Mental disorders associated with kidney diseases

　　1. Etiology

　　The etiology of mental disorders caused by uremia is not yet fully clear. The basic change is caused by metabolic disorders of neurons, and there are roughly the following possible theories:

　　1. Accumulation of Toxins Theory:The kidneys are the main excretory organs of the body. During uremia, their function is impaired, leading to the accumulation of toxins in the body, such as non-protein nitrogen and other toxic substances, which have a toxic effect on the central nervous system, with guanidine and phenolic compounds closely related to the concentration. The increase in urea and uric acid often exacerbates uremia, but some people propose that an increase in urea alone is difficult to explain the relationship between mental disorders and uremia. In recent years, some people have proposed that the retention of middle or low molecular weight toxic substances in the blood is related to the mental disorders of uremia.

　　2. Brain Metabolic Disorders:It is found that when renal encephalopathy is discovered, the cerebral blood flow does not decrease, but is caused by a decrease in brain oxygen consumption, leading to brain metabolic disorders and abnormal brain function, and it is believed that this is related to the occurrence of consciousness disorders.

　　3. Electrolyte metabolism disorder:When renal encephalopathy occurs, due to dehydration, low sodium, low calcium, high potassium, high magnesium, acidosis, and imbalances between blood and cerebrospinal fluid, fluid metabolism and acid-base balance are disturbed, leading to brain edema and brain dysfunction. Brain dysfunction is related to the occurrence of consciousness disorders and other mental and neurological symptoms. Other theories include abnormal permeability of blood vessel cell membranes, metabolic poisoning, and neurotransmitter metabolism disorders.

　　In summary, renal encephalopathy or uremic encephalopathy is a serious mental disorder and neurological symptom caused by various reasons, mainly characterized by nitrogen retention. The vast majority of them are caused by chronic renal failure due to various chronic kidney diseases, and a few can be caused by acute renal failure due to bleeding, shock, or complete urinary tract obstruction.

　　2. Pathogenesis

　　The pathogenesis has not been fully elucidated, and there are several theories.

　　1. Blood-brain barrier barrier theory:During dialysis, the concentration of blood urea nitrogen decreases sharply, while the concentration of blood urea nitrogen in cerebrospinal fluid and brain tissue decreases slowly. The osmotic pressure of cerebrospinal fluid is higher than that of blood, leading to increased intracranial pressure and brain edema, resulting in mental disorders. According to Prill's research, the concentration of urea in cerebrospinal fluid before dialysis is 85% to 95% of the blood urea, and the concentration of urea in cerebrospinal fluid after dialysis is 200% of the blood urea.

　　2. Other triggering factors

　　(1) Physical complications: Such as atherosclerosis, heart and liver diseases can promote the occurrence and exacerbation of mental disorders.

　　(2) Electrolyte disorder: The decline in blood sodium and potassium levels, dehydration, reduced blood circulation volume, and blood pressure changes have a certain impact.

　　(3) Aluminum accumulation: Some reports indicate renal failure. Especially dialysis encephalopathy and demented state are related to aluminum poisoning.

　　(4) Psychological factors: Due to long-term exposure to psychological stress, depression, anxiety, fear, and distress are likely to occur, which subsequently trigger mental disorders.

　　Neurasthenic syndrome often appears or worsens after dialysis, usually transient; anxiety and depression state, mainly anxiety accompanied by fear and depression; personality changes and mild intellectual decline, etc., these symptoms often occur during the renal function recovery period after dialysis. Restlessness, excitement, noisy, impulsive destruction of property, incoherent thinking, and some patients may also appear hallucinations and delusions or manic-like manifestations, some may appear akinetic state, the above symptoms are often sporadic, can also alternate with drowsiness.

　　1. Psychotic symptoms:Neurasthenic syndrome, mostly initial symptoms, often appears in the pre-stage of renal failure and hyper-nitrogenemia; depressive state, a mixed manifestation of depression and anxiety; disturbance of consciousness, from drowsiness to delirium and then to coma; some present with a akinetic state, known as uremic coma or renal coma; demented state, often occurs in chronic renal failure.

　　1. Encephalopathic syndrome:It often occurs in the early symptoms of uremia, commonly appearing in the pre-stage of renal failure and hyper-nitrogenemia, with symptoms such as fatigue, dullness, lack of speech and movement, decreased memory, reduced interest, inattention, insomnia, and reversed sleep patterns.

　　2. Consciousness disorders:In the initial stage, it is characterized by somnolence, and as the condition worsens, with severe renal failure, it gradually transitions from superficial coma to deep coma, known as uremic coma or renal coma.

　　3. Confusion state:It often occurs in patients with hypertensive encephalopathy or infection, manifesting as restlessness, excitement, disruptive behavior, incoherent thinking, etc. Some patients may also experience hallucinations and delusions or manic-like symptoms. Some may appear a catatonic state. These symptoms are often episodic and may alternate with somnolence.

　　4. Dementia syndrome:During the stage of chronic progressive renal failure, patients may experience memory decline, intellectual poverty, personality changes, and intellectual disabilities.

　　2. Neurological symptoms:Epileptic seizures are common, and symptoms such as neuritis, winged scissor tremors, and tetany are also common. There are cranial nerve injury signs, facial paralysis, nystagmus, changes in pupils, visual and (or) hearing impairment, hyperactive or hyporeflexive Achilles reflexes, meningeal irritation signs, and corticospinal tract signs. There are also symptoms of the cerebellum and paralysis of limbs.

　　3. Characteristics of symptoms:Mental disorders are the initial symptoms of renal encephalopathy and are more common than neurological symptoms. Once they appear, they can serve as an early sign of renal encephalopathy and are also one of the indicators for the efficacy and prognosis of uremia. The symptoms of mental disorders in renal encephalopathy are often fluctuating throughout the course of the disease, with several mental symptoms often intertwined and complex, and there is a tendency for recurrent attacks.

　　4. Mental disorders associated with acute renal insufficiency dialysis

　　1. Mental disorders:Neurasthenia syndrome often appears in the early stage of the disease and is usually transient. Depression is characterized by a mixture of depression and anxiety, with anxiety as the main symptom, accompanied by fear. Excitement state includes excitement, restlessness, irritability, and anxiety. Consciousness disorders include somnolence, drowsiness, or delirium, and disoriented states. Personality changes and mild intellectual decline may also occur.

　　2. Neurological symptoms:Common symptoms include headache, nausea, and vomiting. Other symptoms include winged scissor tremors, muscle jerks, and convulsive seizures. Occasionally, subdural hematoma, subarachnoid hemorrhage, and intracerebral hemorrhage may occur.

　　Dysbalance syndrome refers to mental disorders and neurological symptoms associated with acute renal insufficiency that appear within a few hours after dialysis or after the termination of dialysis. In cases of dysbalance syndrome, there are often cases with明显high nitrogenemia or acidosis. Generally, symptoms appear 3 to 4 hours after treatment, manifesting as somnolence, headache, nausea, vomiting, seizures, excitement, anxiety, and even coma. Symptoms may subside or disappear within 1 to 2 days after treatment. Some believe that if dialysis is performed slowly, it can prevent the occurrence of this syndrome.

　　Progressive dialytic encephalopathy, also known as dialytic dementia, often occurs in patients with long-term dialysis, presenting with persistent mental and neurological disorders characterized by dementia, including depressive states (such as hypoactivity, apathy, loneliness, indifference, lack of interest in surroundings, etc.); dementia states (such as forgetfulness of recent events, disorientation, impaired calculation ability, poverty of thought, etc.); personality changes (such as irritability, lack of politeness, shame, and morality, etc.); occasionally, there may be auditory and visual hallucinations, but without disturbance of consciousness.

　　Fifth, mental disorders associated with chronic renal insufficiency dialysis

　　1. Mental disorders:Neurotic syndrome often appears or worsens after dialysis and is usually transient; anxiety and depression state, mainly anxiety accompanied by fear and depression; personality change and mild intellectual decline, etc. These symptoms often occur during the renal function recovery period after dialysis.

　　2. Neurological symptoms:Headache, nausea, vomiting, flapping tremors, myoclonus, occasional epileptic spasms, etc.

　　Sixth, dialysis encephalopathy:Dialysis encephalopathy refers to long-lasting mental disorders mainly characterized by dementia that occur after dialysis in patients with kidney disease.

　　1. Psychotic symptoms:Depressive state: less movement, less talkative, lonely, indifferent, not caring about the surroundings, lack of desire, etc.; dementia state: obvious forgetfulness of recent events, poor orientation, poor calculation, lack of thinking, etc.; personality change: easily irritable, lacking politeness, shameless, etc.; occasionally, auditory and visual hallucinations may occur, but without consciousness disturbance.

　　2. Neurological symptoms:Epileptic spasms, tremors, myoclonus, etc.

　　1. Early diagnosis, early treatment, active prevention, and protection of our kidneys.Once a patient is diagnosed with chronic nephritis, hematuria and proteinuria usually will not completely disappear in the short term. Treatment is a long-term process, aiming to improve clinical symptoms, prevent severe complications, protect renal function, and delay glomerulosclerosis. It is important to maintain confidence, keep a good attitude, cooperate with the doctor, and implement comprehensive treatment with rest, diet, and medication as the mainstay.

　　2. Pay attention to rest:Patients with edema, hypertension, and renal insufficiency should rest more, but this does not mean they should be bedridden absolutely. They can engage in some mild activities. Patients without obvious edema or hypertension can participate in general activities but should avoid strenuous exercise.

　　3. Scientific diet:The kidneys are most忌讳 salt, and a light diet is good for kidney health. Salt causes the greatest damage to the human kidney and liver, so it is important to reduce salt intake when eating. The diet of patients with nephritis should first limit salt intake, about 2-3g/d for edema, hypertension, and renal insufficiency. Avoid foods high in alkali and preserved foods, monosodium glutamate, etc. Secondly, protein intake should be controlled. In patients with chronic nephritis and renal insufficiency, the intake of protein in food should be limited according to the condition of renal function, generally 30-40g/d [0.6-0.8g/(kg·d)], and pay attention to providing high-quality protein (such as eggs, milk, lean meat, etc.) in the diet to supplement the essential amino acids in the body. If the patient's renal function is normal but the amount of urinary protein is high, the protein intake can be appropriately increased, but it is best not to exceed 1 gram per kilogram of body weight per day. At the same time, appropriate increase in carbohydrate intake can be made while on a low-protein diet, eat more vegetables and fruits, and pay attention to supplementing the necessary vitamins for the human body.

　　4. Proper medication use:Close cooperation with the doctor is essential, follow medical advice, persist in medication, and do not arbitrarily reduce dosage, change medication, or discontinue medication. This is particularly important for patients using hormone and cytotoxic drugs, as failure to do so may lead to deterioration of the condition or severe consequences. Professor Li Ying especially reminds patients not to blindly follow the promotion of certain drugs and use them arbitrarily, which may worsen the condition.

　　5. Regular check-ups:Regularly review blood and urine routine tests, 24-hour urine protein quantification, serum creatinine, and glomerular filtration rate, etc., to observe the progression of renal lesions.

　　6. Prevention of infection:Infection is often a factor that aggravates chronic nephritis or causes a rapid deterioration of renal function, therefore, it is crucial to prevent infection and adjust immune function. Common infections include respiratory infections, followed by infections in the digestive tract, urinary system, skin and soft tissue, and women should pay attention to reproductive system infections. Try to minimize visits to public places, and pay attention to diet and personal hygiene. When treating infections, antibiotics should be used rationally, and nephrotoxic drugs such as aminoglycosides and sulfonamide antibiotics should be avoided.

　　7. Control blood pressure:Hypertension is an important factor that accelerates glomerulosclerosis and promotes the deterioration of renal function. It is very important to actively control hypertension. The requirements for blood pressure control are different according to the patient's urine protein level. For patients with 24-hour urine protein excretion ≤ 1.0 gram, blood pressure control should be controlled. For patients with a 24-hour urine protein excretion of 1.0 gram, blood pressure control should be stricter, and it should

　　For patients undergoing dialysis, psychological work should be done before dialysis treatment, and psychological treatment can be done if necessary to obtain the patient's cooperation; attention should be paid to the treatment of somatic complications; when selecting dialysis patients, it is best to select those who still have some renal function, and the blood urea nitrogen should not exceed 35.7mmol/L. The dialysis time should be controlled at about 4 hours each time. The sodium concentration of the dialysate can be appropriately increased to 140mmol/L.

　　Conform to the positive changes in the laboratory examination of the primary kidney disease.

　　The EEG shows a slowing of the basic rhythm, an increase in slow wave rhythm, bilateral synchronous periodic slow waves, suppression of alpha rhythm, and diffuse high-amplitude slow waves. Occasional发作性 slow waves in the frontal-temporal area can be seen, as well as seizures. The overbreathing test often causes an increase in slow waves. As the consciousness disorder of renal encephalopathy becomes more severe, the EEG changes become more obvious. When the consciousness disorder is significant, delta waves may appear, and the severity of EEG changes can be one of the indicators of the degree of renal encephalopathy.

　　During dialysis, the electroencephalogram (EEG) shows symmetrical high-amplitude rhythmic delta wave groups, basic amplitude increase, irregular slow wave, alpha wave decrease, and sharp waves and spike waves can also be seen. Generally, patients with severe EEG abnormalities before dialysis are more likely to show slow wave changes. This EEG change can be seen 3 hours after dialysis, and it can recover to the state before dialysis 1-2 days after dialysis stops.

　　Scientific Diet:The kidneys are most忌讳 salt, and a light diet is good for kidney health. Salt causes the greatest damage to the human kidney and liver, so it is important to reduce salt intake when eating. The diet of patients with nephritis should first limit salt intake, about 2-3g/d for edema, hypertension, and renal insufficiency. Avoid foods high in alkali and preserved foods, monosodium glutamate, etc. Secondly, protein intake should be controlled. In patients with chronic nephritis and renal insufficiency, the intake of protein in food should be limited according to the condition of renal function, generally 30-40g/d [0.6-0.8g/(kg·d)], and pay attention to providing high-quality protein (such as eggs, milk, lean meat, etc.) in the diet to supplement the essential amino acids in the body. If the patient's renal function is normal but the amount of urinary protein is high, the protein intake can be appropriately increased, but it is best not to exceed 1 gram per kilogram of body weight per day. At the same time, appropriate increase in carbohydrate intake can be made while on a low-protein diet, eat more vegetables and fruits, and pay attention to supplementing the necessary vitamins for the human body.

　　I. Treatment

　　Actively prevent and treat the primary disease, and it is crucial to prevent kidney function failure; avoid the triggering factors of mental disorders such as inflammation, fever, trauma, surgery, tooth extraction, and psychological factors; correct metabolic products in the blood, the accumulation of non-protein nitrogen, and maintain the balance of water and electrolytes; for patients with excitement, restlessness, or delirium, diazepam (Valium) can be used when necessary, and antipsychotic drugs, sedative-hypnotics, and other drugs should be used with caution; dialysis treatment is effective for both physical and brain symptoms.

　　1. Actively treat the primary disease to prevent further aggravation of kidney function failure and the occurrence of uremia. Pay attention to avoid all诱发factors such as infection, trauma, heart failure, and the use of drugs that damage the kidneys. Control infection. Improve kidney function, enhance the excretion of toxic substances. Timely treatment of metabolic acidosis and correction of water and electrolyte balance disorders.

　　2. For patients with excitement and restlessness, intramuscular injections of benzodiazepines such as diazepam (Valium) or oral risperidone with fewer side effects can be given, but barbiturates and chlorpromazine should be avoided or used with caution to prevent the induction or aggravation of consciousness disorders. Antianxiety and antidepressant agents can be given to patients in a state of anxiety or depression, but the dose should be small. Although controlling psychiatric symptoms is very important, medication must be used with caution. Since drug excretion is受阻 when kidney function fails, the dose of psychiatric drugs must also be small. Chlorpromazine and fluphenazine can be appropriately used intramuscularly for patients with excitement and restlessness. If oral administration is possible, chlorpromazine (chlorpromazine) 2mg can be used twice a day.

　　3. Prepare for dialysis in advance, patiently explain the purpose, method, efficacy, precautions, and possible problems of dialysis therapy, reduce concerns, enhance confidence, and prevent emotions such as fear, panic, anxiety, and unease. Correct water and electrolyte disorders and metabolic acidosis. Small doses of psychiatric drugs and antispasmodic drugs can be used for symptomatic treatment, but attention should be paid to the side effects of drugs. Controlling psychiatric symptoms is very important, but medication must be used with caution. Since drug excretion is受阻 when kidney function fails, the dose of psychiatric drugs must also be small. Chlorpromazine and fluphenazine can be appropriately used intramuscularly for patients with excitement and restlessness. If oral administration is possible, chlorpromazine (chlorpromazine) 2mg can be used twice a day. Antianxiety or antidepressant drugs can be appropriately selected for patients with anxiety or depression.

　　II. Prognosis

　　Depends on the primary disease.