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NDT Advance Access originally published online on February 18, 2008
Nephrology Dialysis Transplantation 2008 23(5):1775-1776; doi:10.1093/ndt/gfn017
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© The Author [2008]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org


Cardiovascular abnormalities in patients with epilepsy receiving renal replacement therapy with dialysis: a true convergence of clinical cardiology, nephrology and neurology

Correspondence and offprint requests to: E-mail: scorza.nexp{at}epm.br

Sir,

We read with great interest a very comprehensive review article entitled ‘Kidney disease in cardiology’ by Professor Charles Herzog [1] published in the January issue of Nephrology Dialysis Transplantation.

Epilepsy is the most common serious neurological condition. Approximately 50 million people worldwide have epilepsy [2]. In the United States each year, ~100 000 new cases of epilepsy are diagnosed [3,4]. In the UK between 1 in 140 and 1 in 200 people (at least 300 000 people) are currently being treated for epilepsy [5]. Epidemiological studies suggest that between 70 and 80% of people developing epilepsy will go into remission, while the remaining patients continue to have seizures and are refractory to treatment with the currently available therapies [6,7]. The most common risk factors for epilepsy are cerebrovascular diseases, brain tumours, alcohol, traumatic head injuries, malformations of cortical development, genetic inheritance and infections of the central nervous system [8]. In resource-poor countries, endemic infections, such as malaria and neurocysticercosis, seem to be major risk factors [9]. Moreover, the risk of death for a person with epilepsy increases 2- to 3-fold when compared with the risk for the general population [10,11]. Information concerning risk factors for premature death in epilepsy is conflicting, but potential risk factors include age and gender, seizure type and epilepsy syndrome, duration of epilepsy, severity of epilepsy, and congenital neurological deficits and learning disabilities [10]. Additionally, the underlying pathophysiology of premature death in epilepsy is unknown; however, it is very probable that cardiac arrhythmia plays a potential role. In this way, Rugg-Gunn and colleagues, using implantable loop recorders, demonstrated that some patients with refractory partial epilepsy may have potentially life-threatening cardiac arrhythmias [12]. Moreover, it has been established that repetitive seizures can alter the regulation of cardiac activity by the autonomic nervous system (ANS), and ANS dysregulation is thought to be associated with higher morbidity and mortality in patients with epilepsy [13]. From an experimental point of view, a recent study by our group evaluated the heart rate, in vivo (ECG) and isolated ex vivo preparation (Langendorf preparation), of rats with epilepsy [14]. The results showed differences in the mean heart rate in vivo, but surprisingly, no differences in the heart rate could be observed in the isolated ex vivo situation, suggesting a central nervous system modulation on the heart, which could result in cardiac death in epilepsy [14].

In accordance with this reasoning, we postulated the following question: is there a possible relation between epilepsy, renal dysfunction and cardiovascular abnormalities?

Cardiac disease is the major cause of death in patients with end-stage renal disease (ESRD), accounting for ~43% of all deaths [15,16]. In dialysis patients, ~20% of cardiac deaths are attributed to acute myocardial infarction, a catastrophic clinical event in this group of patients [15,17]. In parallel, an estimated incidence of seizure of ~10% in patients with chronic renal failure has been reported [18]. In addition, Plum and Posner [19] also noted that convulsions occurred in one-third of patients with ESRD and was frequently a preterminal event. The seizures in this series were usually generalized tonic–clonic type; however, the mechanism of reduced seizure threshold in renal failure is still unknown. Haemodialysis-associated seizure (HAS) is a common complication of haemodialysis [20]. HAS occurs in 7–50% of children with ESRD, and their seizures are usually reported as generalized tonic–clonic seizures [21]. Risk factors for HAS include young age, prior history of seizures, malignant hypertension, microvascular diseases, uraemic encephalopathy and cardiomyopathy. Moreover, induced brain-water disequilibrium, hypocalcaemia, uraemic toxins, the use of acetate in the dialysate, intracranial haemorrhage due to systemic heparinization, treatment with recombinant erythropoietin, homodynamic and metabolic defects, and drugs such as penicillin and theophilline are also considered responsible for HAS [21,22,23]. If all these data are taken together, information on the management of seizures in renal failure should be disseminated among professionals treating systemic diseases. In the mean time, there is an urgent need for a large-scale, prospective, international, community-based study of cardiovascular abnormalities in patients with epilepsy receiving renal replacement therapy with dialysis to explore more closely the risk factors so that preventive strategies can be planned.

Finally, we express our congratulations to Professor Herzog for the stimulating review [1] and we are totally in agreement with his conclusion that with regard to kidney disease in cardiology, it should be apparent that a true convergence of clinical cardiology and nephrology has to exist; however, we also believe that neurology could be added in this context.

Conflict of interest statement. None declared.

Fulvio A. Scorza1, Ricardo M. Arida2 and Esper A. Cavalheiro1

1 Disciplina de Neurologia Experimental 2 Departamento de Fisiologia, Universidade Federal de São Paulo/Escola, Paulista de Medicina (UNIFESP/EPM), São Paulo, Brazil

References

  1. Herzog CA. Kidney disease in cardiology. Nephrol Dial Transplant (2008) 23:41–45.
  2. Sander JW. The epidemiology of epilepsy revisited. Curr Opin Neurol (2003) 16:165–170.[CrossRef][Web of Science][Medline]
  3. Begley CE, Annegers JF, Lairson LB, et al. Epilepsy incidence, prognosis, and use of medical care in Houston, Texas, and Rochester, Minnesota. Epilepsia (1998) 39:222.
  4. Annegers JF. Epidemiology of epilepsy. In: The Treatment of Epilepsy: Principles and Practice—Wyllie E., ed. (1997) Baltimore, MD: Williams & Wilkins. 165–172.
  5. Yuen AW, Sander JW. Is omega-3 fatty acid deficiency a factor contributing to refractory seizures and SUDEP? A hypothesis. Seizure (2004) 13:104–107.[CrossRef][Medline]
  6. Sander JW. Some aspects of prognosis in the epilepsies: a review. Epilepsia (1993) 34:1007–1016.[CrossRef][Web of Science][Medline]
  7. Kwan P, Sander JW. The natural history of epilepsy: an epidemiological view. J Neurol Neurosurg Psychiatry (2004) 75:1376–1381.[Abstract/Free Full Text]
  8. Halatchev VN. Epidemiology of epilepsy—recent achievements and future. Folia Med (Plovdiv) (2000) 42:17–22.[Medline]
  9. Duncan JS, Sander JW, Sisodiya SM, et al. Adult epilepsy. Lancet (2006) 367:1087–1100.[CrossRef][Web of Science][Medline]
  10. Hitiris N, Mohanraj R, Norrie J, et al. Mortality in epilepsy. Epilepsy Behav (2007) 10:363–376.[CrossRef][Medline]
  11. Lhatoo SD, Sander JW. Cause-specific mortality in epilepsy. Epilepsia (2005) 46:36–39.[CrossRef][Medline]
  12. Rugg-Gunn FJ, Simister RJ, Squirrell M, et al. Cardiac arrhythmias in focal epilepsy: a prospective long-term study. Lancet (2004) 364:2212–2219.[CrossRef][Web of Science][Medline]
  13. Harnod T, Yang CC, Hsin YL, et al. Heart rate variability in children with refractory generalized epilepsy. Seizure (2008) (in press).
  14. Colugnati DB, Gomes PA, Arida RM, et al. Analysis of cardiac parameters in animals with epilepsy: possible cause of sudden death? Arq Neuropsiquiatr (2005) 63:1035–1041.[Medline]
  15. Herzog CA. Cardiac arrest in dialysis patients: taking a small step. Semin Dial (2004) 17:184–185.[CrossRef][Web of Science][Medline]
  16. U.S. Renal Data System (USRDS). 2003 Annual Data Report. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2003.
  17. U.S. Renal Data System (USRDS). 1999 Annual Data Report. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 1999, 89–100.
  18. Bergen DC, Ristanovic R, Gorelick PB, et al. Seizures and renal failures. Int J Artif Organs (1994) 17:247–251.[Medline]
  19. Plum F, Posner JB. Metabolic brain diseases causing coma. In: The Diagnosis of Stupor and Coma—Plum F, Posner JB, eds. (1972) Philadelphia, PA: Davis.
  20. Sönmez F, Mir S, Tütüncüoglu S. Potential prophylatic use of benzodiazepines for hemodialysis-associated seizures. Pediatr Nephrol (2000) 14:367–369.[CrossRef][Medline]
  21. Glenn CM, Astley SJ, Watkins SL. Dialysis associated seizures in children and adolescents. Pediatr Nephrol (1992) 6:182–186.[CrossRef][Medline]
  22. Schwartz RD. Hemodialysis associated seizures. In: Dialysis Therapy—Nissensen AR, Fine RN, eds. (1993) Philadelphia, PA: Hanley Balfus. 88–90.
  23. Swash M, Rowan AJ. Electroencephalographic criteria of hypocalcemia and hypercalcemia. Arch Neurol (1972) 26:218–228.[Abstract/Free Full Text]

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This Article
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