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Case Presentation

PMH:. CHF, RNV on 1/99 showed EF 23

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Case Presentation

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    1. Case Presentation Chief complaint: Jerking HPI: 67 y.o. A.A. male, 3 d. prior to admission awoke with oscillating, rapid, intermittent, jerking movements in his right hand and leg.

    2. PMH: CHF, RNV on 1/99 showed EF 23% CAD CRI Type II DM HTN h/o Bladder Outlet Obstruction GERD Anemia

    3. Medications ECASA Furosemide 80 bid CaCO3 1.25 tid FeSO4 325 qd Isosorbide dinitrate 20 tid Glyburide 2.5 qd

    4. Uremic Encephalopathy Tim Johnston November 5, 1999

    5. Epidemiology Usually in association with untreated renal failure Also associated with dialyzed patients More severe and rapidly progressive in those with acute deteriorations in renal fxn. Presence correlates poorly with numerical measures of uremia

    6. Pathophysiology UNKNOWN ? decreased cerebral blood flow or metabolism? ? electrolyte imbalance--autopsy studies most remarkable for much increased (2x) Calcium levels

    7. Pathophysiology, cont. Toxin accumulation inhibits synaptic transmission via GABA in test tubes ? N-terminal PTH? Vit D treatment and parathyroidectomy have normalized EEGs (most evidence seems to support this as a major factor)

    8. Clinical Characteristics VARIABILITY: over both the short and long term Mild sx: Fatigue / apathy, clumsiness, impaired concentration, ?myoclonus? Moderate sx: Emotional lability, frontal lobe dysfunction Severe sx: Delirium, hallucinations, mid-& high freq. hearing loss, agitation, stupor, coma, seizures.

    9. What is Myoclonus? Characteristics: Rapid, brief, irregular Usually multifocal and asymmetric Can be: spontaneous at rest induced by stimuli assoc. with voluntary movements

    10. M-M-M-More M-M-Myoclonus Clonus differs in that it is rhythmic and monophasic Types of myoclonus Segmental: restricted group of muscles Multiplex: widespread, lightning-like

    11. What causes myoclonus? Metabolic disorders: resp. failure, CRI, hepatic failure, electrolyte disturbance Encephalitis Epilepsy (juvenile myoclonic epilepsy) Posthypoxic intention myoclonus Creutzfeldt-Jacob Lipid storage disorders

    12. Severe Encephalopathy Seizures usually T-C, but can be focal Common neuro. signs: hyperreflexia, frontal release signs, asterixis, meningism Tremor, increased tone Asymmetry common: may even have hemiparesis, which can be alternating

    13. Laboratory Variable level of azotemia CT or MRI may show atrophy; no good studies of MRI findings in uremic encephalopathy CSF often abnormal; studies before routine dialysis: In one series, 12% of those with BUN >75mg/dL had >5 nucs / mm3 and 58% with prot >100mg/dL

    14. Laboratory, cont. EEG: Diffuse slowing! percentage of slow waves on the EEG has been proposed as a way to follow adequacy of dialysis

    15. Treatment Renal Replacement

    16. Other Neurologic Complications in Pts. with Renal Failure Dialysis disequilibrium syndrome Chronic encephalopathy Myopathy Uremic neuropathy Dialysis dementia Subdural hematoma Wernickes Encephalopathy Gangrenous calcification

    17. Dialysis Disequilibrium Syndrome Non-specific symptoms: nausea, headache, restlessness up to confusion and seizures Acute onset Starting dialysis in profoundly uremic pt. ??? Due to brain swelling from lag in osmolar shifts ??? Self-limited

    18. Chronic encephalopathy Even dialyzed patients sometimes aint quite right Sluggishness, sleep disturbances Memory / Judgment impaired Neuropsychological testing shows increased reaction time, problems with perception and learning in CAPD, HD patients alike

    19. Uremic Neuropathy Present in the majority of patients with renal failure severe enough to require dialysis or transplantation Affects axons--??Ca++; ??PTH Distal, symmetric neuropathy- sensory +/- motor, and ascending Restless legs; reflex loss Cured with transplantation; better with HD

    20. References Adams, Raymond. 1997. Principles of Neurology (6th ed.). McGraw-Hill, pp. 102-105, 722-728. Burn, DJ and Bates, D. Neurology and the Kidney. J Neurol Neurosurg Psychiatry 1998; 65:810-821. Fauci, et al. 1998. Principles of Internal Medicine. McGraw-Hill, p.114. Lockwood, Alan H. Neurologic Complications of Renal Disease. Neurologic Clinics 1989; 7(3): 617-627. Moe, S.M. and Sprague, S.M. Uremic encephalopathy. Clinical Nephrology 1994; 42(4):251-256.

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