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Hemodialysis linked with decline in cognitive function
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According to recently published findings of a prospective observational cohort, patients on chronic hemodialysis may have a transient decline in cerebral blood flow that is linked with intradialytic cognitive dysfunction.
“We hypothesized that dialysis was capable of reducing blood flow to the brain and that this would have a direct effect on the brain’s cognitive functions, such as memory,” Mark D. Findlay, MBChB, MRCP, told Nephrology News & Issues. “The take-home message is we have now described, in detail, this previously presumed ‘side effect’ of dialysis, including a potential mechanism, and that in those able to undergo transplantation, there is demonstrable improvement in both cognitive function and MRI changes following transplant.”
Progressive cerebrovascular disease occurred in patients continuing dialysis, but not in transplanted patients. Post-transplant, both cognitive function and cerebral diffusion improved, according to the researchers.
Overall, 97 patients participated in the study and had a median age of 59 years. All patients were aged 18 to 85 years and were receiving hospital hemodialysis for ESRD.
The researchers used transcranial Doppler ultrasound to measure cerebral arterial mean flow velocity (MFV) for the duration of dialysis treatments. A modified 30-minute National Institute of Neurologic Disorders and Stroke-Canadian Stroke Network neuropsychological battery was used to determine cognitive function. MRIs were utilized to test correlations between MFV and cognitive scores, as well as assess atrophy, white matter hyperintensities and diffusion parameters. Cognitive impairment was present in 43% of patients who previously reported none before, based on the material cognitive assessment. MFV declined after dialysis for a median decrease of -10%. Additionally, participants scored lower in assessments of executive function during dialysis, according to the researchers.
“In nephrology, this has immediate effects affecting clinical practice,” Findlay added. “Complex discussions with those on dialysis should not take place whilst the patient is attached to the dialysis machine and, in the longer term, opens the door to future research designed to limit the harmful effects of on-going dialysis on the brain. " - by Joe Gramigna
Disclosures: The researchers report no relevant financial disclosures.
Perspective
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Kathryn Aebel-Groesch, MSW, LCSW
In a recent interview with Healio/Nephrology, Mark Findlay, MBCHB, MRCP, described his team’s research on the impact of in-center hemodialysis on patients’ cerebral arterial blood flow and cognitive function — the “side effect” of dialysis. Using transcranial Doppler ultrasound, cerebral MRI and a neuropsychological battery, Findlay’s team measured physiological effects and cognitive function, respectively, among patients on in-center hemodialysis. They reported that patients who received renal transplant demonstrated improved cerebral diffusion and cognitive functioning.
Findlay concludes, “In nephrology, this has immediate effects affecting clinical practice. Complex discussions with those on dialysis should not take place whilst the patient is attached to the dialysis machine and, in the longer term, opens the door to future research designed to limit the harmful effects of on-going dialysis on the brain.”
Cognitive impairment, even transient, impacts patients’ health literacy, the ability to understand medical information, participate in the care planning and adhere to their treatment regimen. Clinicians should be mindful that even patients who do not initially present with any cognitive impairment could experience such changes over the course of their dialysis history.
The entire treatment team (nephrologist, nurse, dietitian, social worker and dialysis technician) must adapt educational approaches to accommodate patients’ cognitive needs. Engaging patients earlier in their treatment sessions along with incorporating video or tactile tools could enhance comprehension and retention of chairside education. With their permission, involving patients’ loved ones could reinforce education and provide insight into their comprehension of the treatment regimen and modality options.
Findlay’s findings provoke the question: Could more frequent dialysis, such as PD or home hemodialysis, or gentler nocturnal dialysis reduce the risk of cognitive impairment? Patients who receive more regular and longer dialysis treatments tend to have improved adequacy, with fewer uremic symptoms.
The renal community recognizes the benefits of transplant are plentiful; social workers in dialysis clinics strive to support patients throughout the process of transplant evaluation. However, with the numbers of patients on transplant wait lists, thoughtful promotion of living donations is essential to meet demand. According to the United Network for Organ Sharing, there are currently 102,861 people on waitlist for kidney transplantation. The National Kidney Foundation reports an average of 3,000 people are added to the list each month.
Regular assessment of a patient’s cognitive status could inform the treatment team’s method of delivering education, facilitating engagement in care planning. Promoting the medical benefits of transplant and more frequent dialysis via peritoneal dialysis or home hemodialysis could encourage patients to consider alternatives to traditional, thrice-weekly in-center hemodialysis.
Manager, Social Work Services
DaVita Kidney Care
Denver
Nephrology News & Issues Editorial Advisory Board Member
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