Pre-ESRD Dementia and Post-ESRD Mortality in a Large Cohort of Incident Dialysis Patients

Pretransplant Cognitive Function and Kidney Transplant Outcomes: A Prospective Cohort Study

Background & Hypothesis

Cognitive impairment is common in patients being evaluated for a kidney transplant (KT). The association between pretransplant cognitive function and posttransplant outcomes is unclear.

Study Design

We performed a prospective cohort study to assess the association between pretransplant cognitive function and clinically relevant posttransplant outcomes.

Setting and Population

In this single center study, participants from the transplant clinic were evaluated during their pretransplant clinic visits and followed prospectively.

Outcomes

Our primary outcome measure was allograft function. Secondary outcomes were length of hospitalization for KT, hospital readmission within 30 and 90 days, graft loss, graft rejection within 90 days and 1 year, and mortality.

Analytic Approach

We measured cognitive function with the Montreal Cognitive Assessment (MoCA) test. We assessed the association of pretransplant MoCA score with posttransplant outcomes; we used linear mixed effects models to assess the association with the change in estimated glomerular filtration rate, Poisson regression for length of hospitalization, Cox proportional hazard model for graft loss and mortality, and a logistic regression model for readmission and rejection.

Results

We followed 501 participants for 2.7 ± 1.5 years. The mean age of the patients was 53 ± 14 years and the mean pretransplant MoCA score was 25 ± 3. Lower pretransplant MoCA scores did not adversely affect the primary outcome of allograft function or the secondary outcomes. Although higher MoCA scores predicted a higher decline in graft function (β = -0.28, 95% CI: -0.55 to -0.01, P = 0.04), the effect was small and not clinically significant. Older age was associated with longer hospitalization, lower likelihood of rejection, and higher mortality. Deceased donor KT (vs living donor KT) was associated with longer hospitalization but better graft function. Longer time receiving dialysis before KT was associated with longer hospitalization. A history of diabetes mellitus was associated with higher mortality.

Limitations

Single center study limiting generalizability.

Conclusions

Pretransplant MoCA scores were not associated with the primary outcome of allograft function or the secondary outcomes.

Health-care use and cost for multimorbid persons with dementia in the National Health and Aging Trends Study

BACKGROUND

Most persons with dementia have multiple chronic conditions; however, it is unclear whether co-existing chronic conditions contribute to health-care use and cost.

METHODS

Persons with dementia and ≥2 chronic conditions using the National Health and Aging Trends Study and Medicare claims data, 2011 to 2014.

RESULTS

Chronic kidney disease and ischemic heart disease were significantly associated with increased adjusted risk ratios of annual hospitalizations, hospitalization costs, and direct medical costs. Depression, hypertension, and stroke or transient ischemic attack were associated with direct medical and societal costs, while atrial fibrillation was associated with increased hospital and direct medical costs. No chronic condition was associated with informal care costs.

CONCLUSIONS

Among older adults with dementia, proactive and ambulatory care that includes informal caregivers along with primary and specialty providers, may offer promise to decrease use and costs for chronic kidney disease, ischemic heart disease, atrial fibrillation, depression, and hypertension.

The effects of dialysis modality choice on cognitive functions in patients with end-stage renal failure: a systematic review and meta-analysis

INTRODUCTION

Cognitive dysfunction is a major consequence of end-stage renal disease (ESRD) and has further detrimental effects on both functionality and the quality of life for patients. While peritoneal dialysis is generally advocated in ESRD, there is a substantial knowledge gap about the differential effects of chronic dialysis modalities on cognitive dysfunction and decline. The aim of this meta-analysis is to evaluate cognitive function in peritoneal dialysis versus hemodialysis patients.

METHODS

We performed a systematic review in different databases to identify studies that assessed the effect of different dialysis modalities on cognitive functions. Inclusion criteria for our meta-analysis were all studies that compared the effects of peritoneal dialysis on cognitive functions compared to intermittent hemodialysis. The data collected were the name of the first author, journal title, year of publication, country where the study was conducted, number of patients in the peritoneal dialysis and hemodialysis arms and methods of assessment of cognitive functions.

RESULTS

Out of 2769 abstracts reviewed in different databases, 11 papers were included in our meta-analysis. Altogether, 195,774 patients were included in the final analysis. The forest plot analysis of the rate of cognitive impairment in different dialysis modalities showed decreased risk of cognitive impairment in the peritoneal dialysis population compared to hemodialysis patients (relative risk = 0.634, confidence interval ranges from 0.508 to 0.790). There was evidence of significant heterogeneity among studies with p < 0.0001 and I² = 85.5%. The sensitivity analysis limited to studies on patients younger than 65 years of age showed similar results (relative risk = 0.516; 95% confidence intervals: 0.379-0.704).

CONCLUSION

Patients on peritoneal dialysis demonstrated a lower odd of cognitive dysfunction compared to those on hemodialysis. Future prospective studies should assess cognitive decline as a meaningful outcome in dialysis patients.

The assessment of cognitive function in older adult patients with chronic kidney disease: an integrative review

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.

Predialysis coronary revascularization and postdialysis mortality

Objectives

Coronary artery bypass grafting (CABG) is associated with better survival than percutaneous coronary intervention (PCI) in patients with mild-to-moderate chronic kidney disease (CKD) and End-Stage Renal Disease (ESRD). However, the optimal strategy for coronary artery revascularization in advanced CKD patients who transition to ESRD is unclear.

Methods

We examined a contemporary national cohort of 971 US veterans with incident ESRD, who underwent first CABG or PCI up to 5 years prior to dialysis initiation. We examined the association of a history of CABG versus PCI with all-cause mortality following transition to dialysis, using Cox proportional hazards models adjusted for time between procedure and dialysis initiation, socio-demographics, comorbidities and medications.

Results

582 patients underwent CABG and 389 patients underwent PCI. The mean age was 66±8 years, 99% of patients were male, 79% were white, 19% were African Americans, and 84% were diabetics. The all-cause post-dialysis mortality rates after CABG and PCI were 229/1000 patient-years (PY) [95% CI: 205-256] and 311/1000PY [95% CI: 272-356], respectively. Compared to PCI, patients who underwent CABG had 34% lower risk of death [multivariable adjusted Hazard Ratio (95% CI) 0.66 (0.51-0.86), p=0.002] after initiation of dialysis. Results were similar in all subgroups of patients stratified by age, race, type of intervention, presence/absence of myocardial infarction, congestive heart failure and diabetes.

Conclusion

CABG in advanced CKD patients was associated lower risk of death after initiation of dialysis compared to PCI.