Cognitive alterations in chronic kidney disease: an update

Abstracts

Impairment of cognitive functions occurs frequently in chronic kidney disease (CKD). The conditions most associated with this decline are depression, delirium, mild cognitive impairment and dementia. The mechanisms involved have not been established yet, but some factors, as neuronal damage by uremic toxins, cerebrovascular ischemic lesions, oxidative stress, chronic inflammation, anemia, hyperhomocysteinemia, the endothelial dysfunction may play a critical role. The neuropsychological performance improves with the initiation of dialysis, although some cognitive dysfunctions remain even after treatment, especially in the areas of attention, cognitive flexibility, memory and learning. Kidney transplantation may improve and even reverse some cognitive deficits detected in the dialysis period, despite some compromise in verbal memory and executive functions remain after transplantation. The diagnosis of cognitive decline in patients with CKD may have an important impact on the management and prognosis. This paper presents an update on the decline of cognitive function in patients with CKD.

cognition disorders; dialysis; kidney failure, chronic; kidney transplantation

Prejuízos das funções cognitivas ocorrem com frequência na doença renal crônica (DRC). As condições mais associadas a esses prejuízos são depressão, delirium, comprometimento cognitivo leve e demência. Os mecanismos envolvidos ainda não estão estabelecidos, mas alguns fatores, como dano neuronal induzido pelas toxinas urêmicas, lesões cerebrovasculares isquêmicas, estresse oxidativo, inflamação crônica, anemia, hiper-homocisteinemia e disfunção endotelial, podem ser importantes. O desempenho neuropsicológico tende a melhorar com o início da diálise, apesar de algumas disfunções cognitivas permanecerem alteradas mesmo após a instituição do tratamento, principalmente nos domínios de atenção, flexibilidade cognitiva, memória e aprendizagem. O transplante renal pode melhorar e, inclusive, reverter alguns déficits cognitivos, apesar de prejuízos na memória verbal e nas funções executivas poderem permanecer. O diagnóstico do declínio cognitivo nos pacientes renais crônicos pode ter impacto no manejo e no prognóstico. Este artigo apresenta uma atualização sobre declínio das funções cognitivas nos pacientes com DRC.

cognição; diálise; insuficiência renal crônica; transplante de rim

Introduction

The term "cognition" covers aspects of brain function related to various domains such as attention, language, memory, learning, reasoning, decision making, and problem solving. Cognitive impairment can be understood as a decline in patient baseline functions possibly at a level severe enough to interfere with the performance of activities of daily living by the individual. Cognitive involvement and dementia are commonly seen in patients with chronic kidney disease (CKD), particularly in subjects with advanced stage disease, but are poorly recognized by nephrologists.¹ However, individuals with disease in any stage are susceptible to cognitive disorders² associated with increased risk of death, lower levels of compliance to proposed treatment, higher incidence of cerebrovascular disease, and prolonged hospitalization.^1,3,4

The identification of cognitive deficits may produce positive impacts on patient outcome, particularly when the impairment is secondary to potentially treatable conditions such as depression and delirium.¹ The prevalence of depression symptoms in patients with end-stage renal disease (ESRD) ranges between 20% and 25%,⁵ ranking them second only to hypertension in the roster of comorbidities observed in patients with ESRD.^5,6

Delirium is a syndrome characterized by rapid onset of alternating consciousness and cognitive function alterations caused by the physiologic dysfunctions introduced by a medical condition.⁷ Psychomotor and sleep architecture disorders are commonly seen in patients suffering from delirium.³ The predisposing factors for delirium in patients with CKD include sensory loss, cerebrovascular disease, subclinical metabolic disorders, and polypharmacy. Hospitalization and alterations in the metabolism of certain drugs (opioids, psychotropic drugs, antibiotics, antiviral medication) and their toxic metabolites also boost occurrences of delirium.^3,8

In addition to potentially reversible conditions, mild cognitive involvement and dementia have also been correlated with mental function decline. CKD has been strongly correlated with vascular dementia in particular.^9,10 When compared to the general population, the prevalence of cognitive impairment is higher in individuals with renal failure and even more significant in patients on dialysis.¹¹ In qualitative terms, mild cognitive involvement is similar to dementia, although its impact on the performance of activities of daily living is not as significant as the one produced by dementia.

Dementia appears to complicate the management of patients with ESRD and has been correlated with poorer prognosis.¹ Patients with dementia present deficits in at least two of the following cognitive functional areas: memory, executive function, attention, visuospatial skills, speed of information processing, and language. Signs of decline in lower functional levels materialize as compromised performance in various areas of the affected individual's life, such as work and interpersonal relationships.⁷ Murray et al.¹² looked into the neuropsychological performance of 338 hemodialysis patients through memory, language, and executive function tests and found that over a third of the subjects had three times the prevalence of dementia estimated for the general population.

However, dementia is not limited to cases of advanced kidney disease. Patients initially diagnosed with moderate renal disease without dementia had higher incidences of vascular dementia over six years of follow-up¹⁰ in association with higher serum creatinine levels.

Given the context, this paper aims to present an update on the most frequent cognitive alterations seen in CKD patients and further emphasize the relevance of the topic in nephrology care.

What are the mechanisms involved in the cognitive dysfunctions of patients with CKD?

Most studies suggest that CKD severity and progression of cognitive decline go hand in hand.¹³ Feng et al.¹⁴ followed a group of patients for four years and correlated the estimated glomerular filtration rate (GFR) decreases in CKD patients aged 55 years and older with greater functional and global cognitive decline.

Helmer et al.⁸ studied a cohort of 7,839 patients aged 65 and older and did not report increases in the risk of cognitive impairment or dementia in association with low estimated GFR. In the seven-year follow-up, however, more rapid declines in the GRF were associated with global cognitive impairment and increased incidence of vascular dementia. In any case, other recent studies comparing patients with CKD and subjects without renal disease have confirmed the correlation between all stages of CKD and greater risk of cerebral function impairment.^2,15,16

The mechanisms involved in this process have not been completely elucidated, but research indicates that, in addition to neuronal damage induced by uremic toxins, the risk of cognitive involvement and dementia in these patients may be due to the high prevalence of symptomatic and asymptomatic brain ischemia.² This vascular mechanism may explain the association between the risk factors affecting both the brain and the kidneys and its potential exacerbation in renal disease.⁸

Oxidative stress,^17,18 immuno-inflammatory processes,¹⁸ anemia,^19,20 hyperhomocysteinemia,²¹ and vitamin B12 deficiency²¹ may be involved in neurocognitive performance decline. CKD patients on hemodialysis have more prothrombotic factors,^22,23 endothelial dysfunction,^18,22-24 abnormal vascular reactivity,²⁴ atherosclerosis,²⁵ and cardiovascular events.²⁵ By their turn, renal transplant patients have particularly higher levels of urinary chemokines and cytokines, which may serve as a sign of graft prognosis.²⁶ Figure 1 shows a schematic representation of the pathophysiological mechanisms related to cognitive dysfunction in CKD patients.

Figure 1
Mechanisms involved in cognitive impairment of patients with chronic kidney disease (CKD).

Dialysis and cognition

Although underdiagnosed, the prevalence of cognitive impairment is significant among individuals with CKD on dialysis.¹⁶ A recent study found that patients on dialysis performed more poorly than the general population on tasks assessing executive function, a finding correlated with vascular disease and vascular risk factors.²⁷ Normal scores on the Mini Mental State Examination (MMSE), the main test used for cognitive screening in clinical practice,²⁸ do not rule out cognitive involvement, as individuals scoring high in the MMSE may perform poorly on more comprehensive neuropsychological tests.²⁷

Individuals on hemodialysis had low scores in logical reasoning, verbal learning, motor skills, verbal fluency, visuospatial memory tests.²⁹ The risk of multi-infarct dementia in elderly patients on hemodialysis appears to be seven times greater than in the general population, possibly due to increased prevalence of comorbidities such as diabetes mellitus, atherosclerosis, and hypertension in this patient group.³⁰

Similarly to hemodialysis patients, most individuals on peritoneal dialysis have moderate to severe cognitive impairment, especially in areas related to executive function, decision-making, and capacity for abstraction. Such impairment may interfere with the self-administration of dialysis and compliance with complex medication regimens.³¹ Patients doing well on hemodialysis, in good nutritional condition, and clinically stable do not appear to differ significantly from their counterparts in equal condition on peritoneal dialysis.^16,32

Dialysis processes directly contribute to cognitive involvement by inducing brain ischemia. Acute decreases in intravascular volumes and fluid exchanges occurring during dialysis sessions may cause edema and diminish cerebral perfusion.¹⁶ More specifically, patients with acute kidney injury are more susceptible to cerebral hypoperfusion during intermittent hemodialysis than patients with ESRD.³³

Neuropsychological performance tends to improve after the introduction of dialysis, and patients on dialysis have lesser cognitive deficits than untreated individuals and patients with uremia. Short-term memory improves with maintenance hemodialysis,³⁴ despite the possible persistence of other cognitive dysfunctions in the domains of attention, cognitive flexibility, memory, and learning.³⁴

Cognitive function and kidney transplantation

Studies have described memory improvements after renal transplantation and reversion of some neuropsychological deficits, memory impairments in particular, detected during dialysis.³⁵ Although in a study published in 1984 Fennel et al.³⁶ indicated that improvements in cognitive performance were not sustained in children and adolescents, the benefits of kidney transplantation do not seem to be transient or limited to the early stages of the post-transplant period, and may persist for at least a year after the procedure.^37,38

Improvements in cognition may be observed in intelligence tests after renal transplantation, both in adults and children.^35,39 Nevertheless, after transplantation patients may still have to endure deficits in verbal memory and executive function.⁴⁰ Despite the improvements in the metabolic factors associated with CKD, cognitive impairment is thought to persist as a consequence of the patients' remaining clinical comorbidities.⁴⁰

Evidence suggests that kidney transplantation and dialysis positively impact the cognitive status of patients with CKD. However, the literature does not support the prescription of dialysis based solely on the presence of cognitive impairment. Patients with chronic kidney disease might benefit from therapies devised specifically to improve cognitive performance, such as cognitive rehabilitation, but no specific studies have been carried out on the matter. Likewise, little research has been done on the efficacy and safety of drug therapies for dementia and mild cognitive impairment in the context of kidney disease; management, therefore, must be individualized.

Closing remarks

Depression, delirium and dementia are commonly seen in any stage of CKD, and are generally associated with complications and poorer prognosis.¹² CKD appears to be a risk factor for cognitive impairment and dementia. Renal disease severity walks hand in hand with loss of neurocognitive function.⁹

Although evidence suggests that hemodialysis improves cognition in patients with CKD,⁴ a significant, yet underestimated, portion of the individuals on hemodialysis presents moderate to severe cognitive impairment. There appears to be no difference in the cognitive disorders affecting patients with CKD treated with hemodialysis or peritoneal dialysis.¹⁶

The identification of patients with cognitive impairment is an important step in the process to improve quality of life and mitigate the morbidities associated with this condition. The ideal time to assess cognitive function and the choice of screening scale must take the patient's clinical status into account.¹ Evaluations should take little time, as is the case with the administration of the MMSE,²⁸ the best known and studied screening test for dementia. However, neuropsychological testing requires more time and may be needed in more thorough investigations of the cognitive domains.

The reasons behind the onset of cognitive impairment in patients with CKD are yet unclear, but evidence indicates the involvement of factors such as inflammation, endothelial dysfunction, atherosclerosis, oxidative stress, anemia, hyperhomocysteinemia, and uremic toxins.^18,21,23 More studies are needed to shed light on the possible strategies that may be used to delay or prevent the onset of cognitive impairment in patients with chronic kidney disease.

Referências

• ¹
  Kurella Tamura M, Yaffe K. Dementia and cognitive impairment in ESRD: diagnostic and therapeutic strategies. Kidney Int 2011;79:14-22. PMID: 20861818 DOI: http://dx.doi.org/10.1038/ki.2010.336
  » http://dx.doi.org/10.1038/ki.2010.336
• ²
  Bugnicourt JM, Godefroy O, Chillon JM, Choukroun G, Massy ZA. Cognitive disorders and dementia in CKD: the neglected kidney-brain axis. J Am Soc Nephrol 2013;24:353-63. DOI: http://dx.doi.org/10.1681/ASN.2012050536
  » http://dx.doi.org/10.1681/ASN.2012050536
• ³
  McQuillan R, Jassal SV. Neuropsychiatric complications of chronic kidney disease. Nat Rev Nephrol 2010;6:471-9. DOI: http://dx.doi.org/10.1038/nrneph.2010.83
  » http://dx.doi.org/10.1038/nrneph.2010.83
• ⁴
  Nasser Mel T, Shawki S, El Shahawy Y, Sany D. Assessment of cognitive dysfunction in kidney disease. Saudi J Kidney Dis Transpl 2012;23:1208-14.
• ⁵
  Cukor D, Coplan J, Brown C, Friedman S, Cromwell-Smith A, Peterson RA, et al. Depression and anxiety in urban hemodialysis patients. Clin J Am Soc Nephrol 2007;2:484-90. DOI: http://dx.doi.org/10.2215/CJN.00040107
  » http://dx.doi.org/10.2215/CJN.00040107
• ⁶
  Cukor D, Peterson RA, Cohen SD, Kimmel PL. Depression in end-stage renal disease hemodialysis patients. Nat Clin Pract Nephrol 2006;2:678-87. DOI: http://dx.doi.org/10.1038/ncpneph0359
  » http://dx.doi.org/10.1038/ncpneph0359
• ⁷
  American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington: American Psychiatric Association; 2000.
• ⁸
  Helmer C, Stengel B, Metzger M, Froissart M, Massy ZA, Tzourio C, et al. Chronic kidney disease, cognitive decline, and incident dementia: the 3C Study. Neurology 2011;77:2043-51. PMID: 22116945 DOI: http://dx.doi.org/10.1212/WNL.0b013e31823b4765
  » http://dx.doi.org/10.1212/WNL.0b013e31823b4765
• ⁹
  Cheng KC, Chen YL, Lai SW, Mou CH, Tsai PY, Sung FC. Patients with chronic kidney disease are at an elevated risk of dementia: a population-based cohort study in Taiwan. BMC Nephrol 2012;13:129. DOI: http://dx.doi.org/10.1186/1471-2369-13-129
  » http://dx.doi.org/10.1186/1471-2369-13-129
• ¹⁰
  Seliger SL, Siscovick DS, Stehman-Breen CO, Gillen DL, Fitzpatrick A, Bleyer A, Kuller LH. Moderate renal impairment and risk of dementia among older adults: the Cardiovascular Health Cognition Study. J Am Soc Nephrol 2004;15:1904-11. DOI: http://dx.doi.org/10.1097/01.ASN.0000131529.60019.FA
  » http://dx.doi.org/10.1097/01.ASN.0000131529.60019.FA
• ¹¹
  Gaxatte C, Daroux M, Bloch J, Puisieux F, Deramecourt V, Boulanger E. Cognitive impairment and chronic kidney disease: which links? Nephrol Ther 2011;7:10-7.
• ¹²
  Murray AM, Tupper DE, Knopman DS, Gilbertson DT, Pederson SL, Li S, et al. Cognitive impairment in hemodialysis patients is common. Neurology 2006;67:216-23. DOI: http://dx.doi.org/10.1212/01.wnl.0000225182.15532.40
  » http://dx.doi.org/10.1212/01.wnl.0000225182.15532.40
• ¹³
  Kurella M, Chertow GM, Luan J, Yaffe K. Cognitive impairment in chronic kidney disease. J Am Geriatr Soc 2004;52:1863-9. PMID: 15507063 DOI: http://dx.doi.org/10.1111/j.1532-5415.2004.52508.x
  » http://dx.doi.org/10.1111/j.1532-5415.2004.52508.x
• ¹⁴
  Feng L, Yap KB, Yeoh LY, Ng TP. Kidney function and cognitive and functional decline in elderly adults: findings from the Singapore longitudinal aging study. J Am Geriatr Soc 2012;60:1208-14. DOI: http://dx.doi.org/10.1111/j.1532-5415.2012.04043.x
  » http://dx.doi.org/10.1111/j.1532-5415.2012.04043.x
• ¹⁵
  Kurella Tamura M, Wadley V, Yaffe K, McClure LA, Howard G, Go R, et al. Kidney function and cognitive impairment in US adults: the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study. Am J Kidney Dis 2008;52:227-34. PMID: 18585836 DOI: http://dx.doi.org/10.1053/j.ajkd.2008.05.004
  » http://dx.doi.org/10.1053/j.ajkd.2008.05.004
• ¹⁶
  Radic J, LjuticD, RadicM, KovacicV, Sain M, CurkovicKD. The possible impact of dialysis modality on cognitive function in chronic dialysis patients. Neth J Med 2010;68:153-7. PMID: 20421655
• ¹⁷
  Small DM, Coombes JS, Bennett N, Johnson DW, Gobe GC. Oxidative stress, anti-oxidant therapies and chronic kidney disease. Nephrology (Carlton) 2012;17:311-21. DOI: http://dx.doi.org/10.1111/j.1440-1797.2012.01572.x
  » http://dx.doi.org/10.1111/j.1440-1797.2012.01572.x
• ¹⁸
  Vianna HR, Soares CM, Tavares MS, Teixeira MM, Silva AC. Inflammation in chronic kidney disease: the role of cytokines. J Bras Nefrol 2011;33:351-64. DOI: http://dx.doi.org/10.1590/S0101-28002011000300012
  » http://dx.doi.org/10.1590/S0101-28002011000300012
• ¹⁹
  Murray AM, Li SL, Collins AJ. Anemia as a risk factor for incident dementia in hemodialysis patients. J Am Soc Nephrol 2002;13:628a
• ²⁰
  Singh NP, Sahni V, Wadhwa A, Garg S, Bajaj SK, Kohli R, et al. Effect of improvement in anemia on electroneurophysiological markers (P300) of cognitive dysfunction in chronic kidney disease. Hemodial Int 2006;10:267-73. DOI: http://dx.doi.org/10.1111/j.1542-4758.2006.00107.x
  » http://dx.doi.org/10.1111/j.1542-4758.2006.00107.x
• ²¹
  Troen AM, Scott TM, D'Anci KE, Moorthy D, Dobson B, Rogers G, et al.; FACT Study Investigators. Cognitive dysfunction and depression in adult kidney transplant recipients: baseline findings from the FAVORIT Ancillary Cognitive Trial (FACT). J Ren Nutr 2012;22:268-76. DOI: http://dx.doi.org/10.1053/j.jrn.2011.07.009
  » http://dx.doi.org/10.1053/j.jrn.2011.07.009
• ²²
  Recio-Mayoral A, Banerjee D, Streather C, Kaski JC. Endothelial dysfunction, inflammation and atherosclerosis in chronic kidney disease-a cross-sectional study of predialysis, dialysis and kidney-transplantation patients. Atherosclerosis 2011;216:446-51. PMID: 21414625 DOI: http://dx.doi.org/10.1016/j.atherosclerosis.2011.02.017
  » http://dx.doi.org/10.1016/j.atherosclerosis.2011.02.017
• ²³
  Rios DR, Carvalho Md, Lwaleed BA, Simões e Silva AC, Borges KB, Dusse LM. Hemostatic changes in patients with end stage renal disease undergoing hemodialysis. Clin Chim Acta 2010;411:135-9. PMID: 19945449 DOI: http://dx.doi.org/10.1016/j.cca.2009.11.022
  » http://dx.doi.org/10.1016/j.cca.2009.11.022
• ²⁴
  Hogas SM, Voroneanu L, Serban DN, Segall L, Hogas MM, Serban IL, et al. Methods and potential biomarkers for the evaluation of endothelial dysfunction in chronic kidney disease: a critical approach. J Am Soc Hypertens 2010;4:116-27. DOI: http://dx.doi.org/10.1016/j.jash.2010.03.008
  » http://dx.doi.org/10.1016/j.jash.2010.03.008
• ²⁵
  Lin CY, Lin LY, Kuo HK, Lin JW. Chronic kidney disease, atherosclerosis, and cognitive and physical function in the geriatric group of the National Health and Nutrition Survey 1999-2002. Atherosclerosis 2009;202:312-9. PMID: 18533156 DOI: http://dx.doi.org/10.1016/j.atherosclerosis.2008.04.020
  » http://dx.doi.org/10.1016/j.atherosclerosis.2008.04.020
• ²⁶
  Pereira AB, Rezende NA, Teixeira Junior AL, Teixeira MM, Simões e Silva, AC. Citocinas e quimiocinas no transplante renal. J Bras Nefrol 2009;31:286-96. DOI: http://dx.doi.org/10.1590/S0101-28002009000400007
  » http://dx.doi.org/10.1590/S0101-28002009000400007
• ²⁷
  Sarnak MJ, Tighiouart H, Scott TM, Lou KV, Sorensen EP, Giang LM, et al. Frequency of and risk factors for poor cognitive performance in hemodialysis patients. Neurology 2013;80:471-80. DOI: http://dx.doi.org/10.1212/WNL.0b013e31827f0f7f
  » http://dx.doi.org/10.1212/WNL.0b013e31827f0f7f
• ²⁸
  Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-98. PMID: 1202204 DOI: http://dx.doi.org/10.1016/0022-3956(75)90026-6
  » http://dx.doi.org/10.1016/0022-3956(75)90026-6
• ²⁹
  Lux S, Mirzazade S, Kuzmanovic B, Plewan T, Eickhoff SB, Shah NJ, et al. Differential activation of memory-relevant brain regions during a dialysis cycle. Kidney Int 2010;78:794-802. PMID: 20668428 DOI: http://dx.doi.org/10.1038/ki.2010.253
  » http://dx.doi.org/10.1038/ki.2010.253
• ³⁰
  Fukunishi I, Kitaoka T, Shirai T, Kino K, Kanematsu E, Sato Y. Psychiatric disorders among patients undergoing hemodialysis therapy. Nephron 2002;91:344-7. PMID: 12053079 DOI: http://dx.doi.org/10.1159/000058418
  » http://dx.doi.org/10.1159/000058418
• ³¹
  Kalirao P, Pederson S, Foley RN, Kolste A, Tupper D, Zaun D, et al. Cognitive impairment in peritoneal dialysis patients. Am J Kidney Dis 2011;57:612-20. PMID: 21295896 DOI: http://dx.doi.org/10.1053/j.ajkd.2010.11.026
  » http://dx.doi.org/10.1053/j.ajkd.2010.11.026
• ³²
  Radic J, Ljutic D, Radic M, Kovacic V, Sain M, Dodig-Curkovic K. Is there differences in cognitive and motor functioning between hemodialysis and peritoneal dialysis patients? Ren Fail 2011;33:641-9.
• ³³
  Regolisti G, Maggiore U, Cademartiri C, Cabassi A, Caiazza A, Tedeschi S, et al. Cerebral blood flow decreases during intermittent hemodialysis in patients with acute kidney injury, but not in patients with end-stage renal disease. Nephrol Dial Transplant 2013;28:79-85. PMID: 22711517 DOI: http://dx.doi.org/10.1093/ndt/gfs182
  » http://dx.doi.org/10.1093/ndt/gfs182
• ³⁴
  Pliskin NH, Yurk HM, Ho LT, Umans JG. Neurocognitive function in chronic hemodialysis patients. Kidney Int 1996;49:1435-40. PMID: 8731111 DOI: http://dx.doi.org/10.1038/ki.1996.202
  » http://dx.doi.org/10.1038/ki.1996.202
• ³⁵
  Griva K, Thompson D, Jayasena D, Davenport A, Harrison M, Newman SP. Cognitive functioning pre- to post-kidney transplantation-a prospective study. Nephrol Dial Transplant 2006;21:3275-82. DOI: http://dx.doi.org/10.1093/ndt/gfl385
  » http://dx.doi.org/10.1093/ndt/gfl385
• ³⁶
  Fennell RS 3rd, Rasbury WC, Fennell EB, Morris MK. Effects of kidney transplantation on cognitive performance in a pediatric population. Pediatrics 1984;74:273-8.
• ³⁷
  Harciarek M, Biedunkiewicz B, Lichodziejewska-Niemierko M, Debska-Slizien A, Rutkowski B. Continuous cognitive improvement 1 year following successful kidney transplant. Kidney Int 2011;79:1353-60. PMID: 21389973 DOI: http://dx.doi.org/10.1038/ki.2011.40
  » http://dx.doi.org/10.1038/ki.2011.40
• ³⁸
  Radić J, Ljutić D, Radić M, Kovačić V, Dodig-Ćurković K, Šain M. Kidney transplantation improves cognitive and psychomotor functions in adult hemodialysis patients. Am J Nephrol 2011;34:399-406. DOI: http://dx.doi.org/10.1159/000330849
  » http://dx.doi.org/10.1159/000330849
• ³⁹
  Icard P, Hooper SR, Gipson DS, Ferris ME. Cognitive improvement in children with CKD after transplant. Pediatr Transplant 2010;14:887-90. DOI: http://dx.doi.org/10.1111/j.1399-3046.2010.01359.x
  » http://dx.doi.org/10.1111/j.1399-3046.2010.01359.x
• ⁴⁰
  Gelb S, Shapiro RJ, Hill A, Thornton WL. Cognitive outcome following kidney transplantation. Nephrol Dial Transplant 2008;23:1032-8. DOI: http://dx.doi.org/10.1093/ndt/gfm659
  » http://dx.doi.org/10.1093/ndt/gfm659

Publication Dates

• Publication in this collection
  Apr-Jun 2014

History

• Received
  15 July 2013
• Accepted
  24 Oct 2013