Cognitive Impairment in CKD: Pathophysiology, Management, and Prevention
Cognitive Impairment in CKD: Pathophysiology, Management, and Prevention
复制标题
DOI：
10.1053/j.ajkd.2019.05.017
复制
发表时间：
2019-12-01
影响因子：
13.2
通讯作者：
Sarnak, Mark J.
中科院分区：
文献类型：
--
作者：
Drew, David A.;Weiner, Daniel E.;Sarnak, Mark J.
慢性肾脏病(CKD)患者发生认知功能损害的风险明显高于一般人群，肾小球滤过率低和蛋白尿的存在都与认知损害的发生和认知功能的降低有关。考虑到CKD患者的血管疾病过多，脑血管疾病可能是这些联系的主要病理基础，尽管尿毒症代谢物清除障碍、抑郁、睡眠障碍、贫血和多药联用也可能起到作用。修改血管疾病危险因素可能有助于限制下降，尽管缺乏确切的数据。对于CKD，使用血管紧张素转换酶抑制剂或血管紧张素受体阻滞剂来降低血压和减少蛋白尿可能会减缓认知能力的下降，尽管幅度不大。开始透析可以改善与尿毒症相关的严重损害，但似乎不会影响更轻微的慢性认知损害。相比之下，肾移植似乎会改善许多移植受者的认知功能，这表明透析方法并不能提供与拥有功能正常的肾脏相同的认知益处。对CKD和认知障碍患者的管理应该包括一个全面的计划，包括更频繁的后续访问；让家人参与共同的决策；采取措施改善依从性，如书面指导和药片计数；重点放在提前指示上，同时强调了解患者的生活目标。需要进一步研究新的治疗方法，包括创新的透析方法，旨在限制认知障碍的发展，减缓普遍存在的障碍的下降，并改善认知功能。
Patients with chronic kidney disease (CKD) are at substantially higher risk for developing cognitive impairment compared with the general population, and both lower glomerular filtration rate and the presence of albuminuria are associated with the development of cognitive impairment and poorer cognitive function. Given the excess of vascular disease seen in individuals with CKD, cerebrovascular disease is likely the predominant pathology underlying these associations, though impaired clearance of uremic metabolites, depression, sleep disturbance, anemia, and polypharmacy may also contribute. Modification of vascular disease risk factors may be helpful in limiting decline, though definite data are lacking. Specific to CKD, targeting a low blood pressure and reduction in albuminuria with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers may slow cognitive decline, albeit modestly. Initiation of dialysis can improve severe impairment associated with uremia but does not appear to affect more subtle chronic cognitive impairment. In contrast, kidney transplantation appears to lead to improved cognitive function in many transplant recipients, suggesting that dialysis methods do not provide the same cognitive benefits as having a functioning kidney. Management of patients with both CKD and cognitive impairment should include a comprehensive plan including more frequent follow-up visits; involvement of family in shared decision making; measures to improve compliance, such as written instruction and pill counts; and a focus on advance directives in conjunction with an emphasis on understanding an individual patient's life goals. Further research is needed on novel therapies, including innovative dialysis methods, that aim to limit the development of cognitive impairment, slow decline in those with prevalent impairment, and improve cognitive function.