fatal ventricular fibrillation. Death was associated with longer hemodialysis time and increased age compared with other patients who became ill. 

Ward MK, Pierides AM, Fawcett P. Dialysis encephalopathy syndrome. Proc EDTA 1976 13 348-54. 

Alfrey AC, LeGendre GR, Kaehny WD The dialysis encephalopathy syndrome possible aluminum intoxication. N Engl] Med 294 184-188, 1976 American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000... 

J Neurol Neurosurg Psychiatry 39 411-419, 1976 Chui HC, Damasio AR Progressive dialysis encephalopathy ( dialysis dementia ). J Neurol 222 145-157, 1980... 

Katz GV Metals and metalloids other than mercury and lead, in Neurotoxicity of Industrial and Commercial Chemicals, Vol 1. Edited by O Donoghue JL. Boca Raton, FL, CRC Press, 1985, pp 171-191 Katzman R Alzheimer s disease. N Engl J Med 314 964-973, 1986 Klatzo I, Wisniewski H, Streicher E Experimental production of neurofibrillary degeneration. J Neuropathol Exp Neurol 24 187-199, 1965 Lederman RJ, Henry CE Progressive dialysis encephalopathy. Ann Neurol 4 199-204, 1978... 

O Hare JA, Callaghan NM, Mumaghan DJ Dialysis encephalopathy clinical, electro-encephalographic and interventional aspects. Medicine 62 129-141, 1983... 

Rozas VV, Port FK, Easterling RE An outbreak of dialysis dementia due to aluminum in the dialysate. Journal of Dialysis 2 459-470, 1978a Rozas W, Port FK, Rutt WM Progressive dialysis encephalopathy from dialysate aluminum. Arch Intern Med 138 1375-1377, 1978b Scherp HW, Church CF Neurotoxic action of aluminum salts. Proc Soc Exp Biol Med 36 851-853, 1937... 

Schreeder MT, Favero MS, Hughes JR, et al Dialysis encephalopathy and aluminum exposure an epidemiologic analysis. Journal of Chronic Diseases 36 581-593, 1983 Sedman AB, Wilkening GN, Warady BA, et al Encephalopathy in childhood secondary to aluminum toxicity. J Pediatr 105 836-838, 1984 Terry RD, Pena C Experimental production of neurofibrillary degeneration. J Neuro-pathol Exp Neurol 24 200-210, 1965... 

Ackrill P, Ralston A], Day JP, et al Successful removal of aluminium from patient with dialysis encephalopathy (letter). Lancet 2 692-693,1980 Altmann P, Hamon C, Blair JA, et al Disturbance of cerebral function by aluminium in haemodialysis patients without overt aluminium toxicity. Lancet 2 7-12,1989 Arieff Al, Cooper JD, Armstrong D, et al Dementia, renal failure, and brain aluminum. Ann Intern Med 90 741-747, 1979... 

Etheridge WB, O Neill WM The dialysis encephalopathy syndrome without dialysis. Clin Nephrol 10 250-252, 1978... 

Click ID, Goldfield MD, Kovnat PJ Recognition and management of psychosis associated with hemodialysis. California Medicine 119 56-59,1973 Hart RP, Pederson fA, Czerwinski AW, et al Chronic renal failure, dialysis, and neuropsychological function (abstract). ] Clin Neuropsychol 5 301-312,1983 Ladumer G, Wawschinek O, Poggliysch H, et al Neurophysiological findings and serum aluminium in dialysis encephalopathy. Eur Neurol 21 335-339, 1982... 

Mahurkar SD, Salta R, Smith EC, et al Dialysis dementia. Lancet 1 1412-1415,1973 Masramon J, Ricart MJ, Caralps A, et al Dialysis encephalopathy (letter). Lancet 1 1370,1978... 

Masselot JP, Adhemar JP, Jaudon MC, et al Reversible dialysis encephalopathy role for aluminium-containing gels (letter). Lancet 2 1386-1387,1978 McDermott JR, Smith Al, Ward MK, et al Brain-aluminium concentration in dialysis encephalopathy. Lancet 1 901-904,1978... 

Nadel AM, Wilson WP Dialysis encephalopathy a possible seizure disorder. Neurology 26 1130-1134,1976... 

Smith DB, Lewis JA, Burks JS, et al Dialysis encephalopathy in peritoneal dialysis. JAMA 244 365-366, 1980... 

Sprague SM, Corwin HL, Tanner CM, et al Relationship of aluminum to neurocognitive dysfunction in chronic dialysis patients. Arch Intern Med 148 2169-2172,1988 Trauner DA, dayman M Dialysis encephalopathy treated with clonazepam. Ann Neurol 6 555-556, 1979... 

Parkinson, I.S., Ward, M.K., and Kerr, D.N.S. (1981) Dialysis encephalopathy, bone disease and anaemia the aluminum intoxication syndrome during regular haemodialysis. /. Clin. Pathol., 34, 1285-1294. 

Prolonged, elevated Al accumulation in renally impaired humans can produce the dialysis encephalopathy syndrome (DES) (Alfrey et al 1976). Al was significantly elevated in bulk brain ( 10-fold), neurons, and bone ( 85-fold) in DES (Alfrey etal. 1980, Reusche 1997). Although generally well recognized and avoided, DES still... 

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