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Kennard A, Richardson A, Rainsford S, Hamilton K, Glasgow N, Pumpa K, Douglas A, Talaulikar GS. Longitudinal frailty assessment in the prediction of survival among patients with advanced chronic kidney disease: a prospective observational single-centre cohort study. BMJ Open 2024; 14:e087189. [PMID: 39389597 PMCID: PMC11474908 DOI: 10.1136/bmjopen-2024-087189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 08/30/2024] [Indexed: 10/12/2024] Open
Abstract
OBJECTIVES This study aims to describe the prevalence, characteristics and longitudinal changes in frailty among outpatient chronic kidney disease (CKD) and haemodialysis (HD) populations and their impact on survival. DESIGN Prospective observational cohort study. SETTING Single-centre ambulatory tertiary care setting, metropolitan Australian teaching hospital. PARTICIPANTS Adult patients with advanced CKD (defined as estimated glomerular filtration rate <20 mL/min) or undergoing maintenance HD. Consent model was informed opt-out consent. INTERVENTIONS Fried frailty assessment at baseline, 6 months and 12 months of longitudinal follow-up. PRIMARY OUTCOMES All-cause mortality and kidney transplantation events. RESULTS Frailty was identified in 36.3% of the 256 participants, while an additional 46.5% exhibited prefrailty. Frailty was equally common among CKD and HD cohorts. Frailty outperformed age, comorbidity and laboratory parameters in predicting mortality risk with HR 2.83 (95% CI 1.44 to 5.56, p<0.001). Frailty also substantially reduced access to transplantation. While most participants exhibited static Fried phenotype over longitudinal assessment, improvements in frailty were observed as frequently as frailty progression. Female gender and symptom burden predicted frailty progression. CONCLUSIONS Frailty is highly prevalent and closely aligned with survival outcomes. Frailty among patients attending routine outpatient care may demonstrate responsiveness to intervention with subsequent improvements in mortality and other patient-level outcomes.
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Affiliation(s)
- Alice Kennard
- College of Health and Medicine, Australian National University, Canberra, Australian Capital Territory, Australia
- Department of Renal Medicine, Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | | | - Suzanne Rainsford
- College of Health and Medicine, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Kelly Hamilton
- Department of Renal Medicine, Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Nicholas Glasgow
- College of Health and Medicine, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Kate Pumpa
- University College Dublin, Dublin, Ireland
- University of Canberra, Canberra, Canberra, Australia
| | | | - Girish Scricant Talaulikar
- College of Health and Medicine, Australian National University, Canberra, Australian Capital Territory, Australia
- Department of Renal Medicine, Canberra Hospital, Canberra, Australian Capital Territory, Australia
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Kennard AL, Glasgow NJ, Rainsford SE, Talaulikar GS. Narrative Review: Clinical Implications and Assessment of Frailty in Patients With Advanced CKD. Kidney Int Rep 2024; 9:791-806. [PMID: 38765572 PMCID: PMC11101734 DOI: 10.1016/j.ekir.2023.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 12/12/2023] [Accepted: 12/21/2023] [Indexed: 05/22/2024] Open
Abstract
Frailty is a multidimensional clinical syndrome characterized by low physical activity, reduced strength, accumulation of multiorgan deficits, decreased physiological reserve, and vulnerability to stressors. Frailty has key social, psychological, and cognitive implications. Frailty is accelerated by uremia, leading to a high prevalence of frailty in patients with advanced chronic kidney disease (CKD) and end-stage kidney disease (ESKD) as well as contributing to adverse outcomes in this patient population. Frailty assessment is not routine in patients with CKD; however, a number of validated clinical assessment tools can assist in prognostication. Frailty assessment in nephrology populations supports shared decision-making and advanced communication and should inform key medical transitions. Frailty screening and interventions in CKD or ESKD are a developing research priority with a rapidly expanding literature base.
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Affiliation(s)
- Alice L. Kennard
- Department of Renal Medicine, Canberra Health Services, Australian Capital Territory, Australia
- Australian National University, Canberra, Australian Capital Territory, Australia
| | - Nicholas J. Glasgow
- Australian National University, Canberra, Australian Capital Territory, Australia
| | - Suzanne E. Rainsford
- Australian National University, Canberra, Australian Capital Territory, Australia
| | - Girish S. Talaulikar
- Department of Renal Medicine, Canberra Health Services, Australian Capital Territory, Australia
- Australian National University, Canberra, Australian Capital Territory, Australia
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Komori T, Hoshide S, Turana Y, Sogunuru GP, Kario K. Cognitive impairment in heart failure patients: association with abnormal circadian blood pressure rhythm: a review from the HOPE Asia Network. Hypertens Res 2024; 47:261-270. [PMID: 37749335 DOI: 10.1038/s41440-023-01423-7] [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: 04/13/2023] [Revised: 08/07/2023] [Accepted: 08/10/2023] [Indexed: 09/27/2023]
Abstract
Cognitive impairment (CI) is frequently a comorbid condition in heart failure (HF) patients, and is associated with increased cardiovascular events and death. Numerous factors contribute to CI in HF patients. Decreased cerebral blood flow, inflammation, and activation of neurohumoral factors are all thought to be factors that exacerbate CI. Hypoperfusion of the brain due to decreased systemic blood flow, cerebral venous congestion, and atherosclerosis are the main mechanism of CI in HF patients. Abnormal circadian BP rhythm is one of the other conditions associated with CI. The conditions in which BP does not decrease sufficiently or increases during the night are called non-dipper or riser BP patterns. Abnormal circadian BP rhythm worsens CI in HF patients through cerebral congestion during sleep and atherosclerosis due to pressure overload. Interventions for CI in HF patients include treatment for HF itself using cardiovascular drugs, and treatment for fluid retention, one of the causes of abnormal circadian rhythms. Proposed pathways of cognitive impairment in heart failure through abnormal circadian blood pressure rhythm.
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Affiliation(s)
- Takahiro Komori
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Satoshi Hoshide
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Yuda Turana
- Department of Neurology, School of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia
| | - Guru Prasad Sogunuru
- Fortis Hospitals, Chennai, Tamil Nadu, India
- College of Medical Sciences, Kathmandu University, Bharatpur, Nepal
| | - Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan.
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Babroudi S, Tighiouart H, Schrauben SJ, Cohen JB, Fischer MJ, Rahman M, Hsu CY, Sozio SM, Weir M, Sarnak M, Yaffe K, Tamura MK, Drew D. Blood Pressure, Incident Cognitive Impairment, and Severity of CKD: Findings From the Chronic Renal Insufficiency Cohort (CRIC) Study. Am J Kidney Dis 2023; 82:443-453.e1. [PMID: 37245689 PMCID: PMC10526961 DOI: 10.1053/j.ajkd.2023.03.012] [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: 09/07/2022] [Accepted: 03/05/2023] [Indexed: 05/30/2023]
Abstract
RATIONALE & OBJECTIVE Hypertension is a known risk factor for dementia and cognitive impairment. There are limited data on the relation of systolic blood pressure (SBP) and diastolic blood pressure (DBP) with incident cognitive impairment in adults with chronic kidney disease. We sought to identify and characterize the relationship among blood pressure, cognitive impairment, and severity of decreased kidney function in adults with chronic kidney disease. STUDY DESIGN Longitudinal cohort study. SETTING & PARTICIPANTS 3,768 participants in the Chronic Renal Insufficiency Cohort (CRIC) Study. EXPOSURE Baseline SBP and DBP were examined as exposure variables, using continuous (linear, per 10-mm Hg higher), categorical (SBP<120 [reference], 120 to 140,>140mm Hg; DBP<70 (reference), 70 to 80, > 80mm Hg) and nonlinear terms (splines). OUTCOME Incident cognitive impairment defined as a decline in Modified Mini-Mental State Examination (3MS) score to greater than 1 standard deviation below the cohort mean. ANALYTICAL APPROACH Cox proportional hazard models adjusted for demographics as well as kidney disease and cardiovascular disease risk factors. RESULTS The mean age of participants was 58±11 (SD) years, estimated glomerular filtration rate (eGFR) was 44mL/min/1.73m2 ± 15 (SD), and the median follow-up time was 11 (IQR, 7-13) years. In 3,048 participants without cognitive impairment at baseline and with at least 1 follow-up 3MS test, a higher baseline SBP was significantly associated with incident cognitive impairment only in the eGFR>45mL/min/1.73m2 subgroup (adjusted hazard ratio [AHR], 1.13 [95% CI, 1.05-1.22] per 10mm Hg higher SBP]. Spline analyses, aimed at exploring nonlinearity, showed that the relationship between baseline SBP and incident cognitive impairment was J-shaped and significant only in the eGFR>45mL/min/1.73m2 subgroup (P=0.02). Baseline DBP was not associated with incident cognitive impairment in any analyses. LIMITATIONS 3MS test as the primary measure of cognitive function. CONCLUSIONS Among patients with chronic kidney disease, higher baseline SBP was associated with higher risk of incident cognitive impairment specifically in those individuals with eGFR>45mL/min/1.73m2. PLAIN-LANGUAGE SUMMARY High blood pressure is a strong risk factor for dementia and cognitive impairment in studies of adults without kidney disease. High blood pressure and cognitive impairment are common in adults with chronic kidney disease (CKD). The impact of blood pressure on the development of future cognitive impairment in patients with CKD remains unclear. We identified the relationship between blood pressure and cognitive impairment in 3,076 adults with CKD. Baseline blood pressure was measured, after which serial cognitive testing was performed over 11 years. Fourteen percent of participants developed cognitive impairment. We found that a higher baseline systolic blood pressure was associated with an increased risk of cognitive impairment. We found that this association was stronger in adults with mild-to-moderate CKD compared with those with advanced CKD.
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Affiliation(s)
- Seda Babroudi
- William B. Schwartz Division of Nephrology, Boston, Massachusetts.
| | - Hocine Tighiouart
- Institute for Clinical Research and Health Policy Studies, Boston, Massachusetts; Tufts Medical Center, and School of Medicine, Tufts University, Boston, Massachusetts
| | - Sarah J Schrauben
- Department of Medicine and Department of Epidemiology, Biostatistics and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jordana B Cohen
- Department of Medicine and Department of Epidemiology, Biostatistics and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael J Fischer
- Department of Medicine/Nephrology, University of Illinois, Chicago, Illinois; Medical Service, Jesse Brown VA Medical Center, Chicago, Illinois; Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward J. Hines VA Hospital, Hines, Illinois
| | - Mahboob Rahman
- University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio; Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio
| | - Chi-Yuan Hsu
- Division of Nephrology, San Francisco, California
| | - Stephen M Sozio
- Division of Nephrology, Department of Medicine, School of Medicine, and Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Matthew Weir
- Division of Nephrology, School of Medicine, University of Maryland, Baltimore, Maryland
| | - Mark Sarnak
- William B. Schwartz Division of Nephrology, Boston, Massachusetts
| | - Kristine Yaffe
- University of California-San Francisco, San Francisco, California
| | - Manjula Kurella Tamura
- Division of Nephrology, School of Medicine, Stanford University, Palo Alto, California; Geriatric Research and Education Clinical Center, VA Palo Alto Health Care System, Palo Alto, California
| | - David Drew
- William B. Schwartz Division of Nephrology, Boston, Massachusetts
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Kennard AL, Rainsford S, Glasgow NJ, Talaulikar GS. Use of frailty assessment instruments in nephrology populations: a scoping review. BMC Geriatr 2023; 23:449. [PMID: 37479978 PMCID: PMC10360289 DOI: 10.1186/s12877-023-04101-y] [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: 02/07/2023] [Accepted: 06/09/2023] [Indexed: 07/23/2023] Open
Abstract
BACKGROUND Frailty is a clinical syndrome of accelerated aging associated with adverse outcomes. Frailty is prevalent among patients with chronic kidney disease but is infrequently assessed in clinical settings, due to lack of consensus regarding frailty definitions and diagnostic tools. This study aimed to review the practice of frailty assessment in nephrology populations and evaluate the context and timing of frailty assessment. METHODS The search included published reports of frailty assessment in patients with chronic kidney disease, undergoing dialysis or in receipt of a kidney transplant, published between January 2000 and November 2021. Medline, CINAHL, Embase, PsychINFO, PubMed and Cochrane Library databases were examined. A total of 164 articles were included for review. RESULTS We found that studies were most frequently set within developed nations. Overall, 161 studies were frailty assessments conducted as part of an observational study design, and 3 within an interventional study. Studies favoured assessment of participants with chronic kidney disease (CKD) and transplant candidates. A total of 40 different frailty metrics were used. The most frequently utilised tool was the Fried frailty phenotype. Frailty prevalence varied across populations and research settings from 2.8% among participants with CKD to 82% among patients undergoing haemodialysis. Studies of frailty in conservatively managed populations were infrequent (N = 4). We verified that frailty predicts higher rates of adverse patient outcomes. There is sufficient literature to justify future meta-analyses. CONCLUSIONS There is increasing recognition of frailty in nephrology populations and the value of assessment in informing prognostication and decision-making during transitions in care. The Fried frailty phenotype is the most frequently utilised assessment, reflecting the feasibility of incorporating objective measures of frailty and vulnerability into nephrology clinical assessment. Further research examining frailty in low and middle income countries as well as first nations people is required. Future work should focus on interventional strategies exploring frailty rehabilitation.
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Affiliation(s)
- Alice L Kennard
- Department of Renal Medicine, The Canberra Hospital, Canberra Health Services, Building 15, Yamba Drive, Garran, ACT 2605, Australia.
- Australian National University, Canberra, ACT, Australia.
| | | | | | - Girish S Talaulikar
- Department of Renal Medicine, The Canberra Hospital, Canberra Health Services, Building 15, Yamba Drive, Garran, ACT 2605, Australia
- Australian National University, Canberra, ACT, Australia
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Gavriilaki M, Anyfanti P, Mastrogiannis K, Gavriilaki E, Lazaridis A, Kimiskidis V, Gkaliagkousi E. Association between ambulatory blood pressure monitoring patterns with cognitive function and risk of dementia: a systematic review and meta-analysis. Aging Clin Exp Res 2023; 35:745-761. [PMID: 36995461 PMCID: PMC10115699 DOI: 10.1007/s40520-023-02361-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 01/30/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND The objective of this systematic review and meta-analysis is to investigate whether nocturnal blood pressure fall, expressed by dipping patterns according to 24 h ambulatory blood pressure monitoring (ABPM), is associated with abnormal cognitive function (cognitive impairment or dementia). METHODS We systematically searched PubMed, Embase, and Cochrane databases to identify original articles through December 2022. We included any study with at least ten participants reporting on all-cause dementia or cognitive impairment incidence (primary outcome) or validated cognitive tests (secondary outcome) among ABPM patterns. We assessed risk of bias using Newcastle-Ottawa Quality Assessment Scale. We pooled odds ratios (OR) and standardized mean differences (SMD) using random-effect models for primary and secondary outcome, respectively. RESULTS In the qualitative synthesis, 28 studies examining 7595 patients were included. The pooled analysis of 18 studies showed that dippers had a 51% [OR 0.49(0.35-0.69)] lower risk of abnormal cognitive function and a 63% [OR 0.37(0.23-0.61)] lower risk of dementia alone, compared to non-dippers. Reverse dippers presented an up to sixfold higher risk [OR 6.06(3.15-11.64)] of abnormal cognitive function compared to dippers and an almost twofold higher risk [OR 1.81(1.26-2.6)] compared to non-dippers. Reverse dippers performed worse in global function neuropsychological tests compared with both dippers [SMD - 0.66(- 0.93 to - 0.39)] and non-dippers [SMD - 0.35(- 0.53 to - 0.16)]. CONCLUSION Dysregulation of the normal circadian BP rhythm, specifically non-dipping and reverse dipping is associated with abnormal cognitive function. Further studies are required to determine potential underlying mechanisms and possible prognostic or therapeutic implications. PROTOCOL REGISTRATION PROSPERO database (ID: CRD42022310384).
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Affiliation(s)
- Maria Gavriilaki
- 1st Department of Neurology, AHEPA University Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Panagiota Anyfanti
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Ring Road Nea Efkarpia, 56429, Thessaloniki, Greece
| | - Konstantinos Mastrogiannis
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Ring Road Nea Efkarpia, 56429, Thessaloniki, Greece
| | - Eleni Gavriilaki
- Hematology Department, G. Papanikolaou Hospital, Thessaloniki, Greece
| | - Antonios Lazaridis
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Ring Road Nea Efkarpia, 56429, Thessaloniki, Greece
| | - Vasilios Kimiskidis
- 1st Department of Neurology, AHEPA University Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eugenia Gkaliagkousi
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Ring Road Nea Efkarpia, 56429, Thessaloniki, Greece.
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Gorbunov VM. Position of 24-hour ambulatory blood pressure monitoring in modern practice. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2023. [DOI: 10.15829/1728-8800-2022-3456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Currently, 24-hour ambulatory blood pressure (BP) monitoring (ABPM) is the gold standard for diagnosing hypertension (HTN) and evaluating the effectiveness of antihypertensive therapy. The method provides information about some BP parameters that cannot be obtained in any other way. ABPM is reasonable in any patient with a documented increase in BP, especially if specific BP phenotypes are suspected: white coat HTN and masked HTN. Antihypertensive therapy under the ABPM, on average, is more economical and is not associated with overprescribing of drugs and their combinations. Based on the ABPM data, calculating a number of additional indicators of the 24-hour BP profile is possible, but their scope is still limited to the research field. In the conclusion on ABPM data, the results of office BP measurement and antihypertensive therapy should be indicated.
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Affiliation(s)
- V. M. Gorbunov
- National Medical Research Center for Therapy and Preventive Medicine
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8
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Qipo O, Debain A, Bautmans I. The influence of hypertension management on frailty prevention among older persons aged 65 and over: a systematic review. Aging Clin Exp Res 2022; 34:2645-2657. [PMID: 36195809 DOI: 10.1007/s40520-022-02247-0] [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: 04/08/2022] [Accepted: 08/29/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Frailty and hypertension are interrelated, but it remains unclear whether this relationship is modified by antihypertensive drugs. METHODS AND RESULTS A systematic review of PubMed and Web of Science databases was performed to review the influence of hypertension management on preventing the occurrence or progression of frailty in older people aged 65 and over. Studies providing information on this association regardless of the study setting, or definition of hypertension and frailty were included. Among the initial 2298 articles identified, 7 were included in the review. Three observational studies assessed the association between frailty and hypertension. Two of them reported no relationship between Aldosterone Antagonists use and frailty prevention. No relationship between BP and incidence frailty after adjustment for hypertension treatment was observed in two other articles. An indirect relationship was reported in the RCTs included. Higher AT11RaAb levels (control group), can lead to a generalized weakness/frailty risk shown by a decrease in grip strength (r = -0.57, p < 0.005) and walking speed (r = - 0.47, p < 0.005). No significant differences between int-hypertensive intervention and control were observed in frailty status after a 12-weeks follow-up after applying three different frailty measurement tools in the other RCT. CONCLUSIONS Based on the results of this systematic review we conclude that BP and frailty occur together but whether the treatment with anti-hypertensive drugs modifies this relationship remains unclear and needs to be further investigated.
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Affiliation(s)
- Orgesa Qipo
- Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, B-1090, Brussels, Belgium
| | - Aziz Debain
- Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, B-1090, Brussels, Belgium
| | - Ivan Bautmans
- Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, B-1090, Brussels, Belgium.
- Department of Geriatrics, Universitair Ziekenhuis Brussels (UZBrussels), Laarbeeklaan 101, B-1090, Brussels, Belgium.
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Copur S, Berkkan M, Sarafidis P, Kanbay M. Intensive blood pressure control on dementia in patients with chronic kidney disease: Potential reduction in disease burden. Eur J Intern Med 2022; 101:8-13. [PMID: 35465970 DOI: 10.1016/j.ejim.2022.04.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/10/2022] [Accepted: 04/16/2022] [Indexed: 12/17/2022]
Abstract
Chronic kidney disease (CKD) and dementia are both common comorbidities creating considerable morbidity and mortality, especially in the elderly population with potential interactions. Even though various hypothetical mechanisms underlying the pathophysiology of increased risk of dementia and cognitive impairment in CKD patients have been implicated, no consensus has been reached so far. Recent clinical trials have investigated the therapeutic role of intensive blood pressure control on the risk of dementia in CKD patients with potentially improved outcomes. However, such trials have significant limitations that may influence the outcome and lack specific management guidelines. We reviewed the role of blood pressure and other factors on the risk of dementia in CKD patients which is an issue with high potential for clinical implications that may improve morbidity, mortality, and health expenditures along with its' potential pathophysiological mechanisms and future guidance.
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Affiliation(s)
- Sidar Copur
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Metehan Berkkan
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Greece
| | - Mehmet Kanbay
- Department of Medicine, Division of Nephrology, Koc University School of Medicine, Istanbul, Turkey.
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Lidgard B, Bansal N, Zelnick LR, Hoofnagle A, Chen J, Colaizzo D, Dobre M, Mills KT, Porter AC, Rosas SE, Sarnak MJ, Seliger S, Sondheimer J, Tamura MK, Yaffe K, Kestenbaum B. Association of Proximal Tubular Secretory Clearance with Long-Term Decline in Cognitive Function. J Am Soc Nephrol 2022; 33:1391-1401. [PMID: 35444055 PMCID: PMC9257801 DOI: 10.1681/asn.2021111435] [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: 11/08/2021] [Accepted: 04/05/2022] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND People with chronic kidney disease (CKD) are at high risk for cognitive impairment and progressive cognitive decline. Retention of protein-bound organic solutes that are normally removed by tubular secretion is hypothesized to contribute to cognitive impairment in CKD. METHODS We followed 2362 participants who were initially free of cognitive impairment and stroke in the prospective Chronic Renal Insufficiency Cohort (CRIC) Study. We estimated tubular secretory clearance by the 24-hour kidney clearances of eight endogenous solutes that are primarily eliminated by tubular secretion. CRIC study investigators assessed participants' cognitive function annually using the Modified Mini-Mental State (3MS) Examination. Cognitive decline was defined as a sustained decrease of more than five points in the 3MS score from baseline. Using Cox regression models adjusted for potential confounders, we analyzed associations between secretory solute clearances, serum solute concentrations, and cognitive decline. RESULTS The median number of follow-up 3MS examinations was six per participant. There were 247 incident cognitive decline events over a median of 9.1 years of follow-up. Lower kidney clearances of five of the eight secretory solutes (cinnamoylglycine, isovalerylglycine, kynurenic acid, pyridoxic acid, and tiglylglycine) were associated with cognitive decline after adjustment for baseline eGFR, proteinuria, and other confounding variables. Effect sizes ranged from a 17% to a 34% higher risk of cognitive decline per 50% lower clearance. In contrast, serum concentrations of the solutes were not associated with cognitive decline. CONCLUSIONS Lower kidney clearances of secreted solutes are associated with incident global cognitive decline in a prospective study of CKD, independent of eGFR. Further work is needed to determine the domains of cognition most affected by decreased secretory clearance and the mechanisms of these associations.
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Affiliation(s)
- Benjamin Lidgard
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington
| | - Nisha Bansal
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington
| | - Leila R. Zelnick
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington
| | - Andrew Hoofnagle
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington
| | - Jing Chen
- Department of Medicine, Tulane University, New Orleans, Louisiana
| | | | - Mirela Dobre
- Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | | | - Anna C. Porter
- Department of Medicine, Section of Nephrology, University of Illinois at Chicago, Chicago, Illinois
| | - Sylvia E. Rosas
- Kidney and Hypertension Unit, Joslin Diabetes Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Mark J. Sarnak
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Stephen Seliger
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - James Sondheimer
- Department of Medicine, Division of Nephrology, Wayne State University, Detroit, Michigan
| | - Manjula Kurella Tamura
- Department of Medicine, Stanford University and VA Palo Alto Health Care System, Palo Alto, California
| | - Kristine Yaffe
- Departments of Psychiatry, Neurology, Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, California
| | - Bryan Kestenbaum
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington
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Shoji T, Fujii H, Mori K, Nakatani S, Nagata Y, Morioka T, Inaba M, Emoto M. Associations of cardiovascular disease and blood pressure with cognition in hemodialysis patients: The Osaka Dialysis Complication Study. Nephrol Dial Transplant 2021; 37:1758-1767. [PMID: 34459921 DOI: 10.1093/ndt/gfab247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Previous studies reported mixed results regarding the contributions of cardiovascular disease (CVD) and blood pressure to cognitive impairment in chronic kidney disease. METHODS This was a cross-sectional study in 1213 patients on maintenance hemodialysis from 17 dialysis units in Japan. The main exposures were prior CVD and blood pressure components including systolic (SBP) and diastolic pressure (DBP). The outcome was low cognitive function evaluated with the Modified Mini-Mental State examination (3MS) with a cut-off level of 3MS < 80. RESULTS The median age was 67 years, median duration of dialysis was 71 months, 37% were women, 39% had diabetic kidney disease, and 36% had any pre-existing CVD. Median (interquartile range) of 3MS score was 91 (82 to 97), and 240 patients (20%) had 3MS < 80. Logistic regression analysis showed that 3MS < 80 was associated with the presence of any prior CVD, particularly prior stroke. 3MS < 80 was associated with lower DBP but not with SBP. When patients were stratified by the presence of prior stroke, lower DBP, higher age, and lower education level were factors associated with 3MS < 80 in both subgroups. In the subgroup of patients without prior stroke, diabetic kidney disease was an additional factor associated with 3MS < 80. CVDs other than stroke were not associated with 3MS in either subgroup. CONCLUSIONS Prior stroke and lower DBP were associated with 3MS < 80 in hemodialysis patients. These findings support the hypothesis that these vascular factors contribute to low cognitive performance in patients undergoing hemodialysis.
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Affiliation(s)
- Tetsuo Shoji
- Department of Vascular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan.,Vascular Science Center for Translational Research, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hisako Fujii
- Department of Drug and Food Evaluation, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Katsuhito Mori
- Department of Nephrology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shinya Nakatani
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yuki Nagata
- Department of Vascular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan.,Vascular Science Center for Translational Research, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Tomoaki Morioka
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Masaaki Inaba
- Vascular Science Center for Translational Research, Osaka City University Graduate School of Medicine, Osaka, Japan.,Department of Nephrology, Osaka City University Graduate School of Medicine, Osaka, Japan.,Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Masanori Emoto
- Vascular Science Center for Translational Research, Osaka City University Graduate School of Medicine, Osaka, Japan.,Department of Nephrology, Osaka City University Graduate School of Medicine, Osaka, Japan.,Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
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Cheung AK, Chang TI, Cushman WC, Furth SL, Hou FF, Ix JH, Knoll GA, Muntner P, Pecoits-Filho R, Sarnak MJ, Tobe SW, Tomson CR, Mann JF. KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease. Kidney Int 2021; 99:S1-S87. [PMID: 33637192 DOI: 10.1016/j.kint.2020.11.003] [Citation(s) in RCA: 431] [Impact Index Per Article: 143.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 11/02/2020] [Indexed: 12/19/2022]
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13
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Georgianos PI, Agarwal R. Ambulatory BP Phenotypes and Their Association with Target Organ Damage and Clinical Outcomes in CKD. Clin J Am Soc Nephrol 2020; 15:441-443. [PMID: 32217636 PMCID: PMC7133132 DOI: 10.2215/cjn.02590220] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Panagiotis I Georgianos
- Section of Nephrology and Hypertension, First Department of Medicine, American Hellenic Educational Progressive Association Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece; and
| | - Rajiv Agarwal
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine and Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, Indiana
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