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WORLD HOSPITAL DIRECTORY
Nephrology Medical Nephrology Dialysis Transplantation - current issue
<span class="paragraphSection"><div class="boxTitle">ABSTRACT</div>Chronic kidney disease is associated with cognitive impairment although the underlying mechanisms are still not fully understood. Characterization and efficient monitoring of the cognitive impact of kidney disease and ensuing therapies are critical for the accurate clinical management of patients. A vast array of imaging modalities, biomarkers, and sensors have shown relevance for the assessment of cognitive impairment. Knowing the potential and limitations of these paraclinical techniques is a necessary condition to improve the understanding of this phenomenon and to design monitoring protocols and guidelines applicable to this clinical population. The goal of this review is to provide an overview of current imaging modalities and biomarker sources available to the community, for the benefit of the research and clinical community.</span>
<span class="paragraphSection"><div class="boxTitle">ABSTRACT</div>Cognitive decline is frequently seen in patients with chronic kidney disease (CKD). The causes of cognitive decline in these patients are likely to be multifactorial, including vascular disease, uraemic toxins, blood–brain barrier leakage, and metabolic and endocrine changes. Gut dysbiosis is common in patients with CKD and contributes to the increase in uraemic toxins. However, the gut microbiome modulates local and systemic levels of several metabolites such as short-chain fatty acids or derivatives of tryptophan metabolism, neurotransmitters, endocannabinoid-like mediators, bile acids, hormones such as glucagon-like peptide 1 (GLP1) or cholecystokinin (CCK). These factors can affect gut function, immunity, autonomic nervous system activity and various aspects of brain function. Key areas include blood–brain barrier integrity, nerve myelination and survival/proliferation, appetite, metabolism and thermoregulation, mood, anxiety and depression, stress and local inflammation.Alterations in the composition of the gut microbiota and the production of biologically active metabolites in patients with CKD are well documented and are favoured by low-fiber diets, elevated urea levels, sedentary lifestyles, slow stool transit times and polypharmacy. In turn, dysbiosis can modulate brain function and cognitive processes, as discussed in this review. Thus, the gut microbiome may contribute to alterations in cognition in patients with CKD and may be a target for therapeutic interventions using diet, prebiotics and probiotics.</span>
<span class="paragraphSection"><div class="boxTitle">ABSTRACT</div>Chronic kidney disease affects almost all of the organs. Recently, more attention has been paid to the kidney and the central nervous system connections. In patients on kidney replacement therapy, including kidney transplantation, there is an increased prevalence of cognitive impairment, and depression and other neurological complications, such as cerebrovascular disorders and movement disorders. Kidney transplant recipients need an assessment for the risk factors and the pattern of cognitive impairment (memory, attention and executive function decline). This enables an accurate diagnosis to be made at an earlier stage. Partial post-transplant cognitive impairment recovery is also important. Finally, doctors and patients alike face numerous ethical concerns and challenges regarding the transplantation of kidneys and other solid organs. In this review, we examined some key issues regarding cognitive impairment in kidney transplant patients. We focused on the mechanism of cognitive impairment in kidney transplant recipients, patterns of cognitive impairment; evaluation of patients with cognitive impairment for kidney transplantation, the potential impact of cognitive impairment on waitlisted and transplanted patients on patient care, non-pharmacological interventions and unmet medical needs, psychological and ethical issues in kidney transplantation, and unmet needs. As cognitive impairment in kidney transplant recipients is an underestimated, underrecognized but clinically relevant problem, screening for cognitive function before and after kidney transplantation would be worth considering in standard routine practice.</span>
<span class="paragraphSection"><div class="boxTitle">ABSTRACT</div>Research on cognitive function in individuals with chronic kidney disease (CKD) is critical due to the significant public health challenge posed by both CKD and cognitive impairment. CKD affects approximately 10–15% of the adult population, with higher prevalence in the elderly, who are already at increased risk for cognitive decline. Cognitive impairment is notably higher in CKD patients, particularly those with severe stages of the disease, and progresses more rapidly in those on dialysis.This review explores how data from large biobank studies such as the Alzheimer's Disease Neuroimaging Initiative, UK Biobank, and others could be used to enhance understanding the progression and interplay between CKD and cognitive decline. Each of these data sources has specific strengths and limitations. Strengths include large sample sizes and longitudinal data across different groups, and in different settings. Addressing limitations leads to challenges in dealing with heterogeneous data collection methods, and addressing missing data, which requires the use of sophisticated statistical techniques. Combining data from multiple databases can mitigate individual study limitations, particularly via the ‘epidemiological triangulation’ concept.Using such data appropriately holds immense potential to better understand the pathobiology underlying CKD and cognitive impairment. Addressing the inherent challenges with a clear strategy is crucial for advancing our understanding and improving the lives of those affected by both CKD and cognitive impairment.</span>
<span class="paragraphSection"><div class="boxTitle">ABSTRACT</div>Cancer and kidney diseases (KD) intersect in many ways resulting in worse outcomes. Both conditions are correlated with cognitive impairment, which can be exacerbated in cancer patients by known effects of many antineoplastic drugs on cognition, leading to a phenomenon known as chemotherapy-related cognitive impairment (CRCI). This manifests as poor attention span, disturbed short-term memory, and general mental sluggishness. This literature review explores CRCI and investigates the potential impact of KD on this phenomenon. Additionally, we highlight the shared pathogenetic mechanisms (including neurotoxicity, neuroinflammation, oxidative stress, vascular disease, electrolyte, and acid-base imbalances), clinical presentation and imaging findings between cognitive impairment in KD and CRCI. The disruption of the blood–brain barrier might be a key mechanism for increased brain permeability to anticancer drugs in nephropathic patients with cancer. Based on existing knowledge, we found a potential for heightened neurotoxicity of antineoplastic drugs and a synergistic potentiation of cognitive impairment in cancer patients with KD. However, further translational research is urgently required to validate this hypothesis.</span>
<span class="paragraphSection"><div class="boxTitle">ABSTRACT</div>Various epidemiological datasets and pathophysiological hypotheses have highlighted a significant link between chronic kidney disease (CKD) and cognitive impairment (CI); each condition can potentially exacerbate the other. Here, we review the mutual consequences of CKD and CI on health outcomes and care pathways and highlight the complexities due to the involvement of different specialists. Our narrative review covers (i) the burden of CI among patients with CKD, (ii) the impact of CI on kidney health, (iii) access to kidney replacement therapy for people with CI, (iv) resources in cognitive care and (v) potential models for integrated ‘nephro-cognitive’ care. CI (ranging from mild CI to dementia) has a significant impact on older adults, with a high prevalence and a strong association with CKD. Furthermore, CI complicates the management of CKD and leads to a higher mortality rate, poorer quality of life and higher healthcare costs. Due to difficulties in symptom description and poor adherence to medical guidelines, the presence of CI can delay the treatment of CKD. Access to care for patients with both CKD and CI is hindered by physical, cognitive and systemic barriers, resulting in less intensive, less timely care. Multidisciplinary approaches involving nephrologists, geriatricians, neurologists and other specialists are crucial. Integrated care models focused on person-centred approaches, shared decision-making and continuous co-management may improve outcomes. Future research should focus on the putative beneficial effects of these various strategies on both clinical and patient-reported outcomes.</span>
<span class="paragraphSection"><div class="boxTitle">ABSTRACT</div>Chronic kidney disease (CKD) is commonly accompanied by cognitive dysfunction and dementia, which, in turn, increase the risk of hospitalization, cardiovascular events and death. Over the last 30 years, only four studies focused on genetic markers of cognitive impairment in CKD and kidney failure (KF), indicating a significant gap in research. These studies suggest potential genetic predispositions to cognitive decline in CKD patients but also underscore the necessity for more comprehensive studies. Seventeen reports have established connections between cognitive function and kidney disease markers such as estimated glomerular filtration rate (eGFR), Cystatin C and albuminuria. A rapid eGFR decline has been associated with cognitive deterioration and vascular dementia, and mild to moderate eGFR reductions with diminished executive function in elderly men. Various biomarkers have been associated to Alzheimer's disease or dementia in CKD and KF. These include amyloid beta and phosphorylated tau proteins, uremic toxins, gut microbiota, metabolic indicators, hypertension, endothelial dysfunction, vitamins and inflammation. However, the causal relevance of these associations remains unclear. Overall, the available evidence points to a complex interplay between the different biomarkers and cognitive health in CKD patients, underscoring the need for more research to elucidate these relationships.</span>
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