Kidney Matters - Issue 17 Summer 2022
Your Summer 2022 Kidney Matters magazine is out now! In this issue:
• Chronic kidney disease and the cost of living crisis
• Navigating nephrotic syndrome as a family
• Kidney clinic: coping with brain fog
• Celebrating Ramadan when you're living with CKD
• Kidney Kitchen's fresh-tasting Salad Niçoise – perfect for summer!
We know that being a kidney patient can be tough at times and that accessing the right help at the right time isn’t always easy. We’ve spent a great deal of time talking and listening to kidney patients about what we can do to address this at every stage of kidney disease. The response was overwhelmingly ‘improved communication’ on what is going on in the kidney world, how other patients manage their life with kidney disease and what is available to them in terms of support and how to access it.
Kidney Matters has been developed to tackle this as well as the many other issues kidney patients face in day-to-day life. Along with shared patient experiences, Kidney Matters provides information on how to access emotional and practical support, financial assistance through our grant schemes, advice from leading kidney specialists and tips on how to keep as well as possible by eating a healthy diet whilst on dialysis.
Your Summer 2022 Kidney Matters magazine is out now! In this issue:
• Chronic kidney disease and the cost of living crisis
• Navigating nephrotic syndrome as a family
• Kidney clinic: coping with brain fog
• Celebrating Ramadan when you're living with CKD
• Kidney Kitchen's fresh-tasting Salad Niçoise – perfect for summer!
We know that being a kidney patient can be tough at times and that accessing the right help at the right time isn’t always easy. We’ve spent a great deal of time talking and listening to kidney patients about what we can do to address this at every stage of kidney disease. The response was overwhelmingly ‘improved communication’ on what is going on in the kidney world, how other patients manage their life with kidney disease and what is available to them in terms of support and how to access it.
Kidney Matters has been developed to tackle this as well as the many other issues kidney patients face in day-to-day life. Along with shared patient experiences, Kidney Matters provides information on how to access emotional and practical support, financial assistance through our grant schemes, advice from leading kidney specialists and tips on how to keep as well as possible by eating a healthy diet whilst on dialysis.
10Kidney Clinic‘Kidney brain’: cutting through the fogBrain fog or cognitive impairment iscommon among people with chronickidney disease (CKD). Why does ithappen? And how can it be improved?Although people with CKD commonly report somekind of brain fog or cognitive impairment, it is difficultto know precisely how many people are affected.Estimates vary widely, but one study from the USsuggested that as many as 8 in 10 (80%) of peoplewith kidney failure needing treatment with dialysis hadsome degree of cognitive impairment.What is cognitive impairment?Cognitive function is a general term covering severaldomains or tasks performed by the brain (see Table 1).The degree of impairment varies greatly, but studiesshow that executive function is the most commonlyaffected domain in people with kidney disease.Professor Paddy Mark comments: “Cognitiveimpairment sounds alarming, but it is important todifferentiate between impairment in general—whichmay be permanent or a sign that someone is acutelyunwell and resolves after they get better—and brainfog that happens on dialysis.” Paddy is Professor ofNephrology and Honorary Consultant Nephrologist atthe Glasgow Renal and Transplant Unit at the QueenElizabeth University Hospital Glasgow. He has a specialresearch interest in vascular disease in CKD.What are the risk factors for brain fog?Several ‘traditional’ factors are known increase the riskof cognitive impairment (Table 2). Age is the greatestrisk factor in the general population, doubling foreach 10 years over the age of 60 so that some degreeof cognitive impairment affects about 1 in 4 peopleaged over 80 years. Vascular disease, diabetes andhigh blood pressure all increase the risk of cognitiveimpairment by affecting the small blood vessels of thebrain, while depression and poor sleep both impaircognitive functioning.Paddy says: “Older age is also a risk factor for CKD, andmany people who start dialysis have other medicalproblems. For example, they almost certainly havehigh blood pressure, and diabetes is the commonestcause of CKD in the UK, being present in up to onethird of people needing kidney replacement therapy.“A large study in Sweden showed that, as kidneyfunction declines, the number people diagnosed withTable 1: Domains of cognitive functionDomainMemory and learningLanguageExecutive functionComplex attentionSocial cognitionVisuospatial perceptionDescriptionRecording and retrieving information such as facts and eventsNaming objects, finding one’s words, understanding the meaning of wordsPlanning, making decisions, carrying out and prioritising complex tasksStaying focused, especially when there are distractionsRecognising emotions, empathising with others’ emotionsRecognising and manipulating objects, co-ordinating physical actionswww.kidneycareuk.org
11Table 2: Factors increasing the risk of cognitiveimpairmentTraditional riskfactorsOlder ageVascular diseaseDiabetes, high bloodpressureDepressionSleep disordersFactors related tokidney diseaseBuild-up of uraemic toxinsInflammationStructural changesDialysis** Compared with haemodialysis, peritoneal dialysis may be associated with fewer cognitive effects in the short termBased on: Crowe K et al. Frontiers in Neurology 2021; volume 12; article 787370cognitive impairment increases. Although it is unclearif it is cause or effect, lower levels of kidney functionare associated with cognitive impairment. We knowthat vascular disease becomes more common askidney function declines and small-vessel changes onbrain imaging are also frequent.”Other non-traditional risk factors also play a part inCKD. Several uraemic toxins are known to affect thebrain and may not be completely removed by dialysis.Similarly, inflammation of the lining of the bloodvessels is known to cause vascular problems.Paddy adds: “During haemodialysis, there arerecurrent changes in blood flow to the brain relatingto the dialysis process itself that may be implicatedin cognitive impairment. But this is not a reason to beafraid of dialysis. Actually, by doing dialysis ‘better’,such as by being careful with fluid restriction to reducethe need for fluid removal on dialysis, healthcare teamscan work with you to maintain your vascular health.”How is cognitive impairment diagnosed?Brain fog has serious effects on quality of life andadds to the stress of living with kidney disease. Severalscreening tools are available, but Paddy does notconsider it appropriate to test cognitive functionduring routine visits to the kidney clinic.He explains: “We screen for cognitive impairmentwhen people come into hospital and are acutely ill,but it is not practical during routine appointmentswith your kidney doctor. It is important to rememberthe difference between screening—actively lookingfor a problem when there are no symptoms—andinvestigating when you have reported a problem.“If you find that you have brain fog after dialysis andare fine the next day, be reassured that this is commonand should resolve. However, if your cognitive functionis declining or has suddenly got worse and you areworried, talk to your healthcare team including yourGP. Your GP will have experience of managing otherpeople with memory problems and should be able toaccess appropriate local services.”“Depression and poorsleep both impaircognitive functioning“How can brain fog be treated?Although there is little evidence that the self-helpmeasures in Table 3 (overleaf) directly treat brain fog,they are unlikely to harmful and likely to be beneficialfor your general health.Anyone’s cognitive function may be impaired bymedication, including treatments for chronic painand sleep disorders, and you may feel better if themedication is adjusted or substituted. Other treatablecauses of brain fog might include hypothyroidism (lowlevels of thyroid hormone), other hormonal issuessuch as the menopause, and low vitamin B12 levels.There is currently no drug treatment that has beenshown to directly improve cognitive function inCKD. Treating anaemia with iron and erythropoiesisstimulating agents (ESAs) is likely to improve cognitivefunction by improving the oxygen-carrying capacityof the blood. It may be possible to improve brainfog by addressing mental health problems suchas depression, which is known to affect cognitivefunction and is common at all stages of CKD.“We do not currently have good evidence, but doingdialysis better is likely to be beneficial for brain healthand reduce the risk of ongoing problems. Minimisingyour salt intake will improve your blood pressure andreduce thirst to help you to stick your fluid allowance.Large fluid gains between dialysis sessions mean greaterswings in blood pressure: in our studies, we found thatthe more fluid taken off during dialysis, the greater thechanges in blood flow to the brain,” says Paddy.“Similarly, I think that doing shorter, more frequentdialysis sessions or longer, slower nocturnal dialysisshould result in fewer changes in blood flow to theIssue 17 | Summer 2022
- Page 1 and 2: Summer 2022Issue 17Facing a costof
- Page 3 and 4: 3Welcome toKidney MattersHello all,
- Page 5 and 6: 5When you dialyse, it’s common to
- Page 7 and 8: 7A night to remember: CarlyFamily a
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- Page 13 and 14: “Doing dialysis better islikely t
- Page 15 and 16: 15this, I can choose what she eats.
- Page 17 and 18: 17Graeme Whitworth, Jace Photo Agen
- Page 19 and 20: 19The communication was great. I wa
- Page 21 and 22: 21While I was on dialysis, after ta
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- Page 25 and 26: 25“One piece of advice she would
- Page 27 and 28: 27let our community suffer; this wi
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11
Table 2: Factors increasing the risk of cognitive
impairment
Traditional risk
factors
Older age
Vascular disease
Diabetes, high blood
pressure
Depression
Sleep disorders
Factors related to
kidney disease
Build-up of uraemic toxins
Inflammation
Structural changes
Dialysis*
* Compared with haemodialysis, peritoneal dialysis may be associated with fewer cognitive effects in the short term
Based on: Crowe K et al. Frontiers in Neurology 2021; volume 12; article 787370
cognitive impairment increases. Although it is unclear
if it is cause or effect, lower levels of kidney function
are associated with cognitive impairment. We know
that vascular disease becomes more common as
kidney function declines and small-vessel changes on
brain imaging are also frequent.”
Other non-traditional risk factors also play a part in
CKD. Several uraemic toxins are known to affect the
brain and may not be completely removed by dialysis.
Similarly, inflammation of the lining of the blood
vessels is known to cause vascular problems.
Paddy adds: “During haemodialysis, there are
recurrent changes in blood flow to the brain relating
to the dialysis process itself that may be implicated
in cognitive impairment. But this is not a reason to be
afraid of dialysis. Actually, by doing dialysis ‘better’,
such as by being careful with fluid restriction to reduce
the need for fluid removal on dialysis, healthcare teams
can work with you to maintain your vascular health.”
How is cognitive impairment diagnosed?
Brain fog has serious effects on quality of life and
adds to the stress of living with kidney disease. Several
screening tools are available, but Paddy does not
consider it appropriate to test cognitive function
during routine visits to the kidney clinic.
He explains: “We screen for cognitive impairment
when people come into hospital and are acutely ill,
but it is not practical during routine appointments
with your kidney doctor. It is important to remember
the difference between screening—actively looking
for a problem when there are no symptoms—and
investigating when you have reported a problem.
“If you find that you have brain fog after dialysis and
are fine the next day, be reassured that this is common
and should resolve. However, if your cognitive function
is declining or has suddenly got worse and you are
worried, talk to your healthcare team including your
GP. Your GP will have experience of managing other
people with memory problems and should be able to
access appropriate local services.”
“Depression and poor
sleep both impair
cognitive functioning“
How can brain fog be treated?
Although there is little evidence that the self-help
measures in Table 3 (overleaf) directly treat brain fog,
they are unlikely to harmful and likely to be beneficial
for your general health.
Anyone’s cognitive function may be impaired by
medication, including treatments for chronic pain
and sleep disorders, and you may feel better if the
medication is adjusted or substituted. Other treatable
causes of brain fog might include hypothyroidism (low
levels of thyroid hormone), other hormonal issues
such as the menopause, and low vitamin B12 levels.
There is currently no drug treatment that has been
shown to directly improve cognitive function in
CKD. Treating anaemia with iron and erythropoiesis
stimulating agents (ESAs) is likely to improve cognitive
function by improving the oxygen-carrying capacity
of the blood. It may be possible to improve brain
fog by addressing mental health problems such
as depression, which is known to affect cognitive
function and is common at all stages of CKD.
“We do not currently have good evidence, but doing
dialysis better is likely to be beneficial for brain health
and reduce the risk of ongoing problems. Minimising
your salt intake will improve your blood pressure and
reduce thirst to help you to stick your fluid allowance.
Large fluid gains between dialysis sessions mean greater
swings in blood pressure: in our studies, we found that
the more fluid taken off during dialysis, the greater the
changes in blood flow to the brain,” says Paddy.
“Similarly, I think that doing shorter, more frequent
dialysis sessions or longer, slower nocturnal dialysis
should result in fewer changes in blood flow to the
Issue 17 | Summer 2022
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