Kidney failure is one of the leading causes of disability and death and one of the most disabling features of kidney failure and dialysis is encephalopathy. This is probably caused by the accumulation of uremic toxins. Other important causes are related to the underlying disorders that cause kidney failure, particularly hypertension. The clinical manifestations of uremic encephalopathy include mild confusional states to deep coma, often with associated movement disorders, such as asterixis. Most nephrologists consider cognitive impairment to be a major indication for the initiation of renal replacement therapy with dialysis with or without subsequent transplantation. Sleep disorders, including Ekbom's syndrome (restless legs syndrome) are also common in patients with kidney failure. Renal replacement therapies are also associated with particular neurologic complications including acute dialysis encephalopathy and chronic dialysis encephalopathy, formerly known as dialysis dementia. The treatments and prevention of each are discussed.

An inside-alkaline pH gradient (pH 7.7 inside, 5.5 outside) stimulated Cl uptake in brush-border vesicles from rabbit ileum. The addition of HCO3 without changing the pH gradient further stimulated Cl uptake to a level fourfold greater than equilibrated Cl uptake. Although a K diffusion potential stimulated Cl uptake, this was insensitive to inhibition by 4,4-diisothiocyanostilbene-2,2'-disulfonate (DIDS), whereas pH and HCO3 gradient-stimulated Cl uptake was inhibited by DIDS. pH and HCO3 gradient-stimulated Cl uptake was found to be a saturable function of the Cl concentration with a Km of 3.5 mM and a Vmax of 49 nmol X mg prot-1 X min-1. To distinguish between coupling of Na and Cl transport by cotransport or dual exchange (Na-H and Cl-HCO3 exchange), we determined uptake with high (134 mM Tris-HEPES-MES) internal buffer and low (1.34 mM Tris-HEPES-MES) internal buffer concentrations. Inwardly directed gradients of 50 mM Na, 50 mM K, or 50 mM Na and K did not stimulate Cl uptake, and 50 mM Cl, 50 mM K, or 50 mM KCl did not stimulate Na uptake, with high internal buffer, excluding cotransport. In contrast, 50 mM Na stimulated Cl uptake (inhibited by 1 mM DIDS) and 50 mM Cl stimulated Na uptake (inhibited by 1 mM amiloride) in low buffer media. To determine a role for carbonic anhydrase, Na-stimulated Cl uptake was determined in low buffer media, equilibrated with either 100% N2 or 95% N2-5% CO2. Na stimulated Cl uptake 80% (compared with trimethylammonium control) with CO2 but only 30% with N2 (P less than 0.05). Acetazolamide partially inhibited (P less than 0.025) the stimulation of Cl uptake with CO2 but not with N2. Carbonic anhydrase activity was measured in homogenate and brush-border membrane and was enriched 7.9 +/- 0.4-fold, whereas sucrase was enriched 14.0 +/- 1.1-fold. We conclude that coupled Na and Cl transport occurs by dual exchange (Na-H and Cl-HCO3) and carbonic anhydrase, apparently located on the brush-border membrane, facilitates dual exchange by providing HCO3.

The incidence of kidney stones is common in the United States and treatments for them are very costly. This review article provides information about epidemiology, mechanism, diagnosis, and pathophysiology of kidney stone formation, and methods for the evaluation of stone risks for new and follow-up patients. Adequate evaluation and management can prevent recurrence of stones. Kidney stone prevention should be individualized in both its medical and dietary management, keeping in mind the specific risks involved for each type of stones. Recognition of these risk factors and development of long-term management strategies for dealing with them are the most effective ways to prevent recurrence of kidney stones.