Cognitive Dysfunction In ESRD Patients Undergoing Maintenance Hemodialysis And Its Relationship With Cerebral Small Vessel Disease

Part Ⅰ: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 Objective: 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systematically.Methods: A systematic literature search was conducted in MEDLINE,Embase,Cochrane library and unpublished database Clinicaltrials.gov to identify the studies comparing the cognitive functions or risk of dementia between hemodialysis(HD)and peritoneal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: 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.Part Ⅱ Cognitive dysfunction in ESRD patients undergoing maintenance hemodialysis and its relationship with cerebral small vessel disease Objective: To investigate the prevalence and related factors of cognitive dysfunction in ESRD patients undergoing maintenance hemodialysis(hereinafter referred to as MHD)in the Blood Purification Center of the Second Hospital of Tianjin Medical University.Methods: A total of 99 MHD patients who had no history of stroke in the blood purification center of the Second Hospital of Tianjin Medical University were enrolled.The global cognitive function of MHD patients was evaluated by MoCA scale.The attention of MHD patients were evaluated by digital breadth test and execution function of them were evaluate by digital connection test.using the Hamilton Depression Scale and the Hamilton Anxiety Scale to assess the patient’s depression and anxiety status;and by collecting general information about the patient,including gender,age,dialysis time,the cause of ESRD,and combining other diseases such as high Blood pressure disease,diabetes,coronary heart disease,etc.,statistical biochemical test results: red blood cell count,white blood cell count,hemoglobin,hematocrit,platelet count,average platelet distribution width,serum calcium,serum inorganic phosphorus,serum potassium,parathyroid hormone,Alkaline phosphatase,uric acid,serum albumin,aspartate aminotransferase,triglyceride,total cholesterol,carbon dioxide binding index,analysis of the general data of patients,anxiety,depression,laboratory indicators and cognitive impairment;Results: 1.69.70% of patients with MHD have cognitive impairment;2.65.65% of MHD patients have depression status,and 57.57% of MHD patients have anxiety status;3.Performance of cognitive impairment group in digit span backwards and digit span forwards were worse than the normal cognitive function group(P<0.05),time consuming of CTT-A,and CTT B-A of cognitive impairment group were longer than the normal cognitive group(P<0.05),there was no significant difference in the time of CTT-B(P>0.05).4.There were significant differences in hemoglobin level,parathyroid hormone level and uric acid level between the cognitive impairment group and the normal cognitive function group(P<0.05).Hemoglobin level was negatively correlated with cognitive impairment in MHD patients(OR= 0.634,P<0.05),hematocrit,parathyroid hormone,uric acid were positively correlated with cognitive impairment in patients with MHD(OR=3.856,P<0.05;OR=1.028,P<0.05;OR=1.011,P<0.05);5.MHD patients with diabetes,depression,and anxiety were found to be different between the cognitive impairment group and the normal cognitive function group(P<0.05).Conclusion:1.The prevalence of cognitive impairment in MHD patients is higher,and the prevalence of anxiety and depression is higher.2 The cognitive impairment group’s attention and execution function were worse than the cognitive normal group.3 hemoglobin,parathyroid hormone,uric acid,diabetes may be the influencing factors of cognitive function in patients with MHD.Hemoglobin may be a protective factor for cognitive function in patients with MHD,Diabetes,hematocrit,parathyroid hormone Uric acid may be a risk factor.4 Depressive state and anxiety state may aggravate cognitive impairment in patients with MHD.Part Ⅲ: Relationship between cerebral small vessel disease and cognitive impairment in ESRD patients undergoing maintenance hemodialysis Objective: To investigate the imaging features of asymptomatic stenosis(SLI),microbleeds(CMB),and white matter high signal(WMHs)in cerebral small vessel disease in patients with MHD,and to analyze their relationship with cognitive impairment.Methods: Patients with MHD were given the head MRI scans of T1 WI,T2WI,DWI,FLAIR,and SWAN.The number and location of lesions in SLI,the number and location of lesions in CMB,and the Fazekas score of WMHs were analyzed to analyze its relationship with cognitive impairment..Results:1.The positive rate of SLI in MHD patients was 71.26%,the positive rate of CMB was 39.08%,and the Fazekas scale of WMHs 4-6 was 56.18%.2.The proportion of hypertension in SLI positive group was higher than that in SLI negative group,the difference was statistically significant(P<0.05).The proportion of males in the CMB-positive group was higher than that in the CMB-negative group.The serum calcium and total cholesterol levels were lower than those in the CMB-negative group(P<0.05).The proportion of severe WMHs combined with diabetes was higher than that in the mild WMHs group.The hemoglobin content was lower than that of the mild WMHs group,and the uric acid level was higher than that of the mild WMHs group(P<0.05).3 The number of SLI in the deep white matter and basal ganglia of the cognitive impairment group was higher than that in the normal cognitive group.The Fazekas score of WMHs was higher than that of the normal cognitive group(p<0.05),while the brainstem cerebellum was different.There was no significant difference in the number of SLI,the number of CMB and the difference between the two groups(p>0.05).Conclusions: 1.There is a higher propotion of patients with MHD suffer from SLI,CMB,and WMHs in cerebral small vessel disease.2.MHD patients with hypertension may be more likely to develop SLI,and gender,low serum calcium levels,low cholesterol levels may affect the occurrence of CMB,MHD patients with diabetes,low hemoglobin levels,high uric acid levels may affect the severity of WMHs.3.Cognitive impairment in MHD patients may be related to the increase in the number of SLI in the deep white matter and basal ganglia,and is related to the severity of WMHs.