Cognitive impairment, quality of life and healthcare utilization in patients with chronic kidney disease stages 3 to 5

Health-related Quality of Life in 10 years Long-term Survivors of Chronic Kidney Disease: A From-J Study

OBJECTIVE

The Chronic Kidney Disease (CKD) practice facilitation program in the Frontier of Renal Outcome Modifications in Japan study reduced cardiovascular disease (CVD) events in patients with CKD. 10-year long-term survivors with CKD lived with serious complications, including end-stage kidney disease and CVD. This study aimed to measure health-related quality of life in 10-year long-term CKD survivors and examine the predictors and determinants of clinical indices for measured quality of life (QOL) scores.

METHODS

The EQ-5D-5L, a generic preference-based instrument, was administered to 1,473 CKD survivors enrolled in the Frontier of Renal Outcome Modifications in JapanFrontier of Renal Outcome Modifications in JapanFrontier of Renal Outcome Modifications in Japan study. The 10th-year data collection was performed by either primary care physicians or participants who filled out questionnaires from October 2018 to March 31, 2019.

RESULTS

The response rate was 38.2% (423/1,473). The mean QOL score was 0.893 (95% confidence interval (CI), 0.880-0.906), and the median QOL score was 1.000 (interquartile range (IQR), 0.826-1.000). The mean QOL score in participants with renal replacement therapy was 0.824 (95% CI, 0.767-0.881), and the median was 0.828 (IQR, 0.755-1.000). The mean QOL score in participants with CVD was 0.877 (95% CI, 0.811-0.943), and the median was 1.000 (IQR, 0.723-1.000). The mean QOL score in participants with 50% decline in estimated glomerular filtration was 0.893 (95% CI, 0.860-0.926), and the median was 0.889 (IQR, 0.825-1.000). The decrease in QOL scores with baseline CKD stages was significant according to the Jonckheere-Terpstra test for trend (P = .002). Baseline age, systolic blood pressure, and history of hyperuricemia were significant predictors of 10th-year QOL scores.

CONCLUSION

We suggest that CKD complications negatively affect the QOL scores in 10-year long-term survivors with CKD. CKD guideline-based practices, prevention of end-stage kidney disease/CVD and management of hypertension, diabetes and hyperuricemia, might contribute to future health-related quality of life in patients with CKD.

Sweet, bloody consumption - what we eat and how it affects vascular ageing, the BBB and kidney health in CKD

In today's industrialized society food consumption has changed immensely toward heightened red meat intake and use of artificial sweeteners instead of grains and vegetables or sugar, respectively. These dietary changes affect public health in general through an increased incidence of metabolic diseases like diabetes and obesity, with a further elevated risk for cardiorenal complications. Research shows that high red meat intake and artificial sweeteners ingestion can alter the microbial composition and further intestinal wall barrier permeability allowing increased transmission of uremic toxins like p-cresyl sulfate, indoxyl sulfate, trimethylamine n-oxide and phenylacetylglutamine into the blood stream causing an array of pathophysiological effects especially as a strain on the kidneys, since they are responsible for clearing out the toxins. In this review, we address how the burden of the Western diet affects the gut microbiome in altering the microbial composition and increasing the gut permeability for uremic toxins and the detrimental effects thereof on early vascular aging, the kidney per se and the blood-brain barrier, in addition to the potential implications for dietary changes/interventions to preserve the health issues related to chronic diseases in future.

Chronic Kidney Disease Induces Cognitive Impairment in the Early Stage

OBJECTIVE

Previous research indicates a link between cognitive impairment and chronic kidney disease (CKD), but the underlying factors are not fully understood. This study aimed to investigate the progression of CKD-induced cognitive impairment and the involvement of cognition-related proteins by developing early- and late-stage CKD models in Sprague-Dawley rats.

METHODS

The Morris water maze test and the step-down passive avoidance task were performed to evaluate the cognitive abilities of the rats at 24 weeks after surgery. Histopathologic examinations were conducted to examine renal and hippocampal damage. Real-time PCR, Western blotting analysis, and immunohistochemical staining were carried out to determine the hippocampal expression of brain-derived neurotrophic factor (BDNF), choline acetyltransferase (ChAT), and synaptophysin (SYP).

RESULTS

Compared with the control rats, the rats with early-stage CKD exhibited mild renal damage, while those with late-stage CKD showed significantly increased serum creatinine levels as well as apparent renal and brain damage. The rats with early-stage CKD also demonstrated significantly impaired learning abilities and memory compared with the control rats, with further deterioration observed in the rats with late-stage CKD. Additionally, we observed a significant downregulation of cognition-related proteins in the hippocampus of rats with early-stage CKD, which was further exacerbated with declining renal function as well as worsening brain and renal damage in rats with late-stage CKD.

CONCLUSION

These results suggest the importance of early screening to identify CKD-induced cognitive dysfunction promptly. In addition, the downregulation of cognition-related proteins may play a role in the progression of cognitive dysfunction.

The Impact of Intradialytic Cognitive and Physical Training Program on the Physical and Cognitive Abilities in End-Stage Kidney Disease Patients: A Randomized Clinical Controlled Trial

BACKGROUND

Hemodialysis (HD) patients have lower cognitive functioning and reduced physical fitness than age-matched healthy individuals. Clinicians typically do not recognize the declining cognitive performance in these patients; therefore, cognitive impairment is greatly underestimated and not appropriately treated. This study aimed to evaluate the impact on cognitive function of combining cognitive training with physical exercise and physical performance in HD patients.

METHODS

Using a randomized, single-blinded control design, forty-four HD patients were recruited and randomly assigned to either an intradialytic physical exercise and cognitive training program (EXP group; n = 22; 54% male; 65.7 ± 9.7 years; 77.1 ± 21.9 kg; body mass index 26.8 ± 6.0) or a standard care control group (CON group; n = 21; 77% male; 67.2 ± 12.5 years; 74.2 ± 14.3 kg; body mass index 25.9 ± 3.8). The EXP group performed intradialytic cycling and cognitive training three days per week for 12 weeks. Study outcomes were assessed by the Symbol Digit Modalities Test (SDMT), Montreal Cognitive Assessment (MoCA), 10-repetition sit-to-stand test (10-STS), handgrip strength test (HGS), and stork balance test.

RESULTS

The results showed a significant time*group interaction effect for SDMT (p < 0.001; η2 = 0.267) and MoCA (p < 0.001; η2 = 0.266). Moreover, no significant interaction was observed for 10-STS, HGS, and stork balance test (p > 0.05).

CONCLUSIONS

Our findings suggest that incorporating intradialytic cognitive and physical exercise training could help to improve the functional status of HD patients. The innovative, nonpharmacological, bimodal intervention is cost-effective, safe, and easy to implement during the intradialytic period and offers a potential impact on patients' quality of life and well-being.

Association Between Weight Status and Rate of Cognitive Decline: China Health and Nutrition Survey 1997-2018

BACKGROUND

There is a close relationship between weight status and cognitive impairment in older adults. This study examined the association between weight status and the trajectory of cognitive decline over time in a population-based cohort of older adults in China.

METHODS

We used data from adults aged ≥55 years participating in the China health and nutrition survey (1997-2018). Underweight (body mass index [BMI] ≤ 18.5 kg/m2), normal weight (18.5-23 kg/m2), overweight (23-27.5 kg/m2), and obesity (BMI ≥ 27.5 kg/m2) were defined using the World Health Organization Asian cutpoints. Global cognition was estimated every 2-4 years through a face-to-face interview using a modified telephone interview for cognitive status (scores 0-27). The association between BMI and the rate of global cognitive decline, using a restricted cubic spline for age and age category, was examined with linear mixed-effects models accounting for correlation within communities and individuals.

RESULTS

We included 5 992 adults (53% female participants, mean age of 62 at baseline). We found differences in the adjusted rate of global cognitive decline by weight status (p = .01 in the cubic spline model). Models were adjusted for sex, marital status, current employment status, income, region, urbanization, education status, birth cohort, leisure activity, smoking status, and self-reported diagnosis of hypertension, diabetes, or Myocardial Infarction (MI)/stroke. In addition, significant declines by age in global cognitive function were found for all weight status categories except individuals with obesity.

CONCLUSIONS

In a cohort of adults in China, cognitive decline trajectory differed by weight status. A slower rate of change was observed in participants classified as having obesity.

Emotional and cognitive changes in chronic kidney disease

Chronic kidney disease (CKD) leads to cognitive impairment and emotional changes. However, the precise mechanism underlying the crosstalk between the kidneys and the nervous system is not fully understood. Inflammation and cerebrovascular disease can influence the development of depression in CKD. CKD is one of the strongest risk factors for cognitive impairment. Moreover, cognitive impairment occurs in CKD as patients experience the dysregulation of several brain functional domains due to damage caused to multiple cortical regions and to subcortical modulatory neurons. The differences in structural brain changes between CKD and non-CKD dementia may be attributable to the different mechanisms that occur in CKD. The kidney and brain have similar anatomical vascular systems, which may be susceptible to traditional risk factors. Vascular factors are assumed to be involved in the development of cognitive impairment in patients with CKD. Vascular injury induces white matter lesions, silent infarction, and microbleeds. Uremic toxins may also be directly related to cognitive impairment in CKD. Many uremic toxins, such as indoxyl sulfate, are likely to have an impact on the central nervous system. Further studies are required to identify therapeutic targets to prevent changes in the brain in patients with CKD.

Cognitive Impairment Early After Initiating Maintenance Hemodialysis: A Cross Sectional Study

Background

Abnormalities in cognitive function are almost universal in patients receiving hemodialysis (HD) and are associated with worse quality of life, impaired decision making, increased healthcare utilization and mortality. While cognitive impairment in the HD population is increasingly recognized, it is unclear how quickly it develops after starting HD.

Methods

This was a cross-sectional study of a cohort of low dialysis vintage HD patients (<12 months). We used the validated Cambridge Brain Science (CBS) battery of web-based tests to evaluate cognition compared to age- and sex matched controls across three cognitive domains: verbal processing, reasoning and short-term memory.

Results

Forty-nine HD patients were included in this study; 43 completed the full battery of tests. The average scores for HD patients were consistently below the age and sex-matched controls. Fifty-five percent of HD patients had cognitive impairment in verbal skills, 43% in reasoning and 18% in short-term memory.

Conclusions

There is a high prevalence of CI evident early after starting HD, with the largest deficits seen in reasoning and verbal processing. These deficits may be attributable to the HD treatment itself. Further studies are needed to characterize the natural history of CI in this patient population and to test interventions aimed at preventing or slowing its progression.

Admission kidney function is a strong predictor for the response to nutritional support in patients at nutritional risk

BACKGROUND

Patients with chronic kidney disease (CKD) are at substantial risk of malnutrition, which negatively affects clinical outcomes. We investigated the association of kidney function assessed at hospital admission and effectiveness of nutritional support in hospitalized medical patients at risk of malnutrition.

METHODS

This is a secondary analysis of an investigator-initiated, randomized-controlled, Swiss multicenter trial (EFFORT) that compared individualised nutritional support with usual hospital food on clinical outcomes. We compared effects of nutritional support on mortality in subgroups of patients stratified according to kidney function at the time of hospital admission (estimated glomerular filtration rates [eGFR] <15, 15-29, 30-59, 60-89 and ≥ 90 ml/min/1.73 m²).

RESULTS

We included 1943 of 2028 patients (96%) from the original trial with known admission creatinine levels. Admission eGFR was a strong predictor for the beneficial effects of nutritional support in regard to lowering of 30-day mortality. Patients with an eGFR <15, 15-29 and 30-59 had the strongest mortality benefit (odds ratios [95%CI] of 0.24 [0.05 to 1.25], 0.37 [0.14 to 0.95] and 0.39 [0.21 to 0.75], respectively), while patients with less severe impairment in kidney function had a less pronounced mortality benefits (p for interaction 0.001). A similar stepwise association of kidney function and response to nutritional support was found also for other secondary outcomes.

CONCLUSION

In medical inpatients at nutritional risk, admission kidney function was a strong predictor for the response to nutritional therapy. Initial kidney function may help to individualize nutritional support in the future by identification of patients with most clinical benefit.

CLINICAL TRIAL REGISTRATION

Registered under ClinicalTrials.gov Identifier no. NCT02517476.

Health-related quality of life in patients with chronic kidney disease

Introduction: In the last three decades, health systems have continued to pay increasing attention to the quality of life (QOL) due to definitional changes in the concept of health and disease. The health-related quality of life (HRQOL) in patients with chronic kidney disease (CKD) is significantly affected, regardless of the stage of CKD. Areas covered: We attempt to thoroughly explore how CKD affects HRQOL domains with a quick primer on HRQOL assessment instruments in patients with CKD. Also, we pointed out the factors affecting HRQOL in patients with CKD as well as the clinical application of HRQOL in CKD management. Expert opinion: The general population enjoys higher HRQOL than patients with CKD in all domains. Similarly, pre-dialysis and kidney-transplant patients have better HRQOL than dialysis population. There are many factors which negatively impact HRQOL in CKD which include for example depression, anxiety, and cognitive impairment for the social domain, inactivity, and frailty for the physical domain as well as lack of social support and extroversion in the social domain. Additionally, social disparities and CKD-related factors would influence HRQOL. Of note, there is no global standard HRQOL assessment tool. Finally, HRQOL should be included in future CKD management guidelines.