Dialysis dementia

Antipsychotics and hemodialysis: A systematic review

OBJECTIVE

Antipsychotics play a crucial role in the management of behavioral problems in patients undergoing hemodialysis. Oral and injectable antipsychotics are routinely prescribed to control emergent delirium or exacerbation of previous psychiatric symptoms. However scanty literature is available on the pharmacokinetics of antipsychotics in such patients. Avoiding amisulpride and warning against increasing the dosage in renal failure is the only recommendation by drug manufacturers and clinical guidelines. Hemodialysis affects the volume of distribution (V_d) and blood levels of antipsychotics in a complex manner. It is hence difficult to equate data on renal failure with hemodialysis to reliably predict the treatment response.

METHOD

We systematically analyzed online data from 1981 to 2019 on the use of antipsychotics in hemodialysis. The outcome was defined as the safety and efficacy of AP, measured in terms of adverse effects and relapse of existing or new onset of behavioral symptoms in Hemodialysis.

RESULTS

The data from 182 studies revealed that only 14 case reports and 1 case series met the review criteria. Oral Risperidone, Clozapine, Aripiprazole, Ziprasidone, Haloperidol, and Long-acting Risperidone, Flupenthixol, and Paliperidone were the antipsychotics studied in terms of pharmacokinetics during hemodialysis. AP levels in the blood were found to be unaffected in two studies during HD while the other two studies recommended scheduling of AP regimen w.r.t HD session. Six reports mentioned exacerbation of pre-existing psychiatric ailments in patients undergoing HD, the most common being schizophrenia.

CONCLUSION

Findings of the review reveals modest evidence favoring multiple dosing regimens of oral aripiprazole, ziprasidone, olanzapine, and risperidone. Long-acting risperidone and paliperidone are well tolerated and half of the conventional dose may be effective in the case of paliperidone. Though CYP-3A4 remains relatively and transiently unaltered during hemodialysis, none of the antipsychotics are compromised in HD. While selecting an AP during HD, one has to consider the protein binding, clearance by dialysis, duration of an HD session, route of administration of AP, and impaired bowel absorption in HD.

Multiple Causes of Dementia as Engineered Senescence

All traumas—cranial, cardiovascular, hormone, viral, bacterial, fungi, parasites, misfolded protein, genetic, behavior, environmental and medication—affect the brain. This paper itemizes studies showing the many different causes of dementia including Alzheimer’s disease. Causes interact with each other, act sequentially by preparing the optimal conditions for its successor, initiate other diseases, allow for other traumas to accumulate and degrade protective features of the brain. Since such age-related cognitive impairment is not exclusively a human attribute there might be support for an evolutionary theory of dementia. Relying on theories of antagonistic pleiotropy and polymorphism, the brain has been designed to sequester trauma. Because of increased longevity, the short-term tactic of sequestering trauma becomes a long-term liability. We are engineered to sequester these insults until a tipping point is reached. Dementia is an evolutionary trade-off for longevity. We cannot cure dementia without understanding the overall biology of aging.

The enigma of aluminum deposition in bone tissue from a patient with chronic kidney disease: a case report

About four decades ago, the relationship between dialysis-dementia and aluminum (Al) began to be established. The restriction of drugs containing Al and improvements on water quality used for dialysis resulted in the clinical disappearance of Al intoxication. However, high prevalence of Al deposition in bone tissue from Brazilian dialysis patients is still being detected. Through the case report of a patient on hemodialysis (HD) for one year, presenting significant Al deposition in bone tissue, we speculated if this problem is not being underestimated. We used extensive investigation to identify potential sources of Al exposure with a careful review of medication history and water quality controls. Al concentration was measured by different methods, including mass spectrometry, in poly-electrolyte concentrate solutions and solution for peritoneal dialysis, in an attempt to elucidate the possible sources of contamination. The objective of this case report is to alert the medical community about a potential high prevalence of Al deposition in bone tissue and to discuss the possible sources of contamination in patients with chronic kidney disease (CKD).

Advances in dialysis encephalopathy research: a review

Dialysis encephalopathy (DE) is a progressive, fatal disease with a high mortality rate. Understanding the causes of this disease and the efforts to prevent and treat it would help improve the prognosis and quality of life of affected patients. This paper reviews the etiology, clinical features, methods of examining accessory features, diagnosis, treatment, and prevention of DE. We found that DE is likely to be related to aluminum poisoning. The clinical manifestations of DE include language disorders, mental and behavioral disorders, cognitive decline, and movement disorders. Electroencephalogram (EEG) findings mainly consist of an abundance of low waves, intermittent bilateral synchronous high-amplitude spikes, and ridge waves. Assessing the clinical features and obtaining an EEG are of great value in diagnosis, and DE is treated by both reducing aluminum intake and increasing aluminum excretion. Deferoxamine (DFO) is an effective treatment for DE.

The Alzheimer pandemic: is paracetamol to blame?

HISTORICAL BACKGROUND

The clinical recognition of a form of dementia closely resembling Alzheimer's disease dates from around 1800. The role of analgesics derived from coal-tar in the spread of the pandemic is traced in terms of the introduction of phenacetin (PN) in 1887; its nephrotoxicity; the observation of lesions characteristic of the disease by Fischer and Alzheimer; the discovery of paracetamol (PA) as the major metabolite of PN; the linking of kidney injury and dementia with high PN usage; and the failure of PN replacement by PA to halt and reverse the exponential, inexorable rise in the incidence of Alzheimer-type dementia. Fischer observed his first case before Alzheimer; it is proposed to rename the syndrome Fischer-Alzheimer disease (F-AD). Disease development: PA-metabolising enzymes are localised in the synaptic areas of the frontal cortex and hippocampus, where F-AD lesions arise. The initiating chemical lesions in liver poisoning comprise covalent binding of a highly reactive product of PA metabolism to proteins; similar events are believed to occur in brain, where alterations in the antigenic profiles of cerebral proteins activate the microglia. β-Amyloid forms, and, like PA itself, induces nitric oxide synthase. Peroxynitrite modifies cerebral proteins by nitrating tyrosine residues, further challenging the microglia and exacerbating the amyloid cascade. Spontaneous reinnervation, N-acetyl cysteine administration and tyrosine supplementation may attenuate the early stages of F-AD development.

CONCLUSION

F-AD is primarily a man-made condition with PA as its principal risk factor.

Aluminum Toxicity Following IV Use of Oral Methadone Solution

BACKGROUND

Aluminum toxicity has been reported in renal failure patients exposed to aluminum-contaminated dialysate and oral phosphate binders. We report a case of significant aluminum toxicity in a non-hemodialysis patient.

CASE REPORT

A 43-year-old male IV drug user presented to the hospital with a seizure disorder of recent onset, progressive cognitive decline, ataxia, and dysarthria. The serum aluminum concentration was 180 micrograms/L (6.65 micromol/L). For 3 to 4 years prior, the patient had injected 'cooked' oral methadone. The methadone solution was heated in an aluminum pot to reduce the volume and then injected intravenously (IV). He was treated with IV deferoxamine over 9 months until he failed to return. Serum aluminum level after 9 months of treatment was 64.5 microgram/L (2.39 micromol/L). Neurological symptoms were partially improved.

CONCLUSION

Chronic IV injection of oral methadone solution heated in an aluminum-based cooking utensil may result in significant aluminum toxicity.

Core transcriptional regulatory circuitry in human embryonic stem cells

The transcription factors OCT4, SOX2, and NANOG have essential roles in early development and are required for the propagation of undifferentiated embryonic stem (ES) cells in culture. To gain insights into transcriptional regulation of human ES cells, we have identified OCT4, SOX2, and NANOG target genes using genome-scale location analysis. We found, surprisingly, that OCT4, SOX2, and NANOG co-occupy a substantial portion of their target genes. These target genes frequently encode transcription factors, many of which are developmentally important homeodomain proteins. Our data also indicate that OCT4, SOX2, and NANOG collaborate to form regulatory circuitry consisting of autoregulatory and feedforward loops. These results provide new insights into the transcriptional regulation of stem cells and reveal how OCT4, SOX2, and NANOG contribute to pluripotency and self-renewal.

Interaction of synthetic Alzheimer beta-protein-derived analogs with aqueous aluminum: a low-field 27Al NMR investigation

Synthetic peptides corresponding to the soluble Alzheimer beta-protein, i.e., beta 1-40 and beta 6-25, were utilized to investigate the association of aluminum using low-field 27Al nuclear magnetic resonance (NMR) spectroscopy and reversed-phase high-performance liquid chromatography (RP-HPLC). Addition of beta 1-40 or beta 6-25 to aqueous Al3+ gives rise to a 27Al NMR signal corresponding to the association of Al3+ with the peptides; this effect is not easily reversed by EDTA. Based on the relative intensity of the Al(3+)-peptide signal between pH 4 and 6, there are at least 4 Al3+ ions associated with each peptide molecule. Microheterogeneity is observed with RP-HPLC on incubating solutions of Al3+ with beta 1-40 and beta 6-25. The 27Al NMR spectra of chromatographically pure fractions of beta 1-40 and beta 6-25 indicate that the peptide-associated Al3+ is released below pH 3.5. We propose that soluble beta 1-40 provides an anchor for Al3+ to bind, eventually leading to an increased deposition of amyloid in the Alzheimer brain.

Neuropsychiatric consequences of renal failure

Renal failure is associated with many subtle, and several distinct, alterations in neuropsychiatric function. This review describes the clinical findings, the treatments, and the known pathophysiology of the neuropsychiatric effects of renal failure.

Psychopathology of chronic haemodialysis: is it a behavioural cognitive continuum?

Neuropsychiatric complications of chronic renal haemodialysis cover a wide gamut of clinical syndromes. These pictures can be diagnostically classified as non-psychotic and psychotic-like syndromes. On the basis of a review of the literature, some nosological precisions are formulated, and a hypothesized cognitive-behavioural psychopathological continuum is presented. The hypothesis postulates that a central cognitive disturbance, due to multiple organic aetiopathogenic factors, results in a step-wise decline, initially disguised as an affective, neurotic or personality disorder, and further deteriorating into the well-known "dialysis dementia", with a variety of other clinical presentations in between. Additional research in the biological and psychosocial areas is needed to verify different aspects of these conditions, their validity in the context of the authors' hypothesis, and their relevance to the overall "quality of life" of chronic haemodialysis patients.

The effect of nitrogen fertilization on forest blueberries

In a randomized prospective trial with hens it is shown that artificially fertilized forest blueberries are toxic. In a high dose (1.7 1/hens) the birds died within 72 hours (p less than 0.01). In a lower dose (0.33 1/hens) all survived but a lifelong change in the egg production occurred implying defects of the shells (p less than 0.0000001). It seems that fertilizers change the microflora in the ground, which releases soluble aluminiumnitrate which is absorbed in the berries. Aluminium poisoning has been found to have clinical significance in dialysis patients and probably also in senile dementia. In smaller doses it can be difficult to establish this relation as the symptoms can have a latency period of more than 10 years.

Alzheimer's disease in a patient on long-term hemodialysis: a case report

This case report describes a progressive dementia in a 49-year-old black male on long-term hemodialysis. The initial presentation simulated depression. The dementia persisted after an unsuccessful cadaver homograft transplant. The character of the dementia was nonspecific but typical features of dialysis dementia were lacking. Autopsy revealed a ruptured cerebral aneurysm, polycystic kidneys, moderately severe atherosclerosis, miliary tuberculosis, and neurofibrillary degeneration of the hippocampus. The significance of a possible relationship between end-stage renal disease (ESRD), hemodialysis, and Alzheimer's disease in this case is discussed.

The EEG in progressive dialysis encephalopathy: the EEG in diagnosing and screening for PDE. (Part. I)

An EEG study was carried out on 50 patients undergoing chronic dialysis, 5 of whom had progressive dialysis encephalopathy (PDE), with the aim of confirming the reliability of EEG for diagnosing PDE and detecting patients at risk reported in previous papers. The outcome of the study confirms the high sensitivity of EEG for these purposes.

Progressive multifocal leukoencephalopathy associated with prolonged hemodialysis treatment

The association of progressive multifocal leukoencephalopathy (PML) with prolonged hemodialysis treatment (PHT), not previously reported, was observed in a 56-year-old Japanese man who received PHT for 11 years. He suffered from recurrent bouts of fever and progressive neurological signs, such as irritability, speech disturbance, gait disturbance and dysphagia for seven months, and finally fell into a deep coma and died. Clinical signs and symptoms were highly suggestive of progressive dialysis encephalopathy. Necropsy revealed that the PML mainly involved the brainstem and cerebellar white matter. The aluminium content of the brain tissue was lower than that of controls. Possibly the virus causing PML is one of the causes of progressive dialysis encephalopathy, since clinically PML is not easily distinguished from progressive dialysis encephalopathy. It is essential to differentiate PML of viral etiology from progressive dialysis encephalopathy of unknown cause.

The prophylactic reduction of aluminium intake

The use of modern analytical methods has demonstrated that aluminium salts can be absorbed from the gut and concentrated in various human tissues, including bone, the parathyroids and brain. The neurotoxicity of aluminium has been extensively characterized in rabbits and cats, and high concentrations of aluminium have been detected in the brain tissue of patients with Alzheimer's disease. Various reports have suggested that high aluminium intakes may be harmful to some patients with bone disease or renal impairment. Fatal aluminium-induced neuropathies have been reported in patients on renal dialysis. Since there are no demonstrable consequences of aluminium deprivation, the prophylactic reduction of aluminium intake by many patients would appear prudent. In this report, the major sources of aluminium in foods and non-prescription drugs are summarized and alternative products are described. The most common foods that contain substantial amounts of aluminium-containing additives include some processed cheeses, baking powders, cake mixes, frozen doughs, pancake mixes, self-raising flours and pickled vegetables. The aluminium-containing non-prescription drugs include some antacids, buffered aspirins, antidiarrhoeal products, douches and haemorrhoidal medications. The advisability of recommending a low aluminium diet for geriatric patients is discussed in detail.

Dialysis encephalopathy and aluminum exposure: an epidemiologic analysis

We identified 55 patients with dialysis encephalopathy in six dialysis centers studied by means of a uniform clinical classification. Dialysis encephalopathy was the direct cause of death in most cases, and the disease appeared to significantly shorten survival. The overall attack rate of dialysis encephalopathy was 4% and varied among dialysis centers from 2.2% to 14.7%. In two centers with adequate data, the attack rate for dialysis encephalopathy rose significantly with increasing cumulative aluminum exposure via dialysate, and the mean cumulative aluminum exposure for patients with the disease was significantly higher than that for all other patients at risk. We further demonstrated that the cumulative level of aluminum tolerated by the patient before onset of symptoms was inversely related to the average aluminum concentration of dialysate water.

Senile plaques and tangles in dialysis dementia

The brains of 7 patients treated with hemodialysis were studied. Four of these patients had the dialysis encephalopathy syndrome (DES). Senile plaques and or neurofibrillary tangles were found in 5 of the 7 cases, 3 with and 2 without DES. One case of each group had plaques to an extent compatible with that in Alzheimer's disease, though of a different distribution. Neurofibrillary tangles were generally sparse. Plaques and tangles, both containing paired helical filaments, are the principal changes in Alzheimer's disease. Aluminum has been implicated as a possible etiologic agent behind the paired helical filaments in Alzheimer's disease, where raised cerebral aluminum contents have been demonstrated. Aluminum is known to be increased in the central nervous system also in DES, most likely as a consequence of procedures in connection with the hemodialysis. The finding of neurofibrillary tangles and senile plaques in hemodialyzed patients, some of which have developed DES, may therefore support the theories concerning aluminum as an etiological agent for cerebral changes in Alzheimer's disease.

The clinical biochemistry of aluminum

The methods for aluminum analysis vary from the simple and often nonspecific chemical and physical procedures to the highly sophisticated types such as neutron activation and atomic absorption spectrometry. Atomic absorption procedures are the techniques of choice for most routine hospital laboratories. The wide distribution of aluminum in nature can create severe contamination problems in aluminum analysis. Procedures to avoid contamination are discussed. In recent years aluminum has been implicated as a possible etiological agent in DES and in Alzheimer's Disease. A common finding in these two conditions is an elevated brain aluminum content. The patients with Alzheimer's Disease develop characteristic neurofibrillary tangles which lead to the degeneration of the affected neurons. Similar tangles can be induced in laboratory animals injected intracerebrally with aluminum salts. Even though the laboratory animals develop tangles resembling those seen in patients with Alzheimer's Disease, no evidence has been published to show that the tangles seen in Alzheimer's Disease are induced by the elevated brain aluminum content. Although there are some similar clinical symptoms in both Alzheimer's Disease and DES, the hemodialysis patients with DES do not develop neurofibrillary tangles despite an elevated brain aluminum content. The significance of this difference is not understood. The sources of the increase in tissue aluminum levels found in hemodialysis patients are from the gastrointestinal absorption of aluminum in aluminum containing phosphate-binding gels and by transfer from the dialyzate to the blood during the hemodialysis procedure. Plasma aluminum values may be reduced by the administration of a minimum dosage of phosphate-binding gels and by the use of purified water to make up the dialysate. The incidence of DES is reduced by the use of these procedures to maintain the hemodialysis patients' plasma aluminum at a low concentration. The increased brain aluminum content of patients with Alzheimer's Disease is derived from the environment. Because of the ubiquitous occurrence of aluminum, we are exposed to it daily in our food, water, and in the air. The low levels of aluminum absorbed from the environment may explain why susceptible patients do not develop Alzheimer's Disease until after many years of exposure, if indeed aluminum is the etiological agent in Alzheimer's Disease. The many papers that have been published concerning aluminum, DES, and Alzheimer's Disease make a strong case for linking elevated tissue aluminum content with these conditions. However, conclusive evidence to support this theory has not been published. Until the effect of aluminum on cellular chemistry is more fully understood, the possibility that DES and Alzheimer's Disease may result from other causes or from aluminum and another agent acting concomitantly must be considered.

Dialysis encephalopathy in a non-dialysed uraemic boy treated with aluminium hydroxide orally

Brain aluminium concentration has been found significantly higher in patients dying with dialysis encephalopathy than in uraemic patients without this syndrome, and it has previously been reported only in haemodialysed patients. We report a case of high brain aluminium concentration in a uraemic boy showing symptoms of severe encephalopathy. He was never dialysed but only treated with aluminium hydroxide orally. Baluarte reported corresponding symptoms in nondialysed uraemic children, but brain aluminium concentrations were not reported. His patients as well as our had very high levels of parathormone which may play a role in the resorption and distribution of aluminium. Aluminium preparations should be avoided in children with renal failure.

Oral aluminum and neuropsychological functioning. A study of dialysis patients receiving aluminum hydroxide gels

Nine dialysis patients with significantly increased serum-aluminum levels due to chronic ingestion of aluminum hydroxide gels and eleven dialysis patients with normal serum-aluminum levels were tested neuropsychologically for generalized functions (intelligence, reasoning, memory) and for more specific abilities (visual memory, verbal and reading fluency, manual dexterity). All tests did not reveal any significant difference in neurophyscholigical functioning between the two groups. This finding seems to indicate that oral aluminum is not neurotoxic for man, even under circumstances of renal failure. This contradicts the idea that oral aluminum plays a role in etiology of dialysis dementia. However, the possibility cannot be excluded that aluminum overload in the present sample was not sufficient to induce changes in CNS functioning. Thus, until the importance of oral aluminum has been decided, it seems wise to keep all sorces of aluminum overload as low as possible.

Psychological measurement of memory deficits in dialysis patients

In light of recent research on "dialysis dementia," two questions were raised: (1) Is such dementia an all-or-none phenomenon or is it distributed in severity throughout the population of dialysis patients? (2) Is the dementia related to the uremia itself or to some aspect of dialysis? Memory decline was used as the operational definition of dementia. The Russell revision of the Wechsler Memory Scale was used to measure short- and long-term semantic and figural memory. Results suggested that both semantic and figural memory disturbances were distributed in varying degrees throughout the population of dialysis patients (n = 28). Further findings suggested that figural memory functioning was negatively correlated with the number of dialysis sessions and with the amount of time elapsed since the first dialysis session. Suggestions are made for further research and clinical considerations.

Progressive dialysis encephalopathy ("dialysis dementia")

Sixty cases of distinctive progressive and fatal encephalopathy have been reported in patients undergoing long-term hemodialysis. An analysis of their records reveals that mean duration of hemodialysis prior to onset is 2.5 years, while mean duration of clinical course until death is 6.3 months. The most frequent clinical manifestations include disturbances in communication (87%), cognition (66%) and movement (93%). Nonspecific electroencephalographic abnormalities are present in all cases. The condition is possibly related to some yet unidentified metabolic disorder. There is no effective therapy.

Progressive dialysis encephalopathy

The clinical features of 42 patients with the only recently recognized and generally fatal neurological syndrome of progressive dialysis encephalopathy are reviewed and the electroencephalographic and neuropathological findings are summarized. Despite apparently successful hemodialysis, these patients develop a wide spectrum of neurological abnormalities. Of these, sudden onset of hesitant, nonfluent speech is the most characteristic and usually the earliest sign. Both dysphasic and dysarthritic elements are found, though the former predominate. Myoclonus, dementia, seizures, and gait difficulty are also seen in the majority of these patients. EEGs are more abnormal than would be expected for the clinical severity, with some type of high-voltage spike-wave pattern intermixed with abundant slow activity. The combination of clinical and EEG features in the appropriate setting is virtually diagnostic. Transient episodes with variable periods of complete or partial remission have been recognized. Neuropathological changes are surprisingly mild and nonspecific. The cause is uncertain; current speculation focuses on aluminum as the offending neurotoxin. Treatment remains unsatisfactory.

Intellectual impairment in chronic renal failure

In a dialysis centre with a high tap water aluminium content and a known high incidence of dialysis encephalopathy, 29 patients undertaking regular home dialysis, without clinical evidence of encephalopathy, were studied with a battery of psychological tests that have proved useful in detecting early organic intellectual deterioration in other conditions. Full-scale intelligence quotient, as measured by the Wechsler Adult Intelligence Scale, did not differ significantly from that of the normal population, but the patients showed significant deficiencies in three tests of performance--namely, digit symbol, block design, and picture arrangement. The ability to acquire new information in relation to performance was impaired and the abnormality increased with time on dialysis. Such tests should be useful in early detection of dialysis dementia at a reversible stage.

Electroencephalographic and radionuclide studies in dialysis dementia

Six maintenance hemodialysis patients with dialysis dementia (severe mental deterioration, speech disturbances, apraxia, facial grimacing, and myoclonus) were studied. They were matched with respect to age, duration of dialysis, and underlying renal disease with six patients who had no dementia and who acted as controls for the electroencephalographic (EEC) studies. The dementia patients had marked slowing of the EEG rhythm to 5--7 Hz with high voltage biphasic or triphasic spikes, and were clearly separated by frequency distribution analysis from the controls. Radio-iodinated serum albumin (RISA) cisternography in dementia patients demonstrated ventricular reflux, prolonged stasis, late appearance of the parasagittal strip, and persistence of RISA for up to 72--96 hr, which suggest an alteration in cerebrospinal fluid (CSF) dynamics.

Dialysis dementia -- the Chicago experience

In the four years between 1972 and 1976 twenty out of 160 maintenance dialysis patients developed dialysis dementia. Their illness was characterized by an insidious onset of mental deterioration, speech disturbance, apraxia, and myoclonus. The disease progressed inexorably to a fatal outcome, the onset of seizures being an ominous sign, and the average duration of the illness being seven months. Routine biochemical studies were unremarkable, and osteodystrophy was not a prominent feature. Serial electroencephalograms (EEG) showed progressive slowing of the rhythm, usually antedating the neurologic symptoms. Brain scan and flow studies were normal. Radio-iodinated serum albumin (RISA) scans in seven patients showed changes suggesting altered cerebrospinal fluid (CSF) dynamics. Treatment was generally ineffective, but ventriculo-peritoneal shunting produced transient neurologic improvement in one patient. Epidemiologic investigations showed high aluminum levels in city water during the period of the outbreak.

An outbreak of dialysis dementia due to aluminum in the dialysate

The dialysis dementia syndrome was observed in eight of 21 patients dialyzed in a small center during a 22-month period in which dialysate contained aluminum levels of 618 microgram/liter. This incidence of 38% was significantly higher than the zero incidence of four prior years when no aluminum was added to city water (p less than 0.05) and also when compared to the zero incidence in the 2.5 years subsequent to deionization of dialysis water which lowered its aluminum content to less than 1 microgram/liter (p less than 0.0002). Since other factors were not altered, we conclude that aluminum intoxication from the dialysate was the cause for the outbreak of this progressive encephalopathy.

Psychosis and pseudo dementia associated with hemodialysis

A patient treated with hemodialysis developed psychotic episodes, including visual hallucinations and delusions, as well as symptoms similar to the fatal dialysis dementia. His hospital course seems to demonstrate an original organic dysfunction with behavioral sequelae that were perpetuated by psychological difficulties. His tendency to overdramatize his disability and to adopt an excessively helpless and passive role made treatment difficult. A one-year followup is provided along with a discussion of the relationship of his case to dialysis dementia.

Drug-induced encephalopathy in patients on maintenance haemodialysis

In five patients who had been on chronic maintenance haemodialysis for more than eight months a syndrome involving altered consciousness, asterixis, and abnormal electroencephalogram developed after they had been given flurazepam and diazepam. All five patients were adequately treated by haemodialysis. Hepatic, pulmonary, and cardiac decompensation were not present. The encephalopathy and other abnormalities cleared when the drugs were withdrawn. Symptoms were also produced by accidental rechallenge.

Progressive dialytic encephalopathy

A subacutely progressive dialytic encephalopathy lasting for three to 15 months in 11 patients who had been on haemodialysis for 14 to 36 months was characterized by dementia, language disorder, myoclonic jerks, behavioural disturbance, distinctive EEG abnormalities, and normal or nonspecific neuropathological findings.