Uremic encephalopathy presents with cognitive defects, memory loss, slurred speech, and asterixis. The progressive neurologic symptoms of uremia are the most common indications for initiating HD. It should remain a diagnosis of exclusion until structural, vascular, infectious, toxic, and metabolic causes of neurologic dysfunction have been ruled out. Peripheral neuropathy, manifested by paresthesias, diminished deep tendon reflexes, impaired vibration sense, muscle wasting, and weakness, occurs in 60% to 100% of patients with ESRD. Autonomic dysfunction, characterized by postural dizziness, gastric fullness, bowel dysfunction, reduced sweating, reduced heart rate variability, and baroreceptor control impairment, is common in ESRD patients, but is not responsible for intradialytic hypotension. Stroke is seen in 6% of HD patients, with 52% of cases caused by intracranial hemorrhage (subdural hematoma in particular). Stroke may be caused by cerebrovascular disease, head trauma, bleeding dyscrasias, anticoagulation, excessive ultrafiltration, or hypertension. It should be considered in any ESRD patient presenting with a change in mental status.