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Am J Kidney Dis. 2018 Oct;72(4):499-508. doi: 10.1053/j.ajkd.2018.02.361. Epub 2018 May 2.

Cognitive Impairment in Non-Dialysis-Dependent CKD and the Transition to Dialysis: Findings From the Chronic Renal Insufficiency Cohort (CRIC) Study.

Author information

1
Division of Nephrology and Hypertension, Drexel University College of Medicine, Philadelphia, PA. Electronic address: mnh52@drexel.edu.
2
Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
3
Division of Nephrology, University of California, San Francisco, San Francisco, CA; Division of Research, Kaiser Permanente Northern California, Oakland, CA.
4
Division of Biostatistics, University of California, San Francisco, San Francisco, CA; Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA.
5
Division of Research, Kaiser Permanente Northern California, Oakland, CA; Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA; Department of Medicine, University of California, San Francisco, San Francisco, CA.
6
Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Welch Center for Prevention, Epidemiology, and Clinical Research, Baltimore, MD.
7
Division of Nephrology, University of Maryland School of Medicine, Baltimore, MD.
8
Division of Nephrology, Department of Medicine, Tulane School of Medicine, New Orleans, LA.
9
Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA.
10
Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH.
11
Department of Medicine, Loyola University Medical Center, Maywood, IL.
12
Department of Medicine, University of Illinois at Chicago, Chicago, IL.
13
Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA; Department of Psychiatry, University of California, San Francisco, CA; Department of Neurology, University of California, San Francisco, CA; San Francisco VA Medical Center, San Francisco, CA.
14
Geriatric Research and Education Clinical Center, VA Palo Alto, Palo Alto, CA; Stanford University School of Medicine, Palo Alto, CA.

Abstract

BACKGROUND:

Advanced chronic kidney disease is associated with elevated risk for cognitive impairment. However, it is not known whether and how cognitive impairment is associated with planning and preparation for end-stage renal disease.

STUDY DESIGN:

Retrospective observational study.

SETTING & PARTICIPANTS:

630 adults participating in the CRIC (Chronic Renal Insufficiency Cohort) Study who had cognitive assessments in late-stage CKD, defined as estimated glome-rular filtration rate ≤ 20mL/min/1.73m2, and subsequently initiated maintenance dialysis therapy.

PREDICTOR:

Predialysis cognitive impairment, defined as a score on the Modified Mini-Mental State Examination lower than previously derived age-based threshold scores. Covariates included age, race/ethnicity, educational attainment, comorbid conditions, and health literacy.

OUTCOMES:

Peritoneal dialysis (PD) as first dialysis modality, preemptive permanent access placement, venous catheter avoidance at dialysis therapy initiation, and preemptive wait-listing for a kidney transplant.

MEASUREMENTS:

Multivariable-adjusted logistic regression.

RESULTS:

Predialysis cognitive impairment was present in 117 (19%) participants. PD was the first dialysis modality among 16% of participants (n=100), 75% had preemptive access placed (n=473), 45% avoided using a venous catheter at dialysis therapy initiation (n=279), and 20% were preemptively wait-listed (n=126). Predialysis cognitive impairment was independently associated with 78% lower odds of PD as the first dialysis modality (adjusted OR [aOR], 0.22; 95% CI, 0.06-0.74; P=0.02) and 42% lower odds of venous catheter avoidance at dialysis therapy initiation (aOR, 0.58; 95% CI, 0.34-0.98; P=0.04). Predialysis cognitive impairment was not independently associated with preemptive permanent access placement or wait-listing.

LIMITATIONS:

Potential unmeasured confounders; single measure of cognitive function.

CONCLUSIONS:

Predialysis cognitive impairment is associated with a lower likelihood of PD as a first dialysis modality and of venous catheter avoidance at dialysis therapy initiation. Future studies may consider addressing cognitive function when testing strategies to improve patient transitions to dialysis therapy.

KEYWORDS:

CKD to ESRD transition; Chronic kidney diseases (CKDs); central venous catheter (CVC); cognitive impairment; dementia; dialysis access; dialysis modality; end-stage renal disease (ESRD); executive function; incident ESRD; memory; peritoneal dialysis (PD); transplant waitlisting

PMID:
29728316
PMCID:
PMC6153064
[Available on 2019-10-01]
DOI:
10.1053/j.ajkd.2018.02.361

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