Neuropsychological functioning post-renal transplantation: A prospective comparison of a steroid avoidance and a steroid maintenance protocol in relation to chronic prednisone therapy

Thirty-nine participants, 17 in a chronic steroid group (CS) and 22 in a steroid avoidance group (SA) were compared with regard to their cognitive performance. It was predicted that participants in the SA group would outperform those in the CS group on the domains of declarative memory and complex attention. For participants in the CS group, age and prednisone duration but not dose were predicted to significantly contribute to the score on the declarative memory composite score. Group-wise comparisons were not significant for the domains of declarative memory, complex attention, or processing speed. The CS group outperformed the SA group on the domain of simple attention. Regression analysis, for the CS group, indicated that duration of dialysis prior to transplant accounted for a significant portion of the variance in the declarative memory composite score. After controlling for months since transplant, prednisone dose also accounted for approximately 26% of the variance in the declarative memory score. Patients maintained on 5 mg of prednisone performed relatively worse than those maintained on 2.5 mg with regard to declarative memory. The clinical and theoretical significance of the findings relative to recent literature is discussed

Aerobic exercise with blood flow restriction for patients undergoing dialysis

This study demonstrated that blood flow restriction aerobic exercise performed during dialysis is both haemodynamically safe and efficacious for enhancing strength and physical function among patients with end-stage kidney disease. The findings positively support blood flow restriction as an adjunct to exercise for dialysis patients afflicted with marked physical impairment

The association of physical function and physical activity with all-cause mortality and adverse clinical outcomes in non-dialysis chronic kidney disease : a systematic review

Objective: People with nondialysis-dependent chronic kidney disease (CKD) and renal transplant recipients (RTRs) have compromised physical function and reduced physical activity (PA) levels. Whilst established in healthy older adults and other chronic diseases, this association remains underexplored in CKD. We aimed to review the existing research investigating poor physical function and PA with clinical outcome in nondialysis CKD. Data sources: Electronic databases (PubMed, MEDLINE, EMBASE, Web of Science, Cochrane Central Register of Controlled Trials) were searched until December 2017 for cohort studies reporting objective or subjective measures of PA and physical function and the associations with adverse clinical outcomes and all-cause mortality in patients with nondialysis CKD stages 1–5 and RTRs. The protocol was registered on the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42016039060). Review methods: Study quality was assessed using the Newcastle-Ottawa Scale and the Agency for Healthcare and Research Quality (AHRQ) standards. Results: A total of 29 studies were included; 12 reporting on physical function and 17 on PA. Only eight studies were conducted with RTRs. The majority were classified as ‘good’ according to the AHRQ standards. Although not appropriate for meta-analysis due to variance in the outcome measures reported, a coherent pattern was seen with higher mortality rates or prevalence of adverse clinical events associated with lower PA and physical function levels, irrespective of the measurement tool used. Sources of bias included incomplete description of participant flow through the study and over reliance on self-report measures. Conclusions: In nondialysis CKD, survival rates correlate with greater PA and physical function levels. Further trials are required to investigate causality and the effectiveness of physical function and PA interventions in improving outcomes. Future work should identify standard assessment protocols for PA and physical function

Delirium in older hospitalized patients—A prospective analysis of the detailed course of delirium in geriatric inpatients

Background: Delirium in older hospitalized patients (> 65) is a common clinical syndrome, which is frequently unrecognized. Aims: We aimed to describe the detailed clinical course of delirium and related cognitive functioning in geriatric patients in a mainly non-postoperative setting in association with demographic and clinical parameters and additionally to identify risk factors for delirium in this common setting. Methods: Inpatients of a geriatric ward were screened for delirium and in the case of presence of delirium included into the study. Patients received three assessments including Mini-Mental-Status-Examination (MMSE) and the Delirium Rating Scale Revised 98 (DRS-R-98). We conducted correlation and linear mixed-effects model analyses to detect associations. Results: Overall 31 patients (82 years (mean)) met the criteria for delirium and were included in the prospective observational study. Within one week of treatment, mean delirium symptom severity fell below the predefined cut-off. While overall cognitive functioning improved over time, short- and long-term memory deficits remained. Neuroradiological conspicuities were associated with cognitive deficits, but not with delirium severity. Discussion: The temporal stability of some delirium symptoms (short-/long-term memory, language) on the one hand and on the other hand decrease in others (hallucinations, orientation) shown in our study visualizes the heterogeneity of symptoms attributed to delirium and their different courses, which complicates the differentiation between delirium and a preexisting cognitive decline. The recovery from delirium seems to be independent of preclinical cognitive status. Conclusion: Treatment of the acute medical condition is associated with a fast decrease in delirium severity. Given the high incidence and prevalence of delirium in hospitalized older patients and its detrimental impact on cognition, abilities and personal independence further research needs to be done

Resistance (exercise) training in non-dialysis dependent chronic kidney disease (ckd stage 3) and validation of ultrasound in the measurement of muscle size and structure in haemodialysis patients (ckd stage 5)

AIM: This thesis set out to make an original contribution to knowledge with regard to methods of assessing muscle size and architecture in the CKD and ESRD population, and to assess the ability to improve the muscle size and architecture, and symptoms of uraemia, by implementing an anabolic intervention (resistance exercise training) in the CKD population. OUTCOME MEASURES: Ultrasound was shown to have high validity (against gold standard MRI measures; ICCs: VLACSA 0.96, VL depth 0.99, fat depth 0.98) and intra-rater reliability (ICCs: VL depth 0.98, total muscle depth 0.97, fat depth 0.99; MDC: VL depth 0.14cm, total muscle depth 0.19cm, fat depth 0.22cm) in measuring regional body composition at the mid-VL site in the CKD population. There were significant (p<0.01) correlations between US-derived measures of (mid-VL) muscle size and architecture with strength and function (larger muscle mass and/or pennation angle positively correlated with higher strength and/or functional performance). Patient-reported uraemic symptoms were worse (p<0.01) in those with reduced strength and/or function. INTERVENTION RESULTS: An anabolic (resistance training) intervention (12-weeks, randomized to once [RT1 n=7] or three times [RT3 n=10] per week, 80%1RM) brought about significant improvements over time (p<0.01) in all measures of muscle size and architecture (VL depth, total muscle depth, VLACSA, pennation angle). Interaction effects (group*time) were only seen in pennation angle (p<0.05) and VLACSA (p<0.01) where RT3 gains were greater than RT1 from week 8 onwards. All measures of strength, function, and uraemic symptoms improved over time (p<0.01) with no interaction effects (no difference from greater training frequency/ volume). CLINICAL AND RESEARCH IMPLICATIONS: The intervention results suggest implementing a RT form of “prehabilitation” in early stage (CKD3) patients just once per week is sufficient to bring about statistically and clinically important changes in strength and function that benefit the patient through reduced frequency and/or intrusiveness of uraemic symptoms (improved health-related quality of life), with minimal time-commitment. Further research should examine if there is additional benefit to the significantly greater increases in VLACSA and pennation angle observed in RT3, with regards to long-term maintenance of functional improvements, and whether an RT1 or RT3 programme delays the progression of CKD, the need for RRT, and patient mortality.sub_phyunpub1807_ethesesunpu

Arterial stiffness, cardiovascular risk and physical functioning in the Whitehall II study

BACKGROUND: Arterial stiffness measured by carotid-femoral Pulse Wave Velocity (cf-PWV) is a predictor of cardiovascular events, incident hypertension and a cross-sectional marker of low physical functioning. This thesis aims to expand the knowledge on the bidirectional relationship between cf-PWV and incident hypertension, investigate the predictive value of a second cf-PWV measurement and study its prospective effects on physical function. METHODS: Data from 5236 participants of the Whitehall II study from 2008 to 2019 were used to examine the relationship between incident hypertension and baseline arterial stiffness, as well as arterial stiffness progression among different blood pressure status subgroups. Linear mixed models were used to assess the progression in cf-PWV between subgroups and logistic regression models were used to estimate the odds of incident hypertension. The risk of clinical events was validated through hospital health records and analysed using survival models with a mean follow-up of 11.2 years. The prospective relationship between arterial stiffness and change in standardised measures of physical functioning 8 years later was assessed using linear mixed models. RESULTS: A bidirectional relationship between arterial stiffness and hypertension was observed. Participants in the highest tertile of cf-PWV at baseline had three times higher odds of incident hypertension than participants in the first tertile. Participants with uncontrolled blood pressure at baseline had the highest increase in cf-PWV compared to normotensives. Change between two measurements of a-PWV did not improve the C-statistic but adding a single measurement to the 10-year atherosclerotic cardiovascular disease score improved both the C-statistic and the net reclassification index. Baseline and prospective change of cf-PWV were associated to decline in the scores of the physical component of the SF-36 questionnaire and the instrumental activities of daily living. CONCLUSIONS: The bidirectional relationship between arterial stiffness and hypertension shown in some studies was replicated in the Whitehall II cohort. The sample size allowed for subgroup comparisons that were previously unpowered in previous studies. A second compared to a single measurement of cf-PWV did not seem to improve the predictive ability of cardiovascular risk models. Higher C-statistic and net reclassification index for prediction models using the components of the 10-year atherosclerotic cardiovascular disease score were seen after including cf-PWV. Finally, cf-PWV is a prospective marker of decrease in standardised measures of physical functioning