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Abderrahim E, Moussa AS, Ahmed M, Alobaili S, Dridi A, Jubran IA, Al-Badr WHA, Jacobson SH. Hospitalization patterns in HD patients in the Kingdom of Saudi Arabia: A comprehensive cohort study. Ther Apher Dial 2022; 26:983-991. [PMID: 34990064 DOI: 10.1111/1744-9987.13791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/22/2021] [Accepted: 01/03/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The rate of hospitalization represents a morbidity indicator in HD patients. The study aimed to evaluate hospitalization patterns in a large HD cohort. METHODS All DaVita-KSA HD patients from October 2014 to December 2019 were included. Demographical and clinical characteristics and hospitalization data were recorded. Less than 24 h admission was excluded. Overall and cause-specific hospitalization rates were calculated. RESULTS During the follow-up period, 3982 patients with a mean age of 52.5 ± 16.8 years, 2667 hospitalizations were recorded in 34.1% of the patients and 45.6% had repeated admissions. Infectious causes accounted for 26.6% of all recorded causes vs. 15.6% for cardiovascular complications. The median hospital stay length was 11 days, while the overall annual hospitalization rate of 34.9% and the annual duration of 3.7 days per patient. Hospitalized patients had a higher risk of mortality (p < 0.001). CONCLUSION Infectious complications were the leading cause of hospitalization and had the longest hospital stay.
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Affiliation(s)
- Ezzedine Abderrahim
- DaVita Health Care, Riyadh, Saudi Arabia.,Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Ayman S Moussa
- DaVita Health Care, Riyadh, Saudi Arabia.,Division of Nephrology, El Mansoura International Hospital, Mansoura, Egypt
| | | | - Saad Alobaili
- DaVita Health Care, Riyadh, Saudi Arabia.,Division of Nephrology, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Afef Dridi
- DaVita Health Care, Riyadh, Saudi Arabia
| | | | | | - Stefan H Jacobson
- Division of Nephrology, Department of Clinical Sciences, Karolinska Institute, Danderyd University Hospital, Stockholm, Sweden
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Chen CT, Lin SJ, Kuo LT, Chen TH, Hsu WH, Chen CL, Yu PA, Peng KT, Tsai YH. Effect of chronic kidney disease on outcomes following proximal humerus fragility fracture surgery in diabetic patients: A nationwide population-based cohort study. PLoS One 2021; 16:e0258393. [PMID: 34624055 PMCID: PMC8500432 DOI: 10.1371/journal.pone.0258393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 09/24/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The proximal humerus fracture (PHF) is the third most common fragility fracture. Diabetes mellitus (DM) and chronic kidney disease (CKD) are both risks for fragility fractures; however, the interplay of DM and CKD makes treatment outcomes unpredictable. This study aimed to investigate and compare early and late outcomes following proximal humerus fracture fixation surgery in diabetic patients with different renal function conditions. METHODS DM patients receiving PHF fixation surgery during 1998-2013 were recruited from Taiwan's National Health Insurance Research Database. According to their renal function, patients were divided into three study groups: non-chronic kidney disease (CKD), non-dialysis CKD, and dialysis. Outcomes of interest were early and late perioperative outcomes. Early outcomes included in-hospital newly-onset morbidities. Late outcomes included infection, revision, readmission, and all-cause mortality. RESULTS This study included a total of 10,850 diabetic patients: 2152 had CKD (non-dialysis CKD group), 196 underwent permanent dialysis (dialysis group), and the remaining 8502 did not have CKD (non-CKD group). During a mean follow-up of 5.56 years, the dialysis group showed the highest risk of overall infection, all-cause revision, readmission, and mortality compared to the non-dialysis CKD group and non-CKD group. Furthermore, subgroup analysis showed that CKD patients had a higher risk of surgical infection following PHF surgery than non-CKD patients in cases with a traffic accident or fewer comorbidities (Charlson Comorbidity Index, CCI <3) (P for interaction: 0.086 and 0.096, respectively). Also, CKD patients had an even higher mortality risk after PHF surgery than non-CKD patients, in females, those living in higher urbanization areas, or with more comorbidities (CCI ≥3) (P for interaction: 0.011, 0.057, and 0.069, respectively). CONCLUSION CKD was associated with elevated risks for infection, revision, readmission, and mortality after PHF fixation surgery in diabetic patients. These findings should be taken into consideration when caring for diabetic patients.
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Affiliation(s)
- Chien-Tien Chen
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Su-Ju Lin
- Division of Nephrology, Department of Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Liang-Tseng Kuo
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
- Division of Sports Medicine, Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan
- * E-mail:
| | - Tien-Hsing Chen
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
- Division of Cardiology, Department of Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Wei-Hsiu Hsu
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
- Division of Sports Medicine, Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Chi-Lung Chen
- Division of Sports Medicine, Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Pei-An Yu
- Division of Sports Medicine, Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Kuo-Ti Peng
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yao-Hung Tsai
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
- Division of Sports Medicine, Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan
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Raj R, Thiruvengadam S, Ahuja KDK, Frandsen M, Jose M. Discussions during shared decision-making in older adults with advanced renal disease: a scoping review. BMJ Open 2019; 9:e031427. [PMID: 31767590 PMCID: PMC6887047 DOI: 10.1136/bmjopen-2019-031427] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES This review summarises the information available for clinicians counselling older patients with kidney failure about treatment options, focusing on prognosis, quality of life, the lived experiences of treatment and the information needs of older adults. DESIGN We followed the Joanna Briggs Institute Methodology for Scoping Reviews. The final report conforms to the PRISMA-ScR guidelines. DATA SOURCES PubMed, PsycINFO, CINAHL, Embase, Scopus, Web of Science, TRIP and online repositories (for dissertations, guidelines and recommendations from national renal associations). ELIGIBILITY CRITERIA FOR INCLUSION Articles in English studying older adults with advanced kidney disease (estimated glomerular filtration rate <30 mL/min/1.73 m2); published between January 2000 and August 2018. Articles not addressing older patients separately or those comparing between dialysis modalities were excluded. DATA EXTRACTION AND SYNTHESIS Two independent reviewers screened articles for inclusion and grouped them by topic as per the objectives above. Quantitative data were presented as tables and charts; qualitative themes were identified and described. RESULTS 248 articles were included after screening 15 445 initial results. We summarised prognostic scores and compared dialysis and non-dialytic care. We highlighted potentially modifiable factors affecting quality of life. From reports of the lived experiences, we documented the effects of symptoms, of ageing, the feelings of disempowerment and the need for adaptation. Exploration of information needs suggested that patients want to participate in decision-making and need information, in simple terms, about survival and non-survival outcomes. CONCLUSION When discussing treatment options, validated prognostic scores are useful. Older patients with multiple comorbidities do not do well with dialysis. The modifiable factors contributing to the low quality of life in this cohort deserve attention. Older patients suffer a high symptom burden and functional deterioration; they have to cope with significant life changes and feelings of disempowerment. They desire greater involvement and more information about illness, symptoms and what to expect with treatment.
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Affiliation(s)
- Rajesh Raj
- Department of Nephrology, Launceston General Hospital, Launceston, Tasmania, Australia
- School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | | | | | - Mai Frandsen
- Faculty of Health, University of Tasmania, Launceston, Tasmania, Australia
| | - Matthew Jose
- School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
- Department of Nephrology, Royal Hobart Hospital, Hobart, Tasmania, Australia
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Sourour Y, Houda BA, Maroua T, Mariem BH, Maïssa BJ, Yosra M, Jihene J, Habib F, Raouf K, Jamel D. Hospital morbidity among elderly in the region of Sfax, Tunisia: Epidemiological profile and chronological trends between 2003 and 2015. CLINICAL EPIDEMIOLOGY AND GLOBAL HEALTH 2019. [DOI: 10.1016/j.cegh.2018.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Hall RK, Luciano A, Pieper C, Colón-Emeric CS. Association of Kidney Disease Quality of Life (KDQOL-36) with mortality and hospitalization in older adults receiving hemodialysis. BMC Nephrol 2018; 19:11. [PMID: 29334904 PMCID: PMC5769495 DOI: 10.1186/s12882-017-0801-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 12/18/2017] [Indexed: 11/17/2022] Open
Abstract
Background For older adults receiving dialysis, health-related quality of life is not often considered in prognostication of death or future hospitalizations. To determine if routine health-related quality of life measures may be useful for prognostication, the objective of this study is to determine the extent of association of Kidney Disease Quality of Life (KDQOL-36) subscales with adverse outcomes in older adults receiving dialysis. Methods This is a longitudinal study of 3500 adults aged ≥75 years receiving dialysis in the United States in 2012 and 2013. We used Cox and Fine and Gray models to evaluate the association of KDQOL-36 subscales with risk of death and hospitalization. We adjusted for sociodemographic variables, hemodialysis access type, laboratory values, and Charlson index. Results Three thousand one hundred thirty-two hemodialysis patients completed the KDQOL-36. From KDQOL-36 completion date in 2012, 880 (28.1%) died and 2023 (64.6%) had at least one hospitalization over a median follow-up of 512 and 203 days, respectively. Cohort members with a SF-12 physical component summary (PCS) in the lowest quintile had an increased adjusted risk of death [hazard ratio (HR), 1.55, 95% confidence interval (CI) 1.19–2.03] and hospitalization (HR, 1.29, 95% CI 1.09–1.54) compared with those with scores in the highest quintile. Cohort members with a SF-12 mental component summary in the lowest quintile had an increased risk of hospitalization (HR, 1.39, 95% CI 1.17–1.65) compared with those in the highest quintile. In adjusted analyses, there was no association between the symptoms of kidney disease, effects of kidney disease, and burden of kidney disease subscales with time to death or first hospitalization. Competing risk models showed similar HRs. Conclusions Among the KDQOL-36 subscales, the SF-12 PCS demonstrates the strongest association with both death and future hospitalizations in older adults receiving hemodialysis Further research is needed to assess the value this subscale may add to prognostication. Electronic supplementary material The online version of this article (10.1186/s12882-017-0801-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rasheeda K Hall
- Durham VA Geriatric Research, Education and Clinical Center, 508 Fulton Street, Durham, NC, 27705, USA. .,Duke University Medical Center, Division of Nephrology, Department of Medicine, Box DUMC 2747, 2424 Erwin Road Suite 605, Durham, NC, 27710, USA.
| | - Alison Luciano
- Duke University Medical Center, Division of Geriatrics, Department of Medicine, Box DUMC 3003, Durham, NC, 27710, USA
| | - Carl Pieper
- Duke University, Department of Biostatistics and Bioinformatics, Box DUMC 2721, 2424 Erwin Road, Suite 1102, Durham, NC, 27710, USA
| | - Cathleen S Colón-Emeric
- Durham VA Geriatric Research, Education and Clinical Center, 508 Fulton Street, Durham, NC, 27705, USA.,Duke University Medical Center, Division of Geriatrics, Department of Medicine, Box DUMC 3003, Durham, NC, 27710, USA
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Yan G, Norris KC, Greene T, Yu AJ, Ma JZ, Yu W, Cheung AK. Race/ethnicity, age, and risk of hospital admission and length of stay during the first year of maintenance hemodialysis. Clin J Am Soc Nephrol 2014; 9:1402-9. [PMID: 24948142 DOI: 10.2215/cjn.12621213] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND OBJECTIVES Although patients undergoing maintenance hemodialysis have exceptionally high hospitalization rates, the risk factors for hospitalizations are unclear. This study sought to examine hospitalization rates among hemodialysis patients in the United States according to both race/ethnicity and age. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS US Renal Data System data on 563,281 patients beginning maintenance hemodialysis between 1995 and 2009 were analyzed. Rates of hospital admission and number of hospital days for all-cause and cause-specific hospitalizations during the first year of dialysis were compared among blacks, whites, and Hispanics in the entire cohort and subgroups stratified by age. RESULTS After multiple adjustments, compared with whites, Hispanics overall had lower rates of both all-cause hospital days (adjusted rate ratio [aRR], 0.91; 95% confidence interval [95% CI], 0.90 to 0.93; P<0.001) and hospital admissions (aRR, 0.89; 95% CI, 0.88 to 0.90; P<0.001), whereas blacks had a lower rate of all-cause admissions (aRR, 0.95; 95% CI, 0.94 to 0.96; P<0.001). The racial/ethnic differences, however, varied by age. Hispanics exhibited the lowest rates of hospital days and admissions for all age groups≤70 years, but those >80 years had higher rates than their white counterparts. The adjusted black-to-white rate ratios exhibited a U-shaped pattern with age, with higher rates for blacks in the younger and older age groups. Hospitalization rates for dialysis-related infections were markedly higher in blacks and Hispanics than whites, which were consistent in all age groups for blacks (aRRs for hospital days ranged from 1.09 to 1.36) and all ages>60 years for Hispanics (aRRs ranged from 1.20 to 1.38). CONCLUSIONS There are significant racial/ethnic differences in hospitalization rates within first year of dialysis, which are not consistent across the age groups and also differ by causes of hospitalization. Overall, blacks and Hispanics had lower rates of all-cause hospital admissions than whites. However, younger and older blacks and older Hispanics were at greatest risk.
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Affiliation(s)
- Guofen Yan
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, Virginia;
| | - Keith C Norris
- Department of Medicine, Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | | | - Alison J Yu
- Dornsife College of Letters, Arts, and Sciences and Keck School of Medicine, University of Southern California, Los Angeles, California; and
| | - Jennie Z Ma
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Wei Yu
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Alfred K Cheung
- Division of Nephrology & Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, Utah; Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah
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Nadeau-Fredette AC, Tennankore KK, Kim SJ, Chan CT. Suboptimal initiation of home hemodialysis: determinants and clinical outcomes. Nephron Clin Pract 2013; 124:132-40. [PMID: 24281264 DOI: 10.1159/000356383] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Accepted: 10/14/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Suboptimal initiation of conventional hemodialysis is associated with poor clinical outcomes. In this study, we aimed to ascertain the determinants and adverse events associated with suboptimal starts in home hemodialysis (HHD). METHODS We conducted a retrospective cohort study including consecutive incident HHD patients from January 1996 to December 2011. All patients had HHD as their first renal replacement therapy or returned to HHD after kidney transplantation. A suboptimal start was defined by dialysis initiation as an inpatient or with a central venous catheter. The primary outcome was time to first hospitalization, technique failure or death. Secondary outcomes included hospitalization rate, hospital days and determinants of suboptimal starts. Suboptimal starts were further categorized as unavoidable as adjudicated by two independent observers with prespecified criteria. RESULTS Among 95 incident HHD patients, 44 (46%) and 51 (54%) had optimal and suboptimal starts, respectively. A suboptimal start was associated with a shorter time to the primary outcome (log-rank p < 0.001). In a multivariable Cox proportional hazards model, the hazard ratio for the composite outcome (comparing suboptimal to optimal starts) was 2.94 (95% confidence interval, CI, 1.49-5.78, p = 0.002). Transplantation clinic follow-up (OR 3.18, 95% CI 1.15-8.79) and the Charlson comorbidity index (OR 1.47, 95% CI 1.09-1.97) were associated with higher odds of suboptimal start. CONCLUSION Suboptimal initiation of HHD is associated with adverse clinical events including early hospitalization. Given the high proportion of suboptimal starts in patients returning from transplantation, better incorporation of dialysis planning and renal replacement therapy education is warranted.
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Tennankore KK, Kim SJ, Chan CT. The feasibility of caregiver-assisted home nocturnal hemodialysis. Nephron Clin Pract 2013; 122:17-23. [PMID: 23486225 DOI: 10.1159/000348419] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2012] [Accepted: 01/16/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Home nocturnal hemodialysis (HNHD) has several benefits. However, patients that require caregiver assistance for dialysis may be at risk for poor outcomes. In an effort to determine if HNHD can be extended to assisted patients, an analysis of their outcomes is important. METHODS We examined a single-center cohort of patients that started and completed HNHD training between 01 January 2003 and 31 December 2010 (last follow-up 01 July 2011). Patients were classified as 'dependent' if they required caregiver assistance for dialysis. The primary outcome was time to first hospitalization, technique failure, or death for dependent versus independent patients. Secondary outcomes included hospitalization rate and hospital days. RESULTS A total of 152 patients were included in this study. Dependent patients (n = 47) were older (51 vs. 42 years), more likely to have diabetic end-stage renal disease (26 vs. 8%) and had higher Charlson Comorbidity Index scores (4 vs. 3) compared to independent patients (n = 105). In an adjusted analysis there was no significant difference in the time to composite outcome for dependent versus independent patients (relative hazard 1.25; 95% confidence interval, CI, 0.76-2.04). Adjusted incidence rate ratios for hospitalizations (1.58; 95% CI 0.95-2.65) and hospital days (1.84; 95% CI 0.78-4.34) were not significantly different for dependent versus independent patients. CONCLUSION Our study suggests that outcomes of caregiver-assisted versus independent HNHD patients are likely driven by differences in case mix. The need for caregiver assistance alone should not be a deterrent to HNHD.
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Affiliation(s)
- Karthik K Tennankore
- University Health Network/Toronto General Hospital, University of Toronto, Toronto, Ont, Canada. ktennankore @ gmail.com
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Influence of comorbidities and inactivity on the long-term outcomes of coronary artery bypass graft surgery in a small number of men on chronic hemodialysis. Int Urol Nephrol 2012; 45:293-5. [PMID: 22528585 DOI: 10.1007/s11255-012-0172-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Accepted: 03/30/2012] [Indexed: 10/28/2022]
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KASSAM H, SUN Y, ADENIYI M, AGABA EI, MARTINEZ M, SERVILLA KS, RAJ DS, MURATA GH, TZAMALOUKAS AH. Hospitalizations before and after initiation of chronic hemodialysis. Hemodial Int 2011; 15:341-9. [DOI: 10.1111/j.1542-4758.2011.00551.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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It is not polite to ask a dialysis patient his age! Int Urol Nephrol 2011; 43:1101-5. [PMID: 21547468 DOI: 10.1007/s11255-011-9968-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2011] [Accepted: 04/07/2011] [Indexed: 10/18/2022]
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Yopak KE, Montgomery JC. Brain organization and specialization in deep-sea chondrichthyans. BRAIN, BEHAVIOR AND EVOLUTION 2008; 71:287-304. [PMID: 18431055 DOI: 10.1159/000127048] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2007] [Accepted: 02/08/2008] [Indexed: 11/19/2022]
Abstract
Chondrichthyans occupy a basal place in vertebrate evolution and offer a relatively unexplored opportunity to study the evolution of vertebrate brains. This study examines the brain morphology of 22 species of deep-sea sharks and holocephalans, in relation to both phylogeny and ecology. Both relative brain size (expressed as residuals) and the relative development of the five major brain areas (telencephalon, diencephalon, mesencephalon, cerebellum, and medulla) were assessed. The cerebellar-like structures, which receive projections from the electroreceptive and lateral line organs, were also examined as a discrete part of the medulla. Although the species examined spanned three major chondrichthyan groupings (Squalomorphii, Galeomorphii, Holocephali), brain size and the relative development of the major brain areas did not track phylogenetic groupings. Rather, a hierarchical cluster analysis performed on the deep-sea sharks and holocephalans shows that these species all share the common characteristics of a relatively reduced telencephalon and smooth cerebellar corpus, as well as extreme relative enlargement of the medulla, specifically the cerebellar-like lobes. Although this study was not a functional analysis, it provides evidence that brain variation in deep-sea chondichthyans shows adaptive patterns in addition to underlying phylogenetic patterns, and that particular brain patterns might be interpreted as 'cerebrotypes'.
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Affiliation(s)
- Kara E Yopak
- Leigh Marine Laboratory, The University of Auckland, Leigh, New Zealand.
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