Mental disorders associated with kidney disease
Introduction
Introduction to mental disorders associated with kidney disease Mental disorders associated with kidney disease refer to acute, chronic renal insufficiency and renal encephalopathy caused by various kidney diseases, and include the spirit of dysfunction, renal impairment, depression, and neurasthenia syndrome. Disorders and neurological symptoms, nephro-encephalopathy, also known as uremic encephalopathy, refers to mental disorders associated with renal failure in various kidney diseases. Mostly caused by chronic glomerulonephritis, chronic pyelonephritis and renal arteriosclerosis, a small number of acute renal failure caused by shock, complete urinary tract obstruction. basic knowledge The proportion of illness: 0.001% Susceptible people: no special people Mode of infection: non-infectious Complications: neurasthenia, anxiety
Cause
Causes of mental disorders associated with kidney disease
Toxin savings said (20%):
The kidney is the main excretory organ of the body. When it is uremia, its function is impaired, resulting in the accumulation of toxins in the body, such as non-protein nitrogen and other toxic substances on the central nervous system. Among them, the concentration of phenolic compounds is closely related, urea and The increase of uric acid often makes uremia worse, but it is suggested that the increase of urea alone is difficult to explain the relationship between mental disorder and uremia. In recent years, it has been suggested that the retention of intramolecular or low molecular toxic substances in blood is related to the mental disorder of uremia.
Brain metabolic disorders (29%):
It has been found that cerebral blood flow does not decrease in renal encephalopathy, but brain dysfunction caused by brain oxygen metabolism caused by decreased brain oxygen consumption, and it is considered to be related to the occurrence of disturbance of consciousness.
Electrolyte metabolism disorder (15%):
When suffering from renal encephalopathy due to dehydration, low sodium, low calcium and high potassium, high magnesium, acidosis and balance between blood and cerebrospinal fluid, causing brain fluid metabolism and acid-base balance disorder caused by brain edema leading to brain dysfunction, brain dysfunction It is related to the occurrence of disturbance of consciousness and other mental and neurological symptoms. Others include cerebral vascular cell membrane permeability abnormalities, metabolic poisoning, and neurotransmitter metabolic disorders.
In short, renal encephalopathy, or uremic encephalopathy, is caused by a variety of causes, mainly due to nitrogen retention, showing severe mental disorders and neurological symptoms, most of which are chronic renal failure due to various chronic kidney diseases. A small number may be caused by acute renal failure due to blood loss, shock or complete urinary tract obstruction.
Pathogenesis (15%):
The pathogenesis has not been fully elucidated, and there are several theories.
1. Blood-brain barrier disorder: During the dialysis process, the concentration of urea nitrogen in the blood drops sharply and the blood urea nitrogen in the cerebrospinal fluid and brain tissue decreases slowly. The osmotic pressure of the cerebrospinal fluid is higher than the blood osmotic pressure, which eventually causes the increase of intracranial pressure and cerebral edema. Mental disorders, according to Prill's study, the urea in the cerebrospinal fluid before dialysis is 85% to 95% of the blood urea, and the urea in the cerebrospinal fluid after dialysis is 200% of the urea in the blood.
2. Other triggering factors:
(1) Somatic comorbidities: such as atherosclerosis, heart and liver diseases can promote the occurrence and aggravation of mental disorders.
(2) Electrolyte disorders: blood sodium, blood potassium levels, dehydration, decreased blood circulation, blood pressure changes, etc. have certain effects.
(3) Aluminum accumulation: It has been reported that renal failure, especially dialysis encephalopathy and dementia status is related to aluminum poisoning.
(4) Psychological factors: Because of long-term psychological stress, depression, anxiety, fear and trouble are easy to generate, and then mental disorders are triggered.
Prevention
Prevention of mental disorders associated with kidney disease
Early diagnosis, early treatment, active prevention, protection of our kidneys, once suffering from chronic nephritis, the patient's hematuria, proteinuria generally does not completely disappear in a short period of time, treatment is a long-term process, the purpose is to improve clinical symptoms, prevent Serious complications, protection of kidney function, delay of glomerular sclerosis, build confidence, maintain a good mentality, cooperate with doctors, and implement comprehensive treatment based on rest, diet and drugs.
Pay attention to rest: patients with edema, high blood pressure, and renal insufficiency should take more rest, but this is not to say that they must be absolutely bedridden. They can properly engage in some minor activities. Without obvious edema, patients with high blood pressure can participate in general activities, but Strenuous exercise should be avoided.
Scientific diet: The kidney is most taboo salt, the diet is light and the kidney is healthy. The salt has the greatest damage to the kidney and liver of the human body. When eating, it is necessary to reduce the salt intake. The diet of patients with nephritis must first limit salt, edema, hypertension, kidney. Incomplete function is about 2 ~ 3g / d, do not eat more alkaline and pickled foods, MSG, etc., secondly, should control protein intake, chronic nephritis in patients with renal insufficiency, should be restricted according to the condition of kidney function The intake of protein is generally 30 ~ 40g / d [0.6 ~ 0.8g / (kg · d)], while the diet should pay more attention to the quality of protein (such as eggs, milk, lean meat, etc.) to supplement the body's necessary Amino acids, such as patients with normal renal function, while the amount of urine protein can be more appropriate to relax protein intake, but it is best not to exceed 1 gram per kilogram of body weight per day, while low protein diet, can increase carbohydrate intake, Eat more fruits and vegetables, pay attention to supplement the essential vitamins.
Proper medication: It should be closely coordinated with the doctor, follow the doctor's advice, adhere to the medication, do not reduce the amount, change the medicine and stop the drug. This is especially important for patients who use hormones and cytotoxic drugs. Otherwise, it may lead to worsening of the disease or With serious consequences, Professor Li Ying reminded patients not to blindly follow the propaganda of certain drugs and use drugs on their own to avoid aggravating the condition.
Regular check: Regular review of blood, urine routine, 24h urine protein quantitation, serum creatinine, muscle liver clearance and other indicators to observe the progress of renal lesions.
Prevention of infection: infection is often aggravation of chronic nephritis or a sharp deterioration of renal function, so pay attention to prevent infection, adjust immune function is essential, common infections have respiratory infections, followed by digestive tract, urinary system, skin soft tissue and other parts Infection, women should pay attention to the infection of the reproductive system, try to go to public places as much as possible, pay attention to diet and personal hygiene, and use antibiotics reasonably when treating infections, and avoid the use of nephrotoxic drugs such as aminoglycosides and sulfa antibiotics.
Control blood pressure: Hypertension is an important factor in accelerating glomerular sclerosis and promoting renal function deterioration. Active control of hypertension is an important link. According to the patient's urine protein, the requirements for blood pressure control are different. For 24h urine protein quantification Patients with 1.0 g should control blood pressure <130/80 mmHg; patients with 24-hour urine protein quantitation >1.0 g should have stricter blood pressure control and should be <125/75 mmHg.
Pulmonary patients should do psychological work before dialysis treatment, if necessary, can do psychological treatment to obtain the patient's cooperation; should pay attention to the treatment of physical complications; when choosing dialysis patients, it is best to choose to retain certain renal function The blood urea nitrogen should not exceed 35.7mmol / L, the control dialysis time should be 4h each time, the dialysate sodium concentration can be appropriately increased to 140mmol / L.
Complication
Complications of mental disorders associated with kidney disease Complications, neurasthenia, anxiety
The neurasthenic syndrome often appears or aggravates after dialysis, often transient; anxiety and depression, with anxiety as the main fear and depression; personality changes and mild mental retardation, these symptoms often in the recovery of renal function after dialysis occur. Irritability, excitement, impulsiveness, inconsistency, etc. Some patients may also have hallucinations and delusions or manic-like manifestations, and some may have a stupor state. These symptoms are mostly paroxysmal and can also alternate with lethargy. appear.
Symptom
Symptoms of mental disorders associated with kidney disease Common symptoms Impulsive disorder Nitrogenemia Inattention Discomfort Uneasy mental disorder Orientation disorder Responsive retardation Anxiety Nausea disturbance
1. Psychiatric symptoms: neurasthenic syndrome, mostly initial symptoms, often appear in the early stage of renal failure and hyperazotemia; depression is a mixed manifestation of depression and anxiety; disturbance of consciousness, from lethargy, to coma Migration; some present a stupor state, called uremic coma or renal coma; dementia state, often occurs in chronic renal failure.
(1) cerebral weakness syndrome: mostly occurs in the early symptoms of uremia, often in the early stage of renal failure and hyperammonemia, poor performance, dullness, low speech, memory loss, decreased interest, lack of concentration, Symptoms such as insomnia and sleep inversion.
(2) disturbance of consciousness: early manifestation of lethargy, with the development of the disease, when the renal failure is severe, gradually transition from a shallow coma to a deep coma, called uremic coma or renal coma.
(3) Insanity: Most cases occur when accompanied by hypertensive encephalopathy or infection, irritability, excitement, impulsiveness, inconsistency, etc. Some patients may also have hallucinations and delusions or madness. The stupid state may occur, and the above symptoms are mostly paroxysmal, and may also alternate with lethargy.
(4) Dementia syndrome: Patients with chronic progressive renal failure may have memory loss, poor thinking, personality changes and intellectual disabilities.
2. Neurological symptoms: epileptiform bursts are common, and common neuritis, flapping tremor and hand and foot snoring, cranial nerve damage signs, facial paralysis, nystagmus, pupillary changes, vision and/or hearing impairment, reflexes are slow or dull, meningeal irritation and pyramidal tract signs, cerebellar symptoms, limb paralysis and so on.
3. Symptoms: Mental disorder is the first symptom of renal encephalopathy, and it is more common than neurological symptoms. Once it appears as an early symbol of renal encephalopathy, it is also one of the indicators for the efficacy and prognosis of uremia; the spirit of renal encephalopathy The symptoms are highly volatile throughout the course of the disease. Several mental symptoms are often intertwined, complicated, and often recurrent.
4. Mental disorders associated with acute renal insufficiency dialysis:
(1) Mental disorder: neurasthenic syndrome, often at the beginning of the disease, often transient; depression, mixed with depression and anxiety, with anxiety as the main, accompanied by fear; excited state, excitement, agitation, Irritable, restless, etc.; disturbance of consciousness, sleepiness, lethargy or paralysis, confusion, etc.; personality changes and mild mental decline.
(2) neurological symptoms: headache, nausea, vomiting more common, other flapping tremor, myoclonus, epileptic seizures, etc., occasionally subdural hematoma, subarachnoid hemorrhage, brain parenchymal hemorrhage, etc. .
Balanced imbalance syndrome refers to mental disorders associated with acute renal insufficiency. In the case of mental disorders and neurological symptoms in dialysis or hours after dialysis termination, there is significant hyperazoemia or acidosis in the balance disorder syndrome. Cases occur more often, usually 3 to 4 hours after treatment, manifested as lethargy, headache, malignant, vomiting, seizures, excitement and even coma, symptoms can be alleviated or disappeared 1 to 2 days after the end of treatment, some people It is believed that if dialysis is carried out slowly, the intrinsic occurrence can be prevented.
Progressive dialysis encephalopathy, also known as dialysis dementia, often occurs in patients who have undergone dialysis for a long time. After dialysis, there is a continuous mental disorder that is mainly dementia. The mental symptoms are suppressed (less movement, ignorance, loneliness, coldness, Don't care about the surroundings, lack of desire, etc.); dementia status (nearly forgotten, disorientation, loss of computation, lack of thinking, etc.); personality change (irritability, lack of courtesy, shame, morality, etc.); Listen, illusion, but unconscious obstacles.
5. Chronic renal insufficiency with dialysis associated with mental disorders:
(1) Mental disorders: neurasthenic syndromes often appear or aggravate after dialysis, often transient; anxiety and depression, with anxiety mainly accompanied by fear and depression; personality changes and mild mental retardation, etc. The recovery period of renal function occurs after dialysis.
(2) Neurological symptoms: headache, nausea, vomiting, flapping tremor, myoclonus, occasional epileptic seizures.
6. Dialysis encephalopathy: Dialysis encephalopathy refers to a long-term persistent dementia-related mental disorder after kidney disease.
(1) Psychiatric symptoms: Depressive state: less movement, ignorance, loneliness, coldness, no concern about the surrounding, lack of desire, etc.; dementia status: obvious oblivion, poor orientation, poor calculation, lack of thinking, etc.; personality change: Irritability, lack of courtesy, shamelessness, etc.; occasionally there may be auditory hallucinations, illusions, but unconscious obstacles.
(2) neurological symptoms: epileptic seizures, tremors, myoclonus and so on.
Examine
Examination of mental disorders associated with kidney disease
A positive change in laboratory tests for primary kidney disease.
EEG sees the slowing of the basic rhythm, the increase of slow wave rhythm, paroxysmal synchronous slow wave on both sides, rhythm inhibition and diffuse high amplitude slow wave, even in the frontotemporal main paroxysmal slow wave, epilepsy Sexual attack waves, excessive ventilation test often increase the slow wave, the deeper the consciousness disorder of renal encephalopathy, the more obvious the EEG changes, the wave can appear when the consciousness disorder is obvious, the severity of EEG changes Can be used as a marker of the degree of renal encephalopathy.
When dialysis, EEG can see symmetrical high-amplitude rhythmic wave group, the basic amplitude is increased, irregular slow wave, wave is reduced, and sharp waves are also seen. Spike waves appear. It is easy for patients with abnormal EEG before dialysis. Slow wave formation occurs. This EEG change can be seen 3 hours after dialysis, and the dialysis can be restored to the state before dialysis after 1-2 days.
Diagnosis
Diagnosis and diagnosis of mental disorders associated with kidney disease
Diagnostic criteria:
On the basis of the diagnosis of renal failure, if you find fatigue, weakness, ignorance, less movement, slow response and other mental activities, you should consider the early mental symptoms of renal failure, such as drowsiness, lethargy, convulsions or euphoria, depression With flapping tremors, epileptic seizures, etc., after considering other factors, kidney encephalopathy may be considered.
1. Have a clear history of kidney disease: positive signs of symptoms, signs and laboratory tests of renal failure; mental symptoms with disturbance of consciousness are consistent with changes in renal failure.
2. On the basis of diagnosis of severe renal failure, if fatigue, weakness, lack of movement, ignorance, unresponsiveness and other mental activities are found, and blood non-protein nitrogen and carbon dioxide binding are increased, it should be considered early in renal failure. Symbolic possibility.
2. Drowsiness, lethargy, convulsions or euphoria, depression and flapping tremors, epileptic seizures.
3. After the exclusion of other factors caused by mental disorders, the diagnosis of renal encephalopathy can be established.
4. If necessary, combine EEG changes, and participate in indicators such as increased blood non-protein nitrogen and carbon dioxide binding.
5. Has been diagnosed with renal insufficiency, and has a history of hemodialysis or peritoneal dialysis. On the basis of dialysis, if depression, anxiety or less movement, ignorance, and coldness can be considered as early signs of mental disorders, once found Hemorrhoids or confusion, flapping tremors, epileptic seizures should be considered as a balance disorder syndrome associated with dialysis, but must be excluded from other factors caused by mental disorders, accompanied by EEG changes.
Differential diagnosis:
It should be differentiated from mental disorders caused by heart, lung and liver diseases, differential diagnosis of primary disease, and mental disorders caused by other causes.
