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Between September 1972 and January 1976 an outbreak of dialysis dementia affected 20 patients maintained by long-term hemodialysis. The clinical picture was characterized by an insidious onset of altered behaviour, dementia, speech disturbance, myoclonus, and convulsions. Nineteen patients died, but one patient has survived for 16 months. It was later established that in June 1972 the city had altered its method of water purification and that this resulted in higher water aluminum levels. The temporal relation between periods of high water-aluminum content and the appearance of new cases supports the view that aluminum may play a role in the causation of dialysis dementia.

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Six maintenance hemodialysis patients with dialysis dementia (severe mental deterioration, speech disturbances, apraxia, facial grimacing, and myoclonus) were studied. They were matched with respect to age, duration of dialysis, and underlying renal disease with six patients who had no dementia and who acted as controls for the electroencephalographic (EEC) studies. The dementia patients had marked slowing of the EEG rhythm to 5--7 Hz with high voltage biphasic or triphasic spikes, and were clearly separated by frequency distribution analysis from the controls. Radio-iodinated serum albumin (RISA) cisternography in dementia patients demonstrated ventricular reflux, prolonged stasis, late appearance of the parasagittal strip, and persistence of RISA for up to 72--96 hr, which suggest an alteration in cerebrospinal fluid (CSF) dynamics.

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In the four years between 1972 and 1976 twenty out of 160 maintenance dialysis patients developed dialysis dementia. Their illness was characterized by an insidious onset of mental deterioration, speech disturbance, apraxia, and myoclonus. The disease progressed inexorably to a fatal outcome, the onset of seizures being an ominous sign, and the average duration of the illness being seven months. Routine biochemical studies were unremarkable, and osteodystrophy was not a prominent feature. Serial electroencephalograms (EEG) showed progressive slowing of the rhythm, usually antedating the neurologic symptoms. Brain scan and flow studies were normal. Radio-iodinated serum albumin (RISA) scans in seven patients showed changes suggesting altered cerebrospinal fluid (CSF) dynamics. Treatment was generally ineffective, but ventriculo-peritoneal shunting produced transient neurologic improvement in one patient. Epidemiologic investigations showed high aluminum levels in city water during the period of the outbreak.

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We studied the cognitive and communicative deterioration of two patients who were treated by maintenance dialysis and developed a fatal progressive encephalopathy, "dialysis dementia." Detailed language, speech, and psychological evaluations support the contention that this neurologic syndrome is in fact a dementia. Stuttering and intermittent mutism characterize the disorder and may be valuable in the differentiation of dialysis dementia from other neuropsychiatric syndromes. Some of the speech and language defects are not explicable on the basis of intellectual deterioration and probably represent involvement of the cortical language centers.

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1. Twenty patients with severe or moderate hypertension were treated with minoxidil for 284 patient-months. 2. The blood pressure was controlled in all patients, including those refractory to maximal doses of conventional anti-hypertensive agents. 3. In patients with moderate hypertension control with minoxidil was achieved earlier and more easily than with hydrallazine. 4. Three patients developed secondary resistance and required addition of guanethidine or increased doses of diuretics. 5. Fluid retention and hypertrichosis were the main side effects with minoxidil.

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Two patients with Parkinson's disease and renal insufficiency had excessively high concentrations of amantadine hydrochloride in the blood. The amounts of the drug removed by hemodialysis and peritoneal dialysis were small. However, since extrarenal elimination is negligible in such patients, frequently repeated dialysis may be required to remove the drug.

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Changes in urinary protein excretion induced by standing or by the application of venous tourniquets to the thighs while the patient is in the supine position were studied in patients with mild proteinuria and compared with the changes that occur in severe proteinuria (greater than 1 mg/min). Protein excretion decreased in the majority of patients. Irrespective of the initial degree of proteinuria. The increased rate of protein excretion that occurred in a minority of patients when standing may represent a phenomenon analogous to orthostatic proteinuria.

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High-dose bolus urography was evaluated in 38 patients with severe renal failure. Iothalamate meglumine (Conray 60) (2 ml/kg of body weight) was injected within one minute and nephrotomograms were taken for 30 minutes, with delayed films until 24 hours. Immediate nephrograms were obtained in all cases. The collecting systems, seen in 29 cases, were dilated in three. In the rest, obstruction could be ruled out by a combination of roentgenographic criteria. No untoward reactions occurred, and all the required information was obtained within 30 minutes. The results were superior to plain nephrotomography or infusion pyelography. We conclude that bolus nephrotomography is the procedure of choice in the investigation of severe renal failure.

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Seventeen patients who were partially or totally refractory to maximal doses of conventional antihypertensive agents were treated with minoxidil. Three patients were receiving long-term maintenance dialysis. Propranolol and diuretics were given to prevent reflex tachycardia and fluid retention. Initial control of blood pressure was excellent in 16 patient. In one patient, diastolic blood pressure remained unchanged (120 mm Hg) despite 60 mg of minoxidil and volume depletion. In three other patients, secondary resistance developed, and the addition of guanethidine was necessary. The main side-effects were fluid retention (in eight) and hypertrichosis (in ten), accompanied in some by a peculiar coarsening of the facial features. Renal function stabilized or improved in most, and urine output increased in the three hemodialysis patients. We conclude that minoxidil is a valuable drug in severe hypertension.

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The influence of posture and age on urinary protein excretion was studied in 120 normal men volunteers. The supine excretion rate was less than 140 mug/min in all but two people (median value 38 mug/min) and tended to increase with age. The excretion rate decreased on quiet standing in 80% of people, which corresponded to a fall in creatinine-clearance. In the remaining 20% protein excretion increased on standing but generally remained within normal limits and was dissociated from changes in creatinine clearances. This increase was more prevalent in younger people and may represent a phenomenon analogous to orthostatic proteinuria, differing only quantitatively.

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