Chronic Kidney Disease in Early Life: The Impact on Cognition, Education, and Workforce Integration

The majority of children affected by chronic kidney disease (CKD) will survive to adulthood (1, 2). Adult survivors of childhood onset end stage renal disease (ESRD) will carry with them a legacy of ESRD and its attendant complications, including effects on cognition, education, and employability.

Children with ESRD are at risk for cerebral atrophy, silent and symptomatic cerebrovascular infarctions, and ischemia. However, the cognitive function of children with CKD may be impaired despite normal results on brain imaging. ESRD has been shown to have a negative impact on IQ, memory, and executive functions (2). Furthermore, in the national Chronic Kidney Disease in Children (CKiD) study 30 percent to 40 percent of children with mild to moderate CKD (estimated glomerular filtration rate 40 to 90 ml/min/1.73 m2) scored more than 1 standard deviation below the healthy population normative mean in measures of IQ, academic achievement, attention, memory, and executive function (3). Pilot data have shown that IQ improves by an average of 12 points in children with ESRD after receiving a kidney transplant (4). This finding suggests that some of the cognitive impairments demonstrated in dialysis-dependent children with ESRD may improve with resolution of uremia.

Education is often disrupted in children with ESRD due to medical appointments, procedures, and illnesses. Given the documented challenges to cognitive function and chronic illness, one would expect that 40 percent to 45 percent of children with ESRD would receive special education services. Unfortunately, children with ESRD have the same 15 percent placement rate in special education programs as the general United States population of children (5). Additional research is required to assess the type and value of special education services for children within the CKD/ESRD continuum

Employment status has been evaluated in adult survivors of childhood-onset ESRD (6). In a Dutch cohort, 67 percent of the patients in the study were employed, which is substantially greater than published employment rates of 25 percent to 50 percent of adults with adult-onset ESRD in several other studies (610). Compared with healthy age-matched controls, adult survivors of childhood-onset ESRD were more likely to be unemployed involuntarily (19 percent versus 11 percent) and to be employed in positions requiring a lower level of training or education (6). Another study found that adult survivors of childhood-onset ESRD had a 10 point to 15 point decrement in IQ compared with their healthy age-matched counterparts and tended to have a lower final educational/training level than the general population (11). It is hypothesized that health-related disruptions in typical developmental experiences and in education contribute to these findings.

Although additional investigation is required to bolster our understanding of the factors that contribute to the cognitive and educational challenges experienced by children with CKD, we now have evidence documenting the resilience of adult survivors of childhood-onset ESRD based on their employment rates. Our next step is to identify effective intervention strategies to maximize cognitive development, educational achievement, and prospects for employment opportunities equal to the general population.

Notes

[1] Drs. Gipson and Ferris are affiliated with the University of North Carolina–Chapel Hill, Chapel Hill, NC.

References

1. U.S. Renal Data System.USRDS 2003 Annual Data Report: Atlas of End-Stage Renal Disease in the United States, Bethesda, MD, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 2003.

2. Gipson DS, et al. Memory and executive functions in pediatric chronic kidney disease. Child Neuropsychol 2006; 12:391–405.

3. Hooper SR, et al. Neurocognitive functioning of children and adolescents with mild-to-moderate chronic kidney disease. Clin J Am Soc Nephrol 2011; 6:1824–1830.

4. Icard P, et al. Cognitive improvement in children with CKD after transplant. Pediatr Transplant 2010; 14:887–890.

5. Duquette PJ, et al. Brief report: Intellectual and academic functioning in pediatric chronic kidney disease. J Pediatr Psychol 2007; 32:1011–1017.

6. Groothoff JW, et al. Social consequences in adult life of end-stage renal disease in childhood. J Pediatr 2005; 146:512–517.

7.Keogh AM, Feehally J. A quantitative study comparing adjustment and acceptance of illness in adults on renal replacement therapy. ANNA J 1999; 26:471–477.

8. Blake C, et al. Physical function, employment and quality of life in end-stage renal disease. J Nephrol 2000; 13:142–149.

9.Van Manen JG, et al. Changes in employment status in end-stage renal disease patients during their first year of dialysis. Perit Dial Int 2001; 21:595–601.

10. Curtin RB, et al. Differences between employed and nonemployed dialysis patients. Am J Kidney Dis 1996; 27:533–540.

11. Groothoff JW, et al. Impaired cognition and schooling in adults with end stage renal disease since childhood. Arch Dis Child 2002; 87:380–385.

September 2012 (Vol. 4, Number 9)