Encefalopatia uremica in paziente in trattamento emodialitico cronico: stroke uremico? Descrizione di un caso clinico.

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Pubblicato il 9 aprile 2014

Uremic encephalopathy in regular dialysis treatment: Uremic stroke?

Michele Antonio Prencipe¹, Antonio Del Giudice¹, Giuseppe Di Giorgio¹, Filippo Aucella¹

(1) Unità operativa di Nefrologia e Dialisi Ospedale Casa Sollievo della Sofferenza IRCCS

Corrispondenza a: Michele A. Prencipe; Dirigente Nefrologo presso Ospedale "Casa Sollievo della Sofferenza", IRCCS; Viale Cappuccini, 71013 San Giovanni Rotondo (Foggia); Tel:0882 410399 Fax:0882 410208 Mail: mikprenc@libero.it

Abstract

Il presente caso descrive un insolito e complesso quadro di encefalopatia uremica dovuto a disfunzione dell’accesso vascolare. Paziente di 59 anni in terapia emodialitica regolare giunta alla nostra osservazione per alterazioni neurologiche precedute da caduta a terra e stato soporoso. La TC cranio non mostrava alterazioni cerebrovascolari e giunta presso il nostro Ospedale per approfondimenti di carattere neurologico veniva sottoposta a dialisi urgente a causa di iperkaliemia. Nel corso del trattamento si evidenziava dopo un’ora di dialisi ipokaliemia e pertanto dopo aver eseguito il prelievo al braccio contro laterale che evidenziava iperkaliemia, si provvedeva a proseguire il trattamento attraverso catetere giugulare destro posizionato in urgenza. Proseguendo il trattamento attraverso il catetere giugulare destro si assisteva a regressione della sintomatologia neurologica nei giorni successivi. Pertanto la disfunzione dell’accesso vascolare risultava essere la causa dello stroke uremico. Il suggerimento che deriva da questo caso è quello di effettuare periodicamente e con maggiore attenzione la sorveglianza dell’accesso vascolare soprattutto in paziente già sottoposti a procedure o interventi di correzione dell’accesso vascolare stesso.

Abstract

This case report a 59 years-old male in regular dialysis treatment with neurologic emergency characterized by neurologic signs as deep sopor the cause of which was uremic encephalopathy. At presentation, laboratory investigations revealed creatinine 12,75 mg/dl, BUN 174 mg/% and hyperkalemia 7,5 mq/L. The most common abnormal test results were EEG and ECG. CT brain showed no evidence of hemorrhagic areas or hematoma subdural. The patient was treated with hemodialysis and after the first hour of hemodialysis, laboratory control revealed hypokaliemia with metabolic acidosis due to arteiovenous fistula recirculation. After placement of jugular venous hemodialysis catheter and intensive treatment, the patient showed gradual improvement of uremic stroke due to arteriovenous fistula recirculation for high grade venous stenoses. Arteriovenous fistula dysfunction remains a major contributor to the morbidity and mortality of hemodialysis patients. The failure of a newly created AVF to mature and to develop stenosis in an estabilished AVF are two common clinical predicaments. The goal is to identify a dysfunctional AVF early enough to intervene in a timely manner, either to assist the maturation process or to prevent thrombosis. Most clinical features of neurologic complications in uremics are nonspecific and do not reliable, but it is important to identify specific causes such as vascular access recirculation for adequate treatment and regression of uremic stroke.

BibliografiaReferences

[1] Farrag, Sally, Abulasrar, Sarah, Mohamed et al. TLR-4:”Trojan Horse” in AKI induced encephalophaty Nephrology Dialysis transplantation. Vol 27 S 2.Pages 340-340.Maggio 2012

[2] Rob PM, Niederstadt C, Reusche E et al. Dementia in patients undergoing long-term dialysis: aetiology, differential diagnoses, epidemiology and management. CNS drugs 2001;15(9):691-9

[3] Lacerda G, Krummel T, Hirsch E et al. Neurologic presentations of renal diseases. Neurologic clinics 2010 Feb;28(1):45-59

[4] Schneditz D Recirculation, a seemingly simple concept. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association 1998 Sep;13(9):2191-3 (full text)

[5] Tordoir J, Canaud B, Haage P et al. EBPG on Vascular Access. Nephrology, dialysis,transplantation : official publication of the European Dialysis and Transplant Association-European Renal Association

[6] Stewart SF Effects of transducer, velocity, Doppler angle, and instrument settings on the accuracy of color Doppler ultrasound. Ultrasound in medicine & biology 2001 Apr;27(4):551-64

[7] Krivitski NM Theory and validation of access flow measurement by dilution technique during hemodialysis. Kidney international 1995 Jul;48(1):244-50

[8] Ronco C, Brendolan A, Crepaldi C et al. Noninvasive transcutaneous access flow measurement before and after hemodialysis: impact of hematocrit and blood pressure. Blood purification 2002;20(4):376-9

[9] Ram SJ, Magnasco A, Jones SA et al. In vivo validation of glucose pump test for measurement of hemodialysis access flow. American journal of kidney diseases : the official journal of the National Kidney Foundation 2003 Oct;42(4):752-60

[10] Mercadal L, Hamani A, Béné B et al. Determination of access blood flow from ionic dialysance: theory and validation. Kidney international 1999 Oct;56(4):1560-5 (full text)

[11] Besarab A, Frinak S, Sherman RA et al. Simplified measurement of intra-access pressure. Journal of the American Society of Nephrology : JASN 1998 Feb;9(2):284-9 (full text)

[12] Schwab SJ, Raymond JR, Saeed M et al. Prevention of hemodialysis fistula thrombosis. Early detection of venous stenoses. Kidney international 1989 Oct;36(4):707-11

[13] Basile C, Ruggieri G, Vernaglione L et al. A comparison of methods for the measurement of hemodialysis access recirculation. Journal of nephrology 2003 Nov-Dec;16(6):908-13

[14] Heather L. Gornik, Marie D. Gerhard-Herman, Sanjay Misra, Emile R. Mohler III, R. Eugene Zierler, Peripheral Vascular Ultrasound and Physiological Testing Part II: Testing for Venous Disease and Evaluation of Hemodialysis Access Technical Panel, Appropriate Use Criteria Task Force JACC Vol. 62, No. 7, 2013

[15] Chen R,Young GB. Metabolic Encephalopathies. In: Bolton, CF, Young GB, (Eds), Baillere’s. Clinical Neurology, Balliere Tindall,London 1996. p.577

[16] Vanholder R, De Smet R, Glorieux G et al. Review on uremic toxins: classification, concentration, and interindividual variability. Kidney international 2003 May;63(5):1934-43

[17] Bolton CF, Young GB. Uremic encephalopathy. In:Bolton CF, Young GB (Eds). Neurological complications of renal disease,Buttersworth,Stoneham 1990.p 44.

[18] Young GB,De Rubeis DA. In: Young GB, Ropper AH, Metabolic encephalopathies Bolton CF,(Eds).Coma and impaired conosciousness,McGraw-Hill,1998 p. 307.

[19] Bathla G, Hegde AN MRI and CT appearances in metabolic encephalopathies due to systemic diseases in adults. Clinical radiology 2013 Jun;68(6):545-54

[20] Chen R,Young GB. Metabolic Encephalopathies, In: Bolton, CF,Young GB (Eds), Baillere’s. Clinical Neurology, Balliere Tindall, London 1996.p.557

[21] Rizzo MA, Frediani F, Granata A et al. Neurological complications of hemodialysis: state of the art. Journal of nephrology 2012 Mar-Apr;25(2):170-82 (full text)

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Contenuti articolo

release 1
pubblicata il 09 aprile 2014
Da

Michele Antonio Prencipe¹, Antonio Del Giudice¹, Giuseppe Di Giorgio¹, Filippo Aucella¹

(1) Unità operativa di Nefrologia e Dialisi Ospedale Casa Sollievo della Sofferenza IRCCS

Parole chiave: encefalopatia uremica, iperkaliemia, stroke uremico, terapia emodialitica

Key words: hemodialysis, hyperkalaemia, stroke uremic, uremic encephalopathy

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