Cognitive Impairment in Non-Dialysis-Dependent CKD and the Transition to Dialysis: Findings From the Chronic Renal Insufficiency Cohort (CRIC) Study

Am J Kidney Dis. 2018 Oct;72(4):499-508. doi: 10.1053/j.ajkd.2018.02.361. Epub 2018 May 2.


Background: Advanced chronic kidney disease is associated with elevated risk for cognitive impairment. However, it is not known whether and how cognitive impairment is associated with planning and preparation for end-stage renal disease.

Study design: Retrospective observational study.

Setting & participants: 630 adults participating in the CRIC (Chronic Renal Insufficiency Cohort) Study who had cognitive assessments in late-stage CKD, defined as estimated glome-rular filtration rate ≤ 20mL/min/1.73m2, and subsequently initiated maintenance dialysis therapy.

Predictor: Predialysis cognitive impairment, defined as a score on the Modified Mini-Mental State Examination lower than previously derived age-based threshold scores. Covariates included age, race/ethnicity, educational attainment, comorbid conditions, and health literacy.

Outcomes: Peritoneal dialysis (PD) as first dialysis modality, preemptive permanent access placement, venous catheter avoidance at dialysis therapy initiation, and preemptive wait-listing for a kidney transplant.

Measurements: Multivariable-adjusted logistic regression.

Results: Predialysis cognitive impairment was present in 117 (19%) participants. PD was the first dialysis modality among 16% of participants (n=100), 75% had preemptive access placed (n=473), 45% avoided using a venous catheter at dialysis therapy initiation (n=279), and 20% were preemptively wait-listed (n=126). Predialysis cognitive impairment was independently associated with 78% lower odds of PD as the first dialysis modality (adjusted OR [aOR], 0.22; 95% CI, 0.06-0.74; P=0.02) and 42% lower odds of venous catheter avoidance at dialysis therapy initiation (aOR, 0.58; 95% CI, 0.34-0.98; P=0.04). Predialysis cognitive impairment was not independently associated with preemptive permanent access placement or wait-listing.

Limitations: Potential unmeasured confounders; single measure of cognitive function.

Conclusions: Predialysis cognitive impairment is associated with a lower likelihood of PD as a first dialysis modality and of venous catheter avoidance at dialysis therapy initiation. Future studies may consider addressing cognitive function when testing strategies to improve patient transitions to dialysis therapy.

Keywords: CKD to ESRD transition; Chronic kidney diseases (CKDs); central venous catheter (CVC); cognitive impairment; dementia; dialysis access; dialysis modality; end-stage renal disease (ESRD); executive function; incident ESRD; memory; peritoneal dialysis (PD); transplant waitlisting.

Publication types

  • Comparative Study
  • Observational Study
  • Research Support, N.I.H., Extramural

MeSH terms

  • Adult
  • Age Factors
  • Aged
  • Cognitive Behavioral Therapy / methods
  • Cognitive Dysfunction / diagnosis
  • Cognitive Dysfunction / epidemiology*
  • Cohort Studies
  • Disease Progression
  • Female
  • Humans
  • Incidence
  • Kidney Failure, Chronic / diagnosis
  • Kidney Failure, Chronic / pathology
  • Kidney Failure, Chronic / therapy
  • Logistic Models
  • Male
  • Middle Aged
  • Multivariate Analysis
  • Neuropsychological Tests
  • Predictive Value of Tests
  • Prognosis
  • Renal Dialysis / adverse effects*
  • Renal Dialysis / methods
  • Renal Dialysis / psychology
  • Renal Insufficiency, Chronic / diagnosis
  • Renal Insufficiency, Chronic / psychology*
  • Renal Insufficiency, Chronic / therapy*
  • Retrospective Studies
  • Risk Assessment
  • Severity of Illness Index
  • Sex Factors
  • Transitional Care / organization & administration*
  • Treatment Outcome