The Role of Dialysis in the Pathogenesis and Treatment of Dementia

Dearbhla M. Kelly

Disclosures

Nephrol Dial Transplant. 2019;34(7):1080-1083. 

In This Article

Classification, Aetiology and Pathology

Originally, 'dialysis dementia' was a progressive and fatal condition described in patients in the 1960s attributed to the aluminium found in phosphorus binders and dialysate water.[5] However, owing to modern techniques of water purification and the use of non-aluminium phosphorus binders, 'dialysis dementia' is now considered a rare adverse effect of dialysis with a current estimated prevalence of 0.6–1.0%.[6]

Currently, the major dementia syndromes described in those with and without CKD include Alzheimer's disease (AD), vascular dementia, dementia with Lewy bodies and frontotemporal dementia. AD is the most common cause of dementia in the general elderly population.[7]

The hallmarks of AD pathology are accumulation of extracellular amyloid-β (Aβ) plaques in the brain followed by intracellular neurofibrillary tangle (NFT) growth.[8] Aβ upregulates the generation of NFTs, leading to the phosphorylation of tau that self-assembles to form NFTs.[9] Accumulation of Aβ plaques, soluble Aβ oligomers and NFTs leads to neuron damage, diminished brain mass and cognitive dysfunction.

Among patients with CKD and end-stage kidney disease (ESKD), stroke is also a major risk factor for cognitive decline and dementia, and in contrast to the general population, the incidence of vascular dementia may approach or exceed the incidence of AD.[10] The particular preponderance of vascular cognitive impairment and dementia in dialysis patients may be reflected in their pattern of poor cognitive performance on tests of executive functioning in the Boston dialysis study.[11] Executive dysfunction strongly associates with the concurrent presence of systemic cardiovascular disease.[12] However, both memory and executive function were moderately-to-severely affected in an earlier larger cohort of HD patients.[3]

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