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Chan GCK, Kalantar-Zadeh K, Ng JKC, Tian N, Burns A, Chow KM, Szeto CC, Li PKT. Frailty in patients on dialysis. Kidney Int 2024; 106:35-49. [PMID: 38705274 DOI: 10.1016/j.kint.2024.02.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 02/09/2024] [Accepted: 02/12/2024] [Indexed: 05/07/2024]
Abstract
Frailty is a condition that is frequently observed among patients undergoing dialysis. Frailty is characterized by a decline in both physiological state and cognitive state, leading to a combination of symptoms, such as weight loss, exhaustion, low physical activity level, weakness, and slow walking speed. Frail patients not only experience a poor quality of life, but also are at higher risk of hospitalization, infection, cardiovascular events, dialysis-associated complications, and death. Frailty occurs as a result of a combination and interaction of various medical issues in patients who are on dialysis. Unfortunately, frailty has no cure. To address frailty, a multifaceted approach is necessary, involving coordinated efforts from nephrologists, geriatricians, nurses, allied health practitioners, and family members. Strategies such as optimizing nutrition and chronic kidney disease-related complications, reducing polypharmacy by deprescription, personalizing dialysis prescription, and considering home-based or assisted dialysis may help slow the decline of physical function over time in subjects with frailty. This review discusses the underlying causes of frailty in patients on dialysis and examines the methods and difficulties involved in managing frailty among this group.
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Affiliation(s)
- Gordon Chun-Kau Chan
- Carol & Richard Yu Peritoneal Dialysis Research Centre, The Chinese University of Hong Kong, Hong Kong, China; Department of Medicine & Therapeutics, Prince of Wales Hospital, Hong Kong, China
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, Harbor-University of California, Los Angeles Medical Center, Torrance, California, USA
| | - Jack Kit-Chung Ng
- Carol & Richard Yu Peritoneal Dialysis Research Centre, The Chinese University of Hong Kong, Hong Kong, China; Department of Medicine & Therapeutics, Prince of Wales Hospital, Hong Kong, China
| | - Na Tian
- Department of Nephrology, General Hospital of Ning Xia Medical University, Yin Chuan, China
| | - Aine Burns
- Division of Nephrology, University College London, Royal Free Hospital, London, UK
| | - Kai-Ming Chow
- Carol & Richard Yu Peritoneal Dialysis Research Centre, The Chinese University of Hong Kong, Hong Kong, China; Department of Medicine & Therapeutics, Prince of Wales Hospital, Hong Kong, China
| | - Cheuk-Chun Szeto
- Carol & Richard Yu Peritoneal Dialysis Research Centre, The Chinese University of Hong Kong, Hong Kong, China; Department of Medicine & Therapeutics, Prince of Wales Hospital, Hong Kong, China; Li Ka Shing Institute of Health Sciences (LiHS), Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Philip Kam-Tao Li
- Carol & Richard Yu Peritoneal Dialysis Research Centre, The Chinese University of Hong Kong, Hong Kong, China; Department of Medicine & Therapeutics, Prince of Wales Hospital, Hong Kong, China.
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Bogataj Š, Roelands B, Pajek M, Pajek J. Intradialytic cycling and cognitive training to mitigate decreased functional and physiological status in haemodialysis patients. Nephrol Dial Transplant 2024; 39:1198-1200. [PMID: 38429977 PMCID: PMC11210983 DOI: 10.1093/ndt/gfae044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Indexed: 03/03/2024] Open
Affiliation(s)
- Špela Bogataj
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Sport, University of Ljubljana, Ljubljana, Slovenia
| | - Bart Roelands
- Human Physiology and Sports Physiotherapy Research Group, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium
- BruBotics, Vrije Universiteit Brussel, Brussels, Belgium
| | - Maja Pajek
- Faculty of Sport, University of Ljubljana, Ljubljana, Slovenia
| | - Jernej Pajek
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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Bogataj Š, Pajek M, Mesarič KK, Kren A, Pajek J. Twelve weeks of combined physical and cognitive intradialytic training preserves alertness and improves gait speed: a randomized controlled trial. Aging Clin Exp Res 2023; 35:2119-2126. [PMID: 37493889 PMCID: PMC10520202 DOI: 10.1007/s40520-023-02511-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 07/16/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND Hemodialysis (HD) patients often experience cognitive deficits and reduced mobility. While studies have shown promising results of physical and/or cognitive training in older adults, their effects in HD patients remain understudied. AIMS This study aimed to evaluate the impact of a 12-week intradialytic training program combining cognitive training with physical exercise on attention domains and spontaneous gait speed (SGS) in HD patients. METHODS Forty-four HD patients were randomly assigned to either intradialytic cognitive and physical exercise training (EXP group; n = 22) or a standard care control group (CON group; n = 22). The EXP group performed intradialytic cycling and tablet-based cognitive training three days per week for 12 weeks. The primary outcome of the study was performance on the computerized test battery 'Test of Attentional Performance.' Secondary study outcome was patient mobility assessed by the four-meter SGS. Outcomes were assessed pre- and post-intervention. RESULTS Significant group x time interaction was observed in alertness (F(1,41) = 6.15, p = 0.017) and SGS (F(1,41) = 18.33, p < 0.001) in favor of the EXP group. Within-group analysis revealed a significant pre-post decline in the CON group in alertness test (-26.7 s; p = 0.04) and an improvement of SGS in EXP group (+ 0.07 s; p < 0.001). DISCUSSION This original study demonstrated that a combined physical and cognitive intradialytic training intervention led to improvements in SGS and preservation in alertness compared to a deterioration in the CON group. CONCLUSION Findings suggest that the intervention may serve as an effective tool to prevent the physical and cognitive decline in this patient population.
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Affiliation(s)
- Špela Bogataj
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia.
| | - Maja Pajek
- Faculty of Sport, University of Ljubljana, Ljubljana, Slovenia
| | - Katja Kurnik Mesarič
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Aljaž Kren
- Faculty of Health Sciences, University of Novo Mesto, Novo Mesto, Slovenia
| | - Jernej Pajek
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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Pépin M, Klimkowicz-Mrowiec A, Godefroy O, Delgado P, Carriazo S, Ferreira AC, Golenia A, Malyszko J, Grodzicki T, Giannakou K, Paolisso G, Barbieri M, Garneata L, Mocanu CA, Liabeuf S, Spasovski G, Zoccali C, Bruchfeld A, Farinha A, Arici M, Capasso G, Wiecek A, Massy ZA. Cognitive disorders in patients with chronic kidney disease: Approaches to prevention and treatment. Eur J Neurol 2023; 30:2899-2911. [PMID: 37326125 DOI: 10.1111/ene.15928] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 06/12/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND Cognitive impairment is common in patients with chronic kidney disease (CKD), and early intervention may prevent the progression of this condition. METHODS Here, we review interventions for the complications of CKD (anemia, secondary hyperparathyroidism, metabolic acidosis, harmful effects of dialysis, the accumulation of uremic toxins) and for prevention of vascular events, interventions that may potentially be protective against cognitive impairment. Furthermore, we discuss nonpharmacological and pharmacological methods to prevent cognitive impairment and/or minimize the latter's impact on CKD patients' daily lives. RESULTS A particular attention on kidney function assessment is suggested during work-up for cognitive impairment. Different approaches are promising to reduce cognitive burden in patients with CKD but the availabe dedicated data are scarce. CONCLUSIONS There is a need for studies assessing the effect of interventions on the cognitive function of patients with CKD.
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Affiliation(s)
- Marion Pépin
- INSERM (Institut National de la Santé et de la recherche médicale) Unit 1018, Clinical Epidemiology, CESP (Centre d'Epidemiologie et de Santé des Populations), Hôpital Paul Brousse, Paris-Saclay University and Versailles Saint-Quentin-en-Yvelines University, Villejuif, France
- Department of Geriatrics, Ambroise Paré University Hospital, APHP (Assistance Publique - Hôpitaux de Paris), Boulogne-Billancourt/Paris, France
| | | | - Olivier Godefroy
- Department of Neurology, Amiens University Hospital, and Laboratory of Functional Neurosciences (Research Unit 4559), Jules Verne University of Picardie (UPJV), Amiens, France
| | - Pilar Delgado
- Department of Neurology, Vall d'Hebron Hospital, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Sol Carriazo
- Department of Nephrology and Hypertension, Instituto de Investigacion Sanitaria (IIS)-Fundacion Jimenez Diaz, Autonomous University of Madrid (UAM), Madrid, Spain
| | - Ana Carina Ferreira
- Department of Nephrology, Centro Hospitalar e Universitário de Lisboa Central-Hospital Curry Cabral, Lisbon, Portugal
- Universidade Nova de Lisboa-Faculdade de Ciências Médicas-Nephology, Lisbon, Portugal
| | | | - Jolanta Malyszko
- Department of Nephrology, Dialysis, and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Tomasz Grodzicki
- Department of Internal Medicine and Gerontology, Jagiellonian University Medical College, Cracow, Poland
| | - Konstantinos Giannakou
- Department of Health Sciences, School of Sciences, European University Cyprus, Nicosia, Cyprus
| | - Giuseppe Paolisso
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
- UniCAMILLUS, International Medical University, Roma, Italy
| | - Michelangela Barbieri
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Liliana Garneata
- Department of Internal Medicine and Nephrology, "Carol Davila" University of Medicine and Pharmacy, "Dr Carol Davila" Teaching Hospital of Nephrology, Bucharest, Romania
| | - Carmen Antonia Mocanu
- Department of Internal Medicine and Nephrology, "Carol Davila" University of Medicine and Pharmacy, "Dr Carol Davila" Teaching Hospital of Nephrology, Bucharest, Romania
| | - Sophie Liabeuf
- Pharmacology Department, Amiens University Medical Center, Amiens, France
- MP3CV (Mécanismes physiopathologiques et Conséquences des Calcifications Cardio-Vasculaires) Laboratory, EA7517, University of Picardie Jules Verne, Amiens, France
| | - Goce Spasovski
- University Department of Nephrology, Clinical Center "Mother Theresa", University of Saints Cyril and Methodius, Skopje, North Macedonia
| | - Carmine Zoccali
- Renal Research Institute, New York, New York, USA
- Associazione Ipertensione Nefrologia Trapianto Renale, Reggio Calabria, Italy
| | - Annette Bruchfeld
- Department of Health, Medicine, and Caring Sciences, Linköping University, Linköping, Sweden
- CLINTEC, Renal Medicine, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Ana Farinha
- Department of Nephrology, Centro Hospitalar de Setúbal, Setubal, Portugal
| | - Mustafa Arici
- Department of Internal Medicine, Division of Nephrology, Hacetepe University, Faculty of Medicine, Ankara, Turkey
| | - Giovambattista Capasso
- Biogem (Molecular Biology and Genetics Research Institute), Ariano Irpino, Italy
- Department of Translational Medical Sciences, University of Campania, Naples, Italy
| | - Andrzej Wiecek
- Department of Nephrology, Transplantation, and Internal Medicine, Medical University of Silesia in Katowice, Katowice, Poland
| | - Ziad A Massy
- INSERM (Institut National de la Santé et de la recherche médicale) Unit 1018, Clinical Epidemiology, CESP (Centre d'Epidemiologie et de Santé des Populations), Hôpital Paul Brousse, Paris-Saclay University and Versailles Saint-Quentin-en-Yvelines University, Villejuif, France
- Department of Nephrology, Ambroise Paré University Hospital, APHP, Boulogne-Billancourt/Paris, France
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5
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Kren A, Bogataj Š. The Impact of Intradialytic Cognitive and Physical Training Program on the Physical and Cognitive Abilities in End-Stage Kidney Disease Patients: A Randomized Clinical Controlled Trial. Brain Sci 2023; 13:1228. [PMID: 37626584 PMCID: PMC10452887 DOI: 10.3390/brainsci13081228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/14/2023] [Accepted: 08/18/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Hemodialysis (HD) patients have lower cognitive functioning and reduced physical fitness than age-matched healthy individuals. Clinicians typically do not recognize the declining cognitive performance in these patients; therefore, cognitive impairment is greatly underestimated and not appropriately treated. This study aimed to evaluate the impact on cognitive function of combining cognitive training with physical exercise and physical performance in HD patients. METHODS Using a randomized, single-blinded control design, forty-four HD patients were recruited and randomly assigned to either an intradialytic physical exercise and cognitive training program (EXP group; n = 22; 54% male; 65.7 ± 9.7 years; 77.1 ± 21.9 kg; body mass index 26.8 ± 6.0) or a standard care control group (CON group; n = 21; 77% male; 67.2 ± 12.5 years; 74.2 ± 14.3 kg; body mass index 25.9 ± 3.8). The EXP group performed intradialytic cycling and cognitive training three days per week for 12 weeks. Study outcomes were assessed by the Symbol Digit Modalities Test (SDMT), Montreal Cognitive Assessment (MoCA), 10-repetition sit-to-stand test (10-STS), handgrip strength test (HGS), and stork balance test. RESULTS The results showed a significant time*group interaction effect for SDMT (p < 0.001; η2 = 0.267) and MoCA (p < 0.001; η2 = 0.266). Moreover, no significant interaction was observed for 10-STS, HGS, and stork balance test (p > 0.05). CONCLUSIONS Our findings suggest that incorporating intradialytic cognitive and physical exercise training could help to improve the functional status of HD patients. The innovative, nonpharmacological, bimodal intervention is cost-effective, safe, and easy to implement during the intradialytic period and offers a potential impact on patients' quality of life and well-being.
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Affiliation(s)
- Aljaž Kren
- Faculty of Health Sciences, University of Novo Mesto, 8000 Novo Mesto, Slovenia;
| | - Špela Bogataj
- Faculty of Health Sciences, University of Novo Mesto, 8000 Novo Mesto, Slovenia;
- Department of Nephrology, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia
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6
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Effects of exposure to immersive computer-generated virtual nature and control environments on affect and cognition. Sci Rep 2023; 13:220. [PMID: 36604527 PMCID: PMC9815073 DOI: 10.1038/s41598-022-26750-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 12/20/2022] [Indexed: 01/06/2023] Open
Abstract
Previous research has shown that exposure to immersive virtual nature environments is able to induce positive affective and physiological effects. However, research on the effects on cognitive performance is scarce. Additionally, the effects of virtual nature exposure compared to a virtual control environment with a comparable amount of virtual objects have not been examined so far. Therefore, we conducted an experiment with 27 participants to study the psychological effects of such exposure. The virtual nature consisted of a 3D model of a typical forest environment, whereas the control environment was an abstract replication of the virtual forest environment. In both environments, a virtual wooden cart was used to transport the users from the start to the end of the virtual road. The typical background noise of moving such a cart was integrated into both environments as well. In addition, the virtual nature environment included typical forest sounds in the background, whereas the control condition did not have such background sounds. Both environments were compared with regard to their effects on cognitive performance (using trail making tests (TMTA, TMTB, and TMTB-A) as well as digit span forward and digit span backward tests), perceived restorativeness, mood, stress, sense of presence, and simulator sickness. The results showed that in comparison to the control environment, exposure to the virtual nature resulted in significantly higher cognitive performance, higher perceived restorativeness, higher positive affect, higher sense of presence, lower perceived stress, and lower simulator sickness.
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7
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Chu NM, Bae S, Chen X, Ruck J, Gross AL, Albert M, Neufeld KJ, Segev DL, McAdams-DeMarco MA. Delirium, changes in cognitive function, and risk of diagnosed dementia after kidney transplantation. Am J Transplant 2022; 22:2892-2902. [PMID: 35980673 PMCID: PMC10138281 DOI: 10.1111/ajt.17176] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 07/25/2022] [Accepted: 08/15/2022] [Indexed: 01/25/2023]
Abstract
Kidney transplant (KT) recipients with delirium, a preventable surgical complication, are likely to reap cognitive benefits from restored kidney function, but may be more vulnerable to longer-term neurotoxic stressors post-KT (i.e., aging, immunosuppression). In this prospective cohort study, we measured delirium (chart-based), global cognitive function (3MS), and executive function (Trail Making Test Part B minus Part A) in 894 recipients (2009-2021) at KT, 1/3/6-months, 1-year, and annually post-KT. Dementia was ascertained using linked Medicare claims. We described repeated measures of cognitive performance (mixed effects model) and quantified dementia risk (Fine & Gray competing risk) by post-KT delirium. Of 894 recipients, 43(4.8%) had post-KT delirium. Delirium was not associated with global cognitive function at KT (difference = -3.2 points, 95%CI: -6.7, 0.4) or trajectories post-KT (0.03 points/month, 95%CI: -0.27, 0.33). Delirium was associated with worse executive function at KT (55.1 s, 95%CI: 25.6, 84.5), greater improvements in executive function <2 years post-KT (-2.73 s/month, 95%CI: -4.46,-0.99), and greater decline in executive function >2 years post-KT (1.72 s/month, 95%CI: 0.22, 3.21). Post-KT delirium was associated with over 7-fold greater risk of dementia post-KT (adjusted subdistribution hazard ratio = 7.84, 95%CI: 1.22, 50.40). Transplant centers should be aware of cognitive risks associated with post-KT delirium and implement available preventative interventions to reduce delirium risk.
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Affiliation(s)
- Nadia M. Chu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Sunjae Bae
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA
| | - Xiaomeng Chen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jessica Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Alden L. Gross
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
- Department of Mental Health, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Marilyn Albert
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Karin J. Neufeld
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Dorry L. Segev
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA
| | - Mara A. McAdams-DeMarco
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA
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Abdelwahab MMA, Sabri Y, Elkalla IHR, Nassar MK, Abdel-Gawad SM, Gomaa ZAE. Cognitive impairment in different hemodialysis techniques. MIDDLE EAST CURRENT PSYCHIATRY 2022. [DOI: 10.1186/s43045-022-00258-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Abstract
Background
Cognitive impairment is one of the most common, often untreated, comorbidities affecting patients with chronic kidney disease treated with hemodialysis. Increased mortality, poor compliance, depression, and poor quality of life were all linked to cognitive impairment in the hemodialysis population. The intradialytic exercise proved to be beneficial in improving patients’ quality of life, among other positive effects. Cooling dialysate has various positive effects, including improved patients’ mood and decreased hypotensive episodes during hemodialysis. The study aims to assess the effect of intradialytic exercise and cool hemodialysis on cognitive function in patients on hemodialysis.
Results
The study showed no significant effect of both interventions on the patient’s cognitive functions. However, cooling dialysate showed an improvement in the severity of depressive symptoms by Beck’s Depression Inventory II (p = 0.02). On the other hand, Mini-International Neuropsychiatric Interview showed an increase of patients diagnosed with depression in the intradialytic exercise group.
Conclusions
Both interventions had no significant effect on the mean scores of the Montreal Cognitive Assessment, which are lower in our sample than in the general population (23.9–25). Potential implications include the importance of managing psychiatric comorbidities in patients on hemodialysis. Cooling dialysate can be adopted to alleviate depressive symptoms in patients on hemodialysis.
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Bogataj Š, Mesarič KK, Pajek M, Petrušič T, Pajek J. Physical exercise and cognitive training interventions to improve cognition in hemodialysis patients: A systematic review. Front Public Health 2022; 10:1032076. [PMID: 36311587 PMCID: PMC9616536 DOI: 10.3389/fpubh.2022.1032076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/27/2022] [Indexed: 01/29/2023] Open
Abstract
Introduction Patients with chronic kidney disease treated with hemodialysis (HD) have lower cognitive abilities compared to the age-matched healthy population. Recently, physical exercise and cognitive training have been presented as possible interventions to improve cognitive abilities both in the general population and in patients with chronic diseases. To date, there is no general overview of the current knowledge on how these interventions affect cognitive abilities in HD patients and what tests are used to measure these effects. Methods Three electronic databases were searched for randomized controlled studies of physical exercise or cognitive training interventions that examined effects on cognitive abilities/performance in HD patients. Results Six articles were included. All included studies used physical exercise as an intervention, with one study also including tablet-based cognitive training. Four studies included an intradialytic approach and two included a home-based intervention. Intervention lasted. A significant intervention effect was observed in three studies compared with the control condition. Conclusion The present review suggests that physical exercise might improve or at least not worsen cognitive performance in HD patients, whereas the effect of cognitive training has not yet been adequately studied. There is a need for more sensitive and specific cognitive tests to adequately measure the effects of interventions in the HD population.
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Affiliation(s)
- Špela Bogataj
- Department of Nephrology, University Medical Centre Ljubljanag, Ljubljana, Slovenia,*Correspondence: Špela Bogataj
| | - Katja Kurnik Mesarič
- Department of Nephrology, University Medical Centre Ljubljanag, Ljubljana, Slovenia
| | - Maja Pajek
- Faculty of Sport, University of Ljubljana, Ljubljana, Slovenia
| | - Tanja Petrušič
- Faculty of Education, University of Ljubljana, Ljubljana, Slovenia
| | - Jernej Pajek
- Department of Nephrology, University Medical Centre Ljubljanag, Ljubljana, Slovenia
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10
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Shrestha P, Van Pilsum Rasmussen SE, Fazal M, Chu NM, Garonzik-Wang JM, Gordon EJ, McAdams-DeMarco M, Humbyrd CJ. Patient Perspectives on the Use of Frailty, Cognitive Function, and Age in Kidney Transplant Evaluation. AJOB Empir Bioeth 2022; 13:263-274. [PMID: 35802563 DOI: 10.1080/23294515.2022.2090460] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND The allocation of scarce deceased donor kidneys is a complex process. Transplant providers are increasingly relying on constructs such as frailty and cognitive function to guide kidney transplant (KT) candidate selection. Patient views of the ethical issues surrounding the use of such constructs are unclear. We sought to assess KT candidates' attitudes and beliefs about the use of frailty and cognitive function to guide waitlist selection. METHODS KT candidates were randomly recruited from an ongoing single-center cohort study of frailty and cognitive function. Semi-structured interviews were conducted, and thematic analysis was performed. Inductively derived themes were mapped onto bioethics principles. RESULTS Twenty interviews were conducted (65% contact rate, 100% participation rate) (60% male; 70% White). With respect to the use of frailty and cognitive function in waitlisting decisions, four themes emerged in which participants: (1) valued maximizing a scarce resource (utility); (2) prioritized equal access to all patients (equity); (3) appreciated a proportional approach to the use of equity and utility (precautionary utility); and (4) sought to weigh utility- and equity-based concerns regarding social support. While some participants believed frailty and cognitive function were useful constructs to maximize utility, others believed their use would jeopardize equity. Patients were uncomfortable with using single factors such as frailty or cognitive impairment to deny someone access to transplantation; participants instead encouraged using the constructs to identify opportunities for intervention to improve frailty and cognitive function prior to KT. CONCLUSIONS KT candidates' values mirrored the current allocation strategy, seeking to balance equity and utility in a just manner, albeit with conflicting viewpoints on the appropriate use of frailty and cognitive impairment in waitlisting decisions.
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Affiliation(s)
- Prakriti Shrestha
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Maria Fazal
- Johns Hopkins, University School of Medicine, Baltimore, MD, USA
| | - Nadia M Chu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Elisa J Gordon
- Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Casey Jo Humbyrd
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
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11
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Liu H, Song Y, Zhao D, Zhan M. Effect of exercise on cognitive impairment in patients undergoing haemodialyses: A systematic review and meta-analysis of randomised controlled trials. J Ren Care 2022; 48:243-252. [PMID: 35338760 DOI: 10.1111/jorc.12420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 03/10/2022] [Accepted: 03/10/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND The influence of exercise on cognition in patients undergoing haemodialysis has been examined. However, evidence elucidating the effects in this patient group is scarce. OBJECTIVE To examine the effect of exercise on cognitive impairment in patients undergoing haemodialysis and provide insight into the effects of various characteristics of exercise on cognitive impairment in this population. DESIGN A systematic review and meta-analysis, following the guidance of PRISMA was undertaken. PARTICIPANTS Adult patients undergoing haemodialysis. RESULTS This review found that exercise significantly improved cognitive impairment in patients undergoing haemodialysis (SMD = 0.37, 95% CI: 0.13, 0.60, p = 0.002). Subgroup analyses demonstrated that both intradialytic exercise (SMD = 0.82, 95% CI: 0.37, 1.26, p < 0.001) and interdialytic exercise (SMD = 0.24, 95% CI: 0.01, 0.47, p = 0.038), exercise for 16 weeks or over (SMD = 0.33, 95% CI: 0.07, 0.58, p = 0.012), and lasting for more than 30 minutes (SMD = 0.52, 95% CI: 0.17, 0.86, p = 0.004) significantly alleviated cognitive impairment. The effect of exercise on cognitive impairment in patients less than 65 years of age (SMD = 0.39, 95% CI: 0.10, 0.68, p = 0.009) was significantly better than those over 65. CONCLUSION Exercise significantly improves cognitive impairment in patients undergoing haemodialysis. Both Intradialytic and interdialytic exercise of at least 30 minutes duration, 3 times weekly, and at least for 16 weeks may play a significant role in alleviating cognitive impairment in patients under 65 years of age.
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Affiliation(s)
- Huan Liu
- Medical School, Nantong University, Nantong, China
| | - Yan Song
- Medical School, Nantong University, Nantong, China
| | - Danyan Zhao
- Medical School, Nantong University, Nantong, China
| | - Minqi Zhan
- Medical School, Nantong University, Nantong, China
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Bogataj Š, Trajković N, Pajek M, Pajek J. Effects of Intradialytic Cognitive and Physical Exercise Training on Cognitive and Physical Abilities in Hemodialysis Patients: Study Protocol for a Randomized Controlled Trial. Front Psychol 2022; 13:835486. [PMID: 35145465 PMCID: PMC8821650 DOI: 10.3389/fpsyg.2022.835486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 01/04/2022] [Indexed: 11/21/2022] Open
Abstract
The prevalence of cognitive impairment in hemodialysis (HD) patients is extremely high. Despite the well-documented benefits of interventions on cognitive function, there is a widespread call for effective strategies that will show the long-term consequences in patients undergoing dialysis. The aim of this research protocol was to investigate the effect of cognitive training combined with physical exercise on cognitive function, physical performance, and frailty indicators in the HD population. We will conduct a randomized controlled intervention trial to examine the effects of a combined non-pharmacological intervention in the form of intradialytic physical exercise and intradialytic cognitive training on cognitive function, indicators of frailty, and physical performance measures in HD patients. The group of patients receiving the study intervention will be compared to the control group receiving standard HD care. The duration of the intervention will be 12 weeks. We will use sensitive instruments (cognitive domain tests) to assess cognitive functions. The primary outcome of the study at 12 weeks will be performance on the Alertness subtest of the computerized Test of Attentional Performance. Secondary study outcomes are: Performance in other domains of cognitive function (executive function, psychomotor speed, information processing efficiency, working memory, and attention), physical fitness (10 repetition sit-to-stand test, timed up and go test, handgrip strength test, spontaneous gait speed, and stork balance test), and assessment of frailty (Edmonton Frail Scale). Study outcomes will be assessed at baseline, immediately after the 12-week intervention, and 6 months after the end of the study without specific further intervention (retention effect assessment). This study will be among the first to test the synergistic effects of a uniquely designed physical exercise and cognitive training intervention on functional status in HD patients. We believe our results will contribute to dementia prevention research by demonstrating the long-term efficacy of our combined intervention. Clinical Trial Registration: ClinicalTrials.Gov, NCT05150444.
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Affiliation(s)
- Špela Bogataj
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Nebojša Trajković
- Faculty of Sport and Physical Education, University of Niš, Niš, Serbia
| | - Maja Pajek
- Faculty of Sport, University of Ljubljana, Ljubljana, Slovenia
| | - Jernej Pajek
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia
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13
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Bernier-Jean A, Beruni NA, Bondonno NP, Williams G, Teixeira-Pinto A, Craig JC, Wong G. Exercise training for adults undergoing maintenance dialysis. Cochrane Database Syst Rev 2022; 1:CD014653. [PMID: 35018639 PMCID: PMC8752366 DOI: 10.1002/14651858.cd014653] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Dialysis treatments weigh heavily on patients' physical and psychosocial health. Multiple studies have assessed the potential for exercise training to improve outcomes in adults undergoing dialysis. However, uncertainties exist in its relevance and sustainable benefits for patient-important outcomes. This is an update of a review first published in 2011. OBJECTIVES To assess the benefits and safety of regular structured exercise training in adults undergoing dialysis on patient-important outcomes including death, cardiovascular events, fatigue, functional capacity, pain, and depression. We also aimed to define the optimal prescription of exercise in adults undergoing dialysis. SEARCH METHODS In this update, we conducted a systematic search of the Cochrane Kidney and Transplant Register of Studies up to 23 December 2020. The Register includes studies identified from CENTRAL, MEDLINE, EMBASE, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov as well as kidney-related journals and the proceedings of major kidney conferences. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs of any structured exercise programs of eight weeks or more in adults undergoing maintenance dialysis compared to no exercise or sham exercise. DATA COLLECTION AND ANALYSIS Two authors independently assessed the search results for eligibility, extracted the data and assessed the risk of bias using the Cochrane risk of bias tool. Whenever appropriate, we performed random-effects meta-analyses of the mean difference in outcomes. The primary outcomes were death (any cause), cardiovascular events and fatigue. Secondary outcomes were health-related quality of life (HRQoL), depression, pain, functional capacity, blood pressure, adherence to the exercise program, and intervention-related adverse events. MAIN RESULTS We identified 89 studies involving 4291 randomised participants, of which 77 studies (3846 participants) contributed to the meta-analyses. Seven studies included adults undergoing peritoneal dialysis. Fifty-six studies reported aerobic exercise interventions, 21 resistance exercise interventions and 19 combined aerobic and resistance training within the same study arm. The interventions lasted from eight weeks to two years and most often took place thrice weekly during dialysis treatments. A single study reported death and no study reported long-term cardiovascular events. Five studies directly assessed fatigue, 46 reported HRQoL and 16 reported fatigue or pain through their assessment of HRQoL. Thirty-five studies assessed functional capacity, and 21 reported resting peripheral blood pressure. Twelve studies reported adherence to exercise sessions, and nine reported exercise-related adverse events. Overall, the quality of the included studies was low and blinding of the participants was generally not feasible due to the nature of the intervention. Exercise had uncertain effects on death, cardiovascular events, and the mental component of HRQoL due to the very low certainty of evidence. Compared with sham or no exercise, exercise training for two to 12 months may improve fatigue in adults undergoing dialysis, however, a meta-analysis could not be conducted. Any exercise training for two to 12 months may improve the physical component of HRQoL (17 studies, 656 participants: MD 4.12, 95% CI 1.88 to 6.37 points on 100 points-scale; I² = 49%; low certainty evidence). Any exercise training for two to 12 months probably improves depressive symptoms (10 studies, 441 participants: SMD -0.65, 95% CI -1.07 to -0.22; I² = 77%; moderate certainty evidence) and the magnitude of the effect may be greater when maintaining the exercise beyond four months (6 studies, 311 participants: SMD -0.30, 95% CI 0.14 to -0.74; I² = 71%). Any exercise training for three to 12 months may improve pain (15 studies, 872 participants: MD 5.28 95% CI -0.12 to 10.69 points on 100 points-scale; I² = 63%: low certainty evidence) however, the 95% CI indicates that exercise training may make little or no difference in the level of pain. Any exercise training for two to six months probably improves functional capacity as it increased the distance reached during six minutes of walking (19 studies, 827 participants: MD 49.91 metres, 95% CI 37.22 to 62.59; I² = 34%; moderate certainty evidence) and the number of sit-to-stand cycles performed in 30 seconds (MD 2.33 cycles, 95% CI 1.71 to 2.96; moderate certainty evidence). There was insufficient evidence to assess the safety of exercise training for adults undergoing maintenance dialysis. The results were similar for aerobic exercise, resistance exercise, and a combination of both aerobic and resistance exercise. AUTHORS' CONCLUSIONS It is uncertain whether exercise training improves death, cardiovascular events, or the mental component of HRQoL in adults undergoing maintenance dialysis. Exercise training probably improves depressive symptoms, particularly when the intervention is maintained beyond four months. Exercise training is also likely to improve functional capacity. Low certainty evidence suggested that exercise training may improve fatigue, the physical component of quality of life, and pain. The safety of exercise training for adults undergoing dialysis remains uncertain.
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Affiliation(s)
- Amelie Bernier-Jean
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Nadim A Beruni
- Resident Support Unit, Western Sydney Local Health District, Westmead, Australia
| | - Nicola P Bondonno
- School of Biomedical Sciences, The University of Western Australia, Royal Perth Hospital, Perth, Australia
- School of Medical and Health Sciences, Edith Cowan University, Perth, Australia
| | - Gabrielle Williams
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | | | - Jonathan C Craig
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Germaine Wong
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
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Crowe K, Quinn TJ, Mark PB, Findlay MD. "Is It Removed During Dialysis?"-Cognitive Dysfunction in Advanced Kidney Failure-A Review Article. Front Neurol 2021; 12:787370. [PMID: 34925220 PMCID: PMC8674209 DOI: 10.3389/fneur.2021.787370] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 11/08/2021] [Indexed: 12/02/2022] Open
Abstract
Cognitive impairment is independently associated with kidney disease and increases in prevalence with declining kidney function. At the stage where kidney replacement therapy is required, with dialysis or transplantation, cognitive impairment is up to three times more common, and can present at a younger age. This is not a new phenomenon. The cognitive interactions of kidney disease are long recognized from historical accounts of uremic encephalopathy and so-called "dialysis dementia" to the more recent recognition of cognitive impairment in those undergoing kidney replacement therapy (KRT). The understanding of cognitive impairment as an extra-renal complication of kidney failure and effect of its treatments is a rapidly developing area of renal medicine. Multiple proposed mechanisms contribute to this burden. Advanced vascular aging, significant multi-morbidity, mood disorders, and sleep dysregulation are common in addition to the disease-specific effects of uremic toxins, chronic inflammation, and the effect of dialysis itself. The impact of cognitive impairment on people living with kidney disease is vast ranging from increased hospitalization and mortality to decreased quality of life and altered decision making. Assessment of cognition in patients attending for renal care could have benefits. However, in the context of a busy clinical service, a pragmatic approach to assessing cognitive function is necessary and requires consideration of the purpose of testing and resources available. Limited evidence exists to support treatments to mitigate the degree of cognitive impairment observed, but promising interventions include physical or cognitive exercise, alteration to the dialysis treatment and kidney transplantation. In this review we present the history of cognitive impairment in those with kidney failure, and the current understanding of the mechanisms, effects, and implications of impaired cognition. We provide a practical approach to clinical assessment and discuss evidence-supported treatments and future directions in this ever-expanding area which is pivotal to our patients' quality and quantity of life.
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Affiliation(s)
- Kirsty Crowe
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Terence J. Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Patrick B. Mark
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, United Kingdom
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Mark D. Findlay
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, United Kingdom
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Otobe Y, Yamada M, Hiraki K, Onari S, Taki Y, Sumi H, Hachisuka R, Han W, Takahashi M, Suzuki M, Kimura Y, Koyama S, Masuda H, Shibagaki Y, Tominaga N. Physical Exercise Improves Cognitive Function in Older Adults with Stage 3-4 Chronic Kidney Disease: A Randomized Controlled Trial. Am J Nephrol 2021; 52:929-939. [PMID: 34847564 DOI: 10.1159/000520230] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 10/09/2021] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Patients with chronic kidney disease (CKD) exhibit a higher probability of having cognitive impairment or dementia than those without CKD. The beneficial effects of physical exercise on cognitive function are known in the general older population, but more research is required in older adults with CKD. METHODS Eighty-one outpatients (aged ≥65 years) with CKD stage G3-G4 were assessed for eligibility. Among them, 60 were randomized (single-center, unblinded, and stratified) and 53 received the allocated intervention (exercise n = 27, control n = 26). Patients in the exercise group undertook group-exercise training at our facility once weekly and independent exercises at home twice weekly or more, for 24 weeks. Patients in the control group received general care. General and specific cognitive functions (memory, attention, executive, and verbal) were measured, and differences in their scores at baseline and at the 24-week follow-up visit were assessed between the 2 groups. RESULTS Forty-four patients completed the follow-up at 24 weeks (exercise n = 23, control n = 21). Patients in the exercise group showed significantly greater changes in Wechsler Memory Scale-Revised Logical Memory delayed recall (exercise effect: 2.82, 95% CI: 0.46-5.19, p = 0.03), and immediate and delayed recall (exercise effect: 5.97, 95% CI: 1.13-10.81, p = 0.02) scores than those in the control group. CONCLUSIONS The 24-week exercise intervention significantly improved the memory function in older adults with pre-dialysis CKD. This randomized controlled trial suggests that physical exercise is a useful nonpharmacological strategy for preventing cognitive decline in these patients.
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Affiliation(s)
- Yuhei Otobe
- Department of Rehabilitation Medicine, Kawasaki Municipal Tama Hospital, Kawasaki, Japan
- Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tokyo, Japan
| | - Minoru Yamada
- Faculty of Human Sciences, University of Tsukuba, Tokyo, Japan
| | - Koji Hiraki
- Rehabilitation Center, St. Marianna University School of Medicine Hospital, Kawasaki, Japan
| | - Satoshi Onari
- Department of Rehabilitation Medicine, Kawasaki Municipal Tama Hospital, Kawasaki, Japan
| | - Yasuhiro Taki
- Division of Nephrology and Hypertension, Department of Internal Medicine, Kawasaki Municipal Tama Hospital, Kawasaki, Japan
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Hirofumi Sumi
- Division of Nephrology and Hypertension, Department of Internal Medicine, Kawasaki Municipal Tama Hospital, Kawasaki, Japan
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Rina Hachisuka
- Division of Nephrology and Hypertension, Department of Internal Medicine, Kawasaki Municipal Tama Hospital, Kawasaki, Japan
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Wei Han
- Division of Nephrology and Hypertension, Department of Internal Medicine, Kawasaki Municipal Tama Hospital, Kawasaki, Japan
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Masaki Takahashi
- Department of Medical Informatics, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Mizue Suzuki
- Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tokyo, Japan
| | - Yosuke Kimura
- Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tokyo, Japan
- Department of Electrical Engineering, Health and Sports Technology Course, Kanto Gakuin University, Yokohama, Japan
| | - Shingo Koyama
- Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tokyo, Japan
| | - Hiroaki Masuda
- Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tokyo, Japan
| | - Yugo Shibagaki
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Naoto Tominaga
- Division of Nephrology and Hypertension, Department of Internal Medicine, Kawasaki Municipal Tama Hospital, Kawasaki, Japan
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
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Chu NM, Hong J, Harasemiw O, Chen X, Fowler KJ, Dasgupta I, Bohm C, Segev DL, McAdams-DeMarco MA. Chronic kidney disease, physical activity, and cognitive function in older adults- results from the National Health and Nutrition Examination Survey (2011-2014). Nephrol Dial Transplant 2021; 37:2180-2189. [PMID: 34850174 DOI: 10.1093/ndt/gfab338] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Cognitive impairment is common among persons with chronic kidney disease (CKD) due in part to reduced kidney function. Given that physical activity (PA) is known to mitigate cognitive decline, we examined whether associations between CKD stage and global/domain-specific cognitive function differs by PA. METHODS We leveraged 3,223 participants (aged≥60years) enrolled in National Health and Nutrition Examination Survey (NHANES,2011-2014), with at least one measure of objective cognitive function (immediate recall [CERAD-WL], delayed recall [CERAD-DR], verbal fluency [AF], executive function/processing speed [DSST], global [average of 4 tests]) or self-perceived memory decline [SCD]. We quantified the association between CKD stage (no CKD: eGFR≥60 mL/min/1.73m2 and albuminuria(ACR)<30 mg/g; stage G1-G3: eGFR≥60mL/min/1.73m2 and ACR≥30mg/g or eGFR 30-59mL/min/1.73m2; stage G4-G5: eGFR<30mL/min/1.73m2) and cognitive function using linear regression (objective measures) and logistic regression (SCD), accounting for sampling weights for nationally-representative estimates. We tested whether associations differed by physical activity (Global Physical Activity Questionnaire, high PA≥600MET*min/week vs. low PA<600MET*min/week) using a Wald test. RESULTS Among NHANES participants, 34.9% had CKD stageG1-G3, 2.6% had stageG4-G5, and 50.7% had low PA. CKD stageG4-G5 was associated with lower global cognitive function (difference = -0.38SD, 95%CI:-0.62,-0.15). This association differed by PA (pinteraction = 0.01). Specifically, among participants with low PA, those with CKD stageG4-G5 had lower global cognitive function (difference = -0.57SD, 95%CI: -0.82,-0.31) compared to those without CKD. Among those with high PA, no difference was found (difference = 0.10SD, 95%CI:-0.29,0.49). Similarly, CKD stage was only associated with immediate recall, verbal fluency, executive function, and processing speed among those with low PA; no associations were observed for delayed recall or self-perceived memory decline. CONCLUSIONS CKD is associated with lower objective cognitive function among those with low, but not high PA. Clinicians should consider screening older patients with CKD who have low PA for cognitive impairment and encourage them to meet PA guidelines.
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Affiliation(s)
- Nadia M Chu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jingyao Hong
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Oksana Harasemiw
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
| | - Xiaomeng Chen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kevin J Fowler
- Principal, The Voice of the Patient, Inc. Chicago, Illinois, USA
| | - Indranil Dasgupta
- University of Warwick, Heartlands Hospital Birmingham and Warwick Medical School, West Midlands, England, UK
| | - Clara Bohm
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Mara A McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Chu NM, Chen X, Gross AL, Carlson MC, Garonzik-Wang JM, Norman SP, Mathur A, Abidi MZ, Brennan DC, Segev DL, McAdams-DeMarco MA. Cognitive impairment burden in older and younger adults across the kidney transplant care continuum. Clin Transplant 2021; 35:e14425. [PMID: 34272777 PMCID: PMC8595550 DOI: 10.1111/ctr.14425] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 05/26/2021] [Accepted: 07/06/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Younger kidney transplant (KT) candidates and recipients may have cognitive impairment due to chronic diseases and reliance on dialysis. METHODS To quantify cognitive impairment burden by age across the KT care continuum, we leveraged a two-center cohort study of 3854 KT candidates at evaluation, 1114 recipients at admission, and 405 recipients at 1-year post-KT with measured global cognitive performance (3MS) or executive function (Trail Making Test). We also estimated burden of severe cognitive impairment that affects functional dependence (activities of daily living [ADL] < 6 or instrumental activities of daily living [IADL] < 8). RESULTS Among KT candidates, global cognitive impairment (18-34 years: 11.1%; 35-49 years: 14.0%; 50-64 years: 19.5%; ≥65 years: 22.0%) and severe cognitive impairment burden (18-34 years: 1.1%; 35-49 years: 3.0%; 50-64 years: 6.2%; ≥65 years: 7.7%) increased linearly with age. Among KT recipients at admission, global cognitive impairment (18-34 years: 9.1%; 35-49 years: 6.1%; 50-64 years: 9.3%; ≥65 years: 15.7%) and severe cognitive impairment burden (18-34 years: 1.4%; 35-49 years: 1.4%; 50-64 years: 2.2%; ≥65 years: 4.6%) was lower. Despite lowest burden of cognitive impairment among KT recipients at 1-year post-KT across all ages (18-34 years: 1.7%; 35-49 years: 3.4%; 50-64 years: 4.3%; ≥65 years: 6.5%), many still exhibited severe cognitive impairment (18-34 years: .0%; 35-49 years: 1.9%; 50-64 years: 2.4%; ≥65 years: 3.5%). CONCLUSION Findings were consistent for executive function impairment. While cognitive impairment increases with age, younger KT candidates have a high burden comparable to community-dwelling older adults, with some potentially suffering from severe forms. Transplant centers should consider routinely screening patients during clinical care encounters regardless of age.
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Affiliation(s)
- Nadia M Chu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Xiaomeng Chen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Alden L Gross
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Michelle C Carlson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Silas P Norman
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Aarti Mathur
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Maheen Z Abidi
- Department of Medicine, University of Colorado School of Medicine, Denver, Colorado, USA
| | - Daniel C Brennan
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Mara A McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Dai H, Liu X, Feng D, Li R, Shen H. Evidence-based nursing combined with cognitive function training can reduce the incidence of delirium in ICU patients and improve their cognitive function. Am J Transl Res 2021; 13:3262-3269. [PMID: 34017497 PMCID: PMC8129389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 12/26/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To explore whether evidence-based nursing combined with cognitive function training can reduce the incidences of delirium in intensive care unit (ICU) patients and improve their cognitive function. METHODS ICU patients in our hospital were randomly divided into an evidence-based nursing group (the E group) and an evidence-based nursing combined with cognitive function training group (the EC group). The incidences of delirium, the Pittsburgh Sleep Quality Index (PSQI) scores, the Mini-Mental State Exam (MMSE) scores, the National Institutes of Health Stroke Scale (NIHSS) scores, the Barthel Index levels, and the nursing satisfaction rates were compared between the two groups. RESULTS Before the nursing, there were no significant differences in the MMSE scores, the NIHSS scores, the Barthel Index levels or the PSQI scores between the E group and the EC group (P>0.05). After one week of treatment, the incidences of delirium in the EC group were significantly lower than they were in the E group (P<0.05). The PSQI scores and the NIHSS scores in the EC group were significantly lower than they were in the E group (P<0.001). The MMSE scores and the Barthel Index levels in the EC group were significantly higher than they were in the E group (P<0.01). There was no significant difference in the nursing satisfaction rates between the two groups (P>0.05). CONCLUSION Compared with using evidence-based nursing only, the combined application of evidence-based nursing and cognitive function training has a significantly better effect on the improvement of neurological function, sleep quality and normal living conditions in ICU patients.
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Affiliation(s)
- Hangling Dai
- School of Nursing, Southern Medical UniversityGuangzhou, Guangdong Province, China
- Department of Intensive Care Unit, Fuwai Hospital Chinese Academy of Medical Sciences (Shenzhen)Shenzhen, Guangdong Province, China
| | - Xiling Liu
- Department of Intensive Care Unit, Fuwai Hospital Chinese Academy of Medical Sciences (Shenzhen)Shenzhen, Guangdong Province, China
| | - Dongjie Feng
- Department of Intensive Care Unit, Fuwai Hospital Chinese Academy of Medical Sciences (Shenzhen)Shenzhen, Guangdong Province, China
| | - Rong Li
- Department of Nursing, Fuwai Hospital Chinese Academy of Medical Sciences (Shenzhen)Shenzhen, Guangdong Province, China
| | - Haiyan Shen
- School of Nursing, Southern Medical UniversityGuangzhou, Guangdong Province, China
- Department of Urology, Zhujiang Hospital, Southem Medical UniversityGuangzhou, Guangdong Province, China
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Metzger M, Abdel-Rahman EM, Boykin H, Song MK. A Narrative Review of Management Strategies for Common Symptoms in Advanced CKD. Kidney Int Rep 2021; 6:894-904. [PMID: 33912741 PMCID: PMC8071652 DOI: 10.1016/j.ekir.2021.01.038] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/26/2021] [Accepted: 01/28/2021] [Indexed: 12/19/2022] Open
Abstract
Patients with advanced chronic kidney disease (CKD) experience multiple bothersome symptoms, undermining their quality of life (QOL). With growing attention to the importance of symptom management in advanced CKD, the evidence regarding symptoms is increasing. In this review, we briefly summarize the current evidence of effective pharmacologic and nonpharmacologic interventions to improve symptoms and QOL in patients with advanced CKD, including those on dialysis. We focused on symptoms that are commonly experienced by patients, such as pain, fatigue, sleep disturbances, itching, nausea and vomiting, cognitive impairment, and anxiety and depression. We noted that research in symptom science focused on improving symptom management in CKD is still very limited. In addition to the lack of clinical practice guidelines to address those common symptoms, the major gaps in the current literature include the evidence regarding mechanistic pathways to inform the development of effective symptom management for CKD populations, the evidence to confirm effective pharmacologic interventions in other populations for CKD populations, and research on how to incorporate effective symptom management approaches into clinical care. Although improving mortality remains as an important area in the kidney community, there is an urgent need to focus on improving symptom management to improve QOL in advanced CKD.
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Affiliation(s)
- Maureen Metzger
- University of Virginia School of Nursing, Charlottesville, Virginia, USA
| | - Emaad M. Abdel-Rahman
- Division of Nephrology, Nephrology, University of Virginia, Charlottesville, Virginia, USA
| | - Heather Boykin
- Kidney Palliative Care Clinic, University of North Carolina Healthcare, UNC Medical Center, Chapel Hill, North Carolina, USA
| | - Mi-Kyung Song
- Center for Nursing Excellence in Palliative Care, Nell Hudgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA
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20
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Krishnamurthy V, Sprick JD, Krishnamurthy LC, Barter JD, Turabi A, Hajjar IM, Nocera JR. The Utility of Cerebrovascular Reactivity MRI in Brain Rehabilitation: A Mechanistic Perspective. Front Physiol 2021; 12:642850. [PMID: 33815146 PMCID: PMC8009989 DOI: 10.3389/fphys.2021.642850] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 02/22/2021] [Indexed: 01/06/2023] Open
Abstract
Cerebrovascular control and its integration with other physiological systems play a key role in the effective maintenance of homeostasis in brain functioning. Maintenance, restoration, and promotion of such a balance are one of the paramount goals of brain rehabilitation and intervention programs. Cerebrovascular reactivity (CVR), an index of cerebrovascular reserve, plays an important role in chemo-regulation of cerebral blood flow. Improved vascular reactivity and cerebral blood flow are important factors in brain rehabilitation to facilitate desired cognitive and functional outcomes. It is widely accepted that CVR is impaired in aging, hypertension, and cerebrovascular diseases and possibly in neurodegenerative syndromes. However, a multitude of physiological factors influence CVR, and thus a comprehensive understanding of underlying mechanisms are needed. We are currently underinformed on which rehabilitation method will improve CVR, and how this information can inform on a patient's prognosis and diagnosis. Implementation of targeted rehabilitation regimes would be the first step to elucidate whether such regimes can modulate CVR and in the process may assist in improving our understanding for the underlying vascular pathophysiology. As such, the high spatial resolution along with whole brain coverage offered by MRI has opened the door to exciting recent developments in CVR MRI. Yet, several challenges currently preclude its potential as an effective diagnostic and prognostic tool in treatment planning and guidance. Understanding these knowledge gaps will ultimately facilitate a deeper understanding for cerebrovascular physiology and its role in brain function and rehabilitation. Based on the lessons learned from our group's past and ongoing neurorehabilitation studies, we present a systematic review of physiological mechanisms that lead to impaired CVR in aging and disease, and how CVR imaging and its further development in the context of brain rehabilitation can add value to the clinical settings.
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Affiliation(s)
- Venkatagiri Krishnamurthy
- Center for Visual and Neurocognitive Rehabilitation, Atlanta VAMC, Decatur, GA, United States
- Division of Geriatrics and Gerontology, Department of Medicine, Emory University, Atlanta, GA, United States
- Department of Neurology, Emory University, Atlanta, GA, United States
| | - Justin D. Sprick
- Division of Renal Medicine, Department of Medicine, Emory University, Atlanta, GA, United States
| | - Lisa C. Krishnamurthy
- Center for Visual and Neurocognitive Rehabilitation, Atlanta VAMC, Decatur, GA, United States
- Department of Physics & Astronomy, Georgia State University, Atlanta, GA, United States
| | - Jolie D. Barter
- Division of Geriatrics and Gerontology, Department of Medicine, Emory University, Atlanta, GA, United States
| | - Aaminah Turabi
- Center for Visual and Neurocognitive Rehabilitation, Atlanta VAMC, Decatur, GA, United States
- Department of Biology, Georgia State University, Atlanta, GA, United States
| | - Ihab M. Hajjar
- Department of Neurology, Emory University, Atlanta, GA, United States
| | - Joe R. Nocera
- Center for Visual and Neurocognitive Rehabilitation, Atlanta VAMC, Decatur, GA, United States
- Department of Neurology, Emory University, Atlanta, GA, United States
- Division of Physical Therapy, Department of Rehabilitation Medicine, Emory University, Atlanta, GA, United States
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21
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Chu NM, Segev D, McAdams-DeMarco MA. Interventions to Preserve Cognitive Functioning Among Older Kidney Transplant Recipients. CURRENT TRANSPLANTATION REPORTS 2020; 7:346-354. [PMID: 33777649 PMCID: PMC7992368 DOI: 10.1007/s40472-020-00296-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2020] [Indexed: 12/30/2022]
Abstract
PURPOSE OF REVIEW To summarize the research on effective interventions for preserving cognitive function and prevent cognitive decline in patients with end-stage kidney disease (ESKD) who are undergoing dialysis and/or kidney transplantation (KT). RECENT FINDINGS Among ESKD patients undergoing hemodialysis, exercise training has been administered through home-based and intradialytic interventions. Additionally, one pilot study identified intradialytic cognitive training, electronic brain games, as an intervention to preserve cognitive function among patients undergoing hemodialysis. Fewer studies have investigated interventions to preserver cognitive function among KT recipients. To date, the only randomized controlled trial in this population identified B-vitamin supplements as an intervention to preserve cognitive function. The evidence from these trials support a short-term benefit of cognitive and exercise training as well as B-vitamin supplementation among patients with ESKD. Future studies should: 1) replicate these findings, 2) identify interventions specific to KT candidates, and 3) investigate the synergistic impact of both cognitive and exercise training. SUMMARY Cognitive prehabilitation, with cognitive and/or exercise training, may be novel interventions for KT candidates that not only reduces delirium risk and long-term post-KT cognitive decline but also prevents dementia.
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Affiliation(s)
- Nadia M. Chu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Dorry Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Mara A. McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Jiménez-Prieto CM, González-Tamajón R, Rodolfo Crespo-Montero R. Beneficios del ejercicio físico en la sesión de hemodiálisis. Una revisión sistemática. ENFERMERÍA NEFROLÓGICA 2020. [DOI: 10.37551/s2254-28842020024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Objetivo: El objetivo principal de esta revisión fue conocer los principales beneficios del ejercicio físico durante la sesión de diálisis, en los pacientes en programa de hemodiálisis periódicas.Material y Método: Se llevó a cabo una revisión sistemática a través de las bases de datos Pubmed, Science Direct y Google Académico. Se incluyeron artículos científicos en inglés y español, y se analizaron los artículos que trataban sobre ejercicio físico en la sesión de hemodiálisis. Se excluyeron aquellos artículos que no presentaran resultados y en los que el ejercicio físico fuese domiciliario.Resultados: Se incluyeron 18 artículos publicados entre 2015 y 2019. Todos los artículos fueron de diseño experimental. Se encontró una mejoría significativa de la fuerza muscular, al igual que de la capacidad física y de de la sintomatología depresiva. En menor medida, se observó una disminución de la presión arterial, disminución del proceso inflamatorio, mejoría de los valores nutricionales y mejora de la calidad de vida de estos pacientes.Conclusiones: El ejercicio físico en la sesión de hemodiálisis tiene beneficios para la salud de los pacientes. El ejercicio físico de baja intensidad, así como la electroestimulación neuromuscular en las sesiones de diálisis, mejora objetivamente la fuerza muscular, aumenta la capacidad física, mejora la sintomatología depresiva con un mejor manejo del estrés y la ansiedad. Además, perece que puede mejorar el proceso inflamatorio, parámetros nutricionales y disminuir la presión arterial, así como mejorar la calidad de vida. La electroestimulación neuromuscular y el ejercicio físico de baja intensidad, son los ejercicios más utilizados.
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Affiliation(s)
- Carmen Mª Jiménez-Prieto
- Departamento de Enfermería. Facultad de Medicina y Enfermería. Universidad de Córdoba. Córdoba. España
| | - Rosa González-Tamajón
- Departamento de Enfermería. Facultad de Medicina y Enfermería. Universidad de Córdoba. Córdoba. España
| | - Rodolfo Rodolfo Crespo-Montero
- Departamento de Enfermería. Facultad de Medicina y Enfermería. Universidad de Córdoba. Córdoba. España. Servicio de Nefrología. Hospital Universitario Reina Sofía de Córdoba. Córdoba. España. Instituto Maimónides de Investigación Biomédica de Córdoba. Córdoba. España
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McAdams-DeMarco MA, Chu NM, Steckel M, Kunwar S, González Fernández M, Carlson MC, Fine DM, Appel LJ, Diener-West M, Segev DL. Interventions Made to Preserve Cognitive Function Trial (IMPCT) study protocol: a multi-dialysis center 2x2 factorial randomized controlled trial of intradialytic cognitive and exercise training to preserve cognitive function. BMC Nephrol 2020; 21:383. [PMID: 32883245 PMCID: PMC7469421 DOI: 10.1186/s12882-020-02041-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 08/23/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Kidney disease and dialysis significantly impact cognitive function across the age spectrum. Cognitive training (CT) and/or exercise training (ET) are promising approaches to preserve cognitive function among community-dwelling older adults, but have not been tested for cognition preservation in hemodialysis patients of all ages. In this manuscript, we summarize the protocol for the Interventions Made to Preserve Cognitive Function Trial (IMPCT). METHODS We will perform a 2 × 2 factorial randomized controlled trial (RCT) of eligible adult (≥18 years) hemodialysis initiates (n = 200) to test whether intradialytic CT (brain games on a tablet PC), ET (foot peddlers) and combined CT + ET while undergoing hemodialysis preserves executive function compared to standard of care (SC). Participants will engage in the interventions to which they are randomized for 6 months. The primary objective is to compare, among interventions, the 3-month change in executive function measured using the Trail Making Test A (TMTA) and B (TMTB); specifically, executive function is calculated as TMTB-TMTA to account for psychomotor speed. This primary outcome was selected based on findings from our pilot study. The secondary objectives are to compare the risk of secondary cognitive outcomes, ESKD-specific clinical outcomes, and patient-centered outcomes at 3-months and 6-months. All data collection and interventions are conducted in the dialysis center. DISCUSSION We hypothesize that receiving intradialytic CT or ET will better preserve executive function than SC but receiving combined CT + ET, will be the most effective intervention. The current trial will be an important step in understanding how intradialytic interventions might preserve cognitive health. TRIAL REGISTRATION Clinicaltrials.Gov (Date: 8/6/18): # NCT03616535 . Protocol Version: 10 (April 2020). FUNDING NIDDK R01DK114074.
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Affiliation(s)
- Mara A McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615, N. Wolfe St, W6033, Baltimore, MD, 21205, USA.
| | - Nadia M Chu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615, N. Wolfe St, W6033, Baltimore, MD, 21205, USA
| | - Malu Steckel
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sneha Kunwar
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Marlís González Fernández
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michelle C Carlson
- Department of Mental Health, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Derek M Fine
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lawrence J Appel
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615, N. Wolfe St, W6033, Baltimore, MD, 21205, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Marie Diener-West
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615, N. Wolfe St, W6033, Baltimore, MD, 21205, USA
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Transitions in frailty state after kidney transplantation. Langenbecks Arch Surg 2020; 405:843-850. [PMID: 32691130 PMCID: PMC7471154 DOI: 10.1007/s00423-020-01936-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 07/10/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE Frailty is the body's failure to return to homeostasis after every day or acute stressful events, causing adverse outcomes. To study its dynamics in kidney transplant recipients (KTR), we determined whether the degree of frailty and its domains are affected by kidney transplantation (KT). METHODS Between 2015 and 2017, 176 KTR were included. Frailty scores were measured using the Groningen Frailty Indicator (GFI), assessed preoperatively and during follow-up. Transitions in frailty state and changes in the individual domains were determined. RESULTS Mean age (±SD) was 51.8 (± 14.1) years, and 63.1% of KTR were male. Thirty patients were considered frail (GFI ≥ 4) at baseline. After a mean follow-up of 22.8 ± 8.3 months, 34 non-frail patients (19.3%) became frail, 125 patients (71.0%) remained the same, and 17 frail patients (9.7%) became non-frail (GFI < 4). In the domain psychosocial functioning, 28.4% of the patients had an increase in GFI score after follow-up. Patients who scored a point in the domain cognition at baseline had a greater chance of becoming frail (OR 4.38, 95% CI 0.59-32.24). CONCLUSION In conclusion, almost one-fifth of non-frail KTR transitioned to a frail state after their transplantation. These results could be used to predict the impact of KT on frailty course and help with implementing prehabilitation for patients at risk.
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Chu NM, Shi Z, Haugen CE, Norman SP, Gross AL, Brennan DC, Carlson MC, Segev DL, McAdams-DeMarco MA. Cognitive Function, Access to Kidney Transplantation, and Waitlist Mortality Among Kidney Transplant Candidates With or Without Diabetes. Am J Kidney Dis 2020; 76:72-81. [PMID: 32029264 PMCID: PMC7311233 DOI: 10.1053/j.ajkd.2019.10.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 10/31/2019] [Indexed: 12/21/2022]
Abstract
RATIONALE & OBJECTIVE Intact cognition is generally a prerequisite for navigating through and completing evaluation for kidney transplantation. Despite kidney transplantation being contraindicated for those with severe dementia, screening for more mild forms of cognitive impairment before referral is rare. Candidates may have unrecognized cognitive impairment, which may prolong evaluation, elevate mortality risk, and hinder access to kidney transplantation. We estimated the burden of cognitive impairment and its association with access to kidney transplantation and waitlist mortality. STUDY DESIGN Prospective cohort study. SETTING & PARTICIPANTS 3,630 participants (January 2009 to June 2018) with cognitive function measured (by the Modified Mini-Mental State Examination [3MS]) at kidney transplantation evaluation at 1 of 2 transplantation centers. PREDICTORS Cognitive impairment (3MS score<80). OUTCOMES Listing, waitlist mortality, and kidney transplantation. ANALYTICAL APPROACH We estimated the adjusted chance of listing (Cox regression), risk for waitlist mortality (competing-risks regression), and kidney transplantation rate (Poisson regression) by cognitive impairment. Given potential differences in cause of cognitive impairment among those with and without diabetes, we tested whether these associations differed by diabetes status using a Wald test. RESULTS At evaluation, 6.4% of participants had cognitive impairment, which was independently associated with 25% lower chance of listing (adjusted HR, 0.75; 95% CI, 0.61-0.91); this association did not differ by diabetes status (Pinteraction=0.07). There was a nominal difference by diabetes status for the association between cognitive impairment and kidney transplantation rate (Pinteraction=0.05), while the association between cognitive impairment and waitlist mortality differed by diabetes status kidney transplantation rates (Pinteraction=0.02). Among candidates without diabetes, those with cognitive impairment were at 2.47 (95% CI, 1.31-4.66) times greater risk for waitlist mortality; cognitive impairment was not associated with this outcome among candidates with diabetes. LIMITATIONS Single measure of cognitive impairment. CONCLUSIONS Cognitive impairment is associated with a lower chance of being placed on the waitlist, and among patients without diabetes, with increased mortality on the waitlist. Future studies should investigate whether implementation of screening for cognitive impairment improves these outcomes.
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Affiliation(s)
- Nadia M Chu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Zhan Shi
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Christine E Haugen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Silas P Norman
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI
| | - Alden L Gross
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Daniel C Brennan
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michelle C Carlson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Mara A McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
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Drazich BF, LaFave S, Crane BM, Szanton SL, Carlson MC, Budhathoki C, Taylor JL. Exergames and Depressive Symptoms in Older Adults: A Systematic Review. Games Health J 2020; 9:339-345. [PMID: 32551982 DOI: 10.1089/g4h.2019.0165] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
To synthesize and critique studies that examined the impact of exergames on depressive symptoms in older adults. Articles were retrieved from the databases CINAHL, Embase, PsychINFO, and Medline. Studies were included in the review if they involved a physical activity/videogame intervention and measured outcomes of depressive symptoms in older adults. The search generated 957 articles for consideration, which were narrowed to 17 articles after applying exclusion criteria. In studies that required depressive symptoms as an inclusion criterion, there was an improvement in depressive symptoms in older adults following the exergame intervention. In studies that did not require depressive symptoms as an inclusion criterion, researchers found mixed results. Future older adult exergame research should measure depression as a primary outcome, utilize control groups with random sampling, consist of larger sample sizes, and include people with disabilities.
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Affiliation(s)
| | - Sarah LaFave
- School of Nursing, Johns Hopkins University, Baltimore, Maryland
| | - Breanna M Crane
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Sarah L Szanton
- School of Nursing, Johns Hopkins University, Baltimore, Maryland.,Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland.,Department of Health Policy and Management, Johns Hopkins University, Baltimore, Maryland
| | - Michelle C Carlson
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | | | - Janiece L Taylor
- School of Nursing, Johns Hopkins University, Baltimore, Maryland
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McAdams-DeMarco MA, Van Pilsum Rasmussen SE, Chu NM, Agoons D, Parsons RF, Alhamad T, Johansen KL, Tullius SG, Lynch R, Harhay MN, Rao MK, Berger J, Cooper M, Tan JC, Cheng XS, Woodside KJ, Parajuli S, Lentine KL, Kaplan B, Segev DL, Kobashigawa JA, Dadhania D. Perceptions and Practices Regarding Frailty in Kidney Transplantation: Results of a National Survey. Transplantation 2020; 104:349-356. [PMID: 31343576 PMCID: PMC6834867 DOI: 10.1097/tp.0000000000002779] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Given the potential utility of frailty, a clinical phenotype of decreased physiologic reserve and resistance to stressors, to predict postkidney transplant (KT) outcomes, we sought to understand the perceptions and practices regarding frailty measurement in US KT programs. METHODS Surveys were emailed to American Society of Transplantation Kidney/Pancreas Community of Practice members and 202 US transplant programs (November 2017 to April 2018). Program characteristics were gleaned from Scientific Registry of Transplant Recipients. RESULTS The 133 responding programs (response rate = 66%) represented 77% of adult KTs and 79% of adult KT candidates in the United States. Respondents considered frailty to be a useful concept in evaluating candidacy (99%) and endorsed a need to develop a frailty measurement specific to KT (92%). Frailty measurement was more common during candidacy evaluation (69%) than during KT admission (28%). Of the 202 programs, 38% performed frailty assessments in all candidates while 23% performed assessments only for older candidates. There was heterogeneity in the frailty assessment method; 18 different tools were utilized to measure frailty. The most common tool was a timed walk test (19%); 67% reported performing >1 tool. Among programs that measure frailty, 53% reported being less likely to list frail patients for KT. CONCLUSIONS Among US KT programs, frailty is recognized as a clinically relevant construct and is commonly measured at evaluation. However, there is considerable heterogeneity in the tools used to measure frailty. Efforts to identify optimal measurement of frailty using either an existing or a novel tool and subsequent standardization of its measurement and application across KT programs should be considered.
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Affiliation(s)
- Mara A McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | - Nadia M Chu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Dayawa Agoons
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ronald F Parsons
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Tarek Alhamad
- Division of Nephrology, Washington University in St. Louis, St. Louis, MO
| | | | - Stefan G Tullius
- Department of Surgery, Division of Transplant Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Raymond Lynch
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Meera N Harhay
- Department of Medicine, Division of Nephrology, Drexel University College of Medicine, Philadelphia, PA
- Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, PA
| | - Maya K Rao
- Division of Nephrology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Joseph Berger
- Division of Nephrology, University of Texas Southwestern Medical School, Dallas, TX
| | - Matthew Cooper
- Department of Surgery, Georgetown University School of Medicine, Washington, DC
| | - Jane C Tan
- Department of Medicine, Division of Nephrology, Stanford University, Stanford, CA
| | - XingXing S Cheng
- Department of Medicine, Division of Nephrology, Stanford University, Stanford, CA
| | - Kenneth J Woodside
- Department of Surgery, Medical School, University of Michigan, Ann Arbor, MI
| | - Sandesh Parajuli
- Department of Medicine, Division of Nephrology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Krista L Lentine
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, MO
| | | | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Jon A Kobashigawa
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Darshana Dadhania
- Division of Nephrology and Hypertension, Weill Cornell Medicine, New York, NY
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Cheung KL, LaMantia MA. Cognitive Impairment and Mortality in Patients Receiving Hemodialysis: Implications and Future Research Avenues. Am J Kidney Dis 2019; 74:435-437. [PMID: 31351689 DOI: 10.1053/j.ajkd.2019.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 06/04/2019] [Indexed: 01/27/2023]
Affiliation(s)
- Katharine L Cheung
- Division of Nephrology, Larner College of Medicine, The University of Vermont, Burlington, VT; Center on Aging, The University of Vermont, Burlington, VT.
| | - Michael A LaMantia
- Center on Aging, The University of Vermont, Burlington, VT; Division of General Internal Medicine and Geriatrics, Larner College of Medicine, The University of Vermont, Burlington, VT
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Chu NM, McAdams-DeMarco MA. Exercise and cognitive function in patients with end-stage kidney disease. Semin Dial 2019; 32:283-290. [PMID: 30903625 PMCID: PMC6606387 DOI: 10.1111/sdi.12804] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
In this review we summarize the research pertaining to the role of exercise in preventing cognitive decline in patients with end-stage kidney disease (ESKD). Impairment in cognitive function, especially in executive function, is common in patients with ESKD, and may worsen with maintenance dialysis as a result of retention of uremic toxins, recurrent cerebral ischemia, and high burden of inactivity. Cognitive impairment may lead to long-term adverse consequences, including dementia and death. Home-based and intradialytic exercise training (ET) are among the nonpharmacologic interventions identified to preserve cognitive function in ESKD. Additionally, cognitive training (CT) is an effective approach recently identified in this population. While short-term benefits of ET and CT on cognitive function were consistently observed in patients undergoing dialysis, more studies are needed to replicate these findings in diverse populations including kidney transplant recipients with long-term follow-up to better understand the health and quality of life consequences of these promising interventions. ET as well as CT are feasible interventions that may preserve or even improve cognitive function for patients with ESKD. Whether these interventions translate to improvements in quality of life and long-term health outcomes, including dementia prevention and better survival, are yet to be determined.
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Affiliation(s)
- Nadia M. Chu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Mara A. McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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30
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Thomas AG, Ruck JM, Shaffer AA, Haugen CE, Ying H, Warsame F, Chu N, Carlson MC, Gross AL, Norman SP, Segev DL, McAdams-DeMarco M. Kidney Transplant Outcomes in Recipients With Cognitive Impairment: A National Registry and Prospective Cohort Study. Transplantation 2019; 103:1504-1513. [PMID: 30153224 PMCID: PMC6393218 DOI: 10.1097/tp.0000000000002431] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Cognitive impairment is common in patients with end-stage renal disease and is associated with poor outcomes on dialysis. We hypothesized that cognitive impairment might be associated with an increased risk of all-cause graft loss (ACGL) in kidney transplant (KT) recipients. METHODS Using the Modified Mini-Mental State (3MS) examination, we measured global cognitive function at KT hospital admission in a prospective, 2-center cohort of 864 KT candidates (August 2009 to July 2016). We estimated the association between pre-KT cognitive impairment and ACGL using Cox regression, adjusting for recipient, donor, and transplant factors. RESULTS In living donor KT (LDKT) recipients, the prevalence was 3.3% for mild impairment (60 ≤ 3MS < 80) and 3.3% for severe impairment (3MS < 60). In deceased donor KT (DDKT) recipients, the prevalence was 9.8% for mild impairment and 2.6% for severe impairment. The LDKT recipients with cognitive impairment had substantially higher ACGL risk than unimpaired recipients (5-year ACGL: 45.5% vs 10.6%; P < 0.01; adjusted hazard ratio [aHR] any impairment, 5.40 (95% confidence interval [CI], 1.78-16.34; P < 0.01); aHR severe impairment, 5.57 (95% CI, 1.29-24.00; P = 0.02). Similarly, DDKT recipients with severe impairment had higher ACGL risk than recipients without severe impairment (5-year ACGL, 53.0% vs 24.2%; P = 0.04); aHR severe impairment, 2.92 (95% CI, 1.13-7.50; P = 0.03). CONCLUSIONS Given the elevated risk of ACGL among KT recipients with cognitive impairment observed in this 2-center cohort, research efforts should explore the mechanisms of graft loss and mortality associated with cognitive impairment and identify potential interventions to improve posttransplant survival.
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Affiliation(s)
- Alvin G. Thomas
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jessica M. Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ashton A. Shaffer
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Christine E. Haugen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Hao Ying
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Fatima Warsame
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nadia Chu
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Michelle C. Carlson
- Department of Mental Health, Johns Hopkins School of Public Health, Baltimore, MD
- Johns Hopkins University Center on Aging and Health, Baltimore, MD
| | - Alden L. Gross
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
- Johns Hopkins University Center on Aging and Health, Baltimore, MD
| | - Silas P. Norman
- Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, MI
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Mara McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
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31
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Warsame F, Haugen CE, Ying H, Garonzik-Wang JM, Desai NM, Hall RK, Kambhampati R, Crews DC, Purnell TS, Segev DL, McAdams-DeMarco MA. Limited health literacy and adverse outcomes among kidney transplant candidates. Am J Transplant 2019; 19:457-465. [PMID: 29962069 PMCID: PMC6312744 DOI: 10.1111/ajt.14994] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 05/08/2018] [Accepted: 06/07/2018] [Indexed: 01/25/2023]
Abstract
More than one-third of US adults have limited health literacy, putting them at risk of adverse clinical outcomes. We evaluated the prevalence of limited health literacy among 1578 adult kidney transplant (KT) candidates (May 2014-November 2017) and examined its association with listing for transplant and waitlist mortality in this pilot study. Limited health literacy was assessed at KT evaluation by using a standard cutoff score ≤5 on the Brief Health Literacy Screen (score range 0-12, lower scores indicate worse health literacy). We used logistic regression and adjusted Cox proportional hazards models to identify risk factors for limited health literacy and to quantify its association with listing and waitlist mortality. We found that 8.9% of candidates had limited health literacy; risk factors included less than college education (adjusted odds ratio [aOR] = 2.87, 95% confidence interval [CI]:1.86-4.43), frailty (aOR = 1.85, 95% CI:1.22-2.80), comorbidity (Charlson comorbidity index [1-point increase] aOR = 1.12, 95% CI: 1.04-1.20), and cognitive impairment (aOR = 3.45, 95% CI: 2.20-5.41) after adjusting for age, sex, race, and income. Candidates with limited health literacy had a 30% (adjusted hazard ratio = 0.70, 95% CI: 0.54-0.91) decreased likelihood of listing and a 2.42-fold (95% CI: 1.16- to 5.05-fold) increased risk of waitlist mortality. Limited health literacy may be a salient mechanism in access to KT; programs to aid candidates with limited health literacy may improve outcomes and reduce disparities.
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Affiliation(s)
- Fatima Warsame
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christine E Haugen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hao Ying
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Niraj M Desai
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rasheeda K Hall
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Rekha Kambhampati
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Deidra C Crews
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tanjala S Purnell
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Mara A McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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32
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Chu NM, Gross AL, Shaffer AA, Haugen CE, Norman SP, Xue QL, Sharrett AR, Carlson MC, Bandeen-Roche K, Segev DL, McAdams-DeMarco MA. Frailty and Changes in Cognitive Function after Kidney Transplantation. J Am Soc Nephrol 2019; 30:336-345. [PMID: 30679381 PMCID: PMC6362628 DOI: 10.1681/asn.2018070726] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Accepted: 11/14/2018] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Restoration of kidney function after kidney transplant generally improves cognitive function. It is unclear whether frail recipients, with higher susceptibility to surgical stressors, achieve such post-transplant cognitive improvements or whether they experience subsequent cognitive decline as they age with a functioning graft. METHODS In this two-center cohort study, we assessed pretransplant frailty (Fried physical frailty phenotype) and cognitive function (Modified Mini-Mental State Examination) in adult kidney transplant recipients. To investigate potential short- and medium-term effects of frailty on post-transplant cognitive trajectories, we measured cognitive function up to 4 years post-transplant. Using an adjusted mixed effects model with a random slope (time) and intercept (person), we characterized post-transplant cognitive trajectories by pretransplant frailty, accounting for nonlinear trajectories. RESULTS Of 665 recipients (mean age 52.0 years) followed for a median of 1.5 years, 15.0% were frail. After adjustment, pretransplant cognitive scores were significantly lower among frail patients compared with nonfrail patients (89.0 versus 90.8 points). By 3 months post-transplant, cognitive performance improved for both frail (slope =0.22 points per week) and nonfrail (slope =0.14 points per week) recipients. Between 1 and 4 years post-transplant, improvements plateaued among nonfrail recipients (slope =0.005 points per week), whereas cognitive function declined among frail recipients (slope =-0.04 points per week). At 4 years post-transplant, cognitive scores were 5.8 points lower for frail recipients compared with nonfrail recipients. CONCLUSIONS On average, both frail and nonfrail recipients experience short-term cognitive improvement post-transplant. However, frailty is associated with medium-term cognitive decline post-transplant. Interventions to prevent cognitive decline among frail recipients should be identified.
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Affiliation(s)
- Nadia M Chu
- Departments of Epidemiology,
- Department of Surgery and
| | | | | | | | - Silas P Norman
- Division of Nephrology, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Qian-Li Xue
- Departments of Epidemiology
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | | | | | - Karen Bandeen-Roche
- Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Dorry L Segev
- Departments of Epidemiology
- Department of Surgery and
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33
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Sherman RA. Briefly Noted. Semin Dial 2018. [DOI: 10.1111/sdi.12748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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34
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Konel JM, Warsame F, Ying H, Haugen CE, Mountford A, Chu NM, Crews DC, Desai NM, Garonzik-Wang JM, Walston JD, Norman SP, Segev DL, McAdams-DeMarco MA. Depressive symptoms, frailty, and adverse outcomes among kidney transplant recipients. Clin Transplant 2018; 32:e13391. [PMID: 30152107 DOI: 10.1111/ctr.13391] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 08/23/2018] [Accepted: 08/23/2018] [Indexed: 12/30/2022]
Abstract
Depressive symptoms and frailty are each independently associated with morbidity and mortality in kidney transplant (KT) recipients. We hypothesized that having both depressive symptoms and frailty would be synergistic and worse than the independent effect of each. In a multicenter cohort study of 773 KT recipients, we measured the Fried frailty phenotype and the modified 18-question Center for Epidemiologic Studies-Depression Scale (CES-D). Using adjusted Poisson regression and survival analysis, we tested whether depressive symptoms (CES-D score > 14) and frailty were associated with KT length of stay (LOS), death-censored graft failure (DCGF), and mortality. At KT admission, 10.0% of patients exhibited depressive symptoms, 16.3% were frail, and 3.6% had both. Recipients with depressive symptoms were more likely to be frail (aOR = 3.97, 95% CI: 2.28-6.91, P < 0.001). Recipients with both depressive symptoms and frailty had a 1.88 times (95% CI: 1.70-2.08, P < 0.001) longer LOS, 6.20-fold (95% CI:1.67-22.95, P < 0.01) increased risk of DCGF, and 2.62-fold (95% CI:1.03-6.70, P = 0.04) increased risk of mortality, compared to those who were nonfrail and without depressive symptoms. There was only evidence of synergistic effect of frailty and depressive symptoms on length of stay (P for interaction < 0.001). Interventions aimed at reducing pre-KT depressive symptoms and frailty should be explored for their impact on post-KT outcomes.
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Affiliation(s)
- Jonathan M Konel
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Fatima Warsame
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Hao Ying
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Christine E Haugen
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Alexandra Mountford
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Nadia M Chu
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Deidra C Crews
- Division of Nephrology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Niraj M Desai
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | | | - Jeremy D Walston
- Division of Geriatric Medicine and Gerontology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Silas P Norman
- Department of Internal Medicine, Division of Nephrology, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Mara A McAdams-DeMarco
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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35
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Warsame F, Ying H, Haugen CE, Thomas AG, Crews DC, Shafi T, Jaar B, Chu NM, Segev DL, McAdams-DeMarco MA. Intradialytic Activities and Health-Related Quality of Life Among Hemodialysis Patients. Am J Nephrol 2018; 48:181-189. [PMID: 30176670 PMCID: PMC6178216 DOI: 10.1159/000492623] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 07/27/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND Health-related quality of life (HRQOL) reflects a patient's perceived disease burden, treatment effectiveness, and health status. Given the time burden and physiologic effects of hemodialysis, patients who spend dialysis time (9-15 h/week) physically or intellectually engaged may have better HRQOL. We characterized the intradialytic activities and explored their association with HRQOL. METHODS In a cross-sectional study of 431 hemodialysis patients, we ascertained kidney-disease-specific quality of life, measured frailty, and surveyed participants about their usual active intradialytic activities (reading, playing games, doing puzzles, chatting, or other) and passive intradialytic activities (watching TV or sleeping). We used adjusted ordered logistic regression to identify correlates of the activity index (the sum of active intradialytic activities) and adjusted linear regression to quantify the association between the activity index and physical-, mental-, and kidney-disease-specific HRQOL. RESULTS The 2 most common intradialytic activities were passive activities (watching TV = 87.9%; sleeping = 72.4%). Participants who were female (aOR 1.85, 95% CI 1.28-2.66; p = 0.001), nonfrail (aOR 1.70, 95% CI 1.06-2.70; p = 0.03), and nonsmokers (aOR 2.61, 95% CI 1.39-4.90; p = 0.003) had a higher intradialytic activity index after adjustment. Higher intradialytic activity index was associated with better mental- (0.83 points, 95% CI 0.04-1.62; p = 0.04) and kidney-disease-specific HRQOL (1.70 points, 95% CI 0.47-2.93; p = 0.007), but not physical HRQOL. CONCLUSIONS Hemodialysis patients with more active intradialytic activities report better mental and kidney-disease-specific HRQOL. These results should be confirmed in a prospective study with a broader cohort of hemodialysis patients. Dialysis providers may consider offering patients with low levels of activity additional support and opportunities to engage in beneficial intradialytic activities.
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Affiliation(s)
- Fatima Warsame
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Hao Ying
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Christine E. Haugen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Alvin G. Thomas
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Deidra C. Crews
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Tariq Shafi
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Bernard Jaar
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
- Nephrology Center of Maryland, Baltimore, MD
| | - Nadia M Chu
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Mara A. McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
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36
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Hall RK, McAdams-DeMarco MA. Breaking the cycle of functional decline in older dialysis patients. Semin Dial 2018; 31:462-467. [PMID: 29642268 DOI: 10.1111/sdi.12695] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Currently, older adults comprise nearly one-third of prevalent US dialysis patients, and this proportion will increase as the population ages. Older dialysis patients experience greater morbidity and mortality than nondialysis patients of the same age, and in part, it is related to progressive functional decline. Progressive functional decline, characterized by need for assistance with more than 2 activities of daily living, contributes to risk of hospitalization, further functional decline, and subsequent nursing home placement when a patient no longer functions independently at home. Progressive functional decline may appear to be unavoidable for older dialysis patients; however, comprehensive geriatric assessment (CGA) may alleviate the prevalence and severity of functional decline. This editorial summarizes common risk factors of functional decline and introduces CGA as a potentially transformative approach to breaking the cycle of functional decline in older dialysis patients.
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Affiliation(s)
- Rasheeda K Hall
- Durham VA Geriatric Research, Education and Clinical Center, Durham, NC, USA.,Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Mara A McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
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