الفهرس 
IntroductionOnly 14 pages are availabe for public view
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Abstract
, often untreated, comorbidities affecting patients with chronic kidney disease treated with hemodialysis. Increased mortality, poor compliance, poor quality of life and increased dependency were all linked to cognitive impairment in hemodialysis population. Therefore, assessment of the prevalence and risk factors of cognitive impairment in Egyptian hemodialysis population was needed. In addition, possible means of preservation of cognitive functions in such venerable group are worth studying. Research about the etiology of cognitive impairment in patients on hemodialysis revealed a strong connection to hemodynamic instability during the dialysis sessions that might lead to white matter disease. Intradialytic hypotension is one of the most frequent complications affecting patients on hemodialysis which explains the poor performance of patients in cognitive tests towards the end of hemodialysis sessions compared to the first half hour of the session despite the removal of uremic toxins. The repeated exposure to hypotensive episodes was linked to increased white matter lesions and higher prevalence of MCI. Intradialytic exercise programs have been adopted in various centers around the world in the past two decades, however there are no guidelines regarding the duration and intensity of exercise sessions. Aerobic and anaerobic exercise sessions were tried with positive outcome and minimal complication with the most common method being cycling during the first half of the hemodialysis session. Decreasing the prevalence of hemodynamic instability, improving psychological wellbeing in addition to increasing muscle strength is a main target of intradialytic exercise programs. Cooling dialysate by 0.5 degree below the patients’ temperature showed positive effect in various aspects including improved patients’ mood and decreasing hypotensive episodes during hemodialysis, possibly by preserving cerebral blood flow during the sessions as a result of vasoconstriction. Additionally, it has multiple positive effects on the quality of hemodialysis. Hypothesis of the work -We hypothesized that the prevalence of cognitive impairment in hemodialysis population is markedly higher than the general population and that applying cool hemodialysis and intradialytic exercise will decrease the negative effect of hemodialysis on cognition. Aim of the work -To compare cognitive functions pre and post intradialytic exercise and cool hemodialysis in patients on hemodialysis for more than three months. The theoretical part of this study had three chapters -Chapter one was enlightening cognitive impairment as a common comorbidity of CKD and the counterintuitive effect of hemodialysis on patents’ cognitive functions. -Chapter two brings into sight cool hemodialysis, intradialytic exercise and remote ischemic preconditioning as techniques to improve hemodialysis quality. -Chapter three discusses the effect of patients’ mood and quality of life on cognitive impairment. The practical part: Study Design Quasi-intervention (Pre- Post comparison). Study Locality Hemodialysis Unit, Nephrology Department, Mansoura University Hospital. The current study is a quasi-intervention study on 60 patients on hemodialysis who were divided into two groups of 30 undergoing either cool hemodialysis or intradialytic exercise. Methods Demographic &clinical data: sociodemographic & clinical data was gathered in questionnaire designed for the purpose of the study. The Montreal Cognitive Assessment (MoCA)(Nasreddine et al., 2005) The validated Arabic version. (Rahman & El Gaafary, 2009b). Arabic Version of Mini International Neuropsychiatric Interview (M.I.N.I.)(Sheehan et al., 1998). Arabic version of the Beck Depression Inventory- second edition (BDI-II) (Beck et al., 1996). (Ghareeb, 2000). Laboratory findings (ferritin, transferrin saturation, PTH, serum calcium, serum PO4, albumin, hemoglobin). Results The results revealed no significant improvement in mean scores of MoCA after either intradialytic exercise or cool hemodialysis which were in the MCI interval 23.9-25. Regarding the effect on psychiatric comorbidities, our results showed an improvement of depressive symptoms in patients who received cool hemodialysis. On the other hand, the exercise group showed an increase in patients in depressive episode. No correlation was found between cognitive impairment and depressive symptoms in our study population. Conclusion In conclusion, this study was able to find the followings: The mean score of cognitive tests in hemodialysis population was lower than the cutoff of mild cognitive impairment. Factors associated with poor cognitive performance were increased age and lower education in sociodemographic data. Laboratory findings related to poor cognitive performance were lower albumin, ferritin and transferrin saturation. High prevalence of depression was found in both groups (40% and 26.7%) before intervention which increased in the exercise group after intervention. The mean scores of depression severity with BDI-II was between 13-15 before intervention. The cooling group showed improvement in mean depression severity scores. Recommendations Research recommendations -More research should be done to detect the extent of cognitive impairment in hemodialysis population. -Further assessment of the effect of CKD and hemodialysis on different cognitive domains. -Means to design individualized exercise programs for different patients, and optimum duration and intensity of exercise for each patient are required. -Further studies should be done about the effect of treating psychiatric comorbidities of patients on hemodialysis on their cognitive performance. Clinical recommendations -The need of regular follow up and management of psychiatric and cognitive comorbidities of CKD and hemodialysis.