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Advanced Neurology Seizures and CKD

of early intervention/delivery [103] . The use of magnesium encephalopathy (HE) [107,108] . Timely diagnostic brain
sulfate may prevent and control eclampsia seizures and imaging is useful if the patient displays initial signs
should they occur [103] . and symptoms of HE, to help distinguish it from other
neurological conditions. Identification of brain edema,
3.3. Seizures caused by electrolyte disturbances through imaging, and papilledema by fundus examination,
In scenarios where seizures are caused by severe acute supports the diagnosis of HE [55,107,108] . Management of
hyponatremia (usually tonic-clonic seizures due to rapid seizures in the setting of uncontrolled hypertension should
reductions in the serum sodium concentration in <24 h), ideally take place in an intensive care setting. In this situation,
100–150 cm of 3% intravenous hypertonic saline may antihypertensive options include calcium antagonists (such
3
be administered over 5–10 min [104] . If there is no clinical as nicardipine), nitroprusside, and labetalol. According
improvement following the first bolus, a second bolus of to the 2020 International Society of Hypertension Global
hypertonic saline may be given. [104] It is recommended Hypertension Practice Guidelines, the clinical team should
that the goal of treatment is to bring serum sodium levels aim to reduce blood pressure by 20–25% in the first couple
to between 120 and 125 mEq/L [104] . The therapeutic goal of hours, and blood pressure should be brought down to
should be to increase serum sodium by 4 – 6 mmol/L in the around 160/100 mmHg within 2 –6 h [107,109] .
first 6 h of treatment. Monitoring for overzealous sodium
correction is recommended to reduce the risks of osmotic 3.6. PRES
demyelination/central pontine myelinolysis. Given the unclear pathogenesis and the wide range of

Intravenous calcium should be considered for CKD etiologies in PRES, it is challenging to recommend a
patients presenting with severe hypocalcemia, especially preventive strategy for complex CKD patients with many
before the first dialysis [105] . If a seizure episode has already comorbidities.
occurred, intravenous infusion of 100 – 300 mg elemental When signs and symptoms of PRES are present, early
calcium over 10 – 20 min may be considered [105] . diagnosis is crucial. PRES can be quickly reversed, if managed
Serum magnesium levels in CKD should also be closely appropriately from an early stage [110] . Classic radiological
monitored and intravenously supplemented as required [106] . changes of PRES include areas of hyperintensities in MRI
When symptomatic hypomagnesemia is present, an T2-weighted images and hypointensities in T1-weighted
injection of 1–2 g of magnesium sulfate over a 5-min period images, reflecting vasogenic edema in the subcortical white
may be administered, followed by an infusion of 1–2 g/h matter and occasionally in the cortical areas, usually in a
over the next few hours [106] . This regime can be repeated if bilateral and symmetrical pattern within the parieto-occipital
[110]
seizures are present or unresolved after initial treatment [106] . region/distribution of the posterior cerebral circulation .
However, other non-posterior areas of the brain, including
3.4. Seizures caused by hypo-hyperglycemia frontal, temporal, and brain stem regions, can occasionally
be affected. Treatment should focus on promptly resolving
Early recognition of the symptoms of hypoglycemia, the underlying cause, for example, acute hypertension
such as anxious behavior, tachycardia, palpitations, [110,111]
hunger, hyperhidrosis, tremors, and paresthesia is (aiming to resolve within 5 days) . The risks of long-
important, because the condition is easily reversible with term neurological deficits and cerebral infarction developing
intravenous glucose and/or intramuscular glucagon, post-PRES are high when convulsions persist for a longer
[111]
which reduces the risk of further complications, including period due to uncontrolled hypertension .
focal neurological deficits . Subsequent review of oral 3.7. Erythropoietin and medication-induced
[57]
hypoglycemic medications and insulin dose may help seizures in CKD, dialysis and transplantation, and
prevent recurrence . Elevating the glucose component dialysis technique-associated seizures
[57]
of dialysates may be required for patients receiving renal
[57]
replacement therapy . Addressing both ketotic and non- ESA-induced seizures are thought to be caused by high ESA
ketotic hyperglycemia in CKD patients at an early stage, as doses and over-rapid correction of anemia, consequently
per local protocols, is particularly relevant in older adults, elevating blood viscosity and blood pressure due to
[71]
given the increased risk this has on the onset and severity increases in peripheral vascular resistance . Prevention
of seizures . and management measures should focus on managing
[59]
ESA dosing .
[55]
3.5. Seizures caused by uncontrolled hypertension Medications such as penicillin, cephalosporin,
Urgent medical management of uncontrolled hypertension carbapenem, and quinolone-group antibiotics, meperidine,
in patients with CKD prevents progression to hypertensive acyclovir, theophylline, lithium, and metoclopramide may

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Volume 2 Issue 2 (2023) olume 2 Issue 2 (2023)
https://doi.org/10.36922/an.314