Hemodialysis in the treatment of chronic schizophrenic patients: a double-blind crossover study

Dialysis and plasmapheresis for schizophrenia: a systematic review

Increasing evidence suggests that circulating factors and immune dysfunction may contribute to the pathogenesis of schizophrenia. In particular, proinflammatory cytokines, complement and autoantibodies against CNS epitopes have recently been associated with psychosis. Related concepts in previous decades led to several clinical trials of dialysis and plasmapheresis as treatments for schizophrenia. These trials may have relevance for the current understanding of schizophrenia. We aimed to identify whether dialysis or plasmapheresis are beneficial interventions in schizophrenia. We conducted a systematic search in major electronic databases for high-quality studies (double-blinded randomised trials with sham controls) applying either haemodialysis or plasmapheresis as an intervention in patients with schizophrenia, published in English from the start of records until September 2018. We found nine studies meeting inclusion criteria, reporting on 105 patients in total who received either sham or active intervention. One out of eight studies reported a beneficial effect of haemodialysis on schizophrenia, one a detrimental effect and six no effect. The sole trial of plasmapheresis found it to be ineffective. Adverse events were reported in 23% of patients. Studies were at unclear or high risk of bias. It is unlikely that haemodialysis is a beneficial treatment in schizophrenia, although the studies were of small size and could not consider potential subgroups. Plasmapheresis was only addressed by one study and warrants further exploration as a treatment modality in schizophrenia.

[Poison in the filter: implementing detoxification procedures in schizophrenia]

In the history of psychiatry a variety of "blood detoxification" procedures have repeatedly been used to treat schizophrenic disorders under the assumption of autointoxication. In the 1970s this led to the use of dialysis. In addition to the historical classification of this therapeutic approach, particularly the protagonists active in the German Democratic Republic (GDR) as well as the dimension of research and science policy are highlighted. Despite the relatively low success rate of the treatment overall, the question of which patients actually had a positive response to the treatment arises. This seemed to primarily be the case for young patients in whom acute catatonic symptoms occurred. From today's perspective there are striking indications that the patients who were successfully treated at that time could belong to the group of autoimmune encephalitis, as they are known today. Autoimmune encephalitis and specifically anti-N-methyl-D-aspartate receptor encephalitis (NMDA-R) demonstrate a characteristic clinical progression with the frequent occurrence of psychiatric symptoms, which also include catatonic symptoms. These can occur in a variety of mental and neurological disorders but are often associated with schizophrenia. To primarily reduce the risk of diagnostic errors, they should initially be considered as non-specific from a diagnostic perspective. In the future, correlating immunological and psychopathological changes may help to delineate groups for whom specific therapies are particularly suitable.

Biological substrates of schizophrenia

Schizophrenia is increasingly believed to represent a group of organic disorders which primarily, although not exclusively, affect the central nervous system. Our purpose is to review a representative sample of twentieth-century literature which speaks to the biological substrates of the syndrome. Subjects reviewed include genetic and environmental contributions to the onset of illness, early and recent findings of gross structural anomalies, and apparent histopathological alterations in cerebral cortex, cerebellar vermis, limbic system, and brain stem, as well as problems of cerebral asymmetry. Data from a diverse group of electrophysiological studies reveal several promising correlates of these areas of investigation. Despite the inconsistent nature of the findings to date, several themes have begun to emerge, including patterns of hypofrontal/hyperparietal regional cerebral flow and glucose utilization, left hemispheric dysfunction, and deficits of interhemispheric information processing. The interpretation and significance of these emerging patterns remains unclear and must await more profound insights into the nature of normal and abnormal cerebral function.

Influence of hemodialysis on monoamine oxidase kinetics in platelets from chronic schizophrenic patients

Platelet monoamine oxidase (MAO) activity in seven chronic schizophrenic patients undergoing hemodialysis treatment was studied. The treatment was performed in a double-blind crossover design. A significant increase in MAO activity was observed after 5 h of active dialysis, whereas inactive dialysis did not significantly alter the enzyme activity. The increase in MAO activity could be explained by the observed significant decrease in apparent Km values for the amine (phenethylamine) studied. During a treatment period of 8 weeks, the MAO activity was not significantly altered with either active or sham dialysis. No relation between clinical ratings and platelet MAO activity was observed. Plasma from the seven patients was collected before and after 5 h of active or inactive dialysis and incubated with rat brain mitochondrial MAO (RBM-MAO). No difference was noted in the RBM-MAO-activity-regulating properties of the plasma sampled during either sham or active dialysis.

Chromatographic analysis of urine and dialysate from schizophrenic patients undergoing hemodialysis

Maladjustments in the central nervous system may result in altered concentrations of neuropeptides in cerebrospinal fluid and urine. Urinary protein-peptide precipitates from psychiatric patients have previously been observed to have different chromatographic profiles with regard to the ultraviolet absorbancy at 280 nm. Hemodialysis has previously been reported to improve some schizophrenic patients and has been recommended in treatment trials. Seven chronic schizophrenic patients were selected for hemodialysis in a double-blind crossover study. Specimens of 24-h urine collections were obtained the day before, the day of, and the day after active and sham dialysis. The chromatographic profiles obtained on Sephadex G-25 gel columns did not change with active dialysis. Materials with ultraviolet absorbancy at 280 nm also precipitated from dialysates and showed the same pattern following active and inactive dialysis. Thus, no biochemical evidence for removal of any pathogenetic humoral substance during hemodialysis could be provided.

Concentrations of 5-hydroxyindoleacetic acid and homovanillic acid in the cerebrospinal fluid of chronic therapy-resistant schizophrenics before and after hemodialysis therapy

The concentrations of the monoamine metabolites 5-hydroxyindoleacetic acid (5-HIAA) and homovanillic acid (HVA) have been determined by high-performance liquid chromatography in samples of lumbar cerebrospinal fluid from chronic therapy-resistant schizophrenics, both before and after either inactive or active hemodialysis for 10 weeks. A reasonable test-retest reliability was found for 5-HIAA during the inactive dialysis, but this was not found during active dialysis.

Serum lipids and lipoproteins in schizophrenic patients with normal renal function treated with hemodialysis

To study the effect of hemodialysis on serum lipids and lipoproteins, five patients with normal renal function who had undergone hemodialysis for schizophrenic symptoms for 10 weeks in a crossover study were investigated. Active or sham (no dialysate flow through the filter) dialysis was instituted randomly. Serum lipids were isolated by ultracentrifugation and precipitation before and after each period. High density lipoprotein (HDL) cholesterol levels were constantly low and correlated negatively with serum alkaline phosphatase concentrations (p less than 0.05). Serum and very low density lipoprotein (VLDL) triglycerides and VLDL cholesterol increased during active, and to a lesser extent during sham, dialysis. Dialysis of this intensity does not affect HDL. The low levels may be secondary to subclinical cholestasis from neuroleptic drug treatment. Some individuals may develop hypertriglyceridemia of unknown pathogenesis during hemodialysis. Both these lipoprotein abnormalities are risk factors for the development of atherosclerosis.

Levomepromazine elimination in patients during active and sham hemodialysis

The effect of active and sham dialysis on the plasma concentration of levomepromazine was studied in seven schizophrenic patients undergoing hemodialysis treatment in a double-blind crossover study. Samples of blood were collected before, after 2 h and 5 h of treatment, and once a week during the treatment program. The plasma concentrations decreased during both active and sham dialysis. The data indicate that there was no significant difference in the elimination of the drug between active and sham hemodialysis.