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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Ayerdem G, Bosma MJ, Vinke JSJ, Ziengs AL, Potgieser ARE, Gansevoort RT, Bakker SJL, De Borst MH, Eisenga MF. Association of Endogenous Erythropoietin Levels and Iron Status With Cognitive Functioning in the General Population. Front Aging Neurosci 2022; 14:862856. [PMID: 35462689 PMCID: PMC9024369 DOI: 10.3389/fnagi.2022.862856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 03/15/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundEmerging data suggest that erythropoietin (EPO) promotes neural plasticity and that iron homeostasis is needed to maintain normal physiological brain function. Cognitive functioning could therefore be influenced by endogenous EPO levels and disturbances in iron status.ObjectiveTo determine whether endogenous EPO levels and disturbances in iron status are associated with alterations in cognitive functioning in the general population.Materials and MethodsCommunity-dwelling individuals from the Prevention of Renal and Vascular End-Stage Disease (PREVEND) study, a general population-based cohort in Groningen, Netherlands, were surveyed between 2003 and 2006. Additionally, endogenous EPO levels and iron status, consisting of serum iron, transferrin, ferritin, and transferrin saturation were analyzed. Cognitive function was assessed by scores on the Ruff Figural Fluency Test (RFFT), as a reflection of executive function, and the Visual Association Test (VAT), as a reflection of associative memory.ResultsAmong 851 participants (57% males; mean age 60 ± 13 years), higher endogenous EPO levels were independently associated with an improved cognitive function, reflected by RFFT scores (ß = 0.09, P = 0.008). In multivariable backward linear regression analysis, EPO levels were among the most important modifiable determinants of RFFT scores (ß = 0.09, P = 0.002), but not of VAT scores. Of the iron status parameters, only serum ferritin levels were inversely associated with cognitive function, reflected by VAT scores, in multivariable logistic regression analysis (odds ratio, 0.77; 95% confidence interval 0.63–0.95; P = 0.02 for high performance on VAT, i.e., ≥11 points). No association between iron status parameters and RFFT scores was identified.ConclusionThe findings suggest that endogenous EPO levels and serum ferritin levels are associated with specific cognitive functioning tests in the general population. Higher EPO levels are associated with better RFFT scores, implying better executive function. Serum ferritin levels, but not other iron status parameters, were inversely associated with high performance on the VAT score, implying a reduced ability to create new memories and recall recent past. Further research is warranted to unravel underlying mechanisms and possible benefits of therapeutic interventions.
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Affiliation(s)
- Gizem Ayerdem
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Matthijs J. Bosma
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Joanna Sophia J. Vinke
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Aaltje L. Ziengs
- Department of Neuropsychology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Adriaan R. E. Potgieser
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Ron T. Gansevoort
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Stephan J. L. Bakker
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Martin H. De Borst
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Michele F. Eisenga
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
- *Correspondence: Michele F. Eisenga,
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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: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Eisenga MF, Gomes-Neto AW, van Londen M, Ziengs AL, Douwes RM, Stam SP, Osté MCJ, Knobbe TJ, Hessels NR, Buunk AM, Annema C, Siebelink MJ, Racz E, Spikman JM, Bodewes FAJA, Pol RA, Berger SP, Drost G, Porte RJ, Leuvenink HGD, Damman K, Verschuuren EAM, de Meijer VE, Blokzijl H, Bakker SJL. Rationale and design of TransplantLines: a prospective cohort study and biobank of solid organ transplant recipients. BMJ Open 2018; 8:e024502. [PMID: 30598488 PMCID: PMC6318532 DOI: 10.1136/bmjopen-2018-024502] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION In the past decades, short-term results after solid organ transplantation have markedly improved. Disappointingly, this has not been accompanied by parallel improvements in long-term outcomes after transplantation. To improve graft and recipient outcomes, identification of potentially modifiable risk factors and development of biomarkers are required. We provide the rationale and design of a large prospective cohort study of solid organ transplant recipients (TransplantLines). METHODS AND ANALYSIS TransplantLines is designed as a single-centre, prospective cohort study and biobank including all different types of solid organ transplant recipients as well as living organ donors. Data will be collected from transplant candidates before transplantation, during transplantation, at 3 months, 6 months, 1 year, 2 years and 5 years, and subsequently every 5 years after transplantation. Data from living organ donors will be collected before donation, during donation, at 3 months, 1 year and 5 years after donation, and subsequently every 5 years. The primary outcomes are mortality and graft failure. The secondary outcomes will be cause-specific mortality, cause-specific graft failure and rejection. The tertiary outcomes will be other health problems, including diabetes, obesity, hypertension, hypercholesterolaemia and cardiovascular disease, and disturbances that relate to quality of life, that is, physical and psychological functioning, including quality of sleep, and neurological problems such as tremor and polyneuropathy. ETHICS AND DISSEMINATION Ethical approval has been obtained from the relevant local ethics committee. The TransplantLines cohort study is designed to deliver pioneering insights into transplantation and donation outcomes. The study design allows comprehensive data collection on perioperative care, nutrition, social and psychological functioning, and biochemical parameters. This may provide a rationale for future intervention strategies to more individualised, patient-centred transplant care and individualisation of treatment. TRIAL REGISTRATION NUMBER NCT03272841.
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Affiliation(s)
- 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
| | - Marco van Londen
- Division of Nephrology, Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Aaltje L Ziengs
- Division of Nephrology, Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Neuropsychology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Rianne M Douwes
- Division of Nephrology, Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Suzanne P Stam
- Division of Nephrology, Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Maryse C J Osté
- Division of Nephrology, Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Tim J Knobbe
- Division of Nephrology, Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Niek R Hessels
- Division of Nephrology, Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Anne M Buunk
- Department of Neuropsychology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Coby Annema
- Groningen Transplant Center, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marion J Siebelink
- Groningen Transplant Center, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Emoke Racz
- Department of Dermatology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jacoba M Spikman
- Department of Neuropsychology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Frank A J A Bodewes
- Department of Pediatrics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Robert A Pol
- Department of Surgery, 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
| | - Gea Drost
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Robert J Porte
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Henri G D Leuvenink
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Kevin Damman
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Erik A M Verschuuren
- Department of Pulmonary Diseases and Tuberculosis, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Vincent E de Meijer
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Hans Blokzijl
- Department of Gastroenterology and Hepatology, 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
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Buunk AM, Groen RJM, Wijbenga RA, Ziengs AL, Metzemaekers JDM, van Dijk JMC, Spikman JM. Mental versus physical fatigue after subarachnoid hemorrhage: differential associations with outcome. Eur J Neurol 2018; 25:1313-e113. [PMID: 29924481 PMCID: PMC6221080 DOI: 10.1111/ene.13723] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 06/19/2018] [Indexed: 12/02/2022]
Abstract
Background and purpose Fatigue is a major consequence of subarachnoid hemorrhage (SAH), but the specific characteristics are unclear. Our objective was to investigate the nature of post‐SAH fatigue (mental or physical) and to determine the relationship with functional outcome in the chronic stage. Also, the possible influence of mood disorders and acute SAH‐related factors [SAH type and external cerebrospinal fluid (CSF) drainage] on the presence of fatigue was investigated. Methods Patients with an aneurysmal SAH (aSAH) or angiographically negative SAH (anSAH) were assessed 3–10 years post‐SAH (N = 221). Questionnaires were used to investigate mental and physical fatigue and mood. Functional outcome was examined with the Glasgow Outcome Scale Extended. Between‐group comparisons and binary logistic regression analysis were performed. Results Frequencies of mental and physical fatigue were 48.4% and 38.5%, respectively, with prevalence of mental fatigue being significantly higher. A two‐way anova with SAH type and external CSF drainage as independent variables and mental fatigue as dependent variable showed a significant main effect of CSF drainage only (P < 0.001). Only mental fatigue explained a significant part of the variance in long‐term functional outcome (model χ2 = 52.99, P < 0.001; Nagelkerke R² = 0.32). Conclusions Mental fatigue after SAH is a serious burden to the patient and is associated with impaired long‐term functional outcome. Distinguishing different aspects of fatigue is relevant as mental post‐SAH fatigue might be a target for treatment aimed to improve long‐term outcome.
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Affiliation(s)
- A M Buunk
- Department of Neurology, Subdepartment of Neuropsychology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - R J M Groen
- Department of Neurosurgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - R A Wijbenga
- Department of Neurology, Subdepartment of Neuropsychology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - A L Ziengs
- Department of Neurology, Subdepartment of Neuropsychology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - J D M Metzemaekers
- Department of Neurosurgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - J M C van Dijk
- Department of Neurosurgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - J M Spikman
- Department of Neurology, Subdepartment of Neuropsychology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Meles SK, Kok JG, De Jong BM, Renken RJ, de Vries JJ, Spikman JM, Ziengs AL, Willemsen ATM, van der Horn HJ, Leenders KL, Kremer HPH. The cerebral metabolic topography of spinocerebellar ataxia type 3. Neuroimage Clin 2018; 19:90-97. [PMID: 30035006 PMCID: PMC6051313 DOI: 10.1016/j.nicl.2018.03.038] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Revised: 02/23/2018] [Accepted: 03/28/2018] [Indexed: 12/11/2022]
Abstract
Introduction We aimed to uncover the pattern of network-level changes in neuronal function in Spinocerebellar ataxia type 3 (SCA3). Methods 17 genetically-confirmed SCA3 patients and 16 controls underwent structural MRI and static resting-state [18F]‑Fluoro‑deoxyglucose Positron Emission Tomography (FDG-PET) imaging. A SCA3-related pattern (SCA3-RP) was identified using a multivariate method (scaled subprofile model and principal component analysis (SSM PCA)). Participants were evaluated with the Scale for Assessment and Rating of Ataxia (SARA) and with neuropsychological examination including tests for language, executive dysfunction, memory, and information processing speed. The relationships between SCA3-RP expression and clinical scores were explored. Voxel based morphology (VBM) was applied on MRI-T1 images to assess possible correlations between FDG reduction and grey matter atrophy. Results The SCA3-RP disclosed relative hypometabolism of the cerebellum, caudate nucleus and posterior parietal cortex, and relatively increased metabolism in somatosensory areas and the limbic system. This topography, which was not explained by regional atrophy, correlated significantly with ataxia (SARA) scores (ρ = 0.72; P = 0.001). SCA3 patients showed significant deficits in executive function and information processing speed, but only letter fluency correlated with SCA3-RP expression (ρ = 0.51; P = 0.04, uncorrected for multiple comparisons). Conclusion The SCA3 metabolic profile reflects network-level alterations which are primarily associated with the motor features of the disease. Striatum decreases additional to cerebellar hypometabolism underscores an intrinsic extrapyramidal involvement in SCA3. Cerebellar-posterior parietal hypometabolism together with anterior parietal (sensory) cortex hypermetabolism may reflect a shift from impaired feedforward to compensatory feedback processing in higher-order motor control. The demonstrated SCA3-RP provides basic insight in cerebral network changes in this disease. A metabolic cerebral pattern could be identified in FDG-PET data of SCA3 patients, which was not explained by regional atrophy. Striatum decreases in the SCA3-pattern reflect extrapyramidal involvement. The SCA3-pattern reflects changes in higher-order motor control.
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Affiliation(s)
- Sanne K Meles
- Department of Neurology, University of Groningen, University Medical Center Groningen, The Netherlands.
| | - Jelmer G Kok
- Department of Neurology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Bauke M De Jong
- Department of Neurology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Remco J Renken
- Neuroimaging Center, Department of Neuroscience, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Jeroen J de Vries
- Department of Neurology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Jacoba M Spikman
- Department of Neuropsychology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Aaltje L Ziengs
- Department of Neuropsychology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Antoon T M Willemsen
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Harm J van der Horn
- Department of Neurology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Klaus L Leenders
- Department of Neurology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Hubertus P H Kremer
- Department of Neurology, University of Groningen, University Medical Center Groningen, The Netherlands
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