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Doerr JM, Juenemann M, Becker A, Nahrgang C, Rainer L, Liese J, Hecker A, Wolter M, Weimer R, Karakizlis H. Cognitive profile of kidney transplant patients and impact of deceased vs. living donor transplantation. J Nephrol 2024:10.1007/s40620-024-02004-8. [PMID: 38990265 DOI: 10.1007/s40620-024-02004-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 06/10/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND It is important to learn more about the prevalence, severity and characteristics (i.e., which cognitive abilities are especially affected) of cognitive impairment in kidney transplant patients. Furthermore, the impact of living vs. deceased donor renal transplantation on cognitive outcome in this patient group needs further studies. METHODS Fifty-nine patients (43 men, age 55 ± 13 years) who received a deceased donor or living donor kidney transplant, completed a comprehensive neuropsychological test assessment. Neuropsychological tests explored the cognitive domains of verbal and visual memory, attention, and executive functions. RESULTS Fifteen percent of the patients had mild, 25% moderate, and 15% severe cognitive impairment. The level of domain-specific cognitive deficit differed between verbal memory, attention, and executive functions (χ2(2) = 7.11, p = 0.029). On average, patients showed the highest deficit in executive functions, and the lowest deficit in verbal memory. Patients who received a kidney graft from a deceased donor were more likely to have a cognitive impairment than those who received a kidney graft from a living donor (OR = 3.03, 95% CI [0.99,9.32], Wald χ2(1) = 3.74, p = 0.053). This effect was independent of time on dialysis as well as of creatinine levels, or creatinine clearance. CONCLUSIONS Our results show that in kidney transplant patients with cognitive impairment, the cognitive domain of executive functions is the most affected one. This might be detrimental for quality of life. The fact that patients who received living donor kidneys seem to do better in terms of cognition than patients with deceased donor kidneys deserves more attention in future research.
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Affiliation(s)
- Johanna Marie Doerr
- Department of Neurology, Justus-Liebig-University of Giessen, Giessen, Germany.
| | - Martin Juenemann
- Department of Neurology, Justus-Liebig-University of Giessen, Giessen, Germany
| | - Anna Becker
- Department of Internal Medicine, Justus-Liebig-University of Giessen, Giessen, Germany
| | - Christian Nahrgang
- Department of Internal Medicine, Justus-Liebig-University of Giessen, Giessen, Germany
| | - Lucy Rainer
- Department of Internal Medicine, Justus-Liebig-University of Giessen, Giessen, Germany
| | - Juliane Liese
- Department of General, Visceral, Thoracic, and Transplant Surgery, Justus-Liebig-University of Giessen, Giessen, Germany
| | - Andreas Hecker
- Department of General, Visceral, Thoracic, and Transplant Surgery, Justus-Liebig-University of Giessen, Giessen, Germany
| | - Martin Wolter
- Department of Internal Medicine, Justus-Liebig-University of Giessen, Giessen, Germany
| | - Rolf Weimer
- Department of Internal Medicine, Justus-Liebig-University of Giessen, Giessen, Germany
| | - Hristos Karakizlis
- Department of Internal Medicine, Justus-Liebig-University of Giessen, Giessen, Germany
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2
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Zhang C, Xue G, Hou Y, Meng P, Gao H, Bai B, Li D. Association between kidney measurements and cognitive performance in patients with ischemic stroke. PLoS One 2023; 18:e0292506. [PMID: 38096197 PMCID: PMC10721055 DOI: 10.1371/journal.pone.0292506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 11/30/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Individuals with chronic kidney disease (CKD) are at a substantially higher risk for stroke, which may predispose individuals to cognitive impairment. However, the association of low estimated glomerular filtration rate (eGFR) and albuminuria with poorer cognitive performance in patients with stroke is not fully understood, and the current evidence for this association is contradictory. Our aim was to retrospectively investigate whether low eGFR and albuminuria, as indicated by the urine albumin-creatinine ratio (UACR), are independently or jointly associated with worse cognitive performance in patients with ischemic stroke. METHODS This retrospective study included 608 patients with acute ischemic stroke. Their UACR and eGFR values were obtained from inpatient medical records. Global cognitive function was assessed with the mini-mental state exam (MMSE) and Montreal Cognitive Assessment (MoCA) one month after hospital discharge. The relationship between renal measures and cognitive performance was assessed using univariate and multiple linear regression analyses. Potential confounders included age, gender, BMI, education, diabetes and hypertension history, NIHSS score, smoking and alcohol consumption status, serum total cholesterol, triglyceride, fasting glucose, uric acid, homocysteine, systolic blood pressure, and either eGFR or UACR. RESULTS Patients had an average age of 66.6±4.1 years, and 48% were females. Average eGFR and UACR were 88.4±12.9 ml/min/1.73m2 and 83.6±314.2 mg/g, respectively. The number of patients with eGFR ≥90, 60-89, and <60 ml/min/1.73 m2 was 371 (61%), 207 (34%), and 30 (5%), respectively, and the percentage of patients with UACR <30 mg/g, 30-300 mg/g, and >300 mg/g was 56%, 39%, and 5%, respectively. Multivariate adjusted models showed that eGFR was independently associated with MMSE (β = -0.4; 95% CI = -0.5,-0.4; p <0.001) and MoCA (β = -0.6; 95% CI = -0.7,-0.5; p <0.001). However, UACR was not significantly correlated with MMSE or MoCA. CONCLUSION In patients with ischemic stroke, reduced eGFR but not albuminuria was associated with lower cognitive performance. These results show that the eGFR decline could be an effective indicator of cognitive impairment after a stroke. Therefore, regular monitoring and early detection of mild renal dysfunction in patients with acute ischemic stroke might be needed.
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Affiliation(s)
- Chunyan Zhang
- Department of Neurology, Second Hospital, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Guofang Xue
- Department of Neurology, Second Hospital, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Yanjuan Hou
- Department of Nephrology, Second Hospital, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Pengfei Meng
- Department of Neurology, Second Hospital, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Huizhong Gao
- Department of Neurology, Second Hospital, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Bo Bai
- Department of Neurology, Second Hospital, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Dongfang Li
- Department of Neurology, Second Hospital, Shanxi Medical University, Taiyuan, Shanxi, China
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3
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Wang L, Li Q, Su B, Zhang E, Zhang S, Tu H, Zhang L, Wang C, Chen G. The estimated glomerular filtration rate was U-shaped associated with abdominal aortic calcification in US adults: findings from NHANES 2013-2014. Front Cardiovasc Med 2023; 10:1261021. [PMID: 38124889 PMCID: PMC10731032 DOI: 10.3389/fcvm.2023.1261021] [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: 07/18/2023] [Accepted: 11/23/2023] [Indexed: 12/23/2023] Open
Abstract
Objectives The high incidence of abdominal aortic calcification (AAC) is well-documented in individuals with severe renal function decline. However, there is limited research on the historical relationship between estimated glomerular filtration rate (eGFR) and the risk of AAC occurrence in the general population undergoing routine medical examinations. The main objective of this study was to investigate the historical relationship between eGFR and AAC in the general population of the United States. Methods We performed a cross-sectional study using the National Health and Nutrition Examination Survey 2013-2014 database. Weighted multivariate linear regression models were used to estimate the associations of eGFR with AAC score. Smooth curve fitting and two-piecewise linear regression were employed to explore the potential non-linear relationship. Results A total of 2,978 participant (48.22% were male) aged 40-80 years were included in this study. The fully-adjusted model demonstrated a negative correlation between eGFR and AAC score (β = -0.015, 95% CI: -0.023 to -0.006). However, when applying the smooth curve fitting method, a U-shaped relationship was identified, and the inflection point was calculated at 76.43 ml/min/1.73 m2 using the two-piecewise linear regression model. Conclusions There was a U-shaped association between eGFR and AAC score in general US adults, with an inflection point at about 76.43 ml/min/1.73 m2.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Gangyi Chen
- Department of Nephrology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou City, Guangdong Province, China
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4
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Li F, Chen H, Mao N, Liu H. Dietary fiber intake and cognitive impairment in older patients with chronic kidney disease in the United States: A cross-sectional study. PLoS One 2023; 18:e0291690. [PMID: 37792684 PMCID: PMC10550150 DOI: 10.1371/journal.pone.0291690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 09/02/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND High-fiber diet has been associated with better cognitive performance. However, the association between dietary fiber intake and cognition in older patients with chronic kidney disease (CKD) remains unknown. Hence, this study aimed to investigate the effect of dietary fiber intake on cognition in older patients with CKD. METHODS This study included participants aged ≥60 years who provided data on social demography, cognitive tests (Consortium to Establish a Registry for Alzheimer's disease Word Learning [CERAD-WL], CERAD Delayed Recall [CERAD-DR], Animal Fluency Test [AFT], and Digit Symbol Substitution Test [DSST]), diet, and other potential cognition-related variables from the National Health and Nutrition Examination Survey 2011-2014. Fully-adjusted multivariate logistic regression subgroup models were performed, and multiple linear regression analyses were employed to examine the association between dietary fiber intake and cognition in patients with CKD. RESULTS A total of 2461 older adults were included, with 32% who suffered from CKD. Participants with CKD scored lower in CERAD-WL, CERAD-DR, AFT, and DSST. Patients with CKD consuming low dietary fiber (≤25 g/day) had a higher risk of CERAD-WL and DSST impairments. High dietary fiber intake eliminated the differences in CERAD-WL and DSST impairments between the CKD and non-CKD participants. However, no associations were observed between CKD and CERAD-DR and AFT impairments regardless of dietary fiber intake. A positive linear relationship between dietary fiber intake and AFT score was observed in older patients with CKD. CONCLUSION High dietary fiber intake may benefit cognitive function in older patients with CKD. High-fiber diet management strategies could potentially mitigate cognitive impairment in this group of patients.
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Affiliation(s)
- Feiyan Li
- School of Clinical Medicine, Chengdu Medical College, Chengdu, Sichuan, China
- Department of Experiment Teaching Center of Clinical Medicine, The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
| | - Hongxi Chen
- Department of Nephrology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
| | - Nan Mao
- Department of Nephrology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
| | - Hong Liu
- School of Clinical Medicine, Chengdu Medical College, Chengdu, Sichuan, China
- Department of Experiment Teaching Center of Clinical Medicine, The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
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Baek SH, Park J, Park S, Yu MY, Kim JE, Park SH, Han K, Kim YC, Kim DK, Joo KW, Kim YS, Lee H. Incident dementia in kidney transplantation recipients: a matched comparative nationwide cohort study in South Korea. Kidney Res Clin Pract 2023; 42:519-530. [PMID: 37551128 PMCID: PMC10407631 DOI: 10.23876/j.krcp.21.182] [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: 08/17/2021] [Revised: 08/29/2022] [Accepted: 09/13/2022] [Indexed: 08/09/2023] Open
Abstract
BACKGROUND Recent studies have shown that patients with end-stage renal disease (ESRD) are at elevated risk of dementia. However, whether kidney transplantation (KT) lowers the risk for incident dementia remains unclear. METHODS From the Korean National Health Insurance Service database, we identified incident KT recipients aged ≥40 years without any history of dementia between 2007 and 2015. We also established a pair of age-, sex-, and inclusion year-matched control cohorts of patients with incident dialysis-dependent ESRD and members of the general population (GP) without a history of dementia, respectively. Cases of incident all-cause dementia, including Alzheimer disease (AD), vascular dementia (VD), and other kinds of dementia, were obtained from baseline until December 31, 2017. RESULTS We followed 8,841 KT recipients, dialysis-dependent ESRD patients, and GP individuals for 48,371, 28,649, and 49,149 patient- years, respectively. Their mean age was 52.5 years, and 60.6% were male. Over the observation period, 55/43/19 KT recipients, 230/188/75 dialysis-dependent ESRD patients, and 38/32/14 GP individuals developed all-cause dementia/AD/VD. The risks of incident all-cause dementia, AD, and VD in KT recipients were similar to those in GP (hazard ratio: 0.74 [p = 0.20], 0.74 [p = 0.24], and 0.59 [p = 0.18], respectively) and significantly lower than those in dialysis-dependent ESRD patients (hazard ratio: 0.17 [p < 0.001], 0.16 [p < 0.001], and 0.16 [p < 0.001], respectively). Older age and diabetes mellitus at the time of KT were risk factors for incident all-cause dementia and AD in KT recipients. CONCLUSION This is the first study to show a beneficial impact of KT on incident dementia compared to dialysis dependency.
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Affiliation(s)
- Seon Ha Baek
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea
| | - Jina Park
- Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sehoon Park
- Department of Biomedical Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Armed Forces Capital Hospital, Seongnam, Republic of Korea
| | - Mi-yeon Yu
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Republic of Korea
| | - Ji Eun Kim
- Department of Internal Medicine, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Sang Hyun Park
- Department of Medical Statistics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Kyungdo Han
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, Republic of Korea
| | - Yong Chul Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Dong Ki Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kwon Wook Joo
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yon Su Kim
- Department of Biomedical Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hajeong Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
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6
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Ghoshal S. Renal and Electrolyte Disorders and the Nervous System. Continuum (Minneap Minn) 2023; 29:797-825. [PMID: 37341331 DOI: 10.1212/con.0000000000001286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
OBJECTIVE Neurologic complications are a major contributor to death and disability in patients with renal disease. Oxidative stress, endothelial dysfunction, accelerated arteriosclerosis, and uremic inflammatory milieu affect both the central and peripheral nervous systems. This article reviews the unique contributions of renal impairment to neurologic disorders and their common clinical manifestations as the prevalence of renal disease increases in a globally aging population. LATEST DEVELOPMENT Advances in the understanding of the pathophysiologic interplay between the kidneys and brain, also referred to as the kidney-brain axis, have led to more widespread recognition of associated changes in neurovascular dynamics, central nervous system acidification, and uremia-associated endothelial dysfunction and inflammation in the central and peripheral nervous systems. Acute kidney injury increases mortality in acute brain injury to nearly 5 times that seen in matched controls. Renal impairment and its associated increased risks of intracerebral hemorrhage and accelerated cognitive decline are developing fields. Dialysis-associated neurovascular injury is increasingly recognized in both continuous and intermittent forms of renal replacement therapy, and treatment strategies for its prevention are evolving. ESSENTIAL POINTS This article summarizes the effects of renal impairment on the central and peripheral nervous systems with special considerations in acute kidney injury, patients requiring dialysis, and conditions that affect both the renal and nervous systems.
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7
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Liu J, Bankir L, Verma A, Waikar SS, Palsson R. Association of the Urine-to-Plasma Urea Ratio With CKD Progression. Am J Kidney Dis 2023; 81:394-405. [PMID: 36356680 DOI: 10.1053/j.ajkd.2022.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 09/01/2022] [Indexed: 11/09/2022]
Abstract
RATIONALE & OBJECTIVES The urine-to-plasma (U/P) ratio of urea is correlated with urine-concentrating capacity and associated with progression of autosomal dominant polycystic kidney disease. As a proposed biomarker of tubular function, we hypothesized that the U/P urea ratio would also be associated with progression of more common forms of chronic kidney disease (CKD). STUDY DESIGN Observational cohort study. SETTING & PARTICIPANTS 3,723 adults in the United States with estimated glomerular filtration rate (eGFR) of 20-70 mL/min/1.73 m2, enrolled in the Chronic Renal Insufficiency Cohort (CRIC) Study. EXPOSURE U/P urea ratio, calculated from 24-hour urine collections and plasma samples at baseline. OUTCOME Associations of U/P urea ratio with eGFR slope, initiation of kidney replacement therapy (KRT), and CKD progression, defined as 50% decline in eGFR or incident KRT. ANALYTICAL APPROACH Multivariable linear mixed-effects models tested associations with eGFR slope. Cox proportional hazards models tested associations with dichotomous CKD outcomes. RESULTS The median U/P urea ratio was 14.8 (IQR, 9.5-22.2). Compared with participants in the highest U/P urea ratio quintile, those in the lowest quintile had a greater eGFR decline by 1.06 mL/min/1.73 m2 per year (P < 0.001) over 7.0 (IQR, 3.0-11.0) years of follow-up observation. Each 1-SD lower natural log-transformed U/P urea ratio was independently associated with CKD progression (HR, 1.22 [95% CI, 1.12-1.33]) and incident KRT (HR, 1.22 [95% CI, 1.10-1.33]). Associations differed by baseline eGFR (P interaction = 0.009). Among those with an eGFR ≥30 mL/min/1.73 m2, each 1-SD lower in ln(U/P urea ratio) was independently associated with CKD progression (HR, 1.30 [95% CI, 1.18-1.45]), but this was not significant among those with eGFR <30 mL/min/1.73 m2 (HR, 1.00 [95% CI, 0.84-1.20]). LIMITATIONS Possibility of residual confounding. Single baseline 24-hour urine collection for U/P urea ratio. CONCLUSIONS In a large and diverse cohort of patients with common forms of CKD, U/P urea was independently associated with disease progression and incident kidney failure. Associations were not significant among those with advanced CKD at baseline.
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Affiliation(s)
- Jing Liu
- Kidney Research Institute, Renal Division, West China Hospital of Sichuan University, Chengdu, People's Republic of China; Section of Nephrology, Boston Medical Center and Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Lise Bankir
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Paris, France; CNRS, ERL 8228, Laboratoire de Physiologie Rénale et Tubulopathies, Paris, France
| | - Ashish Verma
- Section of Nephrology, Boston Medical Center and Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Sushrut S Waikar
- Section of Nephrology, Boston Medical Center and Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Ragnar Palsson
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Medical School, Harvard University, Boston, Massachusetts.
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Maki K, Ohara T, Hata J, Shibata M, Hirabayashi N, Honda T, Sakata S, Furuta Y, Akiyama M, Yamasaki K, Tatewaki Y, Taki Y, Kitazono T, Mikami T, Maeda T, Ono K, Mimura M, Nakashima K, Iga JI, Takebayashi M, Ninomiya T. CKD, Brain Atrophy, and White Matter Lesion Volume: The Japan Prospective Studies Collaboration for Aging and Dementia. Kidney Med 2023; 5:100593. [PMID: 36874508 PMCID: PMC9982615 DOI: 10.1016/j.xkme.2022.100593] [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: 07/06/2022] [Accepted: 10/26/2022] [Indexed: 12/24/2022] Open
Abstract
Rationale & Objective Chronic kidney disease, defined by albuminuria and/or reduced estimated glomerular filtration rate (eGFR), has been reported to be associated with brain atrophy and/or higher white matter lesion volume (WMLV), but there are few large-scale population-based studies assessing this issue. This study aimed to examine the associations between the urinary albumin-creatinine ratio (UACR) and eGFR levels and brain atrophy and WMLV in a large-scale community-dwelling older population of Japanese. Study Design Population-based cross-sectional study. Setting & Participants A total of 8,630 dementia-free community-dwelling Japanese aged greater than or equal to 65 years underwent brain magnetic resonance imaging scanning and screening examination of health status in 2016-2018. Exposures UACR and eGFR levels. Outcomes The total brain volume (TBV)-to-intracranial volume (ICV) ratio (TBV/ICV), the regional brain volume-to-TBV ratio, and the WMLV-to-ICV ratio (WMLV/ICV). Analytical Approach The associations of UACR and eGFR levels with the TBV/ICV, the regional brain volume-to-TBV ratio, and the WMLV/ICV were assessed by using an analysis of covariance. Results Higher UACR levels were significantly associated with lower TBV/ICV and higher geometric mean values of the WMLV/ICV (P for trend = 0.009 and <0.001, respectively). Lower eGFR levels were significantly associated with lower TBV/ICV, but not clearly associated with WMLV/ICV. In addition, higher UACR levels, but not lower eGFR, were significantly associated with lower temporal cortex volume-to-TBV ratio and lower hippocampal volume-to-TBV ratio. Limitations Cross-sectional study, misclassification of UACR or eGFR levels, generalizability to other ethnicities and younger populations, and residual confounding factors. Conclusions The present study demonstrated that higher UACR was associated with brain atrophy, especially in the temporal cortex and hippocampus, and with increased WMLV. These findings suggest that chronic kidney disease is involved in the progression of morphologic brain changes associated with cognitive impairment.
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Affiliation(s)
- Kenji Maki
- Department of Epidemiology and Public Health, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tomoyuki Ohara
- Department of Epidemiology and Public Health, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Department of Neuropsychiatry, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Jun Hata
- Department of Epidemiology and Public Health, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Center for Cohort Studies, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Mao Shibata
- Department of Epidemiology and Public Health, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Center for Cohort Studies, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Department of Psychosomatic Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Naoki Hirabayashi
- Department of Epidemiology and Public Health, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Department of Psychosomatic Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takanori Honda
- Department of Epidemiology and Public Health, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Satoko Sakata
- Department of Epidemiology and Public Health, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Center for Cohort Studies, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshihiko Furuta
- Department of Epidemiology and Public Health, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masato Akiyama
- Department of Ocular Pathology and Imaging Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Keisuke Yamasaki
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yasuko Tatewaki
- Department of Aging Research and Geriatric Medicine, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan
| | - Yasuyuki Taki
- Department of Aging Research and Geriatric Medicine, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Center for Cohort Studies, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tatsuya Mikami
- Department of Preemptive Medicine, Graduate School of Medicine, Hirosaki University, Hirosaki, Japan
| | - Tetsuya Maeda
- Division of Neurology and Gerontology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Iwate, Japan
| | - Kenjiro Ono
- Department of Neurology, Kanazawa University Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Masaru Mimura
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Kenji Nakashima
- National Hospital Organization, Matsue Medical Center, Shimane, Japan
| | - Jun-Ichi Iga
- Department of Neuropsychiatry, Ehime University Graduate School of Medicine, Ehime University, Ehime, Japan
| | - Minoru Takebayashi
- Faculty of Life Sciences, Department of Neuropsychiatry, Kumamoto University, Kumamoto, Japan
| | - Toshiharu Ninomiya
- Department of Epidemiology and Public Health, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Center for Cohort Studies, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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9
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Scheppach JB, Wu A, Gottesman RF, Mosley TH, Arsiwala-Scheppach LT, Knopman DS, Grams ME, Sharrett AR, Coresh J, Koton S. Association of Kidney Function Measures With Signs of Neurodegeneration and Small Vessel Disease on Brain Magnetic Resonance Imaging: The Atherosclerosis Risk in Communities (ARIC) Study. Am J Kidney Dis 2023; 81:261-269.e1. [PMID: 36179945 PMCID: PMC9974563 DOI: 10.1053/j.ajkd.2022.07.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 07/21/2022] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Chronic kidney disease (CKD) is a risk factor for cognitive decline, but evidence is limited on its etiology and morphological manifestation in the brain. We evaluated the association of estimated glomerular filtration rate (eGFR) and urinary albumin-creatinine ratio (UACR) with structural brain abnormalities visible on magnetic resonance imaging (MRI). We also assessed whether this association was altered when different filtration markers were used to estimate GFR. STUDY DESIGN Cross-sectional study nested in a cohort study. SETTING & PARTICIPANTS 1,527 participants in the Atherosclerosis Risk in Communities (ARIC) Study. PREDICTORS Log(UACR) and eGFR based on cystatin C, creatinine, cystatin C and creatinine in combination, or β2-microglobulin (B2M). OUTCOMES Brain volume reduction, infarcts, microhemorrhages, white matter lesions. ANALYTICAL APPROACH Multivariable linear and logistic regression models fit separately for each predictor based on a 1-IQR difference in the predictor value. RESULTS Each 1-IQR lower eGFR was associated with reduced cortex volume (regression coefficient: -0.07 [95% CI, -0.12 to-0.02]), greater white matter hyperintensity volume (logarithmically transformed; regression coefficient: 0.07 [95% CI, 0.01-0.15]), and lower white matter fractional anisotropy (regression coefficient: -0.08 [95% CI, -0.17 to-0.01]). The results were similar when eGFR was estimated with different equations based on cystatin C, creatinine, a combination of cystatin C and creatinine, or B2M. Higher log(UACR) was similarly associated with these outcomes as well as brain infarcts and microhemorrhages (odds ratios per 1-IQR-fold greater UACR of 1.31 [95% CI, 1.13-1.52] and 1.30 [95% CI, 1.12-1.51], respectively). The degree to which brain volume was lower in regions usually susceptible to Alzheimer disease and LATE (limbic-predominant age-related TDP-43 [Tar DNA binding protein 43] encephalopathy) was similar to that seen in the rest of the cortex. LIMITATIONS No inference about longitudinal effects due to cross-sectional design. CONCLUSIONS We found eGFR and UACR are associated with structural brain damage across different domains of etiology, and eGFR- and UACR-related brain atrophy is not selective for regions typically affected by Alzheimer disease and LATE. Hence, Alzheimer disease or LATE may not be leading contributors to neurodegeneration associated with CKD.
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Affiliation(s)
- Johannes B Scheppach
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Aozhou Wu
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Rebecca F Gottesman
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Current affiliation: National Institute of Neurological Disorders and Stroke Intramural Research Program, Bethesda, Maryland
| | - Thomas H Mosley
- The MIND Center, University of Mississippi Medical Center, Jackson, Mississippi
| | | | | | - Morgan E Grams
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Division of Nephrology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - A Richey Sharrett
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Josef Coresh
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Silvia Koton
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Stanley Steyer School of Health Professions, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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10
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Cognitive Sequelae and Hippocampal Dysfunction in Chronic Kidney Disease following 5/6 Nephrectomy. Brain Sci 2022; 12:brainsci12070905. [PMID: 35884712 PMCID: PMC9321175 DOI: 10.3390/brainsci12070905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 06/30/2022] [Accepted: 07/06/2022] [Indexed: 01/18/2023] Open
Abstract
Neurological disorders are prevalent in patients with chronic kidney disease (CKD). Vascular factors and uremic toxins are involved with cognitive impairment in CKD. In addition, vascular dementia-induced alterations in the structure and function of the hippocampus can lead to deficits in hippocampal synaptic plasticity and cognitive function. However, regardless of this clinical evidence, the pathophysiology of cognitive impairment in patients with CKD is not fully understood. We used male Sprague Dawley rats and performed 5/6 nephrectomy to observe the changes in behavior, field excitatory postsynaptic potential, and immunostaining of the hippocampus following CKD progression. We measured the hippocampus volume on magnetic resonance imaging scans in the controls (n = 34) and end-stage renal disease (ESRD) hemodialysis patients (n = 42). In four cognition-related behavior assays, including novel object recognition, Y-maze, Barnes maze, and classical contextual fear conditioning, we identified deficits in spatial working memory, learning and memory, and contextual memory, as well as the ability to distinguish familiar and new objects, in the rats with CKD. Immunohistochemical staining of Na+/H+ exchanger1 was increased in the hippocampus of the CKD rat models. We performed double immunofluorescent staining for aquaporin-4 and glial fibrillary acidic protein and then verified the high coexpression in the hippocampus of the CKD rat model. Furthermore, results from recoding of the field excitatory postsynaptic potential (fEPSP) in the hippocampus showed the reduced amplitude and slope of fEPSP in the CKD rats. ESRD patients with cognitive impairment showed a significant decrease in the hippocampus volume compared with ESRD patients without cognitive impairment or the controls. Our findings suggest that uremia resulting from decreased kidney function may cause the destruction of the blood–brain barrier and hippocampus-related cognitive impairment in CKD.
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11
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Dyer AH, Laird E, Hoey L, Hughes CF, McNulty H, Ward M, Strain JJ, O’Kane M, Tracey F, Molloy AM, Cunningham C, Sexton DJ, McCarroll K. Reduced kidney function is associated with poorer domain-specific cognitive performance in community-dwelling older adults. Int J Geriatr Psychiatry 2022; 37:10.1002/gps.5771. [PMID: 35719039 PMCID: PMC9327725 DOI: 10.1002/gps.5771] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 06/01/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Whilst chronic kidney disease has been associated with cognitive impairment, the association between reduced estimated Glomerular Filtration Rate (eGFR) and domain-specific cognitive performance is less clear and may represent an important target for the promotion of optimal brain health in older adults. METHODS Participants aged >60 years from the Trinity-Ulster-Department of Agriculture study underwent detailed cognitive assessment using the Mini-Mental State Examination (Mini-Mental State Examination (MMSE)), Frontal Assessment Battery (FAB) and Repeatable Battery for Assessment of Neuropsychological Status (RBANS). Poisson and linear regression models assessed the relationship between eGFR strata and cognitive performance. RESULTS In 4887 older adults (73.9 ± 8.3 years; 67.7% female), declining eGFR strata was associated with greater likelihood of error on the MMSE/FAB and poorer overall performance on the RBANS. Following robust covariate adjustment, findings were greatest for GFR <45 ml/ml/1.73 m2 (Incidence Rate Ratio: 1.17; 95% CI 1.08, 1.27; p < 0.001 for MMSE; IRR: 1.13; 95% CI 1.04, 1.13; p < 0.001 for FAB; β: -3.66; 95% CI -5.64, -1.86; p < 0.001 for RBANS). Additionally, eGFR <45 ml/ml/1.73 m2 was associated with poorer performance on all five RBANS domains, with greatest effect sizes for immediate memory, delayed memory and attention. Associations were strongest in those aged 60-70, with no associations observed in those >80 years. CONCLUSIONS Reduced kidney function was associated with poorer global and domain-specific neuropsychological performance. Associations were strongest with eGFR <45 ml/min/1.73 m2 and in those aged 60-70 years, suggesting that this population may potentially benefit from potential multi-domain interventions aimed at promoting optimal brain health in older adults.
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Affiliation(s)
- Adam H. Dyer
- Mercer's Institute for Successful AgeingSt James's HospitalDublinIreland,Wellcome‐HRB Clinical Research FacilitySt James's HospitalDublinIreland,Department of Medical GerontologySchool of MedicineTrinity College DublinDublinIreland
| | - Eamon Laird
- Department of Medical GerontologySchool of MedicineTrinity College DublinDublinIreland
| | - Leane Hoey
- The Nutrition Innovation Centre for Food and Health (NICHE)School of Biomedical SciencesUlster UniversityColeraineNorthern IrelandUK
| | - Catherine F. Hughes
- The Nutrition Innovation Centre for Food and Health (NICHE)School of Biomedical SciencesUlster UniversityColeraineNorthern IrelandUK
| | - Helene McNulty
- The Nutrition Innovation Centre for Food and Health (NICHE)School of Biomedical SciencesUlster UniversityColeraineNorthern IrelandUK
| | - Mary Ward
- The Nutrition Innovation Centre for Food and Health (NICHE)School of Biomedical SciencesUlster UniversityColeraineNorthern IrelandUK
| | - J. J. Strain
- The Nutrition Innovation Centre for Food and Health (NICHE)School of Biomedical SciencesUlster UniversityColeraineNorthern IrelandUK
| | - Maurice O’Kane
- Clinical Chemistry LaboratoryAltnagelvin HospitalWestern Health and Social Care TrustLondonderryNorthern IrelandUK
| | - Fergal Tracey
- Causeway HospitalNorthern Health and Social Care TrustColeraineNorthern IrelandUK
| | | | - Conal Cunningham
- Mercer's Institute for Successful AgeingSt James's HospitalDublinIreland,Wellcome‐HRB Clinical Research FacilitySt James's HospitalDublinIreland
| | - Donal J. Sexton
- Department of Medical GerontologySchool of MedicineTrinity College DublinDublinIreland,School of MedicineTrinity College DublinDublinIreland,Trinity Health Kidney CentreSchool of MedicineTrinity College DublinDublinIreland
| | - Kevin McCarroll
- Mercer's Institute for Successful AgeingSt James's HospitalDublinIreland,Department of Medical GerontologySchool of MedicineTrinity College DublinDublinIreland
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12
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Kurella Tamura M, Gaussoin S, Pajewski NM, Zaharchuk G, Freedman BI, Rapp SR, Auchus AP, Haley WE, Oparil S, Kendrick J, Roumie CL, Beddhu S, Cheung AK, Williamson JD, Detre JA, Dolui S, Bryan RN, Nasrallah IM. Kidney Disease, Hypertension Treatment, and Cerebral Perfusion and Structure. Am J Kidney Dis 2022; 79:677-687.e1. [PMID: 34543687 PMCID: PMC8926938 DOI: 10.1053/j.ajkd.2021.07.024] [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: 03/02/2021] [Accepted: 07/28/2021] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE The safety of intensive blood pressure (BP) targets is controversial for persons with chronic kidney disease (CKD). We studied the effects of hypertension treatment on cerebral perfusion and structure in individuals with and without CKD. STUDY DESIGN Neuroimaging substudy of a randomized trial. SETTING & PARTICIPANTS A subset of participants in the Systolic Blood Pressure Intervention Trial (SPRINT) who underwent brain magnetic resonance imaging studies. Presence of baseline CKD was assessed by estimated glomerular filtration rate (eGFR) and urinary albumin-creatinine ratio (UACR). INTERVENTION Participants were randomly assigned to intensive (systolic BP <120 mm Hg) versus standard (systolic BP <140 mm Hg) BP lowering. OUTCOMES The magnetic resonance imaging outcome measures were the 4-year change in global cerebral blood flow (CBF), white matter lesion (WML) volume, and total brain volume (TBV). RESULTS A total of 716 randomized participants with a mean age of 68 years were enrolled; follow-up imaging occurred after a median 3.9 years. Among participants with eGFR <60 mL/min/1.73 m2 (n = 234), the effects of intensive versus standard BP treatment on change in global CBF, WMLs, and TBV were 3.38 (95% CI, 0.32 to 6.44) mL/100 g/min, -0.06 (95% CI, -0.16 to 0.04) cm3 (inverse hyperbolic sine-transformed), and -3.8 (95% CI, -8.3 to 0.7) cm3, respectively. Among participants with UACR >30 mg/g (n = 151), the effects of intensive versus standard BP treatment on change in global CBF, WMLs, and TBV were 1.91 (95% CI, -3.01 to 6.82) mL/100 g/min, 0.003 (95% CI, -0.13 to 0.13) cm3 (inverse hyperbolic sine-transformed), and -7.0 (95% CI, -13.3 to -0.3) cm3, respectively. The overall treatment effects on CBF and TBV were not modified by baseline eGFR or UACR; however, the effect on WMLs was attenuated in participants with albuminuria (P = 0.04 for interaction). LIMITATIONS Measurement variability due to multisite design. CONCLUSIONS Among adults with hypertension who have primarily early kidney disease, intensive versus standard BP treatment did not appear to have a detrimental effect on brain perfusion or structure. The findings support the safety of intensive BP treatment targets on brain health in persons with early kidney disease. FUNDING SPRINT was funded by the National Institutes of Health (including the National Heart, Lung, and Blood Institute; the National Institute of Diabetes and Digestive and Kidney Diseases; the National Institute on Aging; and the National Institute of Neurological Disorders and Stroke), and this substudy was funded by the National Institutes of Diabetes and Digestive and Kidney Diseases. TRIAL REGISTRATION SPRINT was registered at ClinicalTrials.gov with study number NCT01206062.
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Affiliation(s)
- Manjula Kurella Tamura
- Geriatric Research and Education Clinical Center, Palo Alto VA Health Care System, Palo Alto, CA; Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA.
| | - Sarah Gaussoin
- Departments of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC
| | - Nicholas M Pajewski
- Departments of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC
| | - Greg Zaharchuk
- Department of Radiology, Stanford University School of Medicine, Palo Alto, CA
| | - Barry I Freedman
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Stephen R Rapp
- Psychiatry & Behavioral Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Alexander P Auchus
- Department of Neurology, University of Mississippi Medical Center, Jackson, MS
| | - William E Haley
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, FL
| | - Suzanne Oparil
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Jessica Kendrick
- Department of Medicine, University of Colorado Anschutz Medical Campus, Denver, CO
| | - Christianne L Roumie
- VA Tennessee Valley Healthcare System Geriatrics Research and Education Clinical Center and Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Srinivasan Beddhu
- Division of Nephrology & Hypertension, Department of Internal Medicine, University of Utah and Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, UT
| | - Alfred K Cheung
- Division of Nephrology & Hypertension, Department of Internal Medicine, University of Utah and Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, UT
| | - Jeff D Williamson
- Sticht Center for Healthy Aging and Alzheimer's Prevention, Wake Forest School of Medicine, Winston-Salem, NC
| | - John A Detre
- Departments of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Sudipto Dolui
- Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - R Nick Bryan
- Department of Diagnostic Medicine Dell Medical School, University of Texas Austin Austin, TX
| | - Ilya M Nasrallah
- Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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13
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Steinbach EJ, Harshman LA. Impact of Chronic Kidney Disease on Brain Structure and Function. Front Neurol 2022; 13:797503. [PMID: 35280279 PMCID: PMC8913932 DOI: 10.3389/fneur.2022.797503] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 01/24/2022] [Indexed: 12/29/2022] Open
Abstract
Chronic kidney disease (CKD) affects more than 37 million American adults. Adult-onset CKD is typically attributed to acquired comorbidities such as aging, type II diabetes, and cardiovascular disease. Conversely, congenital abnormalities of the kidney and urinary tract are the most common cause of CKD in children. Both adult and pediatric patients with CKD are at risk for neurocognitive dysfunction, particularly in the domain of executive function. The exact mechanism for neurocognitive dysfunction in CKD is not known; however, it is conceivable that the multisystemic effects of CKD—including hypertension, acidosis, anemia, proteinuria, and uremic milieu—exert a detrimental effect on the brain. Quantitative neuroimaging modalities, such as magnetic resonance imaging (MRI), provide a non-invasive way to understand the neurobiological underpinnings of cognitive dysfunction in CKD. Adult patients with CKD show differences in brain structure; however, much less is known about the impact of CKD on neurodevelopment in pediatric patients. Herein, this review will summarize current evidence of the impact of CKD on brain structure and function and will identify the critical areas for future research that are needed to better understand the modifiable risk factors for abnormal brain structure and function across both pediatric and adult CKD populations.
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Affiliation(s)
- Emily J. Steinbach
- Department of Radiation Oncology, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
| | - Lyndsay A. Harshman
- Division of Nephrology, Dialysis, and Transplantation, University of Iowa Stead Family Children's Hospital, Iowa City, IA, United States
- *Correspondence: Lyndsay A. Harshman
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14
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Li J, Yu S, Tan Z, Yu Y, Luo L, Zhou W, Zhu L, Wang T, Cao T, Tu J, Bao H, Huang X, Cheng X. High Estimated Glomerular Filtration Rate Is Associated With Worse Cognitive Performance in the Hypertensive Population: Results From the China H-Type Hypertension Registry Study. Front Aging Neurosci 2022; 13:706928. [PMID: 35250530 PMCID: PMC8893225 DOI: 10.3389/fnagi.2021.706928] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 12/31/2021] [Indexed: 11/13/2022] Open
Abstract
BackgroundIncreasing studies have focused on the predictive value of high estimated glomerular filtration rate (eGFR) on cardiovascular diseases and mortality; however, the association between high eGFR with cognitive function is still not established. Thus, this study aimed to determine the co-relationship between high eGFR and cognitive performance in the hypertensive population.MethodsWe conducted a baseline cross-sectional study using data from the China H-type Hypertension Registry study. Mini-Mental State Examination (MMSE) assessment was performed to evaluate the cognitive function scale, and serum creatinine was collected to estimate eGFR level. Different MMSE cutoff values were applied in participants with the various educational background to define dementia: <24 in participants with secondary school and above education setting, <20 in those with primary school, and <17 in illiterate participants.ResultsA total of 9,527 hypertensive adults with mean age 63.7 ± 9.8 years and 67% female gender were analyzed. The eGFR cutoff value of 71.52 ml/min/1.73 m2 was found after adjusting for potential covariates in a threshold effect analysis. The MMSE increased significantly with the increment of eGFR (β, 0.27; 95% CI: 0.12–0.41) in participants with eGFR < 71.52 ml/min/1.73 m2 and decreased (β, −0.28; 95% CI: −0.39 to −0.17) in participants with eGFR ≥ 71.52 ml/min/1.73 m2. Individuals with eGFR ≥ 85 ml/min/1.73 m2 have an elevated risk of cognitive impairment than those with eGFR of 65–75 ml/min/1.73 m2. Subgroup analysis showed that a greater reduction degree of MMSE was observed in female individuals and those who had body mass index (BMI) ≥ 24 kg/m2 among participants with eGFR ≥ 71.52 ml/min/1.73 m2.ConclusionOur findings observed an inverted U-shaped relationship between eGFR and cognitive function. Both the low and high levels of eGFR were independently associated with worse cognitive assessment in the hypertensive population.
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Affiliation(s)
- Junpei Li
- Department of Cardiovascular, Nanchang University Second Affiliated Hospital, Nanchang, China
| | | | - Ziheng Tan
- Department of Cardiovascular, Nanchang University Second Affiliated Hospital, Nanchang, China
| | - Yun Yu
- Department of Cardiovascular, Nanchang University Second Affiliated Hospital, Nanchang, China
| | - Linfei Luo
- Department of Cardiovascular, Nanchang University Second Affiliated Hospital, Nanchang, China
| | - Wei Zhou
- Department of Cardiovascular, Nanchang University Second Affiliated Hospital, Nanchang, China
- Center for Prevention and Treatment of Cardiovascular Diseases, Nanchang University Second Affiliated Hospital, Nanchang, China
| | - Linjuan Zhu
- Department of Cardiovascular, Nanchang University Second Affiliated Hospital, Nanchang, China
- Center for Prevention and Treatment of Cardiovascular Diseases, Nanchang University Second Affiliated Hospital, Nanchang, China
| | - Tao Wang
- Department of Cardiovascular, Nanchang University Second Affiliated Hospital, Nanchang, China
- Center for Prevention and Treatment of Cardiovascular Diseases, Nanchang University Second Affiliated Hospital, Nanchang, China
| | - Tianyu Cao
- Department of Biological Anthropology, University of California, Santa Barbara, Santa Barbara, CA, United States
| | - Jianglong Tu
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Huihui Bao
- Department of Cardiovascular, Nanchang University Second Affiliated Hospital, Nanchang, China
- Center for Prevention and Treatment of Cardiovascular Diseases, Nanchang University Second Affiliated Hospital, Nanchang, China
| | - Xiao Huang
- Department of Cardiovascular, Nanchang University Second Affiliated Hospital, Nanchang, China
- *Correspondence: Xiao Huang,
| | - Xiaoshu Cheng
- Department of Cardiovascular, Nanchang University Second Affiliated Hospital, Nanchang, China
- Center for Prevention and Treatment of Cardiovascular Diseases, Nanchang University Second Affiliated Hospital, Nanchang, China
- Xiaoshu Cheng,
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15
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Patients with Dipper and Nondipper High-Normal Blood Pressure Were Associated with Left Ventricular Mass. Int J Hypertens 2021; 2021:6946418. [PMID: 35070446 PMCID: PMC8769863 DOI: 10.1155/2021/6946418] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 12/06/2021] [Indexed: 11/17/2022] Open
Abstract
Purpose High-normal blood pressure has been suggested to associate with target organ damage and higher left ventricular mass index (LVMI). Our aim is to find the association between people with high-normal blood pressure and their left ventricular mass index. Materials and Methods Given a total of 181 people with office blood pressure, 24-hour ambulatory blood pressure monitoring, 35 of them are normotensive (BP < 130/85 mm Hg), and 146 people with high-normal blood pressure (BP 130–139/85–89 mm Hg), divide the high-normal blood pressure group into dipper and nondipper according to their ABPM in 24 hours. All of them were performed with echocardiography to calculate LVMI. Results After adjusting for potential confounding factors, mean systolic blood pressure (BP) of the nondipper group is (119 + 9) mmHg in 24 h, which is significantly higher (p < 0.05) than in the dipper group (116 + 11) mmHg, indicating the mean systolic BP is associated with the dipper type (p < 0.05); furthermore, the higher nocturnal blood pressure is associated with the nondipper group significantly (p < 0.05), and LVMI ((121 ± 11) g/m2) of the nondipper group is also significantly higher than in the dipper group's LVMI ((108 ± 12) g/m2) (p < 0.05). The multivariate linear regression analyses revealed significant and independent associations of LVMI with these factors: triglyceride (TG), total cholesterol (TC), low-density lipoprotein (LDL-C), and coefficient of variation of systolic and diastolic blood pressure in 24 hours. Conclusion After multiple relevant clinical confounding factors were adjusted, patients with dipper and nondipper high-normal blood pressure had higher LVMI. Abnormalities in circadian blood pressure variability may be associated with the left ventricular hypertrophy.
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16
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Miller LM, Kurella Tamura M, Pajewski NM, Rifkin D, Weiner D, Marquine M, Shlipak MG, Ix JH. The Relationship of Kidney Tubule Biomarkers with Brain Imaging in CKD Patients in SPRINT. KIDNEY360 2021; 3:337-340. [PMID: 35373134 PMCID: PMC8967647 DOI: 10.34067/kid.0007702021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/06/2021] [Indexed: 01/10/2023]
Abstract
Urine biomarker concentrations reflecting kidney tubule injury and dysfunction were not associated with brain MRI measures.Higher eGFR was associated with lower total brain cerebral blood flow.This is the first evaluation of the relationship of kidney tubule biomarkers with brain imaging by MRI in patients with CKD.
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Affiliation(s)
- Lindsay M. Miller
- Division of Nephrology-Hypertension, University of California San Diego, San Diego, California,Correspondence: Dr. Lindsay M. Miller, Veterans Medical Research Foundation, Room 117B, Building 13, 3350 La Jolla Village Drive #151A, San Diego, CA 92161.
| | - Manjula Kurella Tamura
- Department of Medicine-Nephrology, Stanford University, Palo Alto, California,Geriatric Research Education and Clinical Center, Veterans Affairs, Palo Alto, Palo Alto, California,Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - Nicholas M. Pajewski
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Dena Rifkin
- Division of Nephrology-Hypertension, University of California San Diego, San Diego, California,Nephrology Section, Veterans Affairs San Diego Healthcare System, San Diego, California
| | - Daniel Weiner
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Maria Marquine
- Department of Medicine and Psychiatry, University of California San Diego, San Diego, California
| | - Michael G. Shlipak
- Division of Epidemiology and Biostatistics, School of Medicine, University of California San Francisco, San Francisco, California,Kidney Health Research Collaborative, Department of Medicine, University of California, San Francisco, San Francisco, California,General Internal Medicine Division, San Francisco Veterans Affairs Healthcare System, San Francisco, California
| | - Joachim H. Ix
- Division of Nephrology-Hypertension, University of California San Diego, San Diego, California,Nephrology Section, Veterans Affairs San Diego Healthcare System, San Diego, California
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17
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Hannan M, Collins EG, Phillips SA, Quinn L, Steffen A, Bronas UG. The Influence of Sedentary Behavior on the Relationship Between Cognitive Function and Vascular Function in Older Adults with and without Chronic Kidney Disease. Nephrol Nurs J 2021; 48:553-561. [PMID: 34935333 PMCID: PMC9113049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Cognitive impairment and vascular dysfunction are common in older adults with and without chronic kidney disease (CKD). Older adults with and without CKD are also sedentary - a behavior associated with cognitive and vascular function. The objective of this study was to explore whether sedentary behavior influenced the relationship between cognitive and vascular function in older adults with preclinical cognitive impairment with and without CKD. In our study, 48 older adults underwent assessment of cognition, vascular compliance, and sedentary behavior, and relationships were explored with regression moderation analysis. Sedentary time and breaks did not moderate the relationship between vascular and cognitive function. Although significant moderation was not found, cognition, vascular function, and sedentary behavior are important to assess when evaluating older adults with and without CKD.
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Affiliation(s)
- Mary Hannan
- Post-Doctoral Fellow, the University of Illinois Chicago, College of Medicine, Department of Medicine, Chicago, IL
- American Society of Nephrology Kidney Cure Sharon Anderson Research Fellow
- member of ANNA's Windy City Chapter
| | - Eileen G Collins
- Dean of the College of Nursing, the University of Illinois Chicago, College of Nursing, Department of Biobehavioral Nursing Science, Chicago, IL
| | - Shane A Phillips
- Professor and the Senior Associate Dean for Clinical Affairs , the University of Illinois Chicago, College of Applied Health Sciences, Department of Physical Therapy, Chicago, IL
| | - Lauretta Quinn
- Professor, the University of Illinois Chicago, College of Nursing, Department of Biobehavioral Nursing Science, Chicago, IL
| | - Alana Steffen
- Research Assistant Professor, the University of Illinois Chicago, College of Nursing, Department of Population Health Nursing Science, Chicago, IL
| | - Ulf G Bronas
- Associate Professor, the University of Illinois Chicago, College of Nursing, Department of Biobehavioral Nursing Science, Chicago, IL
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Hannan M, Collins EG, Phillips SA, Quinn L, Steffen A, Bronas UG. Cognitive and vascular function in older adults with and without CKD. Aging Clin Exp Res 2021; 33:1885-1894. [PMID: 32902822 PMCID: PMC8171583 DOI: 10.1007/s40520-020-01695-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 08/24/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Cognitive impairment is a common complication of aging that is also associated with chronic kidney disease (CKD). Vascular dysfunction has been implicated as a potential cause of cognitive impairment in older adults, with particular deficits noted in those with CKD. AIMS To determine the differences in cognitive function and vascular compliance in older adults with and without CKD with preclinical cognitive impairment and the relationship between these factors. METHODS Utilizing a cross-sectional approach, 48 older adults with preclinical cognitive impairment (24 with and 24 without CKD) were evaluated for performance on a test of global cognition and executive function, and vascular compliance via tonometry and ultrasound. RESULTS Cognitive function and some indicators of vascular function were significantly different in older adults with and without CKD. Global cognition was correlated with carotid-femoral pulse wave velocity (r = - 0.36, p = 0.02) in the entire sample. Vascular function was not correlated with executive function. DISCUSSION Older adults with preclinical cognitive impairment and CKD had different cognitive and vascular function than those without CKD, and an indicator of vascular function may have a relationship with cognitive function in older adults. CONCLUSIONS The findings of this study support the assessment of cognitive and vascular function in older adults with and without CKD with preclinical cognitive impairment.
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Affiliation(s)
- Mary Hannan
- College of Medicine, Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Eileen G Collins
- College of Nursing, Department of Biobehavioral Health Science (M/C 802), University of Illinois at Chicago, 845 S Damen Avenue, Chicago, IL, 60612, USA
| | - Shane A Phillips
- College of Applied Health Sciences, Department of Physical Therapy, University of Illinois at Chicago, Chicago, IL, USA
| | - Lauretta Quinn
- College of Nursing, Department of Biobehavioral Health Science (M/C 802), University of Illinois at Chicago, 845 S Damen Avenue, Chicago, IL, 60612, USA
| | - Alana Steffen
- College of Nursing, Department of Health Systems Science, University of Illinois at Chicago, Chicago, IL, USA
| | - Ulf G Bronas
- College of Nursing, Department of Biobehavioral Health Science (M/C 802), University of Illinois at Chicago, 845 S Damen Avenue, Chicago, IL, 60612, USA.
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19
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Paterson EN, Maxwell AP, Kee F, Cruise S, Young IS, McGuinness B, McKay GJ. Association of renal impairment with cognitive dysfunction in the Northern Ireland Cohort for the Longitudinal Study of Ageing (NICOLA). Nephrol Dial Transplant 2021; 36:1492-1499. [PMID: 34038557 PMCID: PMC8311575 DOI: 10.1093/ndt/gfab182] [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: 10/12/2020] [Accepted: 05/17/2021] [Indexed: 12/17/2022] Open
Abstract
Introduction Chronic kidney disease (CKD) is a recognized risk factor for cognitive impairment. Identification of those at greatest risk of cognitive impairment may facilitate earlier therapeutic intervention. This study evaluated associations between estimated glomerular filtration rate (eGFR) and cognitive function in the Northern Ireland Cohort for the Longitudinal Study of Ageing. Methods Data were available for 3412 participants ≥50 years of age living in non-institutionalized settings who attended a health assessment between February 2014 and March 2016. Measures of serum creatinine (SCr) and cystatin C (cys-C) were used for eGFR. Cognitive function was measured using the Montreal Cognitive Assessment (MoCA) and the Mini-Mental State Examination (MMSE). Results Following adjustment for potential confounders, a single unit decrease in eGFR was significantly associated with reduced cognitive function defined by an MMSE ≤24/30 {eGFR calculated using serum cys-C [eGFRcys]: β = −0.01 [95% confidence interval (CI) −0.001 to −0.01], P = 0.01} and MoCA <26/30 [β = −0.01 (95% CI −0.002 to −0.02), P = 0.02]. Similarly, CKD Stages 3–5 were also associated with a moderate increase in the odds of cognitive impairment (MMSE ≤24) following adjustment for confounders [eGFRcys: odds ratio 2.73 (95% CI 1.38–5.42), P = 0.004]. Conclusions Decreased eGFRcys was associated with a significantly increased risk of cognitive impairment in a population-based cohort of older adults. However, there was no evidence of an association between cognitive impairment and the more commonly used eGFR calculated using SCr. eGFRcys may offer improved sensitivity over eGFRcr in the determination of renal function and associated risk of cognitive impairment.
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Affiliation(s)
- Euan N Paterson
- Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Alexander P Maxwell
- Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Frank Kee
- Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Sharon Cruise
- Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Ian S Young
- Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland, UK
| | | | - Gareth J McKay
- Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland, UK
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20
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Freire de Medeiros CMM, Diógenes da Silva BR, Costa BG, Sartori VF, Meneses GC, Bezerra GF, Martins AMC, Libório AB. Cognitive impairment, endothelial biomarkers and mortality in maintenance haemodialysis patients: a prospective cohort study. Nephrol Dial Transplant 2021; 35:1779-1785. [PMID: 32379316 DOI: 10.1093/ndt/gfaa040] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 01/29/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Haemodialysis (HD) patients have a high prevalence of cardiovascular disease risk factors as well as cognitive impairment. The objective of the present study was to evaluate the interrelationship between cognitive impairment, endothelium-related biomarkers and cardiovascular/non-cardiovascular mortality. METHODS A total of 216 outpatients were recruited from three centres in a dialysis network in Brazil between June 2016 and June 2019. Sociodemographic and clinical data were obtained by applying a patient questionnaire, reviewing medical records data and conducting patient interviews. Cognitive function was assessed using the Cambridge Cognitive Examination. Plasma endothelium-related biomarkers [syndecan-1, intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion protein-1 (VCAM-1) and angiopoietin-2 (AGPT2)] were measured. Patients were followed for 30 months. Cox proportional hazards regression models were used to assess the associations of the cognitive function scores and each endothelium-related biomarker with cardiovascular/non-cardiovascular mortality. RESULTS Cognitive function was associated with cardiovascular mortality {each standard deviation [SD] better cognitive score was associated with a 69% lower risk for cardiovascular mortality [hazard ratio (HR) 0.31 [95% confidence interval (CI) 0.17-0.58]} but not with non-cardiovascular mortality. Moreover, cognitive function was also correlated with all endothelial-related biomarkers, except VCAM-1. ICAM-1, AGPT2 and syndecan-1 were also associated with cardiovascular mortality. The association between cognitive function and cardiovascular mortality remained significant with no HR value attenuation [fully adjusted HR 0.32 (95% CI 0.16-0.59)] after individually including each endothelial-related biomarker in the Cox model. CONCLUSIONS In conclusion, cognitive impairment was associated with several endothelium-related biomarkers. Moreover, cognitive impairment was associated with cardiovascular mortality but not with non-cardiovascular mortality, and the association between cognitive impairment and cardiovascular mortality in HD patients was not explained by any of the endothelial-related biomarkers.
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Affiliation(s)
| | | | - Bruno Gabriele Costa
- Department of Internal Medicine, Medical School, Federal University of Ceará, Fortaleza, Ceará, Brazil.,Universidade de Fortaleza-UNIFOR, Fortaleza, Ceará, Brazil
| | - Vinicius Farina Sartori
- Department of Physiology and Pharmacology, Medical School, Federal University of Ceará, Fortaleza, Ceará, Brazil
| | | | - Gabriela Freire Bezerra
- Department of Physiology and Pharmacology, Medical School, Federal University of Ceará, Fortaleza, Ceará, Brazil
| | - Alice Maria Costa Martins
- Clinical and Toxicological Analysis Department, School of Pharmacy, Federal University of Ceará, Fortaleza, Ceará, Brazil
| | - Alexandre Braga Libório
- Department of Internal Medicine, Medical School, Federal University of Ceará, Fortaleza, Ceará, Brazil.,Universidade de Fortaleza-UNIFOR, Fortaleza, Ceará, Brazil
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21
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Wang M, Ding D, Zhao Q, Wu W, Xiao Z, Liang X, Luo J, Chen J. Kidney function and dementia risk in community-dwelling older adults: the Shanghai Aging Study. Alzheimers Res Ther 2021; 13:21. [PMID: 33430940 PMCID: PMC7798296 DOI: 10.1186/s13195-020-00729-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 11/23/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Association between kidney dysfunction and dementia has been studied in western cohorts, but with inconsistent conclusions which may be due to the different measurements of kidney function. We aim to verify the hypothesis that lower levels of kidney function would be associated with increased risk of incident dementia in Chinese elderly. METHODS One thousand four hundred twelve dementia-free participants aged 60 years or older from the Shanghai Aging Study were enrolled and followed up for 5.3 years on average. Glomerular filtration rate (GFR) was calculated by using combined creatinine-cystatin C CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) equation. Diagnoses of incident dementia and Alzheimer's disease (AD) were established using DSM-IV and NINCDS-ADRDA criteria based on medical, neurological, and neuropsychological examinations to each participant. Cox proportional regression was used to analyze the association of baseline GFRcrcys levels with incident dementia/AD, adjusting age, gender, education years, APOE-ε4, diabetes, hypertension, baseline Mini-Mental State Examination score, and proteinuria. RESULTS A total of 113 (8%) and 84 (7%) participants developed dementia and AD. Comparing to participants with high GFRcrcys (≥ 80 ml/min/1.73 m2), participants with low (< 67 ml/min/1.73 m2) and moderate GFRcrcys (67 ≤ GFR < 80 ml/min/1.73 m2) had increased risk of incident dementia with hazard ratios (HRs) of 1.87 (95% CI 1.02-3.44) and 2.19 (95% CI 1.21-3.95) after adjustment for confounders, respectively. Low (HR = 2.27 [95%CI 1.10-4.68]) and moderate (HR = 2.14 [95% CI 1.04-4.40]) GFRcrcys at baseline was also independently associated with incident AD after adjustments when comparing to high GFRcrcys. The significant association between GFRcrcys and dementia risk was observed in female but not in male participants. CONCLUSIONS GFRcrcys may be considered as a marker of an individual's vulnerability to the increased risk of cognitive decline.
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Affiliation(s)
- Mengjing Wang
- Department of Nephrology, National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, 12 Middle Wurumuqi Road, Shanghai, 200040, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, 12 Middle Wurumuqi Road, Shanghai, 200040, China
| | - Ding Ding
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, 12 Middle Wurumuqi Road, Shanghai, 200040, China.
- Institute of Neurology, Huashan Hospital, Fudan University, Shanghai, China.
| | - Qianhua Zhao
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, 12 Middle Wurumuqi Road, Shanghai, 200040, China
- Institute of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Wanqing Wu
- Institute of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Zhenxu Xiao
- Institute of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiaoniu Liang
- Institute of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Jianfeng Luo
- Department of Biostatistics, School of Public Health, Fudan University, Shanghai, China
- Key Laboratory of Public Health Safety of Ministry of Education (Fudan University), Shanghai, China
| | - Jing Chen
- Department of Nephrology, National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, 12 Middle Wurumuqi Road, Shanghai, 200040, China.
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, 12 Middle Wurumuqi Road, Shanghai, 200040, China.
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22
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Coelho VA, Santos GG, Avesani CM, Bezerra CIL, Silva LCA, Lauar JC, Lindholm B, Stenvinkel P, Jacob-Filho W, Noronha IL, Zatz R, Moysés RMA, Elias RM. Design and methodology of the Aging Nephropathy Study (AGNES): a prospective cohort study of elderly patients with chronic kidney disease. BMC Nephrol 2020; 21:461. [PMID: 33160321 PMCID: PMC7648411 DOI: 10.1186/s12882-020-02116-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 10/20/2020] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Renal replacement therapy (RRT) is usually indicated for patients with chronic kidney disease (CKD) with glomerular filtration rate below 10 ml/ml/min/1.73m2. However, the need for RRT and timing of dialysis initiation are debatable for patients aged 70 years or older. We here describe the study design and methodology of the Aging Nephropathy Study (AGNES) protocol that aims at evaluating to what extent geriatric-related conditions such as frailty, cognitive dysfunction, and presence of comorbidities have an impact on survival and RRT initiation in this group of patients. In this manuscript we provide detailed information about the AGNES study design and methodology. METHODS AGNES is a prospective observational cohort that aim to investigate clinical, biochemical and demographic factors associated with RRT initiation and mortality of patients with CKD stage 4 or 5 who are aged 70 years and older. We plan to include 200 patients over 5 years. Clinically stable outpatients on conservative management for at least 6 months will be recruited from the Nephrogeriatric Clinic at the Hospital das Clinicas da Universidade de Sao Paulo, Brazil. Eligible patients are submitted to a full clinical examination, geriatric assessment, and blood test at baseline. Following the baseline visit the patients are being monitored during an observational follow up period of at least 12 months during which patients will be contacted in the clinic at their regular follow up or by phone until either RRT initiation or death occurs. This cohort includes evaluation of cognition by the education-adjusted 10-point Cognitive Screener (10-CS), frailty by Fried index score, a complete nutritional assessment (by body composition assessment, global subjective assessment and dietary intake), comorbidities by Charlson comorbidity index and biochemical markers including FGF-23 and Klotho. DISCUSSION The AGNES cohort, a real-world study of current clinical practice in elderly patients with advanced CKD prior to dialysis initiation, will shed light into progression of CKD and its complications, indications of RRT and factors determining survival. This investigation will elucidate to what extent geriatric conditions, nutritional status and clinical factors are associated with survival, quality of life and RRT initiation in elderly CKD patients not yet on dialysis. TRIAL REGISTRATION Registered on ClinicalTrials.gov on 18 October 2019 ( NCT04132492 ).
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Affiliation(s)
- Venceslau A Coelho
- LIM 66, Division of Geriatrics, Faculdade de Medicina Universidade de Sao Paulo, Sao Paulo, Brazil.,Division of Geriatrics, Hospital das Clinicas HCFMUSP, Sao Paulo, Brazil
| | - Giovani Gn Santos
- Division of Geriatrics, Hospital das Clinicas HCFMUSP, Sao Paulo, Brazil
| | - Carla M Avesani
- Division of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | | | | | - Julia C Lauar
- Division of Nephrology, Hospital das Clinicas HCFMUSP, Sao Paulo, Brazil
| | - Bengt Lindholm
- Division of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Peter Stenvinkel
- Division of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Wilson Jacob-Filho
- LIM 66, Division of Geriatrics, Faculdade de Medicina Universidade de Sao Paulo, Sao Paulo, Brazil.,Division of Geriatrics, Hospital das Clinicas HCFMUSP, Sao Paulo, Brazil
| | - Irene L Noronha
- Division of Nephrology, Hospital das Clinicas HCFMUSP, Sao Paulo, Brazil.,LIM 29, Division of Nephrology, Faculdade de Medicina Universidade de Sao Paulo, São Paulo, Brazil
| | - Roberto Zatz
- Division of Nephrology, Hospital das Clinicas HCFMUSP, Sao Paulo, Brazil.,LIM 16, Division of Nephrology, Faculdade de Medicina Universidade de Sao Paulo, São Paulo, Brazil
| | - Rosa M A Moysés
- Division of Nephrology, Hospital das Clinicas HCFMUSP, Sao Paulo, Brazil.,LIM 16, Division of Nephrology, Faculdade de Medicina Universidade de Sao Paulo, São Paulo, Brazil
| | - Rosilene M Elias
- Division of Nephrology, Hospital das Clinicas HCFMUSP, Sao Paulo, Brazil.
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23
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González AM, Gutman T, Lopez-Vargas P, Anumudu S, Arce CM, Craig JC, Dunn L, Eckardt KU, Harris T, Levey AS, Lightstone L, Scholes-Robertson N, Shen JI, Teixeira-Pinto A, Wheeler DC, White D, Wilkie M, Jadoul M, Winkelmayer WC, Tong A. Patient and Caregiver Priorities for Outcomes in CKD: A Multinational Nominal Group Technique Study. Am J Kidney Dis 2020; 76:679-689. [DOI: 10.1053/j.ajkd.2020.03.022] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 03/21/2020] [Indexed: 12/30/2022]
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Nixon AC, Brown J, Brotherton A, Harrison M, Todd J, Brannigan D, Ashcroft Q, So B, Pendleton N, Ebah L, Mitra S, Dhaygude AP, Brady ME. Implementation of a frailty screening programme and Geriatric Assessment Service in a nephrology centre: a quality improvement project. J Nephrol 2020; 34:1215-1224. [PMID: 33040293 PMCID: PMC8357770 DOI: 10.1007/s40620-020-00878-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 09/23/2020] [Indexed: 01/10/2023]
Abstract
INTRODUCTION The aims of this quality improvement project were to: (1) proactively identify people living with frailty and CKD; (2) introduce a practical assessment, using the principles of the comprehensive geriatric assessment (CGA), for people living with frailty and chronic kidney disease (CKD) able to identify problems; and (3) introduce person-centred management plans for people living with frailty and CKD. METHODS A frailty screening programme, using the Clinical Frailty Scale (CFS), was introduced in September 2018. A Geriatric Assessment (GA) was offered to patients with CFS ≥ 5 and non-dialysis- or dialysis-dependent CKD. Renal Frailty Multidisciplinary Team (MDT) meetings were established to discuss needs identified and implement a person-centred management plan. RESULTS A total of 450 outpatients were screened using the CFS. One hundred and fifty patients (33%) were screened as frail. Each point increase in the CFS score was independently associated with a hospitalisation hazard ratio of 1.35 (95% CI 1.20-1.53) and a mortality hazard ratio of 2.15 (95% CI 1.63-2.85). Thirty-five patients received a GA and were discussed at a MDT meeting. Patients experienced a median of 5.0 (IQR 3.0) problems, with 34 (97%) patients experiencing at least three problems. CONCLUSIONS This quality improvement project details an approach to the implementation of a frailty screening programme and GA service within a nephrology centre. Patients living with frailty and CKD at risk of adverse outcomes can be identified using the CFS. Furthermore, a GA can be used to identify problems and implement a person-centred management plan that aims to improve outcomes for this vulnerable group of patients.
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Affiliation(s)
- Andrew C Nixon
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Royal Preston Hospital, Sharoe Green Lane, Preston, PR2 9HT, UK. .,Division of Cardiovascular Sciences, University of Manchester, Manchester, UK. .,Centre for Health Research and Innovation, National Institute of Health Research Lancashire Clinical Research Facility, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK.
| | - Julie Brown
- Lancashire Teaching Hospitals Integrated Frailty Team, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Ailsa Brotherton
- Continuous Improvement Team, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Mark Harrison
- Lancashire Teaching Hospitals Integrated Frailty Team, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Judith Todd
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Royal Preston Hospital, Sharoe Green Lane, Preston, PR2 9HT, UK
| | - Dawn Brannigan
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Royal Preston Hospital, Sharoe Green Lane, Preston, PR2 9HT, UK
| | - Quinta Ashcroft
- Department of Business Intelligence, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Beng So
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Royal Preston Hospital, Sharoe Green Lane, Preston, PR2 9HT, UK
| | - Neil Pendleton
- Division of Neuroscience and Experimental Psychology, University of Manchester, Manchester, UK
| | - Leonard Ebah
- Department of Renal Medicine, Manchester University NHS Foundation Trust, Manchester, UK
| | - Sandip Mitra
- Department of Renal Medicine, Manchester University NHS Foundation Trust, Manchester, UK.,Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK.,Devices for Dignity, National Institute of Health Research MedTech and In-vitro Diagnostics Co-operative, Sheffield, UK
| | - Ajay P Dhaygude
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Royal Preston Hospital, Sharoe Green Lane, Preston, PR2 9HT, UK
| | - Mark E Brady
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Royal Preston Hospital, Sharoe Green Lane, Preston, PR2 9HT, UK
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25
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Sedaghat S, Sorond F, Yaffe K, Sidney S, Kramer HJ, Jacobs DR, Launer LJ, Carnethon MR. Decline in kidney function over the course of adulthood and cognitive function in midlife. Neurology 2020; 95:e2389-e2397. [PMID: 32878993 DOI: 10.1212/wnl.0000000000010631] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 05/27/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To test the hypothesis that end-stage renal disease (ESRD) risk exposure during young adulthood is related to worse cognitive performance in midlife. METHODS We included 2,604 participants from the population-based Coronary Artery Risk Development in Young Adults (CARDIA) Study (mean age 35 years, 54% women, 45% Black). Estimated glomerular filtration rate and albumin-to-creatinine ratio were measured every 5 years at year (Y) 10 through Y30. At each visit, moderate/high risk of ESRD according to the Kidney Disease: Improving Global Outcomes guidelines (estimated glomerular filtration rate <60 mL/min/1.73 m2 or albumin-to-creatinine ratio >30 mg/g) was defined, totaled over examinations, and categorized into 0 episodes, 1 episode, and >1 episodes of ESRD risk. At Y30, participants underwent global and multidomain cognitive assessment. We used analysis of covariance to assess the association of ESRD risk categories with cognitive function, controlling for cardiovascular risk factors. RESULTS Over the course of 20 years, 427 participants (16% of the study population) had ≥1 episodes of ESRD risk exposure. Individuals with more risk episodes had lower composite cognitive function (p < 0.001), psychomotor speed (p < 0.001), and executive function (p = 0.007). All these associations were independent of sociodemographic status and cardiovascular risk factors. CONCLUSIONS In this population-based longitudinal study, we show that episodes of decline in kidney function over the young-adulthood course are associated with worse cognitive performance at midlife. Preserving kidney function in young age needs to be investigated as a potential strategy to preserve cognitive function in midlife.
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Affiliation(s)
- Sanaz Sedaghat
- From the Departments of Preventive Medicine (S. Sedaghat, M.R.C.) and Neurology (S. Sedaghat, F.S.), Northwestern University Feinberg School of Medicine, Chicago, IL; Departments of Psychiatry, Neurology, and Epidemiology and Biostatistics (K.Y.), University of California; San Francisco Veterans Affairs Medical Center (K.Y.); Division of Research (S. Sidney), Kaiser Permanente Northern California, Oakland; Department of Public Health Sciences, Medicine, and Division of Nephrology and Hypertension (H.J.K.), Loyola University Medical Center, Maywood, IL; Division of Epidemiology and Community Health (D.R.J.), School of Public Health, University of Minnesota, Minneapolis; and National Institute on Aging (L.J.L.), Baltimore, MD.
| | - Farzaneh Sorond
- From the Departments of Preventive Medicine (S. Sedaghat, M.R.C.) and Neurology (S. Sedaghat, F.S.), Northwestern University Feinberg School of Medicine, Chicago, IL; Departments of Psychiatry, Neurology, and Epidemiology and Biostatistics (K.Y.), University of California; San Francisco Veterans Affairs Medical Center (K.Y.); Division of Research (S. Sidney), Kaiser Permanente Northern California, Oakland; Department of Public Health Sciences, Medicine, and Division of Nephrology and Hypertension (H.J.K.), Loyola University Medical Center, Maywood, IL; Division of Epidemiology and Community Health (D.R.J.), School of Public Health, University of Minnesota, Minneapolis; and National Institute on Aging (L.J.L.), Baltimore, MD
| | - Kristine Yaffe
- From the Departments of Preventive Medicine (S. Sedaghat, M.R.C.) and Neurology (S. Sedaghat, F.S.), Northwestern University Feinberg School of Medicine, Chicago, IL; Departments of Psychiatry, Neurology, and Epidemiology and Biostatistics (K.Y.), University of California; San Francisco Veterans Affairs Medical Center (K.Y.); Division of Research (S. Sidney), Kaiser Permanente Northern California, Oakland; Department of Public Health Sciences, Medicine, and Division of Nephrology and Hypertension (H.J.K.), Loyola University Medical Center, Maywood, IL; Division of Epidemiology and Community Health (D.R.J.), School of Public Health, University of Minnesota, Minneapolis; and National Institute on Aging (L.J.L.), Baltimore, MD
| | - Stephen Sidney
- From the Departments of Preventive Medicine (S. Sedaghat, M.R.C.) and Neurology (S. Sedaghat, F.S.), Northwestern University Feinberg School of Medicine, Chicago, IL; Departments of Psychiatry, Neurology, and Epidemiology and Biostatistics (K.Y.), University of California; San Francisco Veterans Affairs Medical Center (K.Y.); Division of Research (S. Sidney), Kaiser Permanente Northern California, Oakland; Department of Public Health Sciences, Medicine, and Division of Nephrology and Hypertension (H.J.K.), Loyola University Medical Center, Maywood, IL; Division of Epidemiology and Community Health (D.R.J.), School of Public Health, University of Minnesota, Minneapolis; and National Institute on Aging (L.J.L.), Baltimore, MD
| | - Holly J Kramer
- From the Departments of Preventive Medicine (S. Sedaghat, M.R.C.) and Neurology (S. Sedaghat, F.S.), Northwestern University Feinberg School of Medicine, Chicago, IL; Departments of Psychiatry, Neurology, and Epidemiology and Biostatistics (K.Y.), University of California; San Francisco Veterans Affairs Medical Center (K.Y.); Division of Research (S. Sidney), Kaiser Permanente Northern California, Oakland; Department of Public Health Sciences, Medicine, and Division of Nephrology and Hypertension (H.J.K.), Loyola University Medical Center, Maywood, IL; Division of Epidemiology and Community Health (D.R.J.), School of Public Health, University of Minnesota, Minneapolis; and National Institute on Aging (L.J.L.), Baltimore, MD
| | - David R Jacobs
- From the Departments of Preventive Medicine (S. Sedaghat, M.R.C.) and Neurology (S. Sedaghat, F.S.), Northwestern University Feinberg School of Medicine, Chicago, IL; Departments of Psychiatry, Neurology, and Epidemiology and Biostatistics (K.Y.), University of California; San Francisco Veterans Affairs Medical Center (K.Y.); Division of Research (S. Sidney), Kaiser Permanente Northern California, Oakland; Department of Public Health Sciences, Medicine, and Division of Nephrology and Hypertension (H.J.K.), Loyola University Medical Center, Maywood, IL; Division of Epidemiology and Community Health (D.R.J.), School of Public Health, University of Minnesota, Minneapolis; and National Institute on Aging (L.J.L.), Baltimore, MD
| | - Lenore J Launer
- From the Departments of Preventive Medicine (S. Sedaghat, M.R.C.) and Neurology (S. Sedaghat, F.S.), Northwestern University Feinberg School of Medicine, Chicago, IL; Departments of Psychiatry, Neurology, and Epidemiology and Biostatistics (K.Y.), University of California; San Francisco Veterans Affairs Medical Center (K.Y.); Division of Research (S. Sidney), Kaiser Permanente Northern California, Oakland; Department of Public Health Sciences, Medicine, and Division of Nephrology and Hypertension (H.J.K.), Loyola University Medical Center, Maywood, IL; Division of Epidemiology and Community Health (D.R.J.), School of Public Health, University of Minnesota, Minneapolis; and National Institute on Aging (L.J.L.), Baltimore, MD
| | - Mercedes R Carnethon
- From the Departments of Preventive Medicine (S. Sedaghat, M.R.C.) and Neurology (S. Sedaghat, F.S.), Northwestern University Feinberg School of Medicine, Chicago, IL; Departments of Psychiatry, Neurology, and Epidemiology and Biostatistics (K.Y.), University of California; San Francisco Veterans Affairs Medical Center (K.Y.); Division of Research (S. Sidney), Kaiser Permanente Northern California, Oakland; Department of Public Health Sciences, Medicine, and Division of Nephrology and Hypertension (H.J.K.), Loyola University Medical Center, Maywood, IL; Division of Epidemiology and Community Health (D.R.J.), School of Public Health, University of Minnesota, Minneapolis; and National Institute on Aging (L.J.L.), Baltimore, MD
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26
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Miglinas M, Cesniene U, Janusaite MM, Vinikovas A. Cerebrovascular Disease and Cognition in Chronic Kidney Disease Patients. Front Cardiovasc Med 2020; 7:96. [PMID: 32582768 PMCID: PMC7283453 DOI: 10.3389/fcvm.2020.00096] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 05/06/2020] [Indexed: 12/16/2022] Open
Abstract
Chronic kidney disease (CKD) affects both brain structure and function. Patients with CKD have a higher risk of both ischemic and hemorrhagic strokes. Age, prior disease history, hypertension, diabetes, atrial fibrillation, smoking, diet, obesity, and sedimentary lifestyle are most common risk factors. Renal-specific pathophysiologic derangements, such as oxidative stress, chronic inflammation, endothelial dysfunction, vascular calcification, anemia, gut dysbiosis, and uremic toxins are important mediators. Dialysis initiation constitutes the highest stroke risk period. CKD significantly worsens stroke outcomes. It is essential to understand the risks and benefits of established stroke therapeutics in patients with CKD, especially in those on dialysis. Subclinical cerebrovascular disease, such as of silent brain infarction, white matter lesions, cerebral microbleeds, and cerebral atrophy are more prevalent with declining renal function. This may lead to functional brain damage manifesting as cognitive impairment. Cognitive dysfunction has been linked to poor compliance with medications, and is associated with greater morbidity and mortality. Thus, understanding the interaction between renal impairment and brain is important in to minimize the risk of neurologic injury in patients with CKD. This article reviews the link between chronic kidney disease and brain abnormalities associated with CKD in detail.
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Affiliation(s)
- Marius Miglinas
- Nephrology and Kidney Transplantation Unit, Nephrology Center, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania.,Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Ugne Cesniene
- Nephrology and Kidney Transplantation Unit, Nephrology Center, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Marta Monika Janusaite
- Nephrology and Kidney Transplantation Unit, Nephrology Center, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania.,Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Arturas Vinikovas
- Nephrology and Kidney Transplantation Unit, Nephrology Center, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania.,Faculty of Medicine, Vilnius University, Vilnius, Lithuania
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27
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Kurella Tamura M, Gaussoin SA, Pajewski NM, Chelune GJ, Freedman BI, Gure TR, Haley WE, Killeen AA, Oparil S, Rapp SR, Rifkin DE, Supiano M, Williamson JD, Weiner DE. Kidney Disease, Intensive Hypertension Treatment, and Risk for Dementia and Mild Cognitive Impairment: The Systolic Blood Pressure Intervention Trial. J Am Soc Nephrol 2020; 31:2122-2132. [PMID: 32591439 DOI: 10.1681/asn.2020010038] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 05/14/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Intensively treating hypertension may benefit cardiovascular disease and cognitive function, but at the short-term expense of reduced kidney function. METHODS We investigated markers of kidney function and the effect of intensive hypertension treatment on incidence of dementia and mild cognitive impairment (MCI) in 9361 participants in the randomized Systolic Blood Pressure Intervention Trial, which compared intensive versus standard systolic BP lowering (targeting <120 mm Hg versus <140 mm Hg, respectively). We categorized participants according to baseline and longitudinal changes in eGFR and urinary albumin-to-creatinine ratio. Primary outcomes were occurrence of adjudicated probable dementia and MCI. RESULTS Among 8563 participants who completed at least one cognitive assessment during follow-up (median 5.1 years), probable dementia occurred in 325 (3.8%) and MCI in 640 (7.6%) participants. In multivariable adjusted analyses, there was no significant association between baseline eGFR <60 ml/min per 1.73 m2 and risk for dementia or MCI. In time-varying analyses, eGFR decline ≥30% was associated with a higher risk for probable dementia. Incident eGFR <60 ml/min per 1.73 m2 was associated with a higher risk for MCI and a composite of dementia or MCI. Although these kidney events occurred more frequently in the intensive treatment group, there was no evidence that they modified or attenuated the effect of intensive treatment on dementia and MCI incidence. Baseline and incident urinary ACR ≥30 mg/g were not associated with probable dementia or MCI, nor did the urinary ACR modify the effect of intensive treatment on cognitive outcomes. CONCLUSIONS Among hypertensive adults, declining kidney function measured by eGFR is associated with increased risk for probable dementia and MCI, independent of the intensity of hypertension treatment.
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Affiliation(s)
- Manjula Kurella Tamura
- Geriatric Research and Education Clinical Center, Palo Alto VA Health Care System, Palo Alto, California .,Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
| | - Sarah A Gaussoin
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Nicholas M Pajewski
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Gordon J Chelune
- Center for Alzheimer's Care, Imaging and Research, University of Utah School of Medicine, Salt Lake City, Utah
| | - Barry I Freedman
- Section of Nephrology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Tanya R Gure
- Division of General Internal Medicine and Geriatrics, The Ohio State University, Columbus, Ohio
| | - William E Haley
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, Florida
| | - Anthony A Killeen
- Departments of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | - Suzanne Oparil
- Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
| | - Stephen R Rapp
- Department of Psychiatry and Behavioral Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Dena E Rifkin
- Division of Nephrology, University of California San Diego, San Diego, California
| | - Mark Supiano
- Division of Geriatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Jeff D Williamson
- Sticht Center for Healthy Aging and Alzheimer's Prevention and Division of Geriatric Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Daniel E Weiner
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
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28
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Viggiano D, Wagner CA, Martino G, Nedergaard M, Zoccali C, Unwin R, Capasso G. Mechanisms of cognitive dysfunction in CKD. Nat Rev Nephrol 2020; 16:452-469. [PMID: 32235904 DOI: 10.1038/s41581-020-0266-9] [Citation(s) in RCA: 144] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2020] [Indexed: 02/07/2023]
Abstract
Cognitive impairment is an increasingly recognized major cause of chronic disability and is commonly found in patients with chronic kidney disease (CKD). Knowledge of the relationship between kidney dysfunction and impaired cognition may improve our understanding of other forms of cognitive dysfunction. Patients with CKD are at an increased risk (compared with the general population) of both dementia and its prodrome, mild cognitive impairment (MCI), which are characterized by deficits in executive functions, memory and attention. Brain imaging in patients with CKD has revealed damage to white matter in the prefrontal cortex and, in animal models, in the subcortical monoaminergic and cholinergic systems, accompanied by widespread macrovascular and microvascular damage. Unfortunately, current interventions that target cardiovascular risk factors (such as anti-hypertensive drugs, anti-platelet agents and statins) seem to have little or no effect on CKD-associated MCI, suggesting that the accumulation of uraemic neurotoxins may be more important than disturbed haemodynamic factors or lipid metabolism in MCI pathogenesis. Experimental models show that the brain monoaminergic system is susceptible to uraemic neurotoxins and that this system is responsible for the altered sleep pattern commonly observed in patients with CKD. Neural progenitor cells and the glymphatic system, which are important in Alzheimer disease pathogenesis, may also be involved in CKD-associated MCI. More detailed study of CKD-associated MCI is needed to fully understand its clinical relevance, underlying pathophysiology, possible means of early diagnosis and prevention, and whether there may be novel approaches and potential therapies with wider application to this and other forms of cognitive decline.
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Affiliation(s)
- Davide Viggiano
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy.,Biogem Scarl, Ariano Irpino, Italy
| | - Carsten A Wagner
- Institute of Physiology, University of Zurich, Zurich, Switzerland, and National Center of Competence in Research NCCR Kidney.CH, Zurich, Switzerland
| | - Gianvito Martino
- IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Maiken Nedergaard
- University of Rochester Medical Center, School of Medicine and Dentistry, Rochester, NY, USA
| | - Carmine Zoccali
- Institute of Clinical Physiology, National Research Council (CNR), Reggio Calabria Unit, Reggio Calabria, Italy
| | - Robert Unwin
- Department of Renal Medicine, University College London (UCL), Royal Free Campus, London, UK.,Early Clinical Development, Research and Early Development, Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Giovambattista Capasso
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy. .,Biogem Scarl, Ariano Irpino, Italy.
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29
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Microalbuminuria: a sentinel of neurocognitive impairment in HIV-infected individuals? J Neurol 2020; 267:1368-1376. [PMID: 31980868 PMCID: PMC7184056 DOI: 10.1007/s00415-019-09674-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 11/05/2019] [Accepted: 12/11/2019] [Indexed: 12/22/2022]
Abstract
Background According to population-based studies, microalbuminuria is associated with subsequent cognitive decline over a 4–6-year period, because of cerebral small-vessel disease (CSVD). This prospective cross-sectional study (NCT02852772) was designed to evaluate whether a history of microalbuminuria is associated with subsequent cognitive decline in combined antiretroviral therapy (cART)-treated persons living with human immunodeficiency virus (PLHIVs). Methods From our computerized medical database, we identified 30 PLHIVs (median age 52 years), immunovirologically controlled on cART, who had microalbuminuria in 2008 and had undergone, between 2013 and 2015, a comprehensive neuropsychological assessment (NPA) including seven domains (cases): information-processing speed, motor skills, executive functions, attention/working memory, learning/memory, reasoning and verbal fluency. Forty-nine PLHIVs matched for age (median age 48 years; p = 0.19), sex, and year of first HIV-seropositivity without microalbuminuria in 2008 were identified and underwent the same NPA between 2013 and 2015 (controls). Results Cases performed less well than controls for information-processing speed (p = 0.01) and motor skills (p = 0.02), but no differences were found for the other cognitive domains and global z-scores. A multivariable linear-regression model adjusted for confounding factors confirmed the microalbuminuria effect for the information-processing-speed z score. Conclusion cART-treated PLHIVs with a history of microalbuminuria subsequently had worse cognitive performances for the information-processing-speed domain, possibly because of CSVD. Our observations should be considered preliminary findings of a temporal link between microalbuminuria, CSVD, and subsequent cognitive impairment.
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30
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Kelly D, Rothwell PM. Disentangling the multiple links between renal dysfunction and cerebrovascular disease. J Neurol Neurosurg Psychiatry 2020; 91:88-97. [PMID: 31511306 PMCID: PMC6952845 DOI: 10.1136/jnnp-2019-320526] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 07/29/2019] [Accepted: 08/07/2019] [Indexed: 11/30/2022]
Abstract
Chronic kidney disease (CKD) has a rapidly rising global prevalence, affecting as many as one-third of the population over the age of 75 years. CKD is a well-known risk factor for cardiovascular disease and, in particular, there is a strong association with stroke. Cohort studies and trials indicate that reduced glomerular filtration rate increases the risk of stroke by about 40% and that proteinuria increases the risk by about 70%. In addition, CKD is also strongly associated with subclinical cerebrovascular abnormalities, vascular cognitive impairment and dementia. The mechanisms responsible for these associations are currently unclear. CKD is associated with traditional risk factors such as hypertension, diabetes mellitus and atrial fibrillation, but non-traditional risk factors such as uraemia, oxidative stress, mineral and bone abnormalities, and dialysis-related factors, such as changes in cerebral blood flow or cardiac structure, are also postulated to play a role. Kidney disease can also impact and complicate the treatments used in acute stroke and in secondary prevention. In this review, we will outline our current understanding of the epidemiology and pathophysiology of cerebrovascular disease in CKD.
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Affiliation(s)
- Dearbhla Kelly
- Centre for the Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Peter Malcolm Rothwell
- Centre for the Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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31
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Jiang W, Hu CY, Li FL, Hua XG, Huang K, Zhang XJ. Elevated parathyroid hormone levels and cognitive function: A systematic review. Arch Gerontol Geriatr 2019; 87:103985. [PMID: 31770681 DOI: 10.1016/j.archger.2019.103985] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 10/30/2019] [Accepted: 11/14/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To systematically estimate the association between elevated parathyroid hormone (PTH) levels and cognitive function. METHODS This review was conducted on ten papers identified through database searches from inception to 31 October 2018. The quality of studies was assessed using the Downs and Black checklist. RESULTS There is a low volume of data reporting on the impact of elevated PTH levels on cognitive impairment. The quality of the identified studies ranged from poor (37 %) to good (76 %). Although the results from studies were mixed, one cross-sectional study and one prospective study suggested a link between elevated PTH levels and a decrease in the Mini-Mental State Examination (MMSE) score. Three cross-sectional studies that assessed other cognitive domain in specific domains, such as language, memory and executive function provided mixed results for an association between elevated PTH levels and cognitive function. Two studies showed mixed evidence for a link between elevated PTH levels and poor executive function. One prospective study, one cross-sectional study and three case-control studies provide mixed evidence for an association between higher PTH levels and Alzheimer´s disease (AD). Two studies showed limited evidence for an association between elevated PTH levels and vascular dementia. CONCLUSION This review presented that the level of evidence available to support an association between elevated PTH levels and cognitive function was generally weak and inconsistent. Future studies with more better methodological quality are needed.
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Affiliation(s)
- Wen Jiang
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei 230032, China
| | - Cheng-Yang Hu
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei 230032, China
| | - Feng-Li Li
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei 230032, China
| | - Xiao-Guo Hua
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei 230032, China
| | - Kai Huang
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei 230032, China
| | - Xiu-Jun Zhang
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei 230032, China.
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32
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Wang Y, Wang X, Chen W, Shao Y, Zhou J, Chen Q, Lv J. BRAIN FUNCTION ALTERATIONS IN PATIENTS WITH DIABETIC NEPHROPATHY COMPLICATED BY RETINOPATHY UNDER RESTING STATE CONDITIONS ASSESSED BY VOXEL-MIRRORED HOMOTOPIC CONNECTIVITY. Endocr Pract 2019; 26:291-298. [PMID: 31682517 DOI: 10.4158/ep-2019-0355] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Objective: The voxel-mirrored homologous connection (VHMC) technique was applied to detect resting brain function alterations in patients with diabetic nephropathy and retinopathy (DNR), and their relationships with clinical manifestations in the kidneys and eyes are discussed. Methods: Twenty-two patients with DNR and 22 healthy controls (HCs) similarly matched in age, sex, and educational background were recruited. Resting-state functional magnetic resonance imaging scans were performed for all subjects. Retinal fundus photography and renal biopsy were employed to observe the clinical features of the kidney and retina. Pearson correlation analysis was used to analyze the relationship between clinical manifestations and experimental results. Results: Compared with the HCs, patients with DNR showed decreased mean VMHC values in the bilateral middle temporal gyrus, bilateral middle occipital gyrus (BMOG), and bilateral medial frontal gyrus. The receiver operating characteristic curve analysis of each brain region confirmed that the accuracy of the area under the curve was excellent. The results showed that the average VHMC value of BMOG signals was positively correlated with the urinary protein to creatinine ratio in female subjects (r = 0.626; P<.05). Nonetheless, no such correlation was noted among the male subjects. Conclusion: There were significant changes in brain function in DNR patients compared to the control group. Changes in the central nervous system in patients with DNR were mainly due to the dual negative effects of kidney function and diabetes mellitus. Abbreviations: ACR = albumin/creatinine ratio; BMFG = bilateral medial frontal gyrus; BMOG = bilateral middle occipital gyrus; BMTG = bilateral middle temporal gyrus; DN = diabetic nephropathy; DNR = diabetic nephropathy complicated by retinopathy; DR = diabetic retinopathy; fMRI = functional magnetic resonance imaging; HC = healthy control; MRI = magnetic resonance imaging; PCR = protein to creatinine ratio; ROC = receiver operating characteristic; VHMC = voxel-mirrored homologous connection.
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33
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Leitão L, Soares-Dos-Reis R, Neves JS, Baptista RB, Bigotte Vieira M, Mc Causland FR. Intensive Blood Pressure Treatment Reduced Stroke Risk in Patients With Albuminuria in the SPRINT Trial. Stroke 2019; 50:3639-3642. [PMID: 31637971 DOI: 10.1161/strokeaha.119.026316] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Albuminuria is associated with stroke risk among individuals with diabetes. However, the association of albuminuria with incident stroke among nondiabetic patients is less clear. Methods- We performed a post hoc analysis of the SPRINT (Systolic Blood Pressure Intervention Trial), which examined the effect of higher versus lower intensity blood pressure management on mortality in 8913 participants without diabetes. We fit unadjusted and adjusted Cox proportional hazards models to estimate the association of baseline albuminuria (urinary albumin-to-creatinine ratio ≥30 mg/g versus<30 mg/g) with stroke risk. We also assessed effect modification according to treatment arms. Results- Mean age was 68±9 years, 35% were female, and 30% were black. Median follow-up was 3.2 years, and 19% patients had baseline albuminuria. Incident stroke occurred in 129 individuals during follow-up. Albuminuria was associated with increased stroke risk (unadjusted hazard ratio, 2.24; 95% CI, 1.55-3.23; adjusted hazard ratio 1.73; 95% CI, 1.17-2.56). The association of albuminuria with incident stroke differed according to the randomized treatment arm (P interaction=0.03). In the intensive treatment arm, the association of albuminuria and stroke was nonsignificant (unadjusted hazard ratio, 1.25; 95% CI, 0.69-2.28), whereas, in the standard treatment arm, it was significant (unadjusted hazard ratio, 3.44; 95% CI, 2.11-5.61). Conclusions- In a post hoc analysis of SPRINT, baseline albuminuria (versus not) was associated with a higher risk of incident stroke, but this relationship appeared to be restricted to those in the standard treatment arm. Further studies are required to conclusively determine if reduction of albuminuria in itself is beneficial in reducing stroke risk. Clinical Trial Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT01206062.
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Affiliation(s)
- Lia Leitão
- From the Neurology Department, Centro Hospitalar Universitário Lisboa Central, Portugal (L.L.)
| | - Ricardo Soares-Dos-Reis
- Neurology Department (R.S.-d.-R.), Centro Hospitalar Universitário São João, Porto, Portugal.,Department of Clinical Neurosciences and Mental Health, Faculty of Medicine (R.S.-d.-R.), University of Porto, Portugal.,i3S (R.S.-d.-R.), University of Porto, Portugal
| | - João Sérgio Neves
- Department of Endocrinology, Diabetes and Metabolism (J.S.N.), Centro Hospitalar Universitário São João, Porto, Portugal.,Departamento de Cirurgia e Fisiologia, Unidade de Investigação Cardiovascular, Faculdade de Medicina, Universidade do Porto (J.S.N.)
| | - Rute Baeta Baptista
- Pediatrics Department, Hospital de Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, Portugal (R.B.B.).,Faculty of Medicine, University of Lisbon, Portugal (R.B.B.)
| | - Miguel Bigotte Vieira
- Nephrology Department, Hospital Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal (M.B.V.)
| | - Finnian R Mc Causland
- Renal Division, Department of Medicine, Brigham and Women's Hospital; and Harvard Medical School (F.R.M.C.)
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Abstract
The Systolic Blood Pressure Intervention Trial is the first large prospective randomized controlled trial to demonstrate the benefit of an intensive systolic blood pressure (SBP) treatment target (<120 mm Hg) compared to a standard target (<140 mm Hg) in reducing cardiovascular morbidity and mortality and all-cause mortality in high-risk hypertensive patients. The impact of SPRINT on hypertension treatment has been large, but major questions remain about the feasibility of achieving the SPRINT intensive SBP target in routine practice, the generalizability of the SPRINT findings to hypertensive populations that were excluded from the trial, and the cost effectiveness of adopting the SPRINT intensive treatment goal. In this review, we discuss the generalizability of SPRINT data to the general population of adults with hypertension and with various comorbidities, the cost effectiveness of intensive SBP-lowering therapy, and the implications of SPRINT for future hypertension guideline development and clinical practice.
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Affiliation(s)
- Lama Ghazi
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota 55455;
| | - Suzanne Oparil
- Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, Department of Medicine, School of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama 35294;
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Caruso P, Signori R, Moretti R. Small vessel disease to subcortical dementia: a dynamic model, which interfaces aging, cholinergic dysregulation and the neurovascular unit. Vasc Health Risk Manag 2019; 15:259-281. [PMID: 31496716 PMCID: PMC6689673 DOI: 10.2147/vhrm.s190470] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 01/14/2019] [Indexed: 12/14/2022] Open
Abstract
Background Small vessels have the pivotal role for the brain’s autoregulation. The arteriosclerosis-dependent alteration of the brain perfusion is one of the major determinants in small vessel disease. Endothelium distress can potentiate the flow dysregulation and lead to subcortical vascular dementia (sVAD). sVAD increases morbidity and disability. Epidemiological studies have shown that sVAD shares with cerebrovascular disease most of the common risk factors. The molecular basis of this pathology remains controversial. Purpose To detect the possible mechanisms between small vessel disease and sVAD, giving a broad vision on the topic, including pathological aspects, clinical and laboratory findings, metabolic process and cholinergic dysfunction. Methods We searched MEDLINE using different search terms (“vascular dementia”, “subcortical vascular dementia”, “small vessel disease”, “cholinergic afferents”, etc). Publications were selected from the past 20 years. Searches were extended to Embase, Cochrane Library, and LILIACS databases. All searches were done from January 1, 1998 up to January 31, 2018. Results A total of 560 studies showed up, and appropriate studies were included. Associations between traditional vascular risk factors have been isolated. We remarked that SVD and white matter abnormalities are seen frequently with aging and also that vascular and endothelium changes are related with age; the changes can be accelerated by different vascular risk factors. Vascular function changes can be heavily influenced by genetic and epigenetic factors. Conclusion Small vessel disease and the related dementia are two pathologies that deserve attention for their relevance and impact in clinical practice. Hypertension might be a historical problem for SVD and SVAD, but low pressure might be even more dangerous; CBF regional selective decrease seems to be a critical factor for small vessel disease-related dementia. In those patients, endothelium damage is a super-imposed condition. Several issues are still debatable, and more research is needed.
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Affiliation(s)
- Paola Caruso
- Department of Medical, Surgical and Health Sciences, Neurology Clinic, University of Trieste, Trieste, Italy
| | - Riccardo Signori
- Department of Medical, Surgical and Health Sciences, Neurology Clinic, University of Trieste, Trieste, Italy
| | - Rita Moretti
- Department of Medical, Surgical and Health Sciences, Neurology Clinic, University of Trieste, Trieste, Italy
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Drew DA, Weiner DE, Sarnak MJ. Cognitive Impairment in CKD: Pathophysiology, Management, and Prevention. Am J Kidney Dis 2019; 74:782-790. [PMID: 31378643 DOI: 10.1053/j.ajkd.2019.05.017] [Citation(s) in RCA: 158] [Impact Index Per Article: 31.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 05/07/2019] [Indexed: 12/27/2022]
Abstract
Patients with chronic kidney disease (CKD) are at substantially higher risk for developing cognitive impairment compared with the general population, and both lower glomerular filtration rate and the presence of albuminuria are associated with the development of cognitive impairment and poorer cognitive function. Given the excess of vascular disease seen in individuals with CKD, cerebrovascular disease is likely the predominant pathology underlying these associations, though impaired clearance of uremic metabolites, depression, sleep disturbance, anemia, and polypharmacy may also contribute. Modification of vascular disease risk factors may be helpful in limiting decline, though definite data are lacking. Specific to CKD, targeting a low blood pressure and reduction in albuminuria with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers may slow cognitive decline, albeit modestly. Initiation of dialysis can improve severe impairment associated with uremia but does not appear to affect more subtle chronic cognitive impairment. In contrast, kidney transplantation appears to lead to improved cognitive function in many transplant recipients, suggesting that dialysis methods do not provide the same cognitive benefits as having a functioning kidney. Management of patients with both CKD and cognitive impairment should include a comprehensive plan including more frequent follow-up visits; involvement of family in shared decision making; measures to improve compliance, such as written instruction and pill counts; and a focus on advance directives in conjunction with an emphasis on understanding an individual patient's life goals. Further research is needed on novel therapies, including innovative dialysis methods, that aim to limit the development of cognitive impairment, slow decline in those with prevalent impairment, and improve cognitive function.
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Affiliation(s)
- David A Drew
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA
| | - Daniel E Weiner
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA
| | - Mark J Sarnak
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA.
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37
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Moderately increased albuminuria, chronic kidney disease and incident dementia: the HUNT study. BMC Nephrol 2019; 20:261. [PMID: 31299931 PMCID: PMC6626412 DOI: 10.1186/s12882-019-1425-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 06/20/2019] [Indexed: 12/29/2022] Open
Abstract
Background Epidemiologic studies has shown an association of albuminuria and low estimated glomerular filtration rate (eGFR) with dementia, but the findings are inconsistent. This study examines the association between eGFR, MA with dementia and its subtypes: AD, VaD, a mixture of AD/VaD, and other dementias. Methods Data from the second wave of the HUNT 2 Study (1995–1997) were linked with a dementia register known as the Health and Memory Study (HMS) collected during 1995–2011 in Nord-Trøndelag County, Norway. Dementia was ascertained using World Health Organization’s ICD-10 criteria into subtypes: AD,VaD, mixed AD/VaD, and other dementia. eGFR and its association with dementia was examined in 48,508 participants of the HUNT Study, of which 668 were diagnosed with all-cause dementia. Association between MA and dementia were studied in a subset of 7024 participants, and 214 were diagnosed with all-cause dementia. Cox regression models were conducted analyzing the association between dementia and MA using albumin creatine ratio (ACR). Cox regression models and Fine-Gray models were used to examine the association between dementia and eGFR. Results A positive association was found between increasing ACR and dementia. ACR in the fourth quartile (> 1.78 mg/mmol) with increased hazard ratio of VaD, 3.97 (1.12 to 14.07), compared with ACR in the first quartile (<.53 mg/mmol). There was no association between eGFR and dementia or its subgroups. Conclusions Our results strengthens the hypothesis that vascular mechanisms may affect both kidney and brain as an association between MA and dementia was found. However, eGFR was not significantly associated with dementia independent of diabetes mellitus or hypertension. Electronic supplementary material The online version of this article (10.1186/s12882-019-1425-8) contains supplementary material, which is available to authorized users.
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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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Drew DA, Tighiouart H, Duncan S, Rollins J, Gupta A, Scott T, Weiner DE, Sarnak MJ. Blood Pressure and Cognitive Decline in Prevalent Hemodialysis Patients. Am J Nephrol 2019; 49:460-469. [PMID: 31048586 PMCID: PMC6631042 DOI: 10.1159/000500041] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 03/27/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Hypertension is associated with cognitive decline in the general population. It is unclear what impact blood pressure (BP) has on cognitive decline in patients receiving maintenance hemodialysis (HD). METHODS Using a longitudinal cohort of 314 prevalent HD patients without dementia at baseline, we examined the association of predialysis systolic BP (SBP) and diastolic BP (DBP), pulse pressure, and intradialytic SBP change (pre minus post), averaged for a month, with cognitive decline. Cognitive function was determined by a neurocognitive battery, administered yearly. Individual cognitive test results were reduced into 2 domain scores using principal components analysis (by definition mean of 0 and SD of 1), representing memory and executive function. Joint models, allowing for characterization of cognitive score slopes and including adjustment for potential confounders, were utilized to account for competing risks from death, dropout, or kidney transplantation. RESULTS Mean age was 62 years; 54% were men, 23% were black, and 90% had at least a high school education. During median follow-up of 2.1 years (25th-75th: 1.0-4.5), 191 had at least one follow-up test, 148 died, and 43 received kidney transplants. Low predialysis DBP and high pulse pressure were both associated with steeper executive function decline (each 10 mm Hg lower DBP = -0.03 SD [-0.01 to -0.05] per year steeper decline) in executive function (each 10 mm Hg higher pulse pressure = -0.03 SD [-0.06 to -0.01] steeper decline) but not for memory function. SBP and intradialytic change were not associated with steeper decline for either memory or executive function. CONCLUSIONS No relationship was seen between SBP or intradialytic change in BP with cognitive decline. In prevalent HD patients, lower predialysis DBP and wider predialysis pulse pressure are associated with steeper cognitive decline in executive function but not memory.
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Affiliation(s)
- David A Drew
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA,
| | - Hocine Tighiouart
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts, USA
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts, USA
| | - Sarah Duncan
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Jasmine Rollins
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Aditi Gupta
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Tammy Scott
- Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University, Boston, Massachusetts, USA
| | - Daniel E Weiner
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Mark J Sarnak
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
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Hannan M, Steffen A, Quinn L, Collins EG, Phillips SA, Bronas UG. The assessment of cognitive function in older adult patients with chronic kidney disease: an integrative review. J Nephrol 2019; 32:211-230. [PMID: 29802584 PMCID: PMC8174670 DOI: 10.1007/s40620-018-0494-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 05/07/2018] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Chronic kidney disease (CKD) is a common chronic condition in older adults that is associated with cognitive decline. However, the exact prevalence of cognitive impairment in older adults with CKD is unclear likely due to the variety of methods utilized to assess cognitive function. The purpose of this integrative review is to determine how cognitive function is most frequently assessed in older adult patients with CKD. METHODS Five electronic databases were searched to explore relevant literature related to cognitive function assessment in older adult patients with CKD. Inclusion and exclusion criteria were created to focus the search to the assessment of cognitive function with standardized cognitive tests in older adults with CKD, not on renal replacement therapy. RESULTS Through the search methods, 36 articles were found that fulfilled the purpose of the review. There were 36 different types of cognitive tests utilized in the included articles, with each study utilizing between one and 12 tests. The most commonly utilized cognitive test was the Mini Mental State Exam (MMSE), followed by tests of digit symbol substitution and verbal fluency. The most commonly assessed aspect of cognitive function was global cognition. DISCUSSION The assessment of cognitive function in older adults with CKD with standardized tests is completed in various ways. Unfortunately, the common methods of assessment of cognitive function may not be fully examining the domains of impairment commonly found in older adults with CKD. Further research is needed to identify the ideal cognitive test to best assess older adults with CKD for cognitive impairment.
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Affiliation(s)
- Mary Hannan
- Department of Biobehavioral Health Science, College of Nursing, University of Illinois at Chicago, Chicago, IL, USA.
| | - Alana Steffen
- Department of Health Systems Science, College of Nursing, University of Illinois at Chicago, Chicago, IL, USA
| | - Lauretta Quinn
- Department of Biobehavioral Health Science, College of Nursing, University of Illinois at Chicago, Chicago, IL, USA
| | - Eileen G Collins
- Department of Biobehavioral Health Science, College of Nursing, University of Illinois at Chicago, Chicago, IL, USA
| | - Shane A Phillips
- Department of Physical Therapy, College of Allied Health Science, University of Illinois at Chicago, Chicago, IL, USA
| | - Ulf G Bronas
- Department of Biobehavioral Health Science, College of Nursing, University of Illinois at Chicago, Chicago, IL, USA
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Bosch J, O'Donnell M, Swaminathan B, Lonn EM, Sharma M, Dagenais G, Diaz R, Khunti K, Lewis BS, Avezum A, Held C, Keltai M, Reid C, Toff WD, Dans A, Leiter LA, Sliwa K, Lee SF, Pogue JM, Hart R, Yusuf S. Effects of blood pressure and lipid lowering on cognition: Results from the HOPE-3 study. Neurology 2019; 92:e1435-e1446. [PMID: 30814321 PMCID: PMC6453765 DOI: 10.1212/wnl.0000000000007174] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 11/15/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To assess whether long-term treatment with candesartan/hydrochlorothiazide, rosuvastatin, or their combination can slow cognitive decline in older people at intermediate cardiovascular risk. METHODS The Heart Outcomes Prevention Evaluation-3 (HOPE-3) study was a double-blind, randomized, placebo-controlled clinical trial using a 2 × 2 factorial design. Participants without known cardiovascular disease or need for treatment were randomized to candesartan (16 mg) plus hydrochlorothiazide (12.5 mg) or placebo and to rosuvastatin (10 mg) or placebo. Participants who were ≥70 years of age completed the Digit Symbol Substitution Test (DSST), the modified Montreal Cognitive Assessment, and the Trail Making Test Part B at baseline and study end. RESULTS Cognitive assessments were completed by 2,361 participants from 228 centers in 21 countries. Compared with placebo, candesartan/hydrochlorothiazide reduced systolic blood pressure by 6.0 mm Hg, and rosuvastatin reduced low-density lipoprotein cholesterol by 24.8 mg/dL. Participants were followed up for 5.7 years (median), and 1,626 completed both baseline and study-end assessments. Mean participant age was 74 years (SD ±3.5 years); 59% were women; 45% had hypertension; and 24% had ≥12 years of education. The mean difference in change in DSST scores was -0.91 (95% confidence interval [CI] -2.25 to 0.42) for candesartan/hydrochlorothiazide compared with placebo, -0.54 (95% CI -1.88 to 0.80) for rosuvastatin compared with placebo, and -1.43 (95% CI -3.37 to 0.50) for combination therapy vs double placebo. No significant differences were found for other measures. CONCLUSIONS Long-term blood pressure lowering with candesartan plus hydrochlorothiazide, rosuvastatin, or their combination did not significantly affect cognitive decline in older people. CLINICALTRIALSGOV IDENTIFIER NCT00468923. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that for older people, candesartan plus hydrochlorothiazide, rosuvastatin, or their combination does not significantly affect cognitive decline.
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Affiliation(s)
- Jackie Bosch
- From the Population Health Research Institute (J.B., M. O., B.S., E.M.L., M.S., S.F.L., J.M.P., R.H., S.Y.) and Hamilton Health Sciences (J.B.), School of Rehabilitation Science, McMaster University, Ontario; Institut Universitaire de Cardiologie et Pneumologie de Québec (G.D.), Université Laval, Québec; Li Ka Shing Knowledge Institute (L.A.L.), St. Michael's Hospital, University of Toronto, Ontario, Canada; Research Board Clinical Research Facility (M.O.), Department of Medicine, NUI Galway, Ireland; Instituto Cardiovascular de Rosario (R.D.), Argentina; Diabetes Research Centre (K.K.), University of Leicester; Department of Cardiovascular Sciences and the National Institute for Health Research (W.D.T.), Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, University of Leicester, UK; College of Medicine (A.D.), University of the Philippines, Manila, Philippines; Lady Davis Carmel Medical Center (B.S.L.), Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa; Dante Pazzanese Institute of Cardiology (A.A.), São Paulo, Brazil; Department of Medical Sciences (C.H.), Cardiology, Uppsala Clinical Research Center, Uppsala University, Sweden; Semmelweis University (M.K.), Budapest, Hungary; Monash University (C.R.), Melbourne, Victoria; School of Public Health (C.M.R.), Curtin University, Perth, Australia; and Hatter Institute for Cardiovascular Research in Africa (K.S.), Department of Medicine, University of Cape Town, Soweto Cardiovascular Research Group, South Africa.
| | - Martin O'Donnell
- From the Population Health Research Institute (J.B., M. O., B.S., E.M.L., M.S., S.F.L., J.M.P., R.H., S.Y.) and Hamilton Health Sciences (J.B.), School of Rehabilitation Science, McMaster University, Ontario; Institut Universitaire de Cardiologie et Pneumologie de Québec (G.D.), Université Laval, Québec; Li Ka Shing Knowledge Institute (L.A.L.), St. Michael's Hospital, University of Toronto, Ontario, Canada; Research Board Clinical Research Facility (M.O.), Department of Medicine, NUI Galway, Ireland; Instituto Cardiovascular de Rosario (R.D.), Argentina; Diabetes Research Centre (K.K.), University of Leicester; Department of Cardiovascular Sciences and the National Institute for Health Research (W.D.T.), Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, University of Leicester, UK; College of Medicine (A.D.), University of the Philippines, Manila, Philippines; Lady Davis Carmel Medical Center (B.S.L.), Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa; Dante Pazzanese Institute of Cardiology (A.A.), São Paulo, Brazil; Department of Medical Sciences (C.H.), Cardiology, Uppsala Clinical Research Center, Uppsala University, Sweden; Semmelweis University (M.K.), Budapest, Hungary; Monash University (C.R.), Melbourne, Victoria; School of Public Health (C.M.R.), Curtin University, Perth, Australia; and Hatter Institute for Cardiovascular Research in Africa (K.S.), Department of Medicine, University of Cape Town, Soweto Cardiovascular Research Group, South Africa
| | - Balakumar Swaminathan
- From the Population Health Research Institute (J.B., M. O., B.S., E.M.L., M.S., S.F.L., J.M.P., R.H., S.Y.) and Hamilton Health Sciences (J.B.), School of Rehabilitation Science, McMaster University, Ontario; Institut Universitaire de Cardiologie et Pneumologie de Québec (G.D.), Université Laval, Québec; Li Ka Shing Knowledge Institute (L.A.L.), St. Michael's Hospital, University of Toronto, Ontario, Canada; Research Board Clinical Research Facility (M.O.), Department of Medicine, NUI Galway, Ireland; Instituto Cardiovascular de Rosario (R.D.), Argentina; Diabetes Research Centre (K.K.), University of Leicester; Department of Cardiovascular Sciences and the National Institute for Health Research (W.D.T.), Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, University of Leicester, UK; College of Medicine (A.D.), University of the Philippines, Manila, Philippines; Lady Davis Carmel Medical Center (B.S.L.), Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa; Dante Pazzanese Institute of Cardiology (A.A.), São Paulo, Brazil; Department of Medical Sciences (C.H.), Cardiology, Uppsala Clinical Research Center, Uppsala University, Sweden; Semmelweis University (M.K.), Budapest, Hungary; Monash University (C.R.), Melbourne, Victoria; School of Public Health (C.M.R.), Curtin University, Perth, Australia; and Hatter Institute for Cardiovascular Research in Africa (K.S.), Department of Medicine, University of Cape Town, Soweto Cardiovascular Research Group, South Africa
| | - Eva Marie Lonn
- From the Population Health Research Institute (J.B., M. O., B.S., E.M.L., M.S., S.F.L., J.M.P., R.H., S.Y.) and Hamilton Health Sciences (J.B.), School of Rehabilitation Science, McMaster University, Ontario; Institut Universitaire de Cardiologie et Pneumologie de Québec (G.D.), Université Laval, Québec; Li Ka Shing Knowledge Institute (L.A.L.), St. Michael's Hospital, University of Toronto, Ontario, Canada; Research Board Clinical Research Facility (M.O.), Department of Medicine, NUI Galway, Ireland; Instituto Cardiovascular de Rosario (R.D.), Argentina; Diabetes Research Centre (K.K.), University of Leicester; Department of Cardiovascular Sciences and the National Institute for Health Research (W.D.T.), Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, University of Leicester, UK; College of Medicine (A.D.), University of the Philippines, Manila, Philippines; Lady Davis Carmel Medical Center (B.S.L.), Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa; Dante Pazzanese Institute of Cardiology (A.A.), São Paulo, Brazil; Department of Medical Sciences (C.H.), Cardiology, Uppsala Clinical Research Center, Uppsala University, Sweden; Semmelweis University (M.K.), Budapest, Hungary; Monash University (C.R.), Melbourne, Victoria; School of Public Health (C.M.R.), Curtin University, Perth, Australia; and Hatter Institute for Cardiovascular Research in Africa (K.S.), Department of Medicine, University of Cape Town, Soweto Cardiovascular Research Group, South Africa
| | - Mikul Sharma
- From the Population Health Research Institute (J.B., M. O., B.S., E.M.L., M.S., S.F.L., J.M.P., R.H., S.Y.) and Hamilton Health Sciences (J.B.), School of Rehabilitation Science, McMaster University, Ontario; Institut Universitaire de Cardiologie et Pneumologie de Québec (G.D.), Université Laval, Québec; Li Ka Shing Knowledge Institute (L.A.L.), St. Michael's Hospital, University of Toronto, Ontario, Canada; Research Board Clinical Research Facility (M.O.), Department of Medicine, NUI Galway, Ireland; Instituto Cardiovascular de Rosario (R.D.), Argentina; Diabetes Research Centre (K.K.), University of Leicester; Department of Cardiovascular Sciences and the National Institute for Health Research (W.D.T.), Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, University of Leicester, UK; College of Medicine (A.D.), University of the Philippines, Manila, Philippines; Lady Davis Carmel Medical Center (B.S.L.), Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa; Dante Pazzanese Institute of Cardiology (A.A.), São Paulo, Brazil; Department of Medical Sciences (C.H.), Cardiology, Uppsala Clinical Research Center, Uppsala University, Sweden; Semmelweis University (M.K.), Budapest, Hungary; Monash University (C.R.), Melbourne, Victoria; School of Public Health (C.M.R.), Curtin University, Perth, Australia; and Hatter Institute for Cardiovascular Research in Africa (K.S.), Department of Medicine, University of Cape Town, Soweto Cardiovascular Research Group, South Africa
| | - Gilles Dagenais
- From the Population Health Research Institute (J.B., M. O., B.S., E.M.L., M.S., S.F.L., J.M.P., R.H., S.Y.) and Hamilton Health Sciences (J.B.), School of Rehabilitation Science, McMaster University, Ontario; Institut Universitaire de Cardiologie et Pneumologie de Québec (G.D.), Université Laval, Québec; Li Ka Shing Knowledge Institute (L.A.L.), St. Michael's Hospital, University of Toronto, Ontario, Canada; Research Board Clinical Research Facility (M.O.), Department of Medicine, NUI Galway, Ireland; Instituto Cardiovascular de Rosario (R.D.), Argentina; Diabetes Research Centre (K.K.), University of Leicester; Department of Cardiovascular Sciences and the National Institute for Health Research (W.D.T.), Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, University of Leicester, UK; College of Medicine (A.D.), University of the Philippines, Manila, Philippines; Lady Davis Carmel Medical Center (B.S.L.), Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa; Dante Pazzanese Institute of Cardiology (A.A.), São Paulo, Brazil; Department of Medical Sciences (C.H.), Cardiology, Uppsala Clinical Research Center, Uppsala University, Sweden; Semmelweis University (M.K.), Budapest, Hungary; Monash University (C.R.), Melbourne, Victoria; School of Public Health (C.M.R.), Curtin University, Perth, Australia; and Hatter Institute for Cardiovascular Research in Africa (K.S.), Department of Medicine, University of Cape Town, Soweto Cardiovascular Research Group, South Africa
| | - Rafael Diaz
- From the Population Health Research Institute (J.B., M. O., B.S., E.M.L., M.S., S.F.L., J.M.P., R.H., S.Y.) and Hamilton Health Sciences (J.B.), School of Rehabilitation Science, McMaster University, Ontario; Institut Universitaire de Cardiologie et Pneumologie de Québec (G.D.), Université Laval, Québec; Li Ka Shing Knowledge Institute (L.A.L.), St. Michael's Hospital, University of Toronto, Ontario, Canada; Research Board Clinical Research Facility (M.O.), Department of Medicine, NUI Galway, Ireland; Instituto Cardiovascular de Rosario (R.D.), Argentina; Diabetes Research Centre (K.K.), University of Leicester; Department of Cardiovascular Sciences and the National Institute for Health Research (W.D.T.), Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, University of Leicester, UK; College of Medicine (A.D.), University of the Philippines, Manila, Philippines; Lady Davis Carmel Medical Center (B.S.L.), Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa; Dante Pazzanese Institute of Cardiology (A.A.), São Paulo, Brazil; Department of Medical Sciences (C.H.), Cardiology, Uppsala Clinical Research Center, Uppsala University, Sweden; Semmelweis University (M.K.), Budapest, Hungary; Monash University (C.R.), Melbourne, Victoria; School of Public Health (C.M.R.), Curtin University, Perth, Australia; and Hatter Institute for Cardiovascular Research in Africa (K.S.), Department of Medicine, University of Cape Town, Soweto Cardiovascular Research Group, South Africa
| | - Kamlesh Khunti
- From the Population Health Research Institute (J.B., M. O., B.S., E.M.L., M.S., S.F.L., J.M.P., R.H., S.Y.) and Hamilton Health Sciences (J.B.), School of Rehabilitation Science, McMaster University, Ontario; Institut Universitaire de Cardiologie et Pneumologie de Québec (G.D.), Université Laval, Québec; Li Ka Shing Knowledge Institute (L.A.L.), St. Michael's Hospital, University of Toronto, Ontario, Canada; Research Board Clinical Research Facility (M.O.), Department of Medicine, NUI Galway, Ireland; Instituto Cardiovascular de Rosario (R.D.), Argentina; Diabetes Research Centre (K.K.), University of Leicester; Department of Cardiovascular Sciences and the National Institute for Health Research (W.D.T.), Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, University of Leicester, UK; College of Medicine (A.D.), University of the Philippines, Manila, Philippines; Lady Davis Carmel Medical Center (B.S.L.), Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa; Dante Pazzanese Institute of Cardiology (A.A.), São Paulo, Brazil; Department of Medical Sciences (C.H.), Cardiology, Uppsala Clinical Research Center, Uppsala University, Sweden; Semmelweis University (M.K.), Budapest, Hungary; Monash University (C.R.), Melbourne, Victoria; School of Public Health (C.M.R.), Curtin University, Perth, Australia; and Hatter Institute for Cardiovascular Research in Africa (K.S.), Department of Medicine, University of Cape Town, Soweto Cardiovascular Research Group, South Africa
| | - Basil S Lewis
- From the Population Health Research Institute (J.B., M. O., B.S., E.M.L., M.S., S.F.L., J.M.P., R.H., S.Y.) and Hamilton Health Sciences (J.B.), School of Rehabilitation Science, McMaster University, Ontario; Institut Universitaire de Cardiologie et Pneumologie de Québec (G.D.), Université Laval, Québec; Li Ka Shing Knowledge Institute (L.A.L.), St. Michael's Hospital, University of Toronto, Ontario, Canada; Research Board Clinical Research Facility (M.O.), Department of Medicine, NUI Galway, Ireland; Instituto Cardiovascular de Rosario (R.D.), Argentina; Diabetes Research Centre (K.K.), University of Leicester; Department of Cardiovascular Sciences and the National Institute for Health Research (W.D.T.), Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, University of Leicester, UK; College of Medicine (A.D.), University of the Philippines, Manila, Philippines; Lady Davis Carmel Medical Center (B.S.L.), Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa; Dante Pazzanese Institute of Cardiology (A.A.), São Paulo, Brazil; Department of Medical Sciences (C.H.), Cardiology, Uppsala Clinical Research Center, Uppsala University, Sweden; Semmelweis University (M.K.), Budapest, Hungary; Monash University (C.R.), Melbourne, Victoria; School of Public Health (C.M.R.), Curtin University, Perth, Australia; and Hatter Institute for Cardiovascular Research in Africa (K.S.), Department of Medicine, University of Cape Town, Soweto Cardiovascular Research Group, South Africa
| | - Alvaro Avezum
- From the Population Health Research Institute (J.B., M. O., B.S., E.M.L., M.S., S.F.L., J.M.P., R.H., S.Y.) and Hamilton Health Sciences (J.B.), School of Rehabilitation Science, McMaster University, Ontario; Institut Universitaire de Cardiologie et Pneumologie de Québec (G.D.), Université Laval, Québec; Li Ka Shing Knowledge Institute (L.A.L.), St. Michael's Hospital, University of Toronto, Ontario, Canada; Research Board Clinical Research Facility (M.O.), Department of Medicine, NUI Galway, Ireland; Instituto Cardiovascular de Rosario (R.D.), Argentina; Diabetes Research Centre (K.K.), University of Leicester; Department of Cardiovascular Sciences and the National Institute for Health Research (W.D.T.), Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, University of Leicester, UK; College of Medicine (A.D.), University of the Philippines, Manila, Philippines; Lady Davis Carmel Medical Center (B.S.L.), Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa; Dante Pazzanese Institute of Cardiology (A.A.), São Paulo, Brazil; Department of Medical Sciences (C.H.), Cardiology, Uppsala Clinical Research Center, Uppsala University, Sweden; Semmelweis University (M.K.), Budapest, Hungary; Monash University (C.R.), Melbourne, Victoria; School of Public Health (C.M.R.), Curtin University, Perth, Australia; and Hatter Institute for Cardiovascular Research in Africa (K.S.), Department of Medicine, University of Cape Town, Soweto Cardiovascular Research Group, South Africa
| | - Claes Held
- From the Population Health Research Institute (J.B., M. O., B.S., E.M.L., M.S., S.F.L., J.M.P., R.H., S.Y.) and Hamilton Health Sciences (J.B.), School of Rehabilitation Science, McMaster University, Ontario; Institut Universitaire de Cardiologie et Pneumologie de Québec (G.D.), Université Laval, Québec; Li Ka Shing Knowledge Institute (L.A.L.), St. Michael's Hospital, University of Toronto, Ontario, Canada; Research Board Clinical Research Facility (M.O.), Department of Medicine, NUI Galway, Ireland; Instituto Cardiovascular de Rosario (R.D.), Argentina; Diabetes Research Centre (K.K.), University of Leicester; Department of Cardiovascular Sciences and the National Institute for Health Research (W.D.T.), Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, University of Leicester, UK; College of Medicine (A.D.), University of the Philippines, Manila, Philippines; Lady Davis Carmel Medical Center (B.S.L.), Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa; Dante Pazzanese Institute of Cardiology (A.A.), São Paulo, Brazil; Department of Medical Sciences (C.H.), Cardiology, Uppsala Clinical Research Center, Uppsala University, Sweden; Semmelweis University (M.K.), Budapest, Hungary; Monash University (C.R.), Melbourne, Victoria; School of Public Health (C.M.R.), Curtin University, Perth, Australia; and Hatter Institute for Cardiovascular Research in Africa (K.S.), Department of Medicine, University of Cape Town, Soweto Cardiovascular Research Group, South Africa
| | - Matyas Keltai
- From the Population Health Research Institute (J.B., M. O., B.S., E.M.L., M.S., S.F.L., J.M.P., R.H., S.Y.) and Hamilton Health Sciences (J.B.), School of Rehabilitation Science, McMaster University, Ontario; Institut Universitaire de Cardiologie et Pneumologie de Québec (G.D.), Université Laval, Québec; Li Ka Shing Knowledge Institute (L.A.L.), St. Michael's Hospital, University of Toronto, Ontario, Canada; Research Board Clinical Research Facility (M.O.), Department of Medicine, NUI Galway, Ireland; Instituto Cardiovascular de Rosario (R.D.), Argentina; Diabetes Research Centre (K.K.), University of Leicester; Department of Cardiovascular Sciences and the National Institute for Health Research (W.D.T.), Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, University of Leicester, UK; College of Medicine (A.D.), University of the Philippines, Manila, Philippines; Lady Davis Carmel Medical Center (B.S.L.), Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa; Dante Pazzanese Institute of Cardiology (A.A.), São Paulo, Brazil; Department of Medical Sciences (C.H.), Cardiology, Uppsala Clinical Research Center, Uppsala University, Sweden; Semmelweis University (M.K.), Budapest, Hungary; Monash University (C.R.), Melbourne, Victoria; School of Public Health (C.M.R.), Curtin University, Perth, Australia; and Hatter Institute for Cardiovascular Research in Africa (K.S.), Department of Medicine, University of Cape Town, Soweto Cardiovascular Research Group, South Africa
| | - Christopher Reid
- From the Population Health Research Institute (J.B., M. O., B.S., E.M.L., M.S., S.F.L., J.M.P., R.H., S.Y.) and Hamilton Health Sciences (J.B.), School of Rehabilitation Science, McMaster University, Ontario; Institut Universitaire de Cardiologie et Pneumologie de Québec (G.D.), Université Laval, Québec; Li Ka Shing Knowledge Institute (L.A.L.), St. Michael's Hospital, University of Toronto, Ontario, Canada; Research Board Clinical Research Facility (M.O.), Department of Medicine, NUI Galway, Ireland; Instituto Cardiovascular de Rosario (R.D.), Argentina; Diabetes Research Centre (K.K.), University of Leicester; Department of Cardiovascular Sciences and the National Institute for Health Research (W.D.T.), Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, University of Leicester, UK; College of Medicine (A.D.), University of the Philippines, Manila, Philippines; Lady Davis Carmel Medical Center (B.S.L.), Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa; Dante Pazzanese Institute of Cardiology (A.A.), São Paulo, Brazil; Department of Medical Sciences (C.H.), Cardiology, Uppsala Clinical Research Center, Uppsala University, Sweden; Semmelweis University (M.K.), Budapest, Hungary; Monash University (C.R.), Melbourne, Victoria; School of Public Health (C.M.R.), Curtin University, Perth, Australia; and Hatter Institute for Cardiovascular Research in Africa (K.S.), Department of Medicine, University of Cape Town, Soweto Cardiovascular Research Group, South Africa
| | - William D Toff
- From the Population Health Research Institute (J.B., M. O., B.S., E.M.L., M.S., S.F.L., J.M.P., R.H., S.Y.) and Hamilton Health Sciences (J.B.), School of Rehabilitation Science, McMaster University, Ontario; Institut Universitaire de Cardiologie et Pneumologie de Québec (G.D.), Université Laval, Québec; Li Ka Shing Knowledge Institute (L.A.L.), St. Michael's Hospital, University of Toronto, Ontario, Canada; Research Board Clinical Research Facility (M.O.), Department of Medicine, NUI Galway, Ireland; Instituto Cardiovascular de Rosario (R.D.), Argentina; Diabetes Research Centre (K.K.), University of Leicester; Department of Cardiovascular Sciences and the National Institute for Health Research (W.D.T.), Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, University of Leicester, UK; College of Medicine (A.D.), University of the Philippines, Manila, Philippines; Lady Davis Carmel Medical Center (B.S.L.), Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa; Dante Pazzanese Institute of Cardiology (A.A.), São Paulo, Brazil; Department of Medical Sciences (C.H.), Cardiology, Uppsala Clinical Research Center, Uppsala University, Sweden; Semmelweis University (M.K.), Budapest, Hungary; Monash University (C.R.), Melbourne, Victoria; School of Public Health (C.M.R.), Curtin University, Perth, Australia; and Hatter Institute for Cardiovascular Research in Africa (K.S.), Department of Medicine, University of Cape Town, Soweto Cardiovascular Research Group, South Africa
| | - Antonio Dans
- From the Population Health Research Institute (J.B., M. O., B.S., E.M.L., M.S., S.F.L., J.M.P., R.H., S.Y.) and Hamilton Health Sciences (J.B.), School of Rehabilitation Science, McMaster University, Ontario; Institut Universitaire de Cardiologie et Pneumologie de Québec (G.D.), Université Laval, Québec; Li Ka Shing Knowledge Institute (L.A.L.), St. Michael's Hospital, University of Toronto, Ontario, Canada; Research Board Clinical Research Facility (M.O.), Department of Medicine, NUI Galway, Ireland; Instituto Cardiovascular de Rosario (R.D.), Argentina; Diabetes Research Centre (K.K.), University of Leicester; Department of Cardiovascular Sciences and the National Institute for Health Research (W.D.T.), Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, University of Leicester, UK; College of Medicine (A.D.), University of the Philippines, Manila, Philippines; Lady Davis Carmel Medical Center (B.S.L.), Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa; Dante Pazzanese Institute of Cardiology (A.A.), São Paulo, Brazil; Department of Medical Sciences (C.H.), Cardiology, Uppsala Clinical Research Center, Uppsala University, Sweden; Semmelweis University (M.K.), Budapest, Hungary; Monash University (C.R.), Melbourne, Victoria; School of Public Health (C.M.R.), Curtin University, Perth, Australia; and Hatter Institute for Cardiovascular Research in Africa (K.S.), Department of Medicine, University of Cape Town, Soweto Cardiovascular Research Group, South Africa
| | - Lawrence A Leiter
- From the Population Health Research Institute (J.B., M. O., B.S., E.M.L., M.S., S.F.L., J.M.P., R.H., S.Y.) and Hamilton Health Sciences (J.B.), School of Rehabilitation Science, McMaster University, Ontario; Institut Universitaire de Cardiologie et Pneumologie de Québec (G.D.), Université Laval, Québec; Li Ka Shing Knowledge Institute (L.A.L.), St. Michael's Hospital, University of Toronto, Ontario, Canada; Research Board Clinical Research Facility (M.O.), Department of Medicine, NUI Galway, Ireland; Instituto Cardiovascular de Rosario (R.D.), Argentina; Diabetes Research Centre (K.K.), University of Leicester; Department of Cardiovascular Sciences and the National Institute for Health Research (W.D.T.), Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, University of Leicester, UK; College of Medicine (A.D.), University of the Philippines, Manila, Philippines; Lady Davis Carmel Medical Center (B.S.L.), Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa; Dante Pazzanese Institute of Cardiology (A.A.), São Paulo, Brazil; Department of Medical Sciences (C.H.), Cardiology, Uppsala Clinical Research Center, Uppsala University, Sweden; Semmelweis University (M.K.), Budapest, Hungary; Monash University (C.R.), Melbourne, Victoria; School of Public Health (C.M.R.), Curtin University, Perth, Australia; and Hatter Institute for Cardiovascular Research in Africa (K.S.), Department of Medicine, University of Cape Town, Soweto Cardiovascular Research Group, South Africa
| | - Karen Sliwa
- From the Population Health Research Institute (J.B., M. O., B.S., E.M.L., M.S., S.F.L., J.M.P., R.H., S.Y.) and Hamilton Health Sciences (J.B.), School of Rehabilitation Science, McMaster University, Ontario; Institut Universitaire de Cardiologie et Pneumologie de Québec (G.D.), Université Laval, Québec; Li Ka Shing Knowledge Institute (L.A.L.), St. Michael's Hospital, University of Toronto, Ontario, Canada; Research Board Clinical Research Facility (M.O.), Department of Medicine, NUI Galway, Ireland; Instituto Cardiovascular de Rosario (R.D.), Argentina; Diabetes Research Centre (K.K.), University of Leicester; Department of Cardiovascular Sciences and the National Institute for Health Research (W.D.T.), Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, University of Leicester, UK; College of Medicine (A.D.), University of the Philippines, Manila, Philippines; Lady Davis Carmel Medical Center (B.S.L.), Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa; Dante Pazzanese Institute of Cardiology (A.A.), São Paulo, Brazil; Department of Medical Sciences (C.H.), Cardiology, Uppsala Clinical Research Center, Uppsala University, Sweden; Semmelweis University (M.K.), Budapest, Hungary; Monash University (C.R.), Melbourne, Victoria; School of Public Health (C.M.R.), Curtin University, Perth, Australia; and Hatter Institute for Cardiovascular Research in Africa (K.S.), Department of Medicine, University of Cape Town, Soweto Cardiovascular Research Group, South Africa
| | - Shun Fu Lee
- From the Population Health Research Institute (J.B., M. O., B.S., E.M.L., M.S., S.F.L., J.M.P., R.H., S.Y.) and Hamilton Health Sciences (J.B.), School of Rehabilitation Science, McMaster University, Ontario; Institut Universitaire de Cardiologie et Pneumologie de Québec (G.D.), Université Laval, Québec; Li Ka Shing Knowledge Institute (L.A.L.), St. Michael's Hospital, University of Toronto, Ontario, Canada; Research Board Clinical Research Facility (M.O.), Department of Medicine, NUI Galway, Ireland; Instituto Cardiovascular de Rosario (R.D.), Argentina; Diabetes Research Centre (K.K.), University of Leicester; Department of Cardiovascular Sciences and the National Institute for Health Research (W.D.T.), Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, University of Leicester, UK; College of Medicine (A.D.), University of the Philippines, Manila, Philippines; Lady Davis Carmel Medical Center (B.S.L.), Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa; Dante Pazzanese Institute of Cardiology (A.A.), São Paulo, Brazil; Department of Medical Sciences (C.H.), Cardiology, Uppsala Clinical Research Center, Uppsala University, Sweden; Semmelweis University (M.K.), Budapest, Hungary; Monash University (C.R.), Melbourne, Victoria; School of Public Health (C.M.R.), Curtin University, Perth, Australia; and Hatter Institute for Cardiovascular Research in Africa (K.S.), Department of Medicine, University of Cape Town, Soweto Cardiovascular Research Group, South Africa
| | - Janice M Pogue
- From the Population Health Research Institute (J.B., M. O., B.S., E.M.L., M.S., S.F.L., J.M.P., R.H., S.Y.) and Hamilton Health Sciences (J.B.), School of Rehabilitation Science, McMaster University, Ontario; Institut Universitaire de Cardiologie et Pneumologie de Québec (G.D.), Université Laval, Québec; Li Ka Shing Knowledge Institute (L.A.L.), St. Michael's Hospital, University of Toronto, Ontario, Canada; Research Board Clinical Research Facility (M.O.), Department of Medicine, NUI Galway, Ireland; Instituto Cardiovascular de Rosario (R.D.), Argentina; Diabetes Research Centre (K.K.), University of Leicester; Department of Cardiovascular Sciences and the National Institute for Health Research (W.D.T.), Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, University of Leicester, UK; College of Medicine (A.D.), University of the Philippines, Manila, Philippines; Lady Davis Carmel Medical Center (B.S.L.), Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa; Dante Pazzanese Institute of Cardiology (A.A.), São Paulo, Brazil; Department of Medical Sciences (C.H.), Cardiology, Uppsala Clinical Research Center, Uppsala University, Sweden; Semmelweis University (M.K.), Budapest, Hungary; Monash University (C.R.), Melbourne, Victoria; School of Public Health (C.M.R.), Curtin University, Perth, Australia; and Hatter Institute for Cardiovascular Research in Africa (K.S.), Department of Medicine, University of Cape Town, Soweto Cardiovascular Research Group, South Africa
| | - Robert Hart
- From the Population Health Research Institute (J.B., M. O., B.S., E.M.L., M.S., S.F.L., J.M.P., R.H., S.Y.) and Hamilton Health Sciences (J.B.), School of Rehabilitation Science, McMaster University, Ontario; Institut Universitaire de Cardiologie et Pneumologie de Québec (G.D.), Université Laval, Québec; Li Ka Shing Knowledge Institute (L.A.L.), St. Michael's Hospital, University of Toronto, Ontario, Canada; Research Board Clinical Research Facility (M.O.), Department of Medicine, NUI Galway, Ireland; Instituto Cardiovascular de Rosario (R.D.), Argentina; Diabetes Research Centre (K.K.), University of Leicester; Department of Cardiovascular Sciences and the National Institute for Health Research (W.D.T.), Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, University of Leicester, UK; College of Medicine (A.D.), University of the Philippines, Manila, Philippines; Lady Davis Carmel Medical Center (B.S.L.), Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa; Dante Pazzanese Institute of Cardiology (A.A.), São Paulo, Brazil; Department of Medical Sciences (C.H.), Cardiology, Uppsala Clinical Research Center, Uppsala University, Sweden; Semmelweis University (M.K.), Budapest, Hungary; Monash University (C.R.), Melbourne, Victoria; School of Public Health (C.M.R.), Curtin University, Perth, Australia; and Hatter Institute for Cardiovascular Research in Africa (K.S.), Department of Medicine, University of Cape Town, Soweto Cardiovascular Research Group, South Africa
| | - Salim Yusuf
- From the Population Health Research Institute (J.B., M. O., B.S., E.M.L., M.S., S.F.L., J.M.P., R.H., S.Y.) and Hamilton Health Sciences (J.B.), School of Rehabilitation Science, McMaster University, Ontario; Institut Universitaire de Cardiologie et Pneumologie de Québec (G.D.), Université Laval, Québec; Li Ka Shing Knowledge Institute (L.A.L.), St. Michael's Hospital, University of Toronto, Ontario, Canada; Research Board Clinical Research Facility (M.O.), Department of Medicine, NUI Galway, Ireland; Instituto Cardiovascular de Rosario (R.D.), Argentina; Diabetes Research Centre (K.K.), University of Leicester; Department of Cardiovascular Sciences and the National Institute for Health Research (W.D.T.), Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, University of Leicester, UK; College of Medicine (A.D.), University of the Philippines, Manila, Philippines; Lady Davis Carmel Medical Center (B.S.L.), Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa; Dante Pazzanese Institute of Cardiology (A.A.), São Paulo, Brazil; Department of Medical Sciences (C.H.), Cardiology, Uppsala Clinical Research Center, Uppsala University, Sweden; Semmelweis University (M.K.), Budapest, Hungary; Monash University (C.R.), Melbourne, Victoria; School of Public Health (C.M.R.), Curtin University, Perth, Australia; and Hatter Institute for Cardiovascular Research in Africa (K.S.), Department of Medicine, University of Cape Town, Soweto Cardiovascular Research Group, South Africa
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Kelly DM. The role of dialysis in the pathogenesis and treatment of dementia. Nephrol Dial Transplant 2018; 34:1080-1083. [DOI: 10.1093/ndt/gfy359] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Indexed: 11/12/2022] Open
Affiliation(s)
- Dearbhla M Kelly
- Center for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
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Del Pinto R, Ferri C. Hypertension Management at Older Age: An Update. High Blood Press Cardiovasc Prev 2018; 26:27-36. [PMID: 30467638 DOI: 10.1007/s40292-018-0290-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 11/19/2018] [Indexed: 12/16/2022] Open
Abstract
Hypertension is a risk factor for cardiovascular morbidity and mortality with increasing prevalence with age, whose treatment is associated with benefits over fatal and non-fatal cardiovascular events even later in life. However, there are persistent concerns on the short- and long-term weighted benefits of treating hypertension in the very old, particularly in those with specific clinical features. In fact, a broad range of clinical scenarios can be observed at older ages, spanning from the healthy to the frailest patient, and hypertension clinical trials have traditionally excluded the latter, thus preventing the unconditioned application to these patients of the same recommendations as in younger ages. Persistent issues regarding high blood pressure management in the very old adult are mainly related to treatment threshold and targets, which have been differently addressed by American and European guidelines. Herein, we will examine the challenges related to high blood pressure treatment in healthy and frail older and very old adults. We will discuss the evidence behind current recommendations. Finally, we will recapitulate the recommended treatment options for high blood pressure in these patients in the light of the most recent guidelines.
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Affiliation(s)
- Rita Del Pinto
- Department of Life, Health and Environmental Sciences, University of L'Aquila, San Salvatore Hospital, Delta 6 building, 67100, L'Aquila, Italy.
| | - Claudio Ferri
- Department of Life, Health and Environmental Sciences, University of L'Aquila, San Salvatore Hospital, Delta 6 building, 67100, L'Aquila, Italy
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Abstract
PURPOSE OF REVIEW To review the impact of the Systolic Blood Pressure Interventional Trial (SPRINT) on renal function and chronic kidney disease. RECENT FINDINGS Hypertension is a risk factor for cardiovascular and kidney outcomes in patients with chronic kidney disease (CKD). The benefits of intensive blood pressure lowering in the CKD population in previous studies are unclear. The SPRINT compared standard (< 140 mmHg) and intensive (< 120 mmHg) blood pressure management in nondiabetic patients with high risk of cardiovascular disease. In the subgroup of patients with CKD, the most important finding was that intensive blood pressure lowering is associated with lower risk of cardiovascular disease and mortality. Other than lower levels of albuminuria, there was no benefit on clinical kidney outcomes with the intensive treatment group. The risk of incident CKD and episodes of acute kidney injury was higher in patients in the intensive treatment group, though most patients with acute kidney injury recovered kidney function. While the benefit of intensive blood pressure lowering on cardiovascular events and mortality with intensive blood pressure lowering is clear in patients with CKD, longer term follow-up may be needed to fully understand the effect on kidney function.
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Affiliation(s)
- Racquel Wells
- Department of Medicine, University Hospitals Cleveland Medical Center, Louis Stokes Cleveland VA Medical Center, Case Western Reserve University, 11100 Euclid Ave., Cleveland, OH, 44106, USA
| | - Mahboob Rahman
- Department of Medicine, University Hospitals Cleveland Medical Center, Louis Stokes Cleveland VA Medical Center, Case Western Reserve University, 11100 Euclid Ave., Cleveland, OH, 44106, USA.
- Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, Louis Stokes Cleveland VA Medical Center, Case Western Reserve University, 11100 Euclid Ave., Cleveland, OH, 44106, USA.
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Influence of baseline systolic blood pressure on the relationship between intensive blood pressure control and cardiovascular outcomes in the Systolic Blood Pressure Intervention Trial (SPRINT). Clin Res Cardiol 2018; 108:273-281. [DOI: 10.1007/s00392-018-1353-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Accepted: 08/08/2018] [Indexed: 10/28/2022]
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The Impact of Uremic Toxins on Cerebrovascular and Cognitive Disorders. Toxins (Basel) 2018; 10:toxins10070303. [PMID: 30037144 PMCID: PMC6071092 DOI: 10.3390/toxins10070303] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 07/17/2018] [Accepted: 07/19/2018] [Indexed: 12/21/2022] Open
Abstract
Individuals at all stages of chronic kidney disease (CKD) have a higher risk of developing cognitive disorders and dementia. Stroke is also highly prevalent in this population and is associated with a higher risk of neurological deterioration, in-hospital mortality, and poor functional outcomes. Evidence from in vitro studies and in vivo animal experiments suggests that accumulation of uremic toxins may contribute to the pathogenesis of stroke and amplify vascular damage, leading to cognitive disorders and dementia. This review summarizes current evidence on the mechanisms by which uremic toxins may favour the occurrence of cerebrovascular diseases and neurological complications in CKD.
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MacEwen C, Watkinson P, Tarassenko L, Pugh C. Cerebral ischemia during hemodialysis-finding the signal in the noise. Semin Dial 2018; 31:199-203. [PMID: 29430730 DOI: 10.1111/sdi.12679] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Hemodialysis patients have multiple risk factors for small vessel cerebrovascular disease and cognitive dysfunction. Hemodialysis itself may cause clinically significant neurological injury through repetitive cerebral ischemia. However, supporting evidence to date consists of epidemiological associations, expert opinion, and small, single-centre studies of variable methodological quality. Isolating the impact of intra-dialytic hemodynamic instability from underlying renal and vascular disease on clinically relevant functional outcomes would require very large, controlled studies, given the heterogeneity and confounding comorbidities of the population, and the complex relationship between blood pressure and cerebral oxygen delivery. There has been an increase in complementary physiological studies looking directly at intra-dialytic cerebral oxygen balance, which have provided supporting evidence for the occurrence of cerebral ischemia, often independently of hemodynamics. Data suggesting a relationship between these measures of oxygen balance and functional outcomes is only hypothesis-generating at this stage. We advocate the testing of interventions that aim to reduce intra-dialytic cerebral hypoxia (rather than hypotension) in sufficiently powered studies, followed by correlation with validated, longitudinal assessment of clinically relevant neurological damage.
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Affiliation(s)
- Clare MacEwen
- Oxford Kidney Unit, Oxford University Hospitals NHS Trust, Oxford, UK.,Adult Intensive Care Unit, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Peter Watkinson
- Adult Intensive Care Unit, Oxford University Hospitals NHS Trust, Oxford, UK.,Kadoorie Centre for Critical Care Research and Education, Oxford University, Oxford, UK
| | - Lionel Tarassenko
- Institute of Biomedical Engineering, Department of Engineering Science, Oxford University, Oxford, UK
| | - Christopher Pugh
- Oxford Kidney Unit, Oxford University Hospitals NHS Trust, Oxford, UK.,Nuffield Department of Medicine, Oxford University, Oxford, UK
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Neu A, Yee J. Learning From Kids. Adv Chronic Kidney Dis 2017; 24:343-345. [PMID: 29229163 DOI: 10.1053/j.ackd.2017.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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