Identifying neurocognitive outcomes and cerebral oxygenation in critically ill adults on acute kidney replacement therapy in the intensive care unit: the INCOGNITO-AKI study protocol

Natasha Arianne Jawa, Rachel M Holden, Samuel A Silver, Stephen H Scott, Andrew G Day, Patrick A Norman, Benjamin Y M Kwan, David M Maslove, John Muscedere, John Gordon Boyd, Natasha Arianne Jawa, Rachel M Holden, Samuel A Silver, Stephen H Scott, Andrew G Day, Patrick A Norman, Benjamin Y M Kwan, David M Maslove, John Muscedere, John Gordon Boyd

Abstract

Introduction: Initiation of acute kidney replacement therapy (KRT) is common in critically ill adults admitted to the intensive care unit (ICU), and associated with increased morbidity and mortality. KRT has been linked to poor neurocognitive outcomes, leading to reduced quality of life and increased utilisation of healthcare resources. Adults on dialysis in the ICU may be particularly at risk of neurocognitive impairment, as survivors of critical illness are already predisposed to developing cerebrovascular disease and cognitive dysfunction long-term relative to healthy controls. Regional cerebral oxygen saturation may provide a critical early marker of long-term neurocognitive impairment in this population. This study aims to understand cerebral oxygenation in patients undergoing KRT (continuous or intermittent) in the ICU. These findings will be correlated with long-term cognitive and functional outcomes, and structural brain pathology.

Methods and analysis: 108 patients scheduled to undergo treatment for acute kidney injury with KRT in the Kingston Health Sciences Centre ICU will be recruited into this prospective observational study. Enrolled patients will be assessed with intradialytic cerebral oximetry using near infrared spectroscopy. Delirium will be assessed daily with the Confusion Assessment Method-ICU (CAM-ICU) and severity quantified as cumulative CAM-ICU-7 scores. Neurocognitive impairment will be assessed at 3 and 12 months after hospital discharge using the Kinarm and Repeatable Battery for the Assessment of Neuropsychological Status. Structural brain pathology on MRI will also be measured at the same timepoints. Driving safety, adverse events and medication adherence will be assessed at 12 months to evaluate the impact of neurocognitive impairment on functional outcomes.

Ethics and dissemination: This study is approved by the Queen's University Health Sciences/Affiliated Teaching Hospitals Research Ethics Board (DMED-2424-20). Results will be presented at critical care conferences, and a lay summary will be provided to patients in their preferred format.

Trial registration number: NCT04722939.

Keywords: acute renal failure; adult intensive & critical care; adult neurology; dialysis.

Conflict of interest statement

Competing interests: SHS is cofounder and CSO of Kinarm that commercialises the Kinarm robotic technology used in the present study. NAJ, RMH, SAS, AGD, PAN, BYMK, DMM, JM and JGB have no conflicts of interest to declare.

© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
Figure 1
Hypothesised causal pathway. AE, adverse events; AKI, acute kidney injury; KRT, kidney replacement therapy; rSO2, regional cerebral oxygen saturation. Neurocognitive function is defined as performance on the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) and Kinarm tasks.
Figure 2
Figure 2
Study schema. APACHE II, Acute Physiological Assessment and Chronic Health Evaluation; CAM-ICU, Confusion Assessment Method-Intensive Care Unit; CDRS, Clinical Dementia Rating Scale; CFS, Clinical Frailty Scale; CKRT, continuous KRT; iHD, intermittent haemodialysis; KRT, kidney replacement therapy; RBANS, Repeatable Battery for the Assessment of Neuropsychological Status; rSO2, regional cerebral oxygen saturation; MARS, Medication Adherence Rating Scale; MDBQ, Machester Driver Behavior Questionnaire.

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