Comparison of dementia risk between end stage renal disease patients with hemodialysis and peritoneal dialysis--a population based study

Association between dementia diagnosis at dialysis initiation and mortality in older patients with end-stage kidney disease in South Korea

BACKGROUND

The prevalence of dementia is 2- to 7-fold higher among patients with end-stage kidney disease (ESKD) than among the general population; however, its clinical implications in this population remain unclear. Therefore, this study aimed to determine whether comorbid dementia increases mortality among older patients with ESKD undergoing newly initiated hemodialysis.

METHODS

We analyzed data from the Korean Society of Geriatric Nephrology retrospective cohort, which included 2,736 older ESKD patients (≥70 years old) who started hemodialysis between 2010 and 2017. Kaplan-Meier survival and Cox regression analyses were used to examine all-cause mortality between the patients with and without dementia in this cohort.

RESULTS

Of the 2,406 included patients, 8.3% had dementia at the initiation of dialysis; these patients were older (79.6 ± 6.0 years) than patients without dementia (77.7 ± 5.5 years) and included more women (male:female, 89:111). Pre-ESKD diagnosis of dementia was associated with an increased risk of overall mortality (hazard ratio, 1.503; p < 0.001), and this association remained consistent after multivariate adjustment (hazard ratio, 1.268; p = 0.009). In subgroup analysis, prevalent dementia was associated with mortality following dialysis initiation in female patients, those aged <85 years, those with no history of cerebrovascular accidents or severe behavioral disorders, those not residing in nursing facilities, and those with no or short-term hospitalization.

CONCLUSION

A pre-ESKD diagnosis of dementia is associated with mortality following dialysis initiation in older Korean population. In older patients with ESKD, cognitive assessment at dialysis initiation is necessary.

Hyperthyroidism, hypothyroidism, thyroid stimulating hormone, and dementia risk: results from the NHANES 2011-2012 and Mendelian randomization analysis

Introduction

As the world ages, dementia places a heavy burden on society and the economy, but current methods of diagnosing dementia are still limited and there are no better therapies that target the causes of dementia. The purpose of this work is to explore the relationship between thyroid disease, thyroid stimulating hormone (TSH) concentrations, free tetraiodothyronine (FT4) concentrations and cognitive function.

Methods

This study utilized cognitive function and thyroid data from the 2011-2012 National Health and Nutrition Examination Survey (NHANES) to assess the relationship between different groups of TSH and FT4 concentrations and cognitive function using weighted logistic regression and restricted cubic spline (RCS), and then used two-sample Mendelian Randomization (MR) to assess the causal relationship between hyperthyroidism, hypothyroidism, TSH and FT4 concentrations with dementia.

Results

Our analysis of the 2011-2012 NHANES data showed that the individuals with low TSH concentrations had higher Alzheimer's Disease Word List Registry Consortium1 (CERAD1) and CERAD.delay.recall scores than individuals with high TSH concentrations, and individuals with low FT4 concentrations had higher CERAD3 and Animal Fluency Test scores than individuals with high FT4 concentrations. Our results also showed a non-linear relationship between serum TSH and FT4 concentrations and the Animal Fluency Test. The TSH concentrations within the range of 1.703 to 3.145 mIU/L exhibit a positive correlation with Animal Fluency Test, whereas concentrations outside this range are negatively correlated with Animal Fluency Test. The FT4 concentrations exhibited a positive correlation with Animal Fluency Test to the left of the FT4 concentrations inflection point (0.849 ng/L), whereas to the right of this inflection point, correlation was negative. MR analysis results further indicate that genetic predisposition to hyperthyroidism may be associated with a reduced risk of dementia and vascular dementia(VaD). Conversely, genetic predisposition to hypothyroidism appears to be linked with an increased risk of dementia and VaD. Additionally, genetic predisposition to elevated TSH concentrations may be correlated with a heightened risk of risk of Alzheimer's disease (AD).

Conclusion

This study provides evidence of a nonlinear relationship between TSH and FT4 concentrations and cognitive function, with hyperthyroidism decreasing the risk of dementia and VaD, hypothyroidism increasing the risk of dementia and VaD, and elevated serum TSH concentrations increasing the risk of AD. Furthermore, prioritizing early detection, diagnosis, and treatment through the assessment of thyroid function in individuals at high risk for developing dementia is of paramount importance. This strategy has the potential to significantly contribute to the prevention and deceleration of dementia progression.

Cognitive Dysfunction and Health-Related Quality of Life in Patients with End-Stage Renal Disease Undergoing Hemodialysis in Comparison with Patients Undergoing Peritoneal Dialysis: A Cross-Sectional Study

Background

This study compared the effects of peritoneal dialysis and hemodialysis on cognitive dysfunction and health-related quality of life (HRQOL) in end-stage renal disease (ESRD) patients and analyzed other potential influencing factors.

Material/Methods

A total of 265 patients who received dialysis at our hospital were included and divided into the hemodialysis group (n=115) and the peritoneal dialysis group (n=150). The cognitive performance was assessed by the Beijing version of the Montreal Cognitive Assessment. The Kidney Disease Quality of 36-Item Short Form Survey and a kidney disease-related quality of life assessment were used for evaluating HRQOL. Univariate and multivariate linear regression analyses were used to explore the effects of dialysis on cognitive dysfunction and HRQOL.

Results

As compared with the hemodialysis group, the peritoneal dialysis group had lower scores on the Montreal Cognitive Assessment (β=−8.35, 95% CI: −9.85 to −6.86), 36-Item Short Form Survey (β=−10.20, 95% CI: −11.94 to −8.45), and kidney disease-related quality of life assessment (β=−8.67, 95% CI: −10.10 to −7.23). After adjustment for sex, age, BMI, marital status, educational level, income level, presence of diabetes, duration of kidney disease, duration of dialysis, and dialysis frequency, the results were consistent with that of the crude model.

Conclusions

In the present study, patients receiving peritoneal dialysis had worse cognitive dysfunction and worse HRQOL compared to patients receiving hemodialysis, which might lead to poorer outcomes of ESRD patients. The related factors affecting cognitive dysfunction and HRQOL were also explored, which could help clinicians to determine the optimal treatment for ESRD patients.

Development and validation of the dialysis dementia risk score: A retrospective, population-based, nested case-control study

Background

Dementia is prevalent and underdiagnosed in the dialysis population. We aimed to develop and validate a simple dialysis dementia scoring system to facilitate identification of individuals who are at high risk for dementia.

Methods

We applied a retrospective, nested case‐control study design using a national dialysis cohort derived from the National Health Insurance Research Database in Taiwan. Patients aged between 40 and 80 years were included and 2940 patients with incident dementia were matched to 29,248 non‐dementia controls. All subjects were randomly divided into the derivation and validation sets with a ratio of 4:1. Conditional logistic regression models were used to identify factors contributing to the risk score. The cutoff value of the risk score was determined by Youden's J statistic and the graphic method.

Results

The dialysis dementia risk score (DDRS) finally included age and 10 comorbidities as risk predictors. The C‐statistic of the model was 0.71 (95% confidence interval [CI] 0.70–0.72). Calibration revealed a strong linear relationship between predicted and observed dementia risk (R² = 0.99). At a cutoff value of 50 points, the high‐risk patients had an approximately three‐fold increased risk of having dementia compared to those with low risk (odds ratio [OR] 3.03, 95% CI 2.78–3.31). The DDRS performance, including discrimination (C‐statistic 0.71, 95% CI 0.69–0.73) and calibration (p value of Hosmer−Lemeshow test for goodness of fit = 0.18), was acceptable during validation. The OR value (2.82, 95% CI 2.37–3.35) was similar to those in the derivation set.

Conclusion

The DDRS system has the potential to serve as an easily accessible screening tool to determine the high‐risk groups who deserve subsequent neurological evaluation in daily clinical practice.

Mechanisms of cognitive dysfunction in CKD

Cognitive impairment is an increasingly recognized major cause of chronic disability and is commonly found in patients with chronic kidney disease (CKD). Knowledge of the relationship between kidney dysfunction and impaired cognition may improve our understanding of other forms of cognitive dysfunction. Patients with CKD are at an increased risk (compared with the general population) of both dementia and its prodrome, mild cognitive impairment (MCI), which are characterized by deficits in executive functions, memory and attention. Brain imaging in patients with CKD has revealed damage to white matter in the prefrontal cortex and, in animal models, in the subcortical monoaminergic and cholinergic systems, accompanied by widespread macrovascular and microvascular damage. Unfortunately, current interventions that target cardiovascular risk factors (such as anti-hypertensive drugs, anti-platelet agents and statins) seem to have little or no effect on CKD-associated MCI, suggesting that the accumulation of uraemic neurotoxins may be more important than disturbed haemodynamic factors or lipid metabolism in MCI pathogenesis. Experimental models show that the brain monoaminergic system is susceptible to uraemic neurotoxins and that this system is responsible for the altered sleep pattern commonly observed in patients with CKD. Neural progenitor cells and the glymphatic system, which are important in Alzheimer disease pathogenesis, may also be involved in CKD-associated MCI. More detailed study of CKD-associated MCI is needed to fully understand its clinical relevance, underlying pathophysiology, possible means of early diagnosis and prevention, and whether there may be novel approaches and potential therapies with wider application to this and other forms of cognitive decline.

Comparison of prevalence and associated risk factors of cognitive function status among elderly between nursing homes and common communities of China: A STROBE-compliant observational study

Dementia among elderly is a serious problem worldwide. This study was conducted to estimate the prevalence and associated risk factors of dementia and mild cognitive impairment (MCI) in nursing homes (NHs) and common communities (CCs) among elderly in China.A cross-sectional survey was conducted in 4 communities across 12 cities in Southern China from May to November of 2014. Qualified psychiatrists and trained nurses carried out relevant diagnosis, assessments, interviews, and information collection. Screening test of mini-mental state examination was conducted among participants firstly, then confirmed diagnosis was carried out among the ones with positive results. Student t test, χ test, univariate, and multivariate logistic regression analysis were conducted to analyze data.A total of 2015 participants aged 65 or older were included in the final analysis; 908 came from NHs while 1107 came from CCs. The crude prevalence rates of dementia and MCI were 22.0% and 15.8%, respectively among all the participants. Dementia prevalence was 42.4% among those living in NHs, which was significantly higher than that of 5.3% in CCs (P < .0001). There were more moderate and severe dementia in NHs compared with CCs (P < .0001). It showed that older age, illiterate compared with high level of education (adjusted odds ratio, AOR = 3.32, 95% CI: 1.53-7.21), heavy drinking (AOR = 1.51 (1.00-2.24), having a medical history of diabetes (AOR = 1.41, 95% CI: 1.02-2.33), and stroke (AOR = 1.21, 95% CI: 1.01-1.23) were associated with dementia in NHs, and middle socioeconomic status might be a protective factor for dementia (AOR = 0.33, 95% CI: 0.21-0.51).The problem of senile dementia in NHs is much more serious than our estimation, and there are not enough trained nursing staffs in NHs. More population-based strategies in NHs, including conducting cognitive screening accompanied with routine physical examination among elderly population, carrying out related primary prevention policies and public health services, and paying attention to some modifiable associated risk factors such as heavy smoking and drinking are needed.

Caregiving for Older Adults Requiring Hemodialysis: A Comparison Study

This study examined differences in caregiving appraisal between primary family caregivers of disabled older adults receiving hemodialysis (PFCGs-wHD) and disabled older adults not receiving dialysis (PFCGs-woD). A total of 242 PFCGs-wHD and 335 PFCGs-woD were included in the analyses. We used adjustment by propensity score to control for bias by confounding factors. Caregiving appraisal was measured in terms of role strain, emotional exhaustion, and caregiving satisfaction. On the first task, PFCGs-wHD demonstrated significantly worse levels on all three appraisal indicators than did PFCGs-woD. On the second task, only higher emotional exhaustion was significantly mediated by higher role strain in PFCGs-wHD. Further, PFCGs-wHD status directly influenced lower caregiving satisfaction without mediation by higher role strain. Caregiving for disabled older adults receiving HD may be associated with significant challenges for caregivers.

The comparison of cognitive function and risk of dementia in CKD patients under peritoneal dialysis and hemodialysis: A PRISMA-compliant systematic review and meta-analysis

BACKGROUNDS

Cognitive functions (CF) decline has been reported in end-stage renal disease (ESRD) patients. However, the influence of dialysis modalities on CF has not been investigated systematically.

METHODS

A systematic literature search was conducted in MEDLINE, Embase, Cochrane library and unpublished database Clinicaltrials.gov to identify the studies comparing the cognitive functions or risk of dementia between hemodialysis (HD) and peritoneal dialysis (PD). After data extraction, quality of studies was assessed using the Newcastle-Ottawa scale. Both qualitative and quantitative analyses were performed.

RESULTS

After study inclusion, totally 15 cohort or cross-sectional studies were included, comparing the cognitive functions using neuropsychological tests and covering the executive function, memory, orientation, attention, etc. By qualitative analysis, it showed that more studies are inclined to PD compared with HD with better cognitive functions. By quantitative analysis, it showed that PD showed better performance in the tests of Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), stroop interference test and exhibited lower risk of dementia compared with HD.

CONCLUSIONS

In this meta-analysis, we draw preliminary conclusion that patients treated with PD had better cognitive functions and lower dementia risk compared with patients with HD. Still more large-scale and well-conducted prospective cohort studies are needed to draw more convincing conclusions.

Estimation of diagnostic performance of dementia screening tests: Mini-Mental State Examination, Mini-Cog, Clock Drawing test and Ascertain Dementia 8 questionnaire

OBJECTIVE

Dementia is one of the leading causes of dependence in the elderly. This study was conducted to estimate diagnostic performance of dementia screening tests including Mini-Mental State Examination (MMSE), Mini-Cog, Clock Drawing Test (CDT) and Ascertain Dementia 8 questionnaire (AD8) by Bayesian models.

METHOD

A total of 2015 participants aged 65 years or more in eastern China were enrolled. The four screening tests were administered and scored by specifically trained psychiatrists. The prior information of sensitivity and specificity of every screening test was updated via Bayes' theorem to a posterior distribution. Then the results were compared with the estimation based on National Institute of Aging-Alzheimer's Association criteria (NIA-AA).

RESULTS

The diagnostic characteristics of Mini-Cog, including sensitivity, specificity, PPV, NPV, especially the Youden index, performed well, even better than the combinations of several screening tests.

CONCLUSION

The Mini-Cog with excellent screening characteristics, spending less time, could be considered to be used as a screening test to help to screen patients with cognitive impairment or dementia early. And Bayesian method was shown to be a suitable tool for evaluating dementia screening tests.

CONCLUSION

The Mini-Cog with excellent screening characteristics, spending less time, could be considered to be used as a screening test to help to screen patients with cognitive impairment or dementia early. And Bayesian method was shown to be a suitable tool for evaluating dementia screening tests.

Dementia is a risk factor for major adverse cardiac and cerebrovascular events in elderly Korean patients initiating hemodialysis: a Korean national population-based study

Background

Dementia is common in end-stage renal disease (ESRD) patients on hemodialysis (HD) and is associated with worse outcomes. This study aimed to investigate the risk of major adverse cardiac and cerebrovascular event (MACCE) in elderly patients with dementia initiating HD.

Methods

Using the database from the Health Insurance Review & Assessment Service, we analyzed 10,171 patients aged 65 years or older who had initiated dialysis from 2005 to 2008. MACCE was defined as a composite outcome of all-cause mortality, nonfatal acute myocardial infarction, target vessel revascularization, and nonfatal ischemic and hemorrhagic stroke. The Kaplan-Meier method and Cox proportional hazards model were used, and further comparisons using propensity-score matching at 1:2 ratio were also performed.

Results

A total of 303 elderly patients (3.0%) had dementia at initiating HD. During follow-up, dementia was a significant predictor of MACCE after adjustment for confounding variables. In addition, further analyzed in the propensity-score matched groups, dementia was an independent predictor of both nonfatal ischemic stroke and all-cause mortality.

Conclusions

Dementia is an independent risk factor for mortality and ischemic stroke in elderly ESRD patients initiating HD. Patients with dementia who start dialysis should be closely monitored to reduce the risk of mortality and ischemic stroke.

Electronic supplementary material

The online version of this article (doi:10.1186/s12882-017-0547-0) contains supplementary material, which is available to authorized users.

Cysteinyl Leukotriene Receptor Antagonists Decrease Cancer Risk in Asthma Patients

Previous in vitro and in vivo studies have demonstrated the potential of using cysteinyl leukotriene receptor antagonists (LTRAs) for chemoprevention, but this has not been investigated in any clinical setting. We therefore investigated the chemopreventive effect of LTRAs in a nationwide population-based study. From the Taiwan National Health Insurance Research Database, we enrolled adults with newly-diagnosed asthma between 2001 and 2011. Among these patients, each LTRA user was matched with five randomly-selected LTRA non-users by sex, age, asthma diagnostic year and modified Charlson Comorbidity Index score. We considered the development of cancer as the outcome. Totally, 4185 LTRA users and 20925 LTRA non-users were identified. LTRA users had a significantly lower cancer incidence rate than LTRA non-users did. Multivariable Cox regression analyses adjusting for baseline characteristics and comorbidities showed LTRA use was an independent protecting factor (hazard ratio = 0.31 [95% CI: 0.24–0.39]), and cancer risk decreased progressively with higher cumulative dose of LTRAs. In conclusion, this study revealed that the LTRA use decreased cancer risk in a dose-dependent manner in asthma patients. The chemopreventive effect of LTRAs deserves further study.