The Effect of Strict Volume Control on Cognitive Functions in Chronic Hemodialysis Patients

Who should make the decision for renal replacement therapy?

INTRODUCTION

In this study, we aimed to evaluate cognitive functions in Stage 4 and 5 CKD patients using the Montreal Cognitive Assessment (MoCA) Scale, which objectively assesses cognitive dysfunction and various cognitive functions, and to compare them with a control group with normal kidney functions.

METHODS

All participants in our case-control study were administered the Montreal Cognitive Assessment (MoCA) Test, and total scores, subscale scores, and the presence of cognitive dysfunction were recorded.

RESULTS

When the groups were compared in terms of cognitive dysfunction (CD), 12.9% of the control group and 37.1% of the case group were found to have CD, which was statistically significant. When the groups were compared in terms of data and scale scores, the visual construction subscale score, naming, delayed recall subscale score, and total MoCA score were found to be significantly lower in the case group compared to the control group.

CONCLUSION

Our study is the first to use the MoCA test with the correct reference range. The significant impairment observed in the cognitive functions of patients with advanced-stage CKD in our study suggests that the decision for renal replacement therapy should not be made by the patient alone, as it may be incorrect.

Cognitive impairment in CKD patients: a guidance document by the CONNECT network

Cognitive impairment is a prevalent and debilitating complication in patients with chronic kidney disease (CKD). This position paper, developed by the Cognitive Decline in Nephro-Neurology: European Cooperative Target network, provides guidance on the epidemiology, risk factors, pathophysiology, diagnosis and clinical management of CKD-related cognitive impairment. Cognitive impairment is significantly more common in CKD patients compared with the general population, particularly those undergoing haemodialysis. The development of cognitive impairment is influenced by a complex interplay of factors, including uraemic neurotoxins, electrolytes and acid-base disorders, anaemia, vascular damage, metabolic disturbances and comorbidities like diabetes and hypertension. Effective screening and diagnostic strategies are essential for early identification of cognitive impairment utilizing cognitive assessment tools, neuroimaging and circulating biomarkers. The impact of various drug classes, including antiplatelet therapy, oral anticoagulants, lipid-lowering treatments and antihypertensive drugs, on cognitive function is evaluated. Management strategies encompass pharmacological and non-pharmacological interventions, with recommendations for optimizing cognitive function while managing CKD-related complications. This guidance highlights the importance of addressing cognitive impairment in CKD patients through early detection, careful medication management and tailored therapeutic strategies to improve patient outcomes.

Left ventricular hypertrophy and cognitive function: a systematic review

Cognitive impairment is common in patients with hypertension. Left ventricular hypertrophy (LVH) is recognised as a marker of hypertension-related organ damage and is a strong predictor of coronary artery disease, heart failure and stroke. There is evidence that LVH is independently associated with cognitive impairment, even after adjustment for the presence of hypertension. We conducted a systematic review that examined cognitive impairment in adults with LVH. Independent searches were performed in Ovid MEDLINE, Ovid psycInfo and PubMed with the terms left ventricular hypertrophy and cognition. Seventy-three studies were identified when both searches were combined. After limiting the search to studies that were: (1) reported in English; (2) conducted in humans; (3) in adults aged 50 years and older; and (4) investigated the relationship between LVH and cognitive performance, nine papers were included in this systematic review. The majority of studies found an association between LVH and cognitive performance. Inspection of results indicated that individuals with LVH exhibited a lower performance in cognitive tests, when compared to individuals without LVH. Memory and executive functions were the cognitive domains that showed a specific vulnerability to the presence of LVH. A possible mechanism for the relationship between LVH and cognition is the presence of cerebral white matter damage. White matter lesions occur frequently in patients with LVH and may contribute to cognitive dysfunction. Together, the results of this review suggest that memory impairment and executive dysfunction are the cognitive domains that showed a particular association with the presence of LVH.

The effect of the interdialytic interval on cognitive function in patients on haemodialysis

BACKGROUND

Cognitive deficits are common among individuals on haemodialysis (HD). The degree of dysfunction may shift over the course of the interdialytic interval.

OBJECTIVES

To use ecological momentary assessment (EMA) to examine the relationship between the length of the interdialytic interval and reports of cognitive dysfunction.

DESIGN

A quantitative study whereby each patient's cognitive functioning was measured during both short and long interdialytic intervals.

PARTICIPANTS

Adults maintained on HD (Female n = 15, Male n = 11; M_Age  = 42.7 ± 15.8 years) were drawn from a standalone HD unit within a large university medical centre.

MEASUREMENTS

Tests of baseline neurocognitive functioning were undertaken (Mini-Mental Status Examination, Digit Span, California Verbal Learning Test, Benton Visual Retention Test, Trail-Making Test) and smartphone-based electronic diary reports of cognitive impairment were made around six times each day for one week.

RESULTS

Cognitive function and aptitude in this sample, although low, did not reflect clinically-significant impairment, with a mean Mini-Mental Status Exam score of 25.7 ± 3.0. Diary reports of cognitive impairment were also minimal, with an overall mean rating of .22 out of 5. Contrary to expectations, cognitive impairment was significantly greater on the one-day interdialytic days than on Day 2 of the two-day interdialytic interval (β = .094, p = .017).

CONCLUSIONS

Although cognitive impairment appears to be mild in stable, young patients with end stage renal disease, volumetric disruptions caused by HD may exacerbate such dysfunction.

Clinical predictors of individual cognitive fluctuations in patients undergoing hemodialysis

BACKGROUND

Cognitive impairment in hemodialysis (HD) patients is frequent and mediated by several factors. It is unclear which patients are more susceptible to cognitive variations around the dialysis cycle and which clinical factors may play a mediator role. We aimed to answer these issues by investigating intraindividual changes within the dialysis cycle.

STUDY DESIGN

Cross-sectional observational study with repeated measures.

SETTING & PARTICIPANTS

47 HD patients and 40 controls without kidney disease, both without history of neurologic disease.

PREDICTORS

Dialysis vintage, disease duration, vascular risk factors, comorbidity index score, intradialytic weight change, frequency of hypotensive episodes, and biochemical levels (hemoglobin, leukocytes, urea, creatinine, sodium, and potassium). Covariates included demographics (age, education, and sex).

OUTCOMES & MEASUREMENTS

Significant individual deterioration in attention and executive functions (phasic and intrinsic alertness, Stroop test, and Trail Making Test) after dialysis, as measured by a regression-based reliable change method. Regression models were used to identify clinical predictors of individual cognitive decline after dialysis.

RESULTS

After dialysis, patients primarily showed prolonged reaction times and psychomotor slowing. However, individual-based analyses revealed that fluctuations in attention and executive functions were present in only a minority of patients. Significant individual fluctuations on particular attention and executive tasks were associated moderately with intradialytic hypotensive episodes, as well as with psychoactive medication, and were predicted weakly by blood leukocyte count, sodium level, dialysis vintage, and volume.

LIMITATIONS

Small sample size; patient group younger and healthier than the overall HD population, limiting generalizability.

CONCLUSIONS

Only a minority of patients exhibit significant individual cognitive fluctuations, predominantly showing deterioration after dialysis in attention and executive functions. Susceptibility to such fluctuations was predicted in part by both HD-dependent and -independent factors.

Using a mobile application to self-monitor diet and fluid intake among adults receiving hemodialysis

Hemodialysis patients have difficulty self-managing a complex dietary and fluid regimen. The purpose of this feasibility study was to pilot test an electronic self-monitoring intervention based on social cognitive theory. During a 6-week intervention, 24 participants self-monitored diet and fluid intake using the Dietary Intake Monitoring Application (DIMA), and 20 participants served as controls by monitoring their activity using the Daily Activity Monitor Application (DAMA). Results from this pilot study suggest the intervention is feasible and acceptable, although few significant effects on outcomes were found in this small sample. The DIMA has potential to facilitate dietary and fluid self-monitoring but requires additional refinement and further testing.

Measures of blood pressure and cognition in dialysis patients

There are few reports on the relationship of blood pressure with cognitive function in maintenance dialysis patients. The Cognition and Dialysis Study is an ongoing investigation of cognitive function and its risk factors in six Boston area hemodialysis units. In this analysis, we evaluated the relationship between different domains of cognitive function with systolic and diastolic blood pressure, pulse pressure, and intradialytic changes in systolic blood pressure, using univariate and multivariable linear regression models adjusted for age, sex, race, education, and primary cause of end-stage renal disease. Among 314 participants, mean age was 63 years; 47% were female, 22% were African American, and 48% had diabetes. The mean (SD) of systolic blood pressure, diastolic blood pressure, pulse pressure, and intradialytic change in systolic blood pressure were 141 (21), 73 (12), 68 (15), and -10 (24) mmHg, respectively. In univariate analyses, the performance on cognitive tests primarily assessing executive function and processing speeds was worse among participants with lower diastolic blood pressure and higher pulse pressure. These relationships were not statistically significant, however, in multivariable analyses. There was no association between cognitive function and systolic blood pressure or intradialytic change in systolic blood pressure in either univariate or multivariable analyses. We found no association between different measures of blood pressure and cognitive function in cross-sectional analysis. Longitudinal studies are needed to confirm these results.

An offline mobile nutrition monitoring intervention for varying-literacy patients receiving hemodialysis: a pilot study examining usage and usability

OBJECTIVE

Design and evaluation of the dietary intake monitoring application (DIMA) to assist varying-literacy patients receiving hemodialysis to adhere to their prescribed dietary regimen.

METHODS

An iterative, user-centered design process informed by Bandura's social cognitive theory was employed to design DIMA--a mobile application that utilizes touch-screen, visual interfaces; barcode scanning; and voice recording to assist varying-literacy patients receiving hemodialysis to self-monitor their diet. A pilot field study was conducted where 18 patients receiving hemodialysis were recruited face-to-face from two dialysis facilities to use DIMA for 6 weeks. Subjects recorded their dietary intake using DIMA and met with research assistants three times each week. All interactions with DIMA were logged. Subjects' interdialytic weight gain was recorded throughout the study. At the end of the study, two face-to-face questionnaires were administered to assess usability and context of use.

RESULTS

Subjects were able to use DIMA successfully--12 subjects used DIMA as much or more at the end of the study as they did at the beginning and reported that DIMA helped them change their diet. Subjects had difficulty using the barcode scanner. Viewing past meals was the most used of the reflection mechanisms in DIMA.

CONCLUSION

Results suggest that while many design features were useful, some could be improved. In particular, future versions of DIMA will be on a smartphone using a camera for barcode scanning, integrate feedback and past meal reflection into the normal flow of the application, and support visual cues when selecting food items.