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Gupta A, Mahnken JD, Bernal J, Sharma P, Lepping RJ, Montgomery RN, Johnson DK, Parks A, Burns JM, Drew DA, Sarnak MJ, Brooks WM. Changes in Cognitive Function After Kidney Transplantation: A Longitudinal Cohort Study. Am J Kidney Dis 2024; 84:28-37.e1. [PMID: 38423160 DOI: 10.1053/j.ajkd.2023.12.022] [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: 05/31/2023] [Revised: 11/11/2023] [Accepted: 12/23/2023] [Indexed: 03/02/2024]
Abstract
RATIONALE & OBJECTIVE Kidney disease negatively affects cognition. We assessed the effect of kidney transplantation (KT) on different cognitive domains. STUDY DESIGN Prospective cohort study. SETTING & PARTICIPANTS We examined pre- versus post-KT cognition in patients waitlisted for KT at an academic center. PREDICTORS Transplant status. We measured cognitive function before KT (n=101), 3 months after KT (n=78), and 1 year after KT (n = 83). OUTCOMES Our primary outcome was change in cognitive function before versus after KT. We used standard neuropsychological tests to assess global cognition (Mini-Mental State Exam [MMSE]), episodic/declarative memory (Logical Memory), psychomotor speed/visuospatial function (Digit Symbol Substitution Test [DSST], Trail Making Test [TMT] A), working memory/attention (Digit Span), executive function (TMT B), and semantic memory/verbal fluency/language (Category Fluency). ANALYTICAL APPROACH Using linear mixed model analysis, we evaluated the changes in neuropsychological test scores adjusted for age, sex, race, education, and number of assessments. RESULTS Before KT, Logical Memory I and II, DSST, MMSE, Category Fluency (animal naming), and Digit Span backward scores were low compared with normative values from the National Alzheimer's Coordinating Center data. Logical Memory I and II scores improved after KT (pre- vs post-KT, estimated group difference [d]=3.3, P<0.001 for Logical Memory I; d=4.27, P<0.001 for Logical Memory II), such that post-KT scores were similar to normative values (post-KT vs normative values, d = -0.37, P=0.06 for Logical Memory I; d = -0.89, P=0.08 for Logical Memory II). Category Fluency (animal naming; d=2.4, P<0.001) and DSST (d=3.12, P=0.01) scores also improved with KT, but post-KT DSST scores remained lower than normative values (post-KT vs normative values, d = -5.17, P<0.001). MMSE, Digit Span, and TMT A and B scores did not change after KT. LIMITATIONS Single-center study. CONCLUSIONS Episodic and verbal declarative memory normalize after KT. Semantic memory, verbal fluency, language, psychomotor speed, and visuospatial function show partial improvement. Cognitive impairment in kidney disease is therefore at least partly reversible with KT. PLAIN-LANGUAGE SUMMARY Cognitive impairment in kidney disease affects self-esteem, vocational abilities, quality of life, health care costs, and mortality. It is not clear whether kidney transplantation (KT) improves cognition and whether the improvement is uniform across cognitive domains. The distinction between reversible and irreversible cognitive impairment has important implications in the clinical care of patients before and after KT. We assessed cognition before KT and 3 months and 12 months after KT and discovered that episodic and verbal declarative memory normalized with KT. Semantic memory, verbal fluency, language, psychomotor speed, and visuospatial function also improved with KT but did not reach normal levels. Cognitive impairment in kidney disease is therefore at least partly reversible.
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Affiliation(s)
- Aditi Gupta
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas; Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas; University of Kansas Alzheimer's Disease Center, University of Kansas Medical Center, Kansas City, Kansas; Frontiers Clinical and Translational Science Institute, University of Kansas Medical Center, Kansas City, Kansas.
| | - Jonathan D Mahnken
- University of Kansas Alzheimer's Disease Center, University of Kansas Medical Center, Kansas City, Kansas; Frontiers Clinical and Translational Science Institute, University of Kansas Medical Center, Kansas City, Kansas; Department of Biostatistics and Data Science, University of Kansas Medical Center, Kansas City, Kansas
| | - Joshua Bernal
- Department of Biostatistics and Data Science, University of Kansas Medical Center, Kansas City, Kansas
| | - Palash Sharma
- Department of Biostatistics and Data Science, University of Kansas Medical Center, Kansas City, Kansas
| | - Rebecca J Lepping
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas; University of Kansas Alzheimer's Disease Center, University of Kansas Medical Center, Kansas City, Kansas; Hoglund Biomedical Imaging Center, University of Kansas Medical Center, Kansas City, Kansas
| | - Robert N Montgomery
- Department of Biostatistics and Data Science, University of Kansas Medical Center, Kansas City, Kansas
| | - David K Johnson
- Department of Neurology, University of California, Davis, Davis, California
| | - Adam Parks
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas
| | - Jeffrey M Burns
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas; University of Kansas Alzheimer's Disease Center, University of Kansas Medical Center, Kansas City, Kansas
| | - David A Drew
- Division of Nephrology and Hypertension, Department of Internal Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Mark J Sarnak
- Division of Nephrology and Hypertension, Department of Internal Medicine, Tufts Medical Center, Boston, Massachusetts
| | - William M Brooks
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas; University of Kansas Alzheimer's Disease Center, University of Kansas Medical Center, Kansas City, Kansas; Frontiers Clinical and Translational Science Institute, University of Kansas Medical Center, Kansas City, Kansas; Hoglund Biomedical Imaging Center, University of Kansas Medical Center, Kansas City, Kansas
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Quint EE, Pol RA, Segev DL, McAdams-DeMarco MA. Age Is Just a Number for Older Kidney Transplant Patients. Transplantation 2024:00007890-990000000-00760. [PMID: 38771060 DOI: 10.1097/tp.0000000000005073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
The rise in the mean age of the global population has led to an increase in older kidney transplant (KT) patients. This demographic shift, coupled with the ongoing organ shortage, requires a nuanced understanding of which older adults are most suitable for KT. Recognizing the increased heterogeneity among older adults and the limitations of solely relying on chronological age, there is a need to explore alternative aging metrics beyond chronological age. In this review, we discuss the impact of older age on access to KT and postoperative outcomes. Emphasizing the need for a comprehensive evaluation that extends beyond chronological age, we explore alternative aging metrics such as frailty, sarcopenia, and cognitive function, underscoring their potential role in enhancing the KT evaluation process. Most importantly, we aim to contribute to the ongoing discourse, fostering an optimized approach to KT for the rapidly growing population of older adults.
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Affiliation(s)
- Evelien E Quint
- Division of Transplant Surgery, Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Robert A Pol
- Division of Transplant Surgery, Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Dorry L Segev
- Department of Surgery, NYU Grossman School of Medicine and NYU Langone Health, New York, NY
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Mara A McAdams-DeMarco
- Department of Surgery, NYU Grossman School of Medicine and NYU Langone Health, New York, NY
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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Farisco M, Blumblyte IA, Franssen C, Nitsch D, Zecchino I, Capasso G, Hafez G. Cognitive decline related to chronic kidney disease as an exclusion factor from kidney transplantation: results from an international survey. Clin Kidney J 2024; 17:sfae114. [PMID: 38745874 PMCID: PMC11092267 DOI: 10.1093/ckj/sfae114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Indexed: 05/16/2024] Open
Abstract
Background and hypothesis There seems to be a lack of consensus on the necessity and the modality of psychological and specifically cognitive assessment of candidates for kidney transplantation. Both points are often delegated to individual hospitals/centres, whereas international guidelines are inconsistent. We think it is essential to investigate professionals' opinions to advance towards a consistent clinical practice. Methods This paper presents the results of an international survey among clinical professionals, mainly nephrologists from the CONNECT (Cognitive decline in Nephro-Neurology: European Cooperative Target) network and beyond (i.e. from personal contacts of CONNECT members). The survey investigated their opinions about the question of whether cognitive decline in patients with chronic kidney disease may affect their eligibility for kidney transplantation. Results Our results show that most clinicians working with patients affected by chronic kidney disease think that cognitive decline may challenge their eligibility for transplantation despite data that suggest that, in some patients, cognitive problems improve after kidney transplantation. Conclusion We conclude that three needs emerge as particularly pressing: defining agreed-on standards for a multifaceted and multifactorial assessment (i.e. including both clinical/medical and psychosocial factors) of candidates with chronic kidney disease to kidney transplantation; further investigating empirically the causal connection between chronic kidney disease and cognition; and further investigating empirically the possible partial reversibility of cognitive decline after kidney transplantation.
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Affiliation(s)
- Michele Farisco
- Department of Public Health and Caring Sciences, Centre for Research Ethics and Bioethics, Uppsala University, Uppsala, Sweden
- Biogem Molecular Biology and Genetics Research Institute, Ariano Irpino (AV), Italy
| | - Inga A Blumblyte
- Department of Nephrology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Casper Franssen
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Dorothea Nitsch
- UK Renal Registry, UK Kidney Association, Bristol, UK
- Department of Non-communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
- Department of Nephrology, Royal Free London NHS Foundation Trust, London, UK
| | - Irene Zecchino
- Department of Science and Technology, University of Sannio, Benevento, Italy
| | - Giovambattista Capasso
- Department of Public Health and Caring Sciences, Centre for Research Ethics and Bioethics, Uppsala University, Uppsala, Sweden
- Department Translational Medical Science, University Campania Luigi Vanvitelli, Naples, Italy
| | - Gaye Hafez
- Department of Pharmacology, Faculty of Pharmacy, Altinbas University, Istanbul, Turkey
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Schietzel S, Kressig RW, Huynh-Do U. Screening of cognitive performance in kidney transplant recipients: a mini review. FRONTIERS IN NEPHROLOGY 2023; 3:1238501. [PMID: 37780580 PMCID: PMC10539592 DOI: 10.3389/fneph.2023.1238501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 08/21/2023] [Indexed: 10/03/2023]
Abstract
Why should we screen? The prevalence of cognitive impairment in kidney transplant recipients (KTRs) is up to 58%. The 10-year graft loss and mortality rates are above 30% and 50%, respectively, and executive malfunctioning increases disadvantageous outcomes. What causes cognitive impairment in KTRs? Strong risk factors are older age and chronic kidney disease. However, causes are multifactorial and include cardiovascular, cerebrovascular, neurodegenerative, inflammatory, uremic, psychiatric, and lifestyle-related susceptibilities. How should we screen? KTR-specific validated instruments or strategies do not exist. The central element should be a multidomain cognitive screening test that is sensitive to mild cognitive impairment, corrects for age and education, and includes executive functions testing. Cognitive trajectories, effects on everyday life and psychiatric comorbidities should be assessed by integrating the perspectives of both patients and knowledgeable informants. When should we screen? Screening should not be postponed if there is suspicion of impaired cognition. Different time points after transplantation tend to have their own characteristics. Who should conduct the screening? Screening should not be limited to specialists. It can be carried out by any healthcare professional who has received a limited amount of training. What are the benefits of screening? Screening does not provide a diagnosis. However, suggestive results change care in multiple ways. Goals are: Initiation of professional dementia work-up, securing of adherence, anticipation of potential complications (delirium, falls, frailty, functional impairment, malnutrition, etc.), mitigation of behavioral disorders, adjustment of diagnostic and therapeutic "load", reduction of caregiver burden and meeting of changing needs. We summarize data on the prevalence, risk factors and sequelae of cognitive impairment in KTRs. We also discuss the requirements for appropriate screening strategies and provide guiding principles regarding appropriate and safe care.
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Affiliation(s)
- Simeon Schietzel
- Division of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Reto W. Kressig
- University Department of Geriatric Medicine FELIX PLATTER, and University of Basel, Basel, Switzerland
| | - Uyen Huynh-Do
- Division of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Golenia A, Olejnik P, Żołek N, Wojtaszek E, Małyszko J. Cognitive Impairment and Anxiety Are Prevalent in Kidney Transplant Recipients. Kidney Blood Press Res 2023; 48:587-595. [PMID: 37619550 PMCID: PMC10614445 DOI: 10.1159/000533755] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 08/21/2023] [Indexed: 08/26/2023] Open
Abstract
INTRODUCTION Cognitive impairment (CI) is common in end-stage kidney disease (ESKD), including kidney transplant recipients. Patients with cognitive problems may find it difficult to comply with medical recommendations after kidney transplantation (KT), which can be the cause of many complications, poorer prognosis, and increased hospitalization rates after transplantation. Additionally, some patients after KT may experience depression and anxiety, which are prevalent comorbidities in patients with ESKD. METHODS In this single-center, cross-sectional study, we included 56 consecutive adult patients after KT. Cognitive function was assessed using the Addenbrooke Cognitive Test III (ACE III). In addition, all patients were screened for depression and anxiety using the Hospital Anxiety and Depression Scale (HADS). The impact of immunosuppressive therapy and other disease-related variables on cognitive function was also assessed. RESULTS A total of 56 KT patients, with a mean age of 50.3 ± 11.7 years, transplanted ≤35 months ago were included in the study. The prevalence of CI was 30%. Compared with cognitively unimpaired patients, patients with CI scored significantly lower in all cognitive domains. Furthermore, better cognitive functioning after KT was significantly associated with more years of schooling. We found no significant correlation between CI and age at assessment, duration of dialysis before KT, creatinine levels, creatinine clearance, uric acid levels, hemoglobin levels, comorbid cardiovascular diseases, and immunosuppressive therapy. In addition, the prevalence of depression and anxiety in screening tests was 12.5% and 27%, respectively, and patients receiving higher daily dose of prednisone had higher HADS scores on both the depression and anxiety subscales (not statistically significant). DISCUSSION Cognitive disorders are a relevant issue in kidney transplant recipients. There might be many factors, both before and after KT, that have a negative impact on cognition. Therefore, further research is needed to increase knowledge about the course and profile of cognitive function after KT.
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Affiliation(s)
| | | | - Norbert Żołek
- Institute of Fundamental Technological Research, Polish Academy of Sciences, Warsaw, Poland
| | - Ewa Wojtaszek
- Department of Nephrology, Dialysis and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Jolanta Małyszko
- Department of Nephrology, Dialysis and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
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Gupta A. Cognitive Function and Kidney Transplantation: Putting Current Data into Clinical Perspective. Kidney Med 2022; 4:100566. [PMID: 36438024 PMCID: PMC9681637 DOI: 10.1016/j.xkme.2022.100566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Aditi Gupta
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Kanas Medical Center, Kansas City, Kansas
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