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Erythropoietin and Visual Hallucinations in Patients on Dialysis

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TO THE EDITOR: We were interested to read the report by Steinberg and colleagues on their observed association between erythropoietin therapy and visual hallucinations in patients with end-stage renal failure on dialysis.¹ We would like to point out that erythropoietin is known to aggravate hypertension, which may lead to hypertensive encephalopathy.² The latter may be associated with a posterior leukoencephalopathy syndrome,³ which is characterized by edema of the occipital lobes on either computed tomography (CT) or magnetic resonance imaging (MRI), and is usually reversible on discontinuation or reduction of erythropoietin therapy. Posterior leukoencephalopathy is also associated with other causes of hypertensive encephalopthy, such as eclampsia, and can occur in normotensive patients on immunosuppressive therapy with either cyclosporin or tacrolimus. This syndrome can cause visual disturbances, including hallucinations.³, ⁴

Steinberg and colleagues do not provide adequate data on blood pressure in their patients around the time of visual hallucinations. Neuroimaging results, if available, are also not mentioned. The incidence of hypertension reported in their Table 3 is much lower than the reported incidence of hypertension in the dialysis population. The percentage of patients with hypertension and visual hallucinations at one of the institutions studied is not recorded.

It is possible that some of the patients reporting visual hallucinations may have had incipient hypertensive encephalopathy with posterior leukoencephalopthy that quickly reversed on discontinuation of therapy. The salient clinical point is that attention to blood pressure is important in any dialysis patient on erythropoietin who reports visual hallucinations.

REFERENCES

1. Steinberg H, Saravay SM, Wadhwa N, et al: Erythropoietin and visual hallucinations in patients on dialysis. Psychosomatics 1996; 37:556–563[Abstract/Free Full Text]
2. Delanty N, Vaughan C, Frucht S, et al: Erythropoietin-associated hypertensive posterior leukoencephalopathy (abstract). Neurology 1997; 49:686–689[Abstract/Free Full Text]
3. Hinchey J, Chaves C, Appignani B, et al: A reversible posterior leukoencephalopathy syndrome. N Engl J Med 1996; 334:494–500[Abstract/Free Full Text]
4. Steg RE, Garcia EG: Complex visual hallucinations and cyclosporin neurotoxicity. Neurology 1991; 41:1156

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