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Chan FHF, Sim P, Lim PXH, Khan BA, Choo JCJ, Griva K. Exploring the Cognitive Profiles of Haemodialysis Patients using Objective and Subjective Indicators: A Cross-sectional Observational Study. Int J Behav Med 2024:10.1007/s12529-024-10301-6. [PMID: 38918280 DOI: 10.1007/s12529-024-10301-6] [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] [Accepted: 05/20/2024] [Indexed: 06/27/2024]
Abstract
BACKGROUND Cognitive impairment is common in haemodialysis patients and associated with adverse health outcomes. Previous work focused primarily on neuropsychological tests, the gold standard measure of cognition. However, these tests reflect performance under optimal conditions rather than performance in everyday life. This study aims to assess both objective and subjective cognition in haemodialysis patients. METHODS Adult haemodialysis patients completed measures of objective cognitive impairment (Montreal Cognitive Assessment), subjective cognitive complaints, mood and fatigue symptoms, and provided sociodemographic information. Clinical data such as comorbidity were extracted from patients' medical record. RESULTS A total of 268 haemodialysis patients (mean age = 59.87 years; 42.5% female) participated. Only 25.0% of the sample had normal cognition, while the rest had either objective cognitive impairments or clinically significant cognitive complaints, or both (both objective impairments and subjective complaints: 26.1%; objective impairments without complaint: 38.4%; significant complaints without objective impairments: 10.4%). Lower education was associated with the presence of objective cognitive impairments, whereas depression was associated with the presence of clinically significant cognitive complaints. Patients who exhibited both objective cognitive impairments and significant cognitive complaints were more likely to have diabetes and higher dialysis dose (Kt/V). Patients with objective cognitive impairments but no significant complaints were significantly older. CONCLUSIONS The cognitive burden of haemodialysis patients can be manifested as objective impairments and/or subjective complaints. When combined the two indicators may better represent the overall cognitive well-being in this population. There is a need to screen for cognitive difficulties and develop cognitive rehabilitative strategies in dialysis settings.
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Affiliation(s)
- Frederick H F Chan
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Pearl Sim
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Phoebe X H Lim
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Behram A Khan
- Renal Health Services, Singapore, Singapore
- National University Health System, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Jason C J Choo
- National Kidney Foundation, Singapore, Singapore
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Konstadina Griva
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.
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Sánchez-Fernández MDM, Reyes Del Paso GA, Quirós-Ganga PL, Moreno-Salazar AS, Fernández-Serrano MJ. [Neuropsychological impairments in patients undergoing peritoneal dialysis treatment]. Med Clin (Barc) 2024; 162:147-156. [PMID: 38007389 DOI: 10.1016/j.medcli.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 09/09/2023] [Accepted: 09/14/2023] [Indexed: 11/27/2023]
Abstract
BACKGROUND Patients with chronic kidney disease on hemodialysis (HD) often have cognitive deficits. However, there are few studies that have examined the neuropsychological impairments of patients receiving peritoneal dialysis (PD). METHODS Executive functions, processing speed and verbal memory were assessed in 27 PD patients, 42 HD patients, and 42 healthy participants (HP). Systolic blood pressure and total time on renal replacement therapy (RRT) were controlled statistically. Associations between performance and clinical factors were analyzed using correlations and multiple regression. RESULTS The DP group showed better performance compared to the HD group in verbal fluency, working memory, cognitive flexibility, planning and decision making. The DP group showed worse execution than the HP group in verbal inhibition and memory. Executive function scores were positively associated with total months on PD, total months on RRT, total months on HD, albumin, total cholesterol, and phosphorus, and negatively with ferritin. CONCLUSION Global executive functioning was more optimal in PD patients than in HD patients. The results show the positive effect of PD on executive functions, which must be taken into account when choosing the TRS. The associations observed between biochemical factors and performance show the importance of maintaining an adequate nutritional status in these patients.
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Vinke JSJ, Ziengs AL, Buunk AM, van Sonderen L, Gomes-Neto AW, Berger SP, Bakker SJL, Eisenga MF, Spikman JM, De Borst MH. Iron deficiency and cognitive functioning in kidney transplant recipients: findings of the TransplantLines biobank and cohort study. Nephrol Dial Transplant 2023; 38:1719-1728. [PMID: 36662046 PMCID: PMC10310504 DOI: 10.1093/ndt/gfad013] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Neurocognitive impairment is common in kidney transplant recipients (KTRs). Adequate brain functioning requires energy and neurotransmitter activity, for which iron is essential. We aimed to investigate iron deficiency (ID) as a potentially modifiable risk factor for cognitive impairment in KTRs. METHODS We analyzed stable KTRs participating in the TransplantLines Biobank and Cohort study. Participants underwent neuropsychological tests for memory, mental speed, and attention and executive functioning. ID was defined as ferritin <100 µg/mL or 100-299 µg/mL with transferrin saturation (TSAT) ≤20%. Associations between iron status and norm scores of neurocognitive outcomes, corrected for age, sex and education, were assessed using multivariable linear regression analyses adjusted for potential confounders including hemoglobin. RESULTS We included 166 KTRs [median (IQR) age 57 (45-65) years, 59% male, estimated glomerular filtration rate 51±18 mL/min/1.73 m2]. Time since transplantation was 5.8 (1.0-12.0) years. Prevalence of ID was 65%. ID was independently associated with lower scores for mental speed (std.β = -0.19, P = .02) and attention and executive functioning (std.β = -0.19, P = .02), and tended to be associated with worse memory (std.β = -0.16, P = .07). Lower plasma ferritin levels were associated with worse memory (std.β = 0.23, P = .007), mental speed (std.β = 0.34, P < .001), and attention and executive functioning (std.β = 0.30, P = .001). Lower TSAT was associated with worse memory (std.β = 0.19, P = .04) and mental speed (std.β = 0.27, P = .003), and tended to be associated with worse attention and executive functioning (std.β = 0.16, P = .08). CONCLUSIONS Iron-deficient KTRs performed worse on neurocognitive tasks measuring memory, mental speed, and attention and executive functioning. These findings set the stage for prospective studies addressing whether ID correction restores cognitive function after kidney transplantation.
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Affiliation(s)
- Joanna Sophia J Vinke
- Department of Nephrology, University Medical Center Groningen, Groningen, The Netherlands
| | - Aaltje L Ziengs
- Department of Neuropsychology, University Medical Center Groningen, Groningen, The Netherlands
| | - Anne M Buunk
- Department of Neuropsychology, University Medical Center Groningen, Groningen, The Netherlands
| | - Lisanne van Sonderen
- Department of Neuropsychology, University Medical Center Groningen, Groningen, The Netherlands
| | - Antonio W Gomes-Neto
- Department of Nephrology, University Medical Center Groningen, Groningen, The Netherlands
| | - TransplantLines Investigators
- Groningen Transplant Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Stefan P Berger
- Department of Nephrology, University Medical Center Groningen, Groningen, The Netherlands
| | - Stephan J L Bakker
- Department of Nephrology, University Medical Center Groningen, Groningen, The Netherlands
| | - Michele F Eisenga
- Department of Nephrology, University Medical Center Groningen, Groningen, The Netherlands
| | - Jacoba M Spikman
- Department of Neuropsychology, University Medical Center Groningen, Groningen, The Netherlands
| | - Martin H De Borst
- Department of Nephrology, University Medical Center Groningen, Groningen, The Netherlands
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Olczyk P, Jerzak P, Letachowicz K, Gołębiowski T, Krajewska M, Kusztal M. The Influence of Healthy Habits on Cognitive Functions in a Group of Hemodialysis Patients. J Clin Med 2023; 12:jcm12052042. [PMID: 36902829 PMCID: PMC10004511 DOI: 10.3390/jcm12052042] [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: 02/01/2023] [Revised: 02/24/2023] [Accepted: 02/27/2023] [Indexed: 03/08/2023] Open
Abstract
(1) Background: Cognitive impairment (CI) is more prevalent in hemodialysis (HD) patients than in the general population. The purpose of this study was to examine if behavioral, clinical, and vascular variables are linked with CI in individuals with HD. (2) Methods: Initially, 47 individuals with chronic HD volunteered to participate in the trial, but only 27 patients ultimately completed the Montreal Cognitive Assessment (MoCA) and the Computerized Cognitive Assessment Tool (CompBased-CAT). We collected information on smoking, mental activities, physical activity (Rapid Assessment of Physical Activity, RAPA), and comorbidity. The oxygen saturation (rSO2) and pulse wave velocity (PWV; IEM Mobil-O-Graph) of the frontal lobes were measured. (3) Results: Significant associations were discovered between MoCA and rSO2 (r = 0.44, p = 0.02 and r = 0.62, p = 0.001, right/left, respectively), PWV (r = -0.69, p = 0.0001), CCI (r = 0.59, p = 0.001), and RAPA (r = 0.72, p = 0.0001). Those who actively occupied their time during dialysis and non-smokers achieved higher cognitive exam results. A multivariate regression study demonstrated that physical activity (RAPA) and PWV had separate effects on cognitive performance. (4) Conclusions: Cognitive skills are related to inter-dialysis healthy habits (physical activity, smoking) and intra-dialysis activities (tasks and mind games). Arterial stiffness, oxygenation of the frontal lobes, and CCI were linked with CI.
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Binari LA, Kiehl AL, Jackson JC, Feurer ID, Rega SA, Altuhaifi TM, Yankyera RP, Reed M, Sika M, Van J, Collar EM, Forbes RC, Concepcion BP. Neurocognitive Function Changes Following Kidney Transplant: A Prospective Study. Kidney Med 2022; 4:100560. [PMID: 36507052 PMCID: PMC9732409 DOI: 10.1016/j.xkme.2022.100560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Rationale & Objective Patients with advanced kidney disease are at risk for cognitive impairment, which may persist after kidney transplantation. We sought to understand changes in neurocognitive function domains utilizing comprehensive cognitive assessments. Study Design Prospective cohort study. Setting & Population Single-center study of patients undergoing kidney transplantation. Exposure Kidney transplantation. Outcomes Changes in neurocognitive function as measured by the Repeatable Battery for Assessment of Neuropsychological Status (RBANS) and the Trail Making Test Parts A and B (TRAIL A and B) before transplantation (baseline) and compared to 3 months and 12 months posttransplant. Analytical Approach Wilcoxon signed-rank and linear mixed effect models were utilized to assess changes in neurocognitive scores at 3 months and 12 months compared to baseline. Results Thirty-two patients were included with a mean age of 45 years, 47% female, 85% White, and 62% with at least some college education. Hypertension and diabetes were etiologies of kidney disease in 31% and 25% of patients, respectively. Baseline RBANS and TRAIL A and B scores averaged 84.7 ± 14, 40.4 ± 9.9, and 41 ± 11.5, respectively. Although there were posttransplant improvements in immediate and delayed memory at 3 months, these were not sustained at 12 months. There were no significant differences from baseline at 3 months and 12 months in RBANS index scores for language, visuospatial/constructional abilities, and attention. Compared to baseline, TRAIL A scores were not significantly different at 3 months but were significantly improved at 12 months, whereas TRAIL B scores improved significantly at both 3 months and 12 months. Limitations Single-center design and small sample size. Conclusions Utilizing comprehensive cognitive assessments, we found improvements in attention and executive function in the first posttransplant year as measured by TRAIL A and B. However, there was no significant change in global cognition as measured by RBANS. These findings identify cognitive domains for potential intervention in the posttransplant population.
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Affiliation(s)
- Laura A. Binari
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Amy L. Kiehl
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN
- Veteran’s Affairs Tennessee Valley Geriatric Research Education and Clinical Center (GRECC), Nashville, TN
| | - James C. Jackson
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN
- Veteran’s Affairs Tennessee Valley Geriatric Research Education and Clinical Center (GRECC), Nashville, TN
| | - Irene D. Feurer
- Department of Surgery, Department of Biostatistics, Vanderbilt Transplant Center, Vanderbilt University Medical Center, Nashville, TN
| | - Scott A. Rega
- Vanderbilt Transplant Center, Vanderbilt University Medical Center, Nashville, TN
| | - Tareq M. Altuhaifi
- Nephrology Clinical Trials Center, Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Rita P. Yankyera
- Nephrology Clinical Trials Center, Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Malia Reed
- Nephrology Clinical Trials Center, Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Mohammed Sika
- Nephrology Clinical Trials Center, Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Julie Van
- Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN
- Department of Psychology, Neuroscience Center, Brigham Young University, Provo, UT
| | - Erin M. Collar
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN
- Veteran’s Affairs Tennessee Valley Geriatric Research Education and Clinical Center (GRECC), Nashville, TN
| | - Rachel C. Forbes
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Beatrice P. Concepcion
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
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Abdelwahab MMA, Sabri Y, Elkalla IHR, Nassar MK, Abdel-Gawad SM, Gomaa ZAE. Cognitive impairment in different hemodialysis techniques. MIDDLE EAST CURRENT PSYCHIATRY 2022. [DOI: 10.1186/s43045-022-00258-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Abstract
Background
Cognitive impairment is one of the most common, often untreated, comorbidities affecting patients with chronic kidney disease treated with hemodialysis. Increased mortality, poor compliance, depression, and poor quality of life were all linked to cognitive impairment in the hemodialysis population. The intradialytic exercise proved to be beneficial in improving patients’ quality of life, among other positive effects. Cooling dialysate has various positive effects, including improved patients’ mood and decreased hypotensive episodes during hemodialysis. The study aims to assess the effect of intradialytic exercise and cool hemodialysis on cognitive function in patients on hemodialysis.
Results
The study showed no significant effect of both interventions on the patient’s cognitive functions. However, cooling dialysate showed an improvement in the severity of depressive symptoms by Beck’s Depression Inventory II (p = 0.02). On the other hand, Mini-International Neuropsychiatric Interview showed an increase of patients diagnosed with depression in the intradialytic exercise group.
Conclusions
Both interventions had no significant effect on the mean scores of the Montreal Cognitive Assessment, which are lower in our sample than in the general population (23.9–25). Potential implications include the importance of managing psychiatric comorbidities in patients on hemodialysis. Cooling dialysate can be adopted to alleviate depressive symptoms in patients on hemodialysis.
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Ziengs AL, Buunk AM, van Sonderen L, Eisenga MF, Gomes Neto AW, Annema C, Vlagsma T, Navis GJ, Berger SP, Bakker SJL, Spikman JM. Long-term cognitive impairments in kidney transplant recipients: impact on participation and quality of life. Nephrol Dial Transplant 2022; 38:491-498. [PMID: 35175356 PMCID: PMC9923696 DOI: 10.1093/ndt/gfac035] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Cognitive impairment is often present shortly after transplantation in kidney transplant recipients (KTR). To date, it is unknown whether these impairments persist in thelong term, to what extent they are associated with disease-related variables and whether they affect societal participation and quality of life (QoL) of KTR. METHOD This study was part of the TransplantLines Biobank & Cohort Study in the University Medical Center Groningen. A total of 131 KTR, with a mean age of 53.6 years (SD = 13.5) transplanted ≥1 year ago (M = 11.2 years, range 1-41.7 years), were included and compared with 306 healthy controls (HC). KTR and HC were well matched; there were no significant differences regarding age, sex and education. All participants were assessed with neuropsychological tests measuring memory, mental speed, attention and executive functioning, and with questionnaires examining societal participation and QoL. RESULTS Compared with HC, KTR performed significantly worse on memory, mental speed and measures of executive functioning (all P-values <0.05). Moreover, 16% of KTR met the criteria for mild cognitive impairment (MCI), compared with 2.6% of the HC. MCI in KTR was not significantly correlated with age- and disease-related variables. Poorer cognitive functioning was significantly related to lower levels of societal participation and to lower QoL (all P-values <0.01). CONCLUSIONS This study shows long-term cognitive impairments in KTR, which are not related to disease-related variables. Neuropsychological assessment is important to timely signal these impairments, given their serious negative impact on societal participation and QoL.
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Affiliation(s)
| | - Anne M Buunk
- Department of Neurology, Subdepartment of Neuropsychology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Lisanne van Sonderen
- Department of Neurology, Subdepartment of Neuropsychology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Michele F Eisenga
- Division of Nephrology, Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Antonio W Gomes Neto
- Division of Nephrology, Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Coby Annema
- Section of Nursing Science, Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Thialda Vlagsma
- Department of Neurology, Subdepartment of Neuropsychology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Gerjan J Navis
- Division of Nephrology, Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Stefan P Berger
- Division of Nephrology, Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Stephan J L Bakker
- Division of Nephrology, Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jacoba M Spikman
- Department of Neurology, Subdepartment of Neuropsychology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Changes in measures of cognitive function in patients with end-stage kidney disease on dialysis and the effect of dialysis vintage: A longitudinal cohort study. PLoS One 2021; 16:e0252237. [PMID: 34033657 PMCID: PMC8148363 DOI: 10.1371/journal.pone.0252237] [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: 01/03/2021] [Accepted: 05/11/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction Prevalence of cognitive impairment increases with worsening severity of chronic kidney disease (CKD) and majority of end-stage kidney disease (ESKD) patients on dialysis have cognitive impairment. Trends of cognitive function (CF) in this population are less well known with published studies reporting conflicting results. Methods We assessed CF in a cohort of non-dialysis CKD and ESKD patients undergoing dialysis using modified mini-mental state examination (3MS), trail-making test (TMT-A & B) scores and Stroop task, and evaluated demographics, comorbidities and depression using Beck depression inventory at baseline. We repeated tests of CF and depression ≥ 1-year after baseline in both groups and compared change scores in CF and depression between ESKD/ CKD sub-groups. Among ESKD patients we compared change scores between patients with dialysis vintage of <1-year and >1-year. Analysis of covariance was used to adjust for the effect of age on these change scores. Results At baseline (N = 211), compared to CKD (N = 108), ESKD (N = 103) patients had significantly worse CF based on 3MS and TMT-A & B scores, and depression scores. On follow-up (N = 160) 3MS scores, especially the memory subscale significantly improved in ESKD, but worsened in CKD, with no significant changes in TMT A /TMT-B, or depression scores after adjusting for age. Among ESKD patients, 3MS, especially memory subscale improved in patients with dialysis vintage <1-year compared to >1-year. The 51 patients who discontinued after baseline assessment had worse baseline CF scores suggesting differential attrition. Conclusion Though baseline cognitive scores were worse in ESKD patients on dialysis, compared to CKD, their 3MS, especially memory subscale improved on follow-up. Among ESKD patients, the improvement was significant only in patients who have been on dialysis for less than one-year which may indicate a beneficial effect of clearance of uraemic toxins. Differential attrition of study subjects may have impacted the observed results.
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Chu NM, Segev D, McAdams-DeMarco MA. Interventions to Preserve Cognitive Functioning Among Older Kidney Transplant Recipients. CURRENT TRANSPLANTATION REPORTS 2020; 7:346-354. [PMID: 33777649 PMCID: PMC7992368 DOI: 10.1007/s40472-020-00296-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2020] [Indexed: 12/30/2022]
Abstract
PURPOSE OF REVIEW To summarize the research on effective interventions for preserving cognitive function and prevent cognitive decline in patients with end-stage kidney disease (ESKD) who are undergoing dialysis and/or kidney transplantation (KT). RECENT FINDINGS Among ESKD patients undergoing hemodialysis, exercise training has been administered through home-based and intradialytic interventions. Additionally, one pilot study identified intradialytic cognitive training, electronic brain games, as an intervention to preserve cognitive function among patients undergoing hemodialysis. Fewer studies have investigated interventions to preserver cognitive function among KT recipients. To date, the only randomized controlled trial in this population identified B-vitamin supplements as an intervention to preserve cognitive function. The evidence from these trials support a short-term benefit of cognitive and exercise training as well as B-vitamin supplementation among patients with ESKD. Future studies should: 1) replicate these findings, 2) identify interventions specific to KT candidates, and 3) investigate the synergistic impact of both cognitive and exercise training. SUMMARY Cognitive prehabilitation, with cognitive and/or exercise training, may be novel interventions for KT candidates that not only reduces delirium risk and long-term post-KT cognitive decline but also prevents dementia.
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Affiliation(s)
- Nadia M. Chu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Dorry Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Mara A. McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Abstract
Purpose of the review Cognitive impairment is common in kidney transplant recipients and affects quality of life, graft survival, morbidity, and mortality. In this review article we discuss the epidemiology, diagnosis, pathophysiology and future directions for cognitive impairment in kidney transplantation. We describe the potential role of pre-transplant cognition, immunosuppression and peri-transplant factors in post -transplant cognitive impairment. Recent Findings A majority of patients with kidney transplant have cognitive impairment. Cognitive impairment affects both pre-transplant evaluation and post-transplant outcomes. Failure to identify patients with cognitive impairment can withhold appropriate care and timely intervention. Summary Cognitive impairment is common in kidney transplant and affects outcomes. Studies addressing modifiable risk factors and possible interventions to slow cognitive decline in patients with kidney disease are needed.
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Chu NM, Shi Z, Haugen CE, Norman SP, Gross AL, Brennan DC, Carlson MC, Segev DL, McAdams-DeMarco MA. Cognitive Function, Access to Kidney Transplantation, and Waitlist Mortality Among Kidney Transplant Candidates With or Without Diabetes. Am J Kidney Dis 2020; 76:72-81. [PMID: 32029264 PMCID: PMC7311233 DOI: 10.1053/j.ajkd.2019.10.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 10/31/2019] [Indexed: 12/21/2022]
Abstract
RATIONALE & OBJECTIVE Intact cognition is generally a prerequisite for navigating through and completing evaluation for kidney transplantation. Despite kidney transplantation being contraindicated for those with severe dementia, screening for more mild forms of cognitive impairment before referral is rare. Candidates may have unrecognized cognitive impairment, which may prolong evaluation, elevate mortality risk, and hinder access to kidney transplantation. We estimated the burden of cognitive impairment and its association with access to kidney transplantation and waitlist mortality. STUDY DESIGN Prospective cohort study. SETTING & PARTICIPANTS 3,630 participants (January 2009 to June 2018) with cognitive function measured (by the Modified Mini-Mental State Examination [3MS]) at kidney transplantation evaluation at 1 of 2 transplantation centers. PREDICTORS Cognitive impairment (3MS score<80). OUTCOMES Listing, waitlist mortality, and kidney transplantation. ANALYTICAL APPROACH We estimated the adjusted chance of listing (Cox regression), risk for waitlist mortality (competing-risks regression), and kidney transplantation rate (Poisson regression) by cognitive impairment. Given potential differences in cause of cognitive impairment among those with and without diabetes, we tested whether these associations differed by diabetes status using a Wald test. RESULTS At evaluation, 6.4% of participants had cognitive impairment, which was independently associated with 25% lower chance of listing (adjusted HR, 0.75; 95% CI, 0.61-0.91); this association did not differ by diabetes status (Pinteraction=0.07). There was a nominal difference by diabetes status for the association between cognitive impairment and kidney transplantation rate (Pinteraction=0.05), while the association between cognitive impairment and waitlist mortality differed by diabetes status kidney transplantation rates (Pinteraction=0.02). Among candidates without diabetes, those with cognitive impairment were at 2.47 (95% CI, 1.31-4.66) times greater risk for waitlist mortality; cognitive impairment was not associated with this outcome among candidates with diabetes. LIMITATIONS Single measure of cognitive impairment. CONCLUSIONS Cognitive impairment is associated with a lower chance of being placed on the waitlist, and among patients without diabetes, with increased mortality on the waitlist. Future studies should investigate whether implementation of screening for cognitive impairment improves these outcomes.
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Affiliation(s)
- Nadia M Chu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Zhan Shi
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Christine E Haugen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Silas P Norman
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI
| | - Alden L Gross
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Daniel C Brennan
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michelle C Carlson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Mara A McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
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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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Cognitive Improvement After Kidney Transplantation Is Associated With Structural and Functional Changes on MRI. Transplant Direct 2020; 6:e531. [PMID: 32195322 PMCID: PMC7056275 DOI: 10.1097/txd.0000000000000976] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 11/19/2019] [Accepted: 12/08/2019] [Indexed: 02/07/2023] Open
Abstract
Supplemental Digital Content is available in the text. Background. Several studies have reported improved cognitive outcomes after kidney transplantation, but most studies either did not include controls or lacked extensive neuroimaging. In addition, there is uncertainty whether kidney donation is a safe procedure in terms of cognitive outcomes. Methods. We prospectively studied neurocognitive function in kidney transplant recipients. The primary outcome was change in neurocognitive function after 1 year compared with baseline, which was evaluated using the Amsterdam Neuropsychological Task battery and verbal fluency tests. Secondary outcomes included changes in depression and anxiety (measured by the Hospital Anxiety and Depression scale) and changes in fatigue (measured by the Checklist for Individual Strength). We included kidney donors to control for learning effects, socioeconomic status, and surgery. In addition, kidney transplant recipients were evaluated with MRI scans at baseline and at year 1. The MRI protocol included conventional MRI, automated volumetric measurement, diffusion tensor imaging, magnetic resonance spectroscopy, arterial spin labeling, and a resting state functional MRI. Results. Twenty-seven recipients and 24 donors were included. For both recipients and donors, neuropsychologic testing scores improved 1 year after transplantation (donation). Recipient improvement significantly exceeded donor improvement on tasks measuring attention and working memory. These improvements were associated with increases in white matter volume and N-acetylaspartate/creatine (a marker for neuronal integrity). Conclusions. Attention and working memory improve significantly 1 year after kidney transplantation. Learning effects do not account for these improvements because recipient improvement in these areas exceeds donor improvement and correlates with an improvement in white matter integrity after transplantation. Kidney donation appears to be a safe procedure in terms of cognitive outcomes.
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Chu NM, McAdams-DeMarco MA. Exercise and cognitive function in patients with end-stage kidney disease. Semin Dial 2019; 32:283-290. [PMID: 30903625 PMCID: PMC6606387 DOI: 10.1111/sdi.12804] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
In this review we summarize the research pertaining to the role of exercise in preventing cognitive decline in patients with end-stage kidney disease (ESKD). Impairment in cognitive function, especially in executive function, is common in patients with ESKD, and may worsen with maintenance dialysis as a result of retention of uremic toxins, recurrent cerebral ischemia, and high burden of inactivity. Cognitive impairment may lead to long-term adverse consequences, including dementia and death. Home-based and intradialytic exercise training (ET) are among the nonpharmacologic interventions identified to preserve cognitive function in ESKD. Additionally, cognitive training (CT) is an effective approach recently identified in this population. While short-term benefits of ET and CT on cognitive function were consistently observed in patients undergoing dialysis, more studies are needed to replicate these findings in diverse populations including kidney transplant recipients with long-term follow-up to better understand the health and quality of life consequences of these promising interventions. ET as well as CT are feasible interventions that may preserve or even improve cognitive function for patients with ESKD. Whether these interventions translate to improvements in quality of life and long-term health outcomes, including dementia prevention and better survival, are yet to be determined.
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Affiliation(s)
- Nadia M. Chu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Mara A. McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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15
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Chu NM, Gross AL, Shaffer AA, Haugen CE, Norman SP, Xue QL, Sharrett AR, Carlson MC, Bandeen-Roche K, Segev DL, McAdams-DeMarco MA. Frailty and Changes in Cognitive Function after Kidney Transplantation. J Am Soc Nephrol 2019; 30:336-345. [PMID: 30679381 PMCID: PMC6362628 DOI: 10.1681/asn.2018070726] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Accepted: 11/14/2018] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Restoration of kidney function after kidney transplant generally improves cognitive function. It is unclear whether frail recipients, with higher susceptibility to surgical stressors, achieve such post-transplant cognitive improvements or whether they experience subsequent cognitive decline as they age with a functioning graft. METHODS In this two-center cohort study, we assessed pretransplant frailty (Fried physical frailty phenotype) and cognitive function (Modified Mini-Mental State Examination) in adult kidney transplant recipients. To investigate potential short- and medium-term effects of frailty on post-transplant cognitive trajectories, we measured cognitive function up to 4 years post-transplant. Using an adjusted mixed effects model with a random slope (time) and intercept (person), we characterized post-transplant cognitive trajectories by pretransplant frailty, accounting for nonlinear trajectories. RESULTS Of 665 recipients (mean age 52.0 years) followed for a median of 1.5 years, 15.0% were frail. After adjustment, pretransplant cognitive scores were significantly lower among frail patients compared with nonfrail patients (89.0 versus 90.8 points). By 3 months post-transplant, cognitive performance improved for both frail (slope =0.22 points per week) and nonfrail (slope =0.14 points per week) recipients. Between 1 and 4 years post-transplant, improvements plateaued among nonfrail recipients (slope =0.005 points per week), whereas cognitive function declined among frail recipients (slope =-0.04 points per week). At 4 years post-transplant, cognitive scores were 5.8 points lower for frail recipients compared with nonfrail recipients. CONCLUSIONS On average, both frail and nonfrail recipients experience short-term cognitive improvement post-transplant. However, frailty is associated with medium-term cognitive decline post-transplant. Interventions to prevent cognitive decline among frail recipients should be identified.
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Affiliation(s)
- Nadia M Chu
- Departments of Epidemiology,
- Department of Surgery and
| | | | | | | | - Silas P Norman
- Division of Nephrology, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Qian-Li Xue
- Departments of Epidemiology
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | | | | | - Karen Bandeen-Roche
- Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Dorry L Segev
- Departments of Epidemiology
- Department of Surgery and
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Findlay MD, Dawson J, Dickie DA, Forbes KP, McGlynn D, Quinn T, Mark PB. Investigating the Relationship between Cerebral Blood Flow and Cognitive Function in Hemodialysis Patients. J Am Soc Nephrol 2018; 30:147-158. [PMID: 30530658 DOI: 10.1681/asn.2018050462] [Citation(s) in RCA: 107] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 10/08/2018] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND The immediate and longer-term effects of hemodialysis on cerebral circulation, cerebral structure, and cognitive function are poorly understood. METHODS In a prospective observational cohort study of 97 adults (median age 59 years) receiving chronic hemodialysis, we used transcranial Doppler ultrasound to measure cerebral arterial mean flow velocity (MFV) throughout dialysis. Using a well validated neuropsychological protocol, we assessed cognitive function during and off dialysis and after 12 months of treatment. We also used brain magnetic resonance imaging (MRI) to assess atrophy, white matter hyperintensities (WMHs), and diffusion parameters, and tested correlations between MFV, cognitive scores, and changes on MRI. RESULTS MFV declined significantly during dialysis, correlating with ultrafiltrate volumes. Percentage of decline in MFV correlated with intradialytic decline in cognitive function, including global function, executive function, and verbal fluency. At follow-up, 73 patients were available for repeat testing, 34 of whom underwent repeat MRI. In a subgroup of patients followed for 12 months of continued dialysis, percentage of decline in MFV correlated significantly with lower global and executive function and with progression of WMH burden (a marker of small vessel disease). Twelve of 15 patients who received renal transplants during follow-up had both early and follow-up off-dialysis assessments. After transplant, patients' memory (on a delayed recall test) improved significantly; increased fractional anisotropy of white matter (a measure of cerebral diffusion) in these patients correlated with improving executive function. CONCLUSIONS Patients undergoing hemodialysis experience transient decline in cerebral blood flow, correlating with intradialytic cognitive dysfunction. Progressive cerebrovascular disease occurred in those continuing dialysis, but not in transplanted patients. Cognitive function and cerebral diffusion improved after transplant.
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Affiliation(s)
- Mark Duncan Findlay
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK; .,The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK; and
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | | | - Kirsten P Forbes
- Department of Neuroradiology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Deborah McGlynn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK; and
| | - Terry Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Patrick B Mark
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK; .,The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK; and
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Stoessel L, Schieber K, Jank S, Reber S, Grundmann F, Lueker C, Vitinius F, Paslakis G, Eckardt KU, Erim Y. Up to a Third of Renal Transplant Recipients Have Deficiencies in Cognitive Functioning. Prog Transplant 2017; 27:329-338. [PMID: 29187138 DOI: 10.1177/1526924817731883] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Kidney transplantation is beneficial in improving cognitive abilities in patients with chronic kidney disease; however, there is still uncertainty concerning which cognitive domains benefit and to what extent. AIM In the present study, cognitive functioning of renal transplant recipients was compared to normative data. Sociodemographic and clinical parameters that were associated with low cognitive performance were identified. DESIGN A total of 109 renal transplant recipients (63% men) participated in the study, with a mean age of 51.8 (standard deviation [SD] = 14.2) years. The cognitive test battery consisted of measurements assessing memory, attention, executive function, reproductive, and deductive ability. RESULTS In all tests, participants showed mean scores ranging within 1 SD of the population means. However, except for tests measuring memory, the percentage of participants scoring more than 1 SD below normed means was higher than expected in a normal distribution of performance. In certain tests, up to a third of the participants scored below average. Participants with continuous low performance (11%) showed higher age, poorer education, a longer time since transplantation, higher serum levels of urea and creatinine, and were more likely to have a deceased donor allograft. DISCUSSION Altough cognitive performance in renal transplant recipients matches normative data and confirms former findings, the amount of patients scoring more than 1 SD below average suggests that there are a considerable number of patients whose cognitive performance in certain domains lies below those of the general population. The identified sociodemographic and biochemical factors might be helpful to identify renal transplant recipients at risk.
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Affiliation(s)
- Lisa Stoessel
- 1 Department of Psychosomatic Medicine and Psychotherapy, University Hospital of Erlangen, Friedrich-Alexander-University of Erlangen-Nürnberg, Erlangen, Germany
| | - Katharina Schieber
- 1 Department of Psychosomatic Medicine and Psychotherapy, University Hospital of Erlangen, Friedrich-Alexander-University of Erlangen-Nürnberg, Erlangen, Germany
| | - Sabine Jank
- 2 Department of Nephrology and Hypertension, University Hospital of Erlangen, Friedrich-Alexander-University of Erlangen-Nürnberg, Erlangen, Germany
| | - Sandra Reber
- 1 Department of Psychosomatic Medicine and Psychotherapy, University Hospital of Erlangen, Friedrich-Alexander-University of Erlangen-Nürnberg, Erlangen, Germany
| | - Franziska Grundmann
- 3 Department II of Internal Medicine, Nephrology, Rheumatology, Diabetes and General Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Christine Lueker
- 4 Department of Psychosomatic Medicine and Psychotherapy, University Hospital of Cologne, Cologne, Germany
| | - Frank Vitinius
- 4 Department of Psychosomatic Medicine and Psychotherapy, University Hospital of Cologne, Cologne, Germany
| | - Georgios Paslakis
- 1 Department of Psychosomatic Medicine and Psychotherapy, University Hospital of Erlangen, Friedrich-Alexander-University of Erlangen-Nürnberg, Erlangen, Germany
| | - Kai-Uwe Eckardt
- 2 Department of Nephrology and Hypertension, University Hospital of Erlangen, Friedrich-Alexander-University of Erlangen-Nürnberg, Erlangen, Germany
| | - Yesim Erim
- 1 Department of Psychosomatic Medicine and Psychotherapy, University Hospital of Erlangen, Friedrich-Alexander-University of Erlangen-Nürnberg, Erlangen, Germany
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Mauthner O, Claes V, Walston J, Engberg S, Binet I, Dickenmann M, Golshayan D, Hadaya K, Huynh-Do U, Calciolari S, De Geest S. ExplorinG frailty and mild cognitive impairmEnt in kidney tRansplantation to predict biomedicAl, psychosocial and health cost outcomeS (GERAS): protocol of a nationwide prospective cohort study. J Adv Nurs 2016; 73:716-734. [DOI: 10.1111/jan.13179] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2016] [Indexed: 01/25/2023]
Affiliation(s)
- Oliver Mauthner
- Institute of Nursing Science; University of Basel; Switzerland
| | - Veerle Claes
- Institute of Nursing Science; University of Basel; Switzerland
| | - Jeremy Walston
- Center on Aging and Health; Johns Hopkins University; Baltimore Maryland USA
| | - Sandra Engberg
- Institute of Nursing Science; University of Basel; Switzerland
- School of Nursing; University of Pittsburgh; Pennsylvania USA
| | - Isabelle Binet
- Clinic of Nephrology and Transplantation Medicine; Cantonal Hospital St Gallen; Switzerland
| | - Michael Dickenmann
- Department for Transplantation-Immunology and Nephrology; University Hospital Basel; Switzerland
| | - Déla Golshayan
- Transplantation Centre and Transplantation Immunopathology Laboratory; University Hospital Lausanne; Switzerland
| | - Karine Hadaya
- Department of Nephrology; University Hospital Geneva; Switzerland
| | - Uyen Huynh-Do
- University Clinic for Nephrology, Hypertension and Clinical Pharmacology; University Hospital Bern; Switzerland
| | | | - Sabina De Geest
- Institute of Nursing Science; University of Basel; Switzerland
- Academic Center for Nursing and Midwifery; KU Leuven; Belgium
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Sherman RA. Briefly Noted. Semin Dial 2016. [DOI: 10.1111/sdi.12514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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