Treatment of Uremic Encephalopathy

Overview of Treatment

Renal replacement therapy, specifically hemodialysis, is the definitive treatment for uremic encephalopathy, with continuous renal replacement therapy (CRRT) being preferred in hemodynamically unstable patients or those with cerebral edema 1, 2

Initiate renal replacement therapy promptly when severe encephalopathy is present, as recommended by the European Renal Association 1, 2
Indications for immediate renal replacement therapy include overt uremic symptoms, severe encephalopathy, persistent hyperkalemia, and severe metabolic acidosis, as suggested by the American Society of Nephrology 1

CRRT is recommended over intermittent hemodialysis for patients who have or are at risk for cerebral edema, according to the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines 3, 4
CRRT provides advantages in hemodynamically unstable patients due to greater improvement in hemodynamic stability, better control of azotemia and fluid overload, and improved nutritional support, as stated by the European Society of Intensive Care Medicine 1

For active seizures, administer anticonvulsants such as diazepam, phenytoin, or barbiturates, as recommended by the Neurocritical Care Society 5
Consider levetiracetam (10 mg/kg, maximum 500 mg per dose every 12 hours) as it is generally well-tolerated with minimal drug interactions, according to the American Epilepsy Society 5

Check electrolyte levels regularly and consider EEG monitoring to detect epileptic activity and guide treatment in patients with seizures, as suggested by the American Clinical Neurophysiology Society 5

Avoid aluminum-containing phosphate binders when possible, especially in combination with citrate salts which enhance aluminum absorption, as recommended by the National Kidney Foundation 5

Hybrid therapy, which involves sequential HD followed by CRRT, may be beneficial for patients who require rapid reduction of toxins, prevention of rebound effect, or have moderate or severe encephalopathy, as recommended by the Nature Reviews Nephrology 6
For patients requiring ECMO support with CRRT, especially in neonates or those with severe hemodynamic instability, there is an increased risk of cerebrovascular events, according to the Nature Reviews Nephrology 6

The management of precipitating factors such as gastrointestinal bleeding, infection, dehydration, and electrolyte disturbances is crucial in treating uremic encephalopathy, and involves performing endoscopy, complete blood count, and stool blood tests, and treating with transfusion, endoscopic intervention, or vasoactive drugs, as recommended by Clinical and Molecular Hepatology guidelines 7
Identifying and managing infection, dehydration, and electrolyte disturbances is also important, and involves checking complete blood count, C-reactive protein, cultures, assessing skin elasticity, blood pressure, pulse rate, and monitoring serum electrolytes closely, as recommended by Clinical and Molecular Hepatology guidelines 7

In hemodynamically unstable older adults or those with cerebral edema, continuous renal replacement therapy (CRRT) is preferred over intermittent hemodialysis because it offers superior hemodynamic stability, more precise control of azotemia and fluid overload, and better support for nutritional needs. 8, 9

Discussions about patient preferences for dialysis and mechanical ventilation should occur before starting renal replacement therapy, given the high in‑hospital mortality observed in older adults with uremic encephalopathy who require dialysis. 8, 9
The decision to initiate long‑term dialysis must consider multiple factors, including baseline renal function, comorbidities, and anticipated quality‑of‑life outcomes. 8, 9
Advance‑care‑planning preferences should be revisited periodically when prolonged dialysis is anticipated. 8, 9

When oral intake is insufficient, overnight enteral tube feeding should be employed to maintain adequate nutrition while awaiting dialysis. 10
A target energy provision of approximately 35 kcal per kilogram of body weight per day is recommended for stable chronic kidney disease patients. 10
Enteral formulas should be disease‑specific—typically protein‑restricted and low in electrolytes—when nutrition is required for more than five days. 10