Cognitive Functioning

Significant neurocognitive deficits in pediatric patients with CKD have been attributed to aluminum toxicity related to the use of aluminum-based phosphate binders. However, this is not the only explanation. Gipson et al. (2007), in their review of neurode-velopmental deficits in pediatric and adult survivors of childhood-onset CKD, reported that children are at risk for both structural and physiological abnormalities of the central nervous system. An increased risk of brain atrophy and infarction exists particularly in those patients with associated coagulation disorders and in those with a history of hypertensive crises. Reports of nonspecific electroencephalo-graphic abnormalities, delayed myelination of the somatosensory cortex, and slower peripheral nerve conduction velocities have also been published. Furthermore, Gipson et al. (2007) pointed out that general cognitive functioning scores are lower than normal among children with CKD and that attention, executive function, and memory are common areas of concern.

Adults with childhood-onset CKD are at increased risk for lower educational, employment, and occupational levels as well as for neuropsychological impairment and psychiatric difficulties (Icard et al. 2008). Duquette et al. (2007) used a cross-sectional design to compare 30 children with CKD with 41 age-matched healthy controls. Subjects with CKD showed evidence of mild impairments on IQ, math, and reading measures and were more likely than controls to have IQ scores below the average range. Compared with controls, youngsters with CKD met criteria for a learning disability with greater frequency and were at higher risk for grade retention and school absenteeism. Renal function was found to be a significant predictor of intellectual and academic scores.

Slickers et al. (2007) studied 29 children and adolescents with mild to moderate stages of CKD to identify clinical predictors of neurocognitive deficits. In this study, increased CKD severity correlated with lower IQ and memory function. A linear relationship with disease severity was reported, such that IQ scores declined continuously as disease severity worsened. Memory function was also lower in children with a longer duration of disease. In addition, IQ scores were lowest in patients who developed renal disease at younger ages and in patients in whom CKD had been present for a greater percentage of their life.

The identification of modifiable risk factors that contribute to poor neurocognitive outcomes is an area of active investigation in pediatric CKD. Past studies have suggested that low hematocrit (Gerson et al. 2006; Stivelman 2000) and hypertension (Gerson et al. 2006; Lande et al. 2003) are associated with neurocognitive deficits, in particular impaired attention (Lande et al. 2003). However, Slickers et al. (2007) failed to demonstrate a convincing relationship between these deficits and hypertension in children. Additionally, medications (e.g., prednisone and tacrolimis) commonly used in the treatment of ESRD have been implicated as risk factors for poor neurocognitive outcomes (Cornic and Rousset 2008; de Quervain 2006; Kemper et al. 2003; Suwalska et al. 2002).

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