A longitudinal analysis of the effect of anemia on executive functions in children with mild to moderate chronic kidney disease

Pediatr Nephrol. 2023 Mar;38(3):829-837. doi: 10.1007/s00467-022-05682-3. Epub 2022 Jul 21.


Background: Children with chronic kidney disease (CKD) are at risk for cognitive dysfunction. The aim of this study was to investigate associations between executive functions (EF), anemia, and iron deficiency.

Methods: A total of 688 children > 6 years of age enrolled in the Chronic Kidney Disease in Children (CKiD) study who underwent evaluation for EF were included. Hemoglobin (Hgb) was characterized as low (1st-5th percentile) or very low (< 1st percentile) compared to normative values for age, sex, and race irrespective of erythropoiesis-stimulating agent (ESA) usage. Longitudinal analysis was conducted using consecutive visit pairs, with anemia status defined as new onset, resolved, or persistent. Linear mixed models with random intercept were used and adjusted for key covariates.

Results: Anemia was present in 41% of children, and median Hgb was 11.8 gm/dl. New onset anemia was associated with lower digit span total score (- 0.75, 95% CI - 1.36, - 0.15, p = 0.01). Persistent anemia was associated with lower scores on color-word inhibition/switching (β = - 0.98; 95% CI - 1.78, - 0.18, p = 0.02). Errors of omission were significantly higher (worse) in those with persistent anemia (β = 2.67, 95% CI 0.18, 5.17, p = 0.04). Very low Hgb levels were significantly associated with lower color-word inhibition/switching scores (β = - 1.33, 95% CI - 2.16, - 0.51; p = 0.002). Anemia and low GFR were associated with lower category fluency scores compared to non-anemic subjects with higher GFR (β = - 1.09, 95% CI - 2.09, - 0.10, p = 0.03).

Conclusions: The presence of anemia, in addition to its severity and duration in children with CKD, is associated with poorer scores on select measures of EF. A higher resolution version of the Graphical abstract is available as Supplementary information.

Keywords: Anemia; Chronic kidney disease; Neurocognition; Pediatric.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Anemia* / epidemiology
  • Anemia* / etiology
  • Child
  • Executive Function
  • Hematinics* / therapeutic use
  • Hemoglobins / analysis
  • Humans
  • Renal Insufficiency, Chronic* / complications


  • Hemoglobins
  • Hematinics