Cerebrovascular Effects of Hemodialysis in Chronic Kidney Disease

Abstract

Patients with end-stage renal disease (ESRD) undergoing hemodialysis are known to suffer cognitive deficits and stroke of unknown etiology. It has been suspected that the treatment itself may contribute to the syndrome by unknown mechanisms, which we investigated in this study. Endstage renal disease patients on hemodialysis (n = 19) or peritoneal dialysis (PD, n = 5) were compared with 14 healthy controls. Subjects participated in magnetic resonance imaging (MRI) measurements of cerebral atrophy, cerebral blood flow (CBF) arterial spin labeled-MRI (ASL-MRI), quantitative Doppler blood flow through the internal carotid artery, and cerebral oxymetry. The Doppler and oxymetry procedures were also performed at the beginning and end of a single hemodialysis session. End-stage renal disease patients on hemodialysis showed significant cerebral atrophy, associated with longer hemodialysis duration and cognitive deficits, including focal bilateral lesions in the caudate nucleus and midbrain. Cerebral oxygenation was extremely low before dialysis (rSO 2 41613, compared with 7062 in controls, P < 0.02) and improved only slightly after dialysis. Carotid blood flow was also very low at the start of dialysis (115628 mL/sec, versus 193656 in controls, P < 0.005) but normalized at the end of the session (181 mL/sec). The PD patients showed intermediate values, between the hemodialysis and controls. Notably, duration of hemodialysis treatment predicted global gray-matter volume (r = À0.74), change of blood flow during dialysis (r = À0.65), and baseline rSO 2 (r = À0.65). The findings suggest that ESRD patients on hemodialysis suffer low CBF during the interdialytic cycle. Coupled with low cerebral oxygenation levels and atherosclerosis, this may contribute significantly to the etiology of the observed cerebral atrophy, cognitive deficits, and high stroke prevalence.

Prevalence and Correlates of Cognitive Impairment in Hemodialysis Patients

“…For example, in the National Cooperative Dialysis Study, higher levels of urea clearance were correlated with better cognitive performance (7). In addition, cardiovascular and hemodynamic factors (hypertension, and at the other extreme, intradialytic hypotension) may lead to stroke or cerebral ischemia and contribute to cognitive impairment in patients with ESRD (8,9). Anemia has also been associated with poor cognitive function and dementia (1,10).…”

Comparison of Subdural Hematoma Risk between Hemodialysis and Peritoneal Dialysis Patients with ESRD

“…HD patients are also at higher risk of hospitalization for psychiatric illness (30). By contrast, PD patients have greater stability in intracranial pressure and cerebral blood flow due to smaller changes in urea clearance, acid-base status, serum osmolality, and fluid status (31,32). Fewer fluid shifts in PD also contribute to fewer changes in brain volume.…”

Analysis of Risk Factors for Development of Cognitive Disorders in Maintenance Hemodialysis Patients – Pilot Study

“…Taken that predominantly executive and orientation function are affected; it is indicated that risk factors are the same as in vascular diseases (4). Hemodynamic instability during hemodialysis, frequent asymptomatic intradialytic hypotension, especially in elder patients and those with longer treatment period have important role in functionality of sensitive anatomic structures (32)(33)(34).…”