Understanding Vision Impairment in ESKD to Prevent Cognitive Impairment and Dementia/Alzheimer’s disease: the VIS-HD Cohort Study
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Vision impairment impacts ~60% of the 802,000 patients with end-stage kidney disease (ESKD) in the US, and evidence in community-dwelling older adults suggests that vision impairment is a potentially modifiable risk factor for cognitive decline and dementia/Alzheimer’s disease (AD). Identifying and understanding modifiable risk factors for cognitive decline is a priority in geriatric nephrology: 87% of ESKD patients have abnormal cognitive function, resulting in a 21-25% lifetime risk of dementia/AD that is 19-fold higher than age-matched community-dwelling adults. We seek to address 3 knowledge gaps surrounding vision impairment among patients living with ESKD: 1) prevalence, risk factors, and causes/reversibility of vision impairment; 2) cognitive and vision-related sequelae; and 3) vision screening and treatment barriers. First, the true prevalence of vision impairment in ESKD patients is unclear. Refractive errors are common in the general population and small studies suggest that 29-67% of ESKD patients have diabetic retinopathy and 32-80% cataracts. Vision impairment is reversible in 90% of the general population; however, in ESKD vision impairment may be due to retinal damage from vascular disease and diabetes that is unlikely to be reversed. Second, while there is strong evidence of an association between vision and cognitive impairment among community-dwelling older adults, this association is unclear among ESKD patients. Vision impairment directly alters brain structure and reduces cognitive stimulation, and indirectly impacts dementia risk by causing social isolation, depression, and physical inactivity, all of which are common in ESKD. It is likely that the high prevalence of vision impairment may contribute to incident dementia/AD and other vision-related sequelae. Third, eye disease is underdiagnosed and undertreated in ESKD. Vision impairment may be uncorrected given the high burden of hemodialysis and negative social determinants of health borne by ESKD patients. Identifying screening and treatment barriers will help inform interventions to correct vision impairment and ultimately improve the lives of patients living with ESKD. We will leverage the infrastructure of our ongoing intradialytic interventions trial to launch the Vision Impairment Screening in Hemodialysis (VIS-HD) prospective cohort (n=300). Using an efficient study design in which all research will be conducted at 16 dialysis centers, we will assess visual acuity and test for retinopathy during dialysis, then develop interventions to mitigate vision impairment. We seek: 1) To characterize vision impairment prevalence, risk factors, and causes; 2) To identify cognitive and vision- related sequelae of vision impairment; and 3) To identify barriers to correcting vision impairment and develop a multi-modal intervention to mitigate vision impairment. This project will set the groundwork for a subsequent multi-center randomized control trial to correct vision impairment. Our findings will have an immediate impact on the lives of the ~802,000 adults who live with ESKD. With this project, we seek to address a NIA priority: To develop interventions for treating, preventing, or mitigating the impact of age-related conditions.
