A cross-sectional assessment of key cognitive domains affected in Chronic dialysis patients with associated co-morbidities: A pilot study

A cross-sectional assessment of key cognitive domains affected in Chronic dialysis patients with associated co-morbidities: A pilot study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A cross-sectional assessment of key cognitive domains affected in Chronic dialysis patients with associated co-morbidities: A pilot study Ahmad waled shaban, Akash Niman, Dwight Figueiredo, Kajal Dagade, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8228712/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Cognitive impairment is a common but under-recognized complication in patients undergoing dialysis, with limited data available from India. This cross-sectional study assessed the cognitive abilities of 32 patients undergoing chronic dialysis using the Montreal Cognitive Assessment [MoCA]. Methodology A single-center cross-sectional design was used to evaluate 32 adults with CKD stages 3-5. Cognitive function was assessed using the 30-point MoCA tool. Descriptive statistics and non-parametric tests [Mann-Whitney U and Kruskal-Wallis tests] were applied, with significance set at p < 0.05. Ethical approval was obtained from the Institutional Ethics Committee. Results MoCA scores classified 10 patients as normal, 7 with mild impairment, 9 with moderate impairment, and 6 with severe impairment of cognitive function. The most affected domains were delayed recall [1.0 ± 1.3/5], attention [3.8 ± 2.3/6], and abstraction [1.1 ± 0.8/2]. Patients with diabetes showed a trend toward poorer cognitive scores [14.5 ± 7.3] than non-diabetics [19.4 ± 5.8] [p = 0.094]. Individuals with cognitive impairment had significantly lower pulse rates [p = 0.0331] and shorter dialysis durations [p = 0.0329]. Age [r = –0.4122, p = 0.022] and dialysis duration [r = 0.3473, p = 0.051] showed notable associations with MoCA scores, whereas blood pressure, sex, and occupation were not significantly related. Conclusion Most participants demonstrated cognitive impairment, highlighting the importance of routine cognitive screening in long-term dialysis care. Rehabilitation strategies should consider age, dialysis duration, and comorbidities, such as diabetes and hypertension. The findings suggest a link between autonomic function, dialysis adaptation, and cognitive status, underscoring the need for evidence-based cognitive rehabilitation programs to support patients undergoing chronic dialysis. Figures Figure 1 Figure 2 1. Introduction Cognitive impairment [CI] refers to difficulties in mental processes, such as thinking, memory, and attention, which can range from mild to severe. These difficulties can affect decision-making, problem-solving, and daily self-management tasks [ 4 , 41 ] and are increasingly acknowledged as prevalent and clinically significant complications at all stages of chronic kidney disease [CKD] [ 21 ]. CKD is a progressive illness in which the kidneys gradually lose their ability to function. When kidney function falls below 15% [GFR is less than 15 mL/min/1.73 m²] [ 37 , 55 ], the patient enters end-stage renal disease [ESRD], leading to the buildup of harmful levels of waste, fluids, and electrolytes in the body. Dialysis is essential for artificially carrying out kidney functions, helping patients prevent complications such as fluid overload, electrolyte imbalance, and uremic toxicity [ 5 ] [ 22 ]. Numerous studies have shown that individuals with CKD have higher rates of cognitive dysfunction than those without CKD [ 19 , 23 ]. The prevalence rates vary widely from 28.9% to over 70%, depending on the CKD stage and the methods used for cognitive evaluation and assessment [ 6 , 53 ], with vascular risk factors such as hypertension and diabetes significantly exacerbating cognitive decline [ 42 ]. The impact of cognitive impairment [CI] is particularly severe in patients with end-stage renal disease [ESRD], especially in those undergoing hemodialysis [HD]. Angermann et al. [2017] [ 1 ] found that 60.2% of HD patients scored pathologically on the Montreal Cognitive Assessment [MoCA], indicating cognitive impairment. They also identified, for the first time, a connection between cognitive decline and arterial stiffness [pulse wave velocity [PWV]], suggesting that vascular factors may contribute to cognitive impairment in patients undergoing dialysis [ 1 , 24 ]. Foster et al. [2016] [ 2 ] conducted a study assessing cognitive dysfunction in a diverse group of Canadian patients with stage G4–G5 CKD who were not yet on dialysis. The findings revealed that 61% of these patients exhibited cognitive impairments, particularly affecting their attention, memory, and executive function. This suggests that cognitive problems can manifest before the initiation of dialysis [ 35 ], even in the early stages of CKD, and are not exclusive to patients undergoing dialysis [ 2 , 25 ]. A longitudinal study by Iyasere et al. [2017] [ 3 , 52 ] indicated that patients with CKD on dialysis experience faster cognitive decline than those not on dialysis. Among those on dialysis, patients receiving hemodialysis showed a more significant decline in cognitive abilities, especially executive function, than those undergoing peritoneal dialysis [ 43 ]. Furthermore, cognitive outcomes following kidney transplantation are complex and not completely understood. Although transplantation is generally believed to enhance cognitive function by eliminating uremia, studies have indicated that many transplant recipients continue to suffer from cognitive impairment [CI] years after the procedure. Gupta et al. [2017] [ 6 ] discovered that 58% of stable transplant patients had cognitive impairments. This study highlights the need for objective screening of CI incidence and severity in CKD and chronic dialysis populations. Gupta et al. [2018] [ 7 ] demonstrated that relying solely on clinical judgment often leads to inaccurate assessments of CI prevalence, suggesting that regular cognitive assessments, such as the MoCA, should be conducted for dialysis and transplant patients [ 6 , 7 , 27 ]. The link between cognitive impairment in CKD and various outcomes, such as diminished quality of life, impaired decision-making, lower treatment adherence, and increased mortality [ 3 , 18 , 29 , 48 ] is well documented. However, there is a lack of studies measuring cognitive impairment in the dialysis population in India and its surrounding regions. Given the significant clinical and psychosocial impacts of cognitive impairment in CKD, this study aimed to explore the incidence of CI, identify affected domains, and highlight the demographic and clinically modifiable factors influencing CI among patients with CKD. 2. Methods 2.1 Study Design This study utilized a single-center, cross-sectional observational design, concentrating on 32 adults diagnosed with chronic kidney disease [CKD] at stages 3–5. CKD stages were classified based on the estimated glomerular filtration rate [eGFR], which assesses kidney function. Stage 3 CKD is identified by an eGFR ranging from 30 to 59 mL/min/1.73 m² and is further divided into stages 3a [eGFR 45–59] and 3b [eGFR 30–44]. Stage 4 is characterized by an eGFR between 15 and 29 mL/min/1.73 m², signifying a significant reduction in kidney function. Stage 5 CKD, also known as end-stage renal disease [ESRD], is diagnosed when the eGFR drops below 15 mL/min/1.73 m², at which point patients generally need renal replacement therapy, such as dialysis, to manage uremic complications and maintain their lives. [ 5 ]. 2.2 Location & Timelines of Study Individuals were recruited from a single dialysis center at a Tertiary Care Hospital in Pune. The research and data gathering were conducted between April and May 2023. 2.3 Inclusion & Exclusion Criteria of Studied Population To be eligible, participants needed to have a CKD diagnosis, be at least 18 years old, and possess an eGFR of less than 60 ml/min/1.73 m². The criteria for exclusion included being under 18, having neurological disorders like stroke, multiple sclerosis, or epilepsy, undergoing dialysis for a minimum of six months, experiencing severe visual or auditory impairments, being unable to give informed consent, suffering from uncontrolled severe psychiatric conditions such as untreated psychosis, having received a kidney transplant, and starting dialysis less than three months prior to the study. 2.4 Cognitive Screening Strategy Cognitive abilities were evaluated using the Montreal Cognitive Assessment [MoCA], a validated 30-point screening instrument sensitive to mild cognitive impairment, particularly executive dysfunction, which is frequently observed in patients with CKD [ 1 – 3 , 7 , 44 , 46 ]. 2.5 Statistical Analysis All statistical analyses were performed using IBM SPSS Statistics version 27.0 and Prism 5 software. Descriptive statistics were used to summarize the data collected. All continuous variables are reported as mean ± standard deviation [SD] and median with interquartile range [Q1–Q3]. Inferential statistical tests were applied based on the data type and distribution. We used the Mann–Whitney U test to compare the means of two groups for non-normally distributed data. The Kruskal–Wallis test was applied to compare the means between multiple groups, followed by a post-hoc analysis with pairwise comparison of means. Pearson’s correlation was used for bivariate correlations. Statistical significance was set at p < 0.05. 2.6 Ethical considerations The study protocol was reviewed and approved by the Research Ethics Committee of Symbiosis International [Deemed University] [Approval Code: SIU/IEC/486]. All participants provided in-person informed consent before accessing the questionnaire, ensuring adherence to the principles of the Helsinki Declaration [autonomy, justice, beneficence] and current national regulations. 3. Results Table 1 Clinical and Demographic Characteristics of the Study Participants [N = 32] PATIENTS CHARACTERISTICS [N = 32] MEAN ± SD Range MEDIAN [Q1-Q3] Age [yrs] 47.8 ± 15.1 [21–75] 49.5 [34.5–61.5] BP Systolic [mm/Hg] 143.4 ± 30.3 [92–212] 142.5 [120.5- 158.5] BP diastolic [mm/Hg] 90.8 ± 21.9 [45–147] 90 [78.5–101] Pulse [bpm] 75.8 ± 10.6 [42–90] 80 [69- 84.5] Weight [Kg] 61.8 ± 12.4 [40–95] 60.5 [55–70] Hypertension/Duration [yrs] 3.9 ± 3.8 [0–15] 3 [1.75–4.5] Diabetes Mellitus /Duration [yrs] 9.2 ± 5.6 [0–15] 10 [4 − 15] Medication/Duration [yrs] 4.8 ± 4.5 [0–15] 3 [1.75–6.5] Dialysis/Duration [yrs] 2.3 ± 1.9 [0.6–11] 2 [1.5–2.5] In our study, the average age of the participants was 47.8 years, with a standard deviation of 15.1 years [Table 1 ]. The mean systolic blood pressure recorded was 143.4 mmHg with a standard deviation of 30.3, whereas the diastolic pressure averaged 90.8 mmHg with a standard deviation of 21.9 [Table 1 ]. Participants had an average pulse rate of 75.8 beats per minute, with a standard deviation of 10.6 [Table 1 ], and their mean weight was 61.8 kg, with a standard deviation of 12.4 [Table 1 ]. Among the participants, nine were diagnosed with diabetes and 25 with hypertension. The average duration of hypertension was [mean ± SD] 3.9 ± 3.8 years [Table 1 ], while diabetes had been present for an average of 9.2 ± 5.6 years [Table 1 ]. The mean duration of medication use was 4.8 ± 4.5 years [Table 1 ], and dialysis treatment was ongoing for an average of 2.3 ± 1.9 years [Table 1 ]. These statistics provide insights into the health and clinical history of the study population. Table 1 summarizes the baseline characteristics of the participants. 3.1 Cognitive Impairment Assessment The MoCA test revealed a high prevalence of cognitive impairment, affecting 22 of the 32 patients [68.75%] [Figure 1 A]. Of these 22 patients, 7 [31.81%] had mild impairment, 9 [40.9%] had moderate impairment, and 6 [27.27%] had severe impairment [Figure 1 B]. When considering this statistic Among the total chronic dialysis population [N =32], 21.88% had mild impairment, 28.13% had moderate impairment, and 18.75% were classified as severely impaired [Fig 1 A]. These results underscore the significant burden of cognitive decline in the chronic dialysis population. We aimed to identify the MoCA domains that were most affected in our sample. To achieve this, we analyzed the data, finding a visuospatial mean of [2.7 ± 9.2] out of 5, a naming mean of [2.6 ± 0.7] out of 3, an attention mean of [3.8 ± 2.3] out of 2, a language average of [1.7 ± 0.8] out of 2, an abstraction average of [1.1 ± 0.8] out of 2, a delayed recall mean of [1.0 ± 1.3] out of 5, and an orientation average of [5.2 ± 1.2] out of 6 [Table 2]. These findings imply that while certain cognitive domains are relatively intact, others—especially those associated with memory and abstract reasoning—are more susceptible in this group of patients than in healthy individuals. 3.2 Table 2: Cognitive Domain Scores of Dialysis patients Domain [Total Score] Mean ± SD Range Median [Q1-Q3] Visuospatial [ 5 ] 2.7 ± 9.2 [0–5] 3 [0.5-4] Naming [ 3 ] 2.6 ± 0.7 [ 1 – 3 ] 3 [ 2 – 3 ] Attention [ 6 ] 3.8 ± 2.3 [0–6] 4 [1.5-6] Language [ 3 ] 1.7 ± 0.8 [0–3] 2 [ 1 – 2 ] Abstraction [ 2 ] 1.1 ± 0.8 [0–2] 1 [ 1 – 2 ] Delayed Recall [ 5 ] 1.0 ± 1.3 [0–4] 0 [0–2] Orientation [ 6 ] 5.2 ± 1.2 [ 2 – 6 ] 6 [ 5 – 6 ] To better understand the specific cognitive domains affected among patients undergoing dialysis, Table 2 summarizes their performance across the various components of the Montreal Cognitive Assessment [MoCA]. The results revealed considerable variability in cognitive functioning across the domains. Orientation had the highest average score [mean ± SD: 5.2 ± 1.2 out of 6] [Table 2], with a median of 6, indicating relatively preserved awareness of time and place among most participants. Similarly, naming was largely intact [mean: 2.6 ± 0.7 out of 3], with a narrow range [ 1 – 3 ] and high median [ 3 ] [Table 2], suggesting minimal deficits in object recognition and verbal labelling. In contrast, delayed recall showed the lowest performance [mean: 1.0 ± 1.3 out of 5; median: 0] [Table 2], reflecting significant impairments in short-term memory retention. Visuospatial abilities also demonstrated marked variability [mean: 2.7 ± 9.2 out of 5] [Table 2], likely influenced by outliers or possible recording errors, as the standard deviation exceeded the domain's maximum score. Domains such as attention [mean: 3.8 ± 2.3 out of 6], language [1.7 ± 0.8 out of 3], and abstraction [1.1 ± 0.8 out of 2] showed moderate deficits, with median scores falling near the midpoints of their respective scales. Overall, the data suggest that while certain cognitive faculties remain relatively preserved in this population, memory, abstraction, and visuospatial processing may be particularly vulnerable in patients undergoing dialysis. 3.3 Subgroup analysis of MoCA Scores Table 3 Mean MoCA Scores Across Patient Subgroups Based on Clinical and Demographic Characteristic Variable Option MEAN [CI] +_ STD.DEVITATION Median [Q1-Q3] Mean Rank Mann Whitney U p VALUE Diabetes Yes [N = 9] 14.5 [8.9–20.2] + 7.3 11 [8.5–24] 12 63 0.094 No [N = 23] 19.4 [16.9–22] + 5.8 19 [ 16 – 24 ] 18.25 Hypertension Yes [N = 7] 17.08 [14.3–19.8] + 6.7 17 [10.5–24] 15.18 54.5 0.135 No [N = 25] 21.7[17.2–26.2] + 4.9 21 [ 18 – 28 ] 21.21 Med. Duration Yes [N = 8] 17.3 [14.2–20.3] + 7 19 [ 14 – 25 ] 15.61 83 0.409 No [N = 24] 20.2 [16.3–24.2] + 5.2 20 [6.2–24] 18.78 Age > 45 [N = 15] 15 [11.6–18.4] + 6.6 15 [8.5–21.5] 9.25 52 0.585 < 45 [N = 17] 21.4 [19.2–24] + 4.7 22 [ 17 – 25 ] 14.75 Gendre Male [N = 23] 19.6 [17–22.2] + 6 19 [10.5–20.75] 10.25 48 0.729 Female [N = 9] 14.2 [9–19.4] + 6.7 14 [12–23.5] 15.75 Occupation Blue [N = 25] 16.6 [13.9–19.3] + 6.5 16.5[ 9 – 20 ] 11.5 51 0.398 White [N = 7] 22.6 [18.6–26.7] + 4.8 24.5[ 18 – 25 ] 16.5 Systolic BP Normal [N = 19] 18.2 [11.4–22] + 6.3 17 [ 17 – 25 ] 16.25 51 0.639 Abnormal [N = 13] 18 [14.7–21.4] + 7 19 [9.5–19] 11.75 Diastolic BP Normal [N = 29] 18 [15.4–20.6] + 6.8 19[ 18 – 25 ] 16.5 50 0.351 Abnormal [N = 3] 18.7 [8.3–29] + 4.1 20 [8.5–20] 11.5 Pulse Normal [N = 24] 18.2 [15.1–21.2] + 7.2 18.5 [ 18 – 25 ] 16.5 52 0.889 Abnormal [N = 8] 17.9 [13.9–21.9] + 4.8 19 [9–19.5] 11.5 Next, we aimed to identify whether certain demographic and clinical variables influenced the cognitive capacity of patients undergoing dialysis. Patients with diabetes had a lower average MoCA score [14.56 ± 7.35] [Table 3 ] than those without diabetes [19.47 ± 5.84] [Table 3 ]. Although this difference was not statistically significant [p = 0.094] [Table 3 ], it was close to the threshold, indicating a potential association between diabetes and decreased cognitive function. Conversely, hypertension did not show a statistically significant effect [p = 0.138] [Table 3 ], even though individuals without hypertension had slightly higher scores [19.87] than those with hypertension [17.08] [Table 3 ]. A similar trend was observed for medication use: individuals on prescribed medications scored higher [21.71] than those not on medication [17.27] [Table 3 ], but this difference was not statistically significant [p = 0.409] [Table 3 ]. Age also had no significant effect. Individuals aged ≥ 45 years had cognitive scores similar to those aged < 45 years [p = 0.585] [Table 3 ]. Sex had minimal influence, with nearly identical scores between men and women [p = 0.883] [Table 3 ]. Occupational status followed the same pattern, although white-collar workers scored slightly higher [22.63] than blue-collar workers [16.58] [Table 3 ], the difference was not statistically significant [p = 0.738] [Table 3 ]. Other clinical factors, such as systolic [p = 0.639] and diastolic blood pressure [p = 0.351] and pulse rate [p = 0.889] [Table 3 ], classified as normal or abnormal, also showed no significant relationship with cognitive performance, with all p-values above [0.05]. 3.4 Table 4: Comparison of Clinical and Demographic Variables Between Cognitively Normal and Impaired Haemodialysis Patients Patient's Characteristics Normal [N = 10] Impaired [N = 22] mean median [Q1-Q3] mean median [Q1-Q3] P value Age [yrs] 41.1 38.5 [32.5-51.75] 50.9 54 [35-64.25] 0.1159 BP systolic [mmhg] 142.5 146.5 [132.5-156.3] 143.8 140 [113-172.5] 0.7718 BP diastolic [mmhg] 95.8 97.5 [88-100.5] 88.6 83 [70-109.3] 0.1787 pulse [bpm] 81.7 84.5 [78.75-86] 73.2 72.5 [67.25-82] 0.0331* weight [kg] 65 61 [56–71] 60.3 60.5 [51.5–70] 0.4048 hypertension duration [years] 4 2.5 [1.5–6.25] 2.6 1.75 [0.4-3] 0.2594 diabetes duration [years] 4.2 0 [0-12.75] 1.86 0 [0-0.82] 0.6488 medication duration [years] 5.7 3.25 [1.125–12.75] 2.6 1.75 [0-3.25] 0.1442 dialysis duration [years] 3.41 2.5 [2-3.875] 1.8 2 [ 1 – 2 ] 0.0329* To further elucidate the clinical correlates of cognitive impairment, a subgroup analysis was conducted comparing patients with normal cognition to those with any degree of cognitive impairment. A comparative analysis between cognitively normal and impaired patients revealed several clinical and demographic trends that aligned with known contributors to cognitive dysfunction in the dialysis population. The mean age of cognitively impaired individuals was notably higher [50.9 years] compared to the normal group [41.1 years] [Table 4], supporting the well-documented association between advancing age and cognitive decline in chronic kidney disease [CKD] populations, however it wasn’t significant [p = 0.1159] The hemodynamic variables showed mixed patterns. Systolic blood pressure was slightly elevated in the impaired group [mean: 143.8 mmHg vs. 142.5 mmHg] [p = 0.7718], whereas diastolic pressure was notably lower [88.6 mmHg vs. 95.8 mmHg] [p = 0.1787] [Table 4]. This drop in diastolic pressure may reflect impaired vascular compliance or autonomic dysregulation, both of which have been linked to cerebral hypoperfusion and cognitive impairment in previous studies. The pulse rate was also lower in the impaired group [73.2 bpm vs. 81.7 bpm] [Table 4], a finding that could suggest autonomic dysfunction, deconditioning, or medication effects, with a P value of [p = 0.0331], suggesting a significant link between pulse and cognitive health. Weight differences were minimal between the two groups. However, the impaired group had shorter durations of hypertension [2.6 vs. 4 years] [p = 0.2549], diabetes mellitus [1.86 vs. 4.2 years] [p = 0.4048], and overall medication use [2.6 vs. 5.7 years] [p = 0.1442] [Table 4]. While this may appear counterintuitive, it could reflect more recent diagnoses or underreporting, or it may suggest that the cumulative burden over a longer duration contributes more significantly to cognitive preservation than the presence of comorbidities alone. Dialysis duration was substantially longer in the cognitively normal group [mean: 3.41 years] than in the impaired group [1.8 years] [Table 4] [p = 0.0329], which may be due to an adaptation effect or survivorship bias, wherein patients with better baseline cognitive reserve or health are more likely to remain on dialysis longer. These patterns collectively underscore the complex and multifactorial nature of cognitive impairment in CKD, which is shaped by age, vascular dynamics, disease duration, and dialysis exposure. 3.5 Table 5: Compares between clinical and demographic variables of patients segregated into mild, moderate and severe cognitive impairment PATIENTS CHARACTERISTICS NORMAL [ 10 ] MILD [ 8 ] MODERATE [ 8 ] SEVERE [ 6 ] p value MEAN MEDIAN [Q1-Q3] MEAN MEDIAN [Q1-Q3] MEAN MEDIAN [Q1-Q3] MEAN MEDIAN [Q1-Q3] AGE [yrs] 41.1 38.5 [32.5-51.75] 49.38 46.5 [34–64] 45.38 44 [33-56.5] 60.17 60.5 [55–65] 0.091 BP SYSTOLIC [mm Hg] 142.5 146.5 [132.5-156.3] 153.88 148.5 [126–189] 124.38 120.5 [110-132.5] 156.33 160 [140–187] 0.158 BP DIASTOLIC [mm Hg] 95.8 97.5 [88-100.5] 89 83.5 [64.5-116.5] 81.38 83 [71–95] 97.5 85 [80–118] 0.094 PULSE [BPM] 81.7 84.5 [78.75-86] 73.38 69 [66-83.5] 71.75 72.5 [67.5–82.5] 74.83 78.5 [70–80] 0.387 WEIGHT [kg] 65 61 [56–71] 57 59.5 [46.5–67] 66 67.5 [60-74.5] 57.17 53.5 [52–61] 0.236 HYPERTENSION DURATION [YRS] 4 2.5 [1.5–6.25] 0.825 0.35 [0-1.45] 3.58 2.25 [1.05–3.5] 3.83 2.5 [ 2 – 5 ] 0.114 DIABETES MILLETUS DURATION [YRS] 4.2 0 [0-12.75] 0 0 [0–0] 2.25 0 [0–3] 3.43 1 [0–8] 0.254 MEDICATION DURATION [YRS] 5.7 3.25 [1.125–12.75] 0.825 0.35 -1.45 2.89 2.25 [1.05–3.5] 4.67 3.5 [ 2 – 8 ] 0.121 DIALYSIS DURATION [YRS] 3.41 2.5 [2-3.875] 1.675 2 [0.85-2] 1.91 1.75 [1.1–2.5] 1.83 2 [ 2 – 2 ] 0.442 To better understand the clinical context of cognitive impairment in this cohort, Table 5 compares the key demographic and clinical parameters across varying levels of cognitive impairment severity. Table 5 presents a comparative analysis of key demographic and clinical variables across the categories of cognitive function, namely, normal, mild, moderate, and severe impairment. Although none of the differences reached statistical significance [p > 0.05], several notable patterns emerged that aligned with established pathophysiological pathways associated with cognitive decline in chronic kidney disease [CKD] populations. Most prominently, age showed a progressive increase across the cognitive spectrum, rising from a mean of 41.1 years in the cognitively normal group to 60.17 years in the severely impaired group [p = 0.091] [Table 5]. This trend supports the existing literature suggesting that advancing age is a critical risk factor for cognitive dysfunction, particularly in patients with underlying comorbidities such as CKD. Moreover, systolic and diastolic blood pressure values were elevated in patients with severe cognitive impairment [SBP, 156.33 mmHg; DBP, 97.5 mmHg], indicating a potential link between chronic hemodynamic stress and cerebrovascular dysregulation [Table 5]. These hemodynamic changes may contribute to cumulative vascular injury, cerebral hypoperfusion, and structural brain alterations, all of which are known to contribute to cognitive impairment. Additionally, patients with severe impairment also demonstrated longer durations of hypertension and diabetes mellitus, further reinforcing the role of sustained metabolic and vascular insults, particularly microvascular damage and prolonged hyperglycemia, in the pathogenesis of cognitive deterioration. Although dialysis duration, pulse rate, and body weight did not show a consistent trend across cognitive categories, the observed patterns suggest a complex interplay of cardiovascular, metabolic, and age-related factors that may jointly influence neurocognitive outcomes in patients undergoing dialysis. 3.6 MoCA Domain Scores by Cognitive Impairment Category To gain deeper insight into how specific cognitive domains are affected at varying levels of impairment, Table 6 offers a stratified analysis of MoCA subdomain performance across cognitive severity categories, focusing on specific ones. In patients with severe impairment, the most significantly affected areas were visuospatial skills [p < 0.0001], attention [p = 0.0003], and orientation [p = 0.0005] [Table 6], which exhibited the most pronounced declines. This emphasizes the susceptibility of these domains to vascular cognitive dysfunction, which is often observed in patients with advanced CKD. These impairments are likely due to cerebrovascular disease and the neurotoxic impact of accumulated uremic toxins, which particularly affect executive and visuospatial processing abilities. Notably, deficits in abstraction and delayed recall were already apparent in patients with mild-to-moderate impairment, suggesting that these domains may serve as early indicators of cognitive decline. Conversely, naming and language skills remained relatively intact at most cognitive-severity levels. This stability may indicate the robustness of the core verbal functions. The orientation domain, which includes awareness of time and place, was largely unaffected until the most severe impairment stage, suggesting that basic temporal and spatial orientation is maintained for a longer period, even when other cognitive functions deteriorate. Overall, these domain-specific trends highlight the limitations of relying solely on global MoCA scores. Subtle yet significant impairments, particularly in executive, memory, and visuospatial functions, may be overlooked without domain-specific screening. These findings underscore the need for more detailed cognitive assessments in patients with CKD. 3.8 Table 6: Distribution of Montreal Cognitive Assessment [MoCA] Domain Scores by Cognitive Impairment Category Normal Mild Moderate Severe P value MEAN MEDIAN [Q1-Q3] MEAN MEDIAN [Q1-Q3] MEAN MEDIAN [Q1-Q3] MEAN MEDIAN [Q1-Q3] Visuospatial [ 5 ] 4.5 5 [ 4 – 5 ] 3 3.5 [2.5-4] 1.88 2 [0.5-3] 0.17 0 [0–0] < 0.0001*** NAMING [ 3 ] 3 3 [ 3 – 3 ] 2.625 3 [2.5-3] 2.25 2.5 [1.5-3] 2.5 2.5 [ 2 – 3 ] 0.024* ATTENTION [ 6 ] 5.6 6 [ 5 – 6 ] 4.63 5 [4-5.5] 2.88 3 [1.5-4] 0.67 1 [0–1] 0.0003*** LANGUAGE [ 3 ] 2.2 2 [ 2 – 3 ] 2 2 [ 2 – 2 ] 2.38 2.5 [1.5–3.5] 1 1 [ 1 – 1 ] 0.0018** ABSTRACTION [ 2 ] 1.8 2 [ 2 – 2 ] 1.125 1 [1-1.5] 1 1 [ 1 – 1 ] 0.33 0 [0–0] 0.0023** DELAYED RECALL [ 5 ] 2.2 2.5 [ 1 – 3 ] 0.625 1 [0–1] 0.25 0 [0-0.5] 0.33 0 [0–0] 0.0077** OREINTATION [ 6 ] 5.9 6 [ 6 – 6 ] 5.75 6 [5.5-6] 6 [5.5-6] 3 3 [ 2 – 4 ] 0.0005*** 5.5 3.9 Table 7: Multiple Comparisons of MoCA Cognitive Domains Between Severity Groups Category Overall Mild vs. Normal Normal vs. Moderate Severe vs. Normal Moderate vs. Mild Moderate vs. severe Mild vs. Severe Visuospatial < 0.0001**** 0.0983 0.2761 ns < 0.0001**** 0.0106* 0.9587 Naming 0.0409* ns 0.1146 0.862 ns ns ns Attention 0.0001*** ns 0.0244* 0.0002*** 0.6342 0.8381 0.0176* Language 0.0033** ns 0.0522 0.0102* 0.334 ns 0.0813 Abstraction 0.0031** 0.3021 0.1178 0.0019** ns 0.9903 0.5139 Delayed Recall 0.0098** 0.1415 0.0258* 0.043* ns ns ns Orientation 0.0002*** ns ns 0.0002*** ns 0.0113* 0.0021** Next, we wanted to dig deeper, so we started comparing MoCA domains between severity groups to discover the notable differences that were observed in certain cognitive categories when comparing MoCA cognitive domains across groups, underscoring the progressive nature of the impairment. The visuospatial domain exhibited a highly significant difference between the moderate and mild groups [p < 0.0001] and between the moderate and severe groups [p = 0.0106] [Table 7], indicating a marked decline in visuospatial abilities at the moderate stage. Similarly, attention showed statistically significant differences in several comparisons: severe vs. normal [p = 0.0002], mild vs. severe [p = 0.0176], and normal vs. moderate [p = 0.0244] [Table 7], suggesting that attention is one of the earliest and most progressively affected domains. Orientation also demonstrated strong significance in comparisons such as moderate vs. severe [p = 0.0113], severe vs. normal [p = 0.0002], and mild vs. severe [p = 0.0021] [Table 7], highlighting disorientation as a key indicator of advanced cognitive decline. Other domains, such as language, abstraction, and delayed recall, showed significant differences, mainly between the severe and normal groups, further supporting the cumulative burden of cognitive dysfunction in more severe stages. Notably, naming only showed significance in the overall comparison [p = 0.0409] [Table 7], but not between specific pairs, indicating a relatively preserved naming ability across earlier categories. Overall, the statistical analysis highlighted that cognitive decline in patients undergoing dialysis may disproportionately affect specific domains, with attention, orientation, and visuospatial abilities showing the most consistent and significant differences across stages of impairment. 3.10 Table 8: Correlation coefficient and p-value of variables with MoCA scores Variable Correlation Coefficient [r] p value Age -0.4 0.022* Pulse 0.34 0.057 Weight 0.112 0.543 Hypertension Duration 0.077 0.713 Diastolic BP 0.171 0.351 Medication duration -0.088 0.631 Systolic BP 0.35 0.849 Dialysis duration 0.3473 0.051 To examine the potential predictors of cognitive performance, Table 8 presents the correlation analysis between key clinical variables and MoCA scores. In this table, we present the correlation coefficients and associated p-values for a range of clinical variables related to cognitive performance. Notably, age [p = 0.022] and duration of dialysis [p = 0.051] [Table 8] were identified as significant factors. This outcome aligns with expectations, as advancing age and extended dialysis duration are both recognized to have detrimental effects on cognitive function. Interestingly, the pulse rate [p = 0.057] [Table 8] showed a trend towards significance. Although it did not reach the conventional threshold, its proximity to statistical relevance, coupled with the constraints of a small sample size, suggests that it could be a factor worth investigating further. Notably, the pulse rate has not been identified as a significant variable in any of the studies referenced in this paper, making it a potentially new area of research. All other variables analyzed were found to be statistically insignificant. These results underscore the importance of age and dialysis duration as key contributors to cognitive decline, while highlighting the pulse rate as an emerging variable that may merit further study in larger cohorts. 3.11 Table 9: Correlation of MoCA test domains with diabetes/hypertension/Dialysis Duration Diabetes duration r value p value Hypertension duration r value p value Dialysis duration r values p value Visuospatial -0.197 0.694 Visuospatial 0.02439 0.3611 Visuospatial -0.2912 0.167 Naming 0.2621 0.694 Naming 0.3139 0.096 Naming -0.1107 0.883 Attention -0.295 0.681 Attention -0.3506 0.501 Attention 0.2458 0.82 Language -0.542 0.355 Language -0.362 0.38 Language -0.4859 0.018* Delayed Recall -0.24 0.749 Delayed Recall 0.1328 0.913 Delayed Recall -0.1459 0.673 Orientation 0.6495 0.381 Orientation 0.07918 0.709 Orientation 0.2297 0.617 Abstraction -0.124 0.816 Abstraction 0.05075 0.814 Abstraction -0.09515 0.551 To further explore how chronic clinical conditions may differentially impact cognitive function, Table 9 presents domain-specific correlations between the MoCA scores and the duration of diabetes, hypertension, and dialysis. The analysis of cognitive performance across different domains in relation to the duration of diabetes, hypertension, and dialysis highlighted several significant trends. The duration of diabetes did not show any statistically significant links with any of the MoCA domains, and the correlation coefficients varied in both direction and strength, indicating no consistent pattern. For instance, weak correlations were found in the visuospatial [r = -0.197, p = 0.694], naming [r = 0.2621, p = 0.694], and language [r = -0.542, p = 0.355] domains [Table 9], suggesting that the duration of time a patient had diabetes did not independently influence domain-specific cognitive abilities in this group. Conversely, the duration of hypertension was significantly negatively correlated with visuospatial performance [r = -0.3611, p = 0.024] [Table 9], indicating that prolonged high blood pressure may impair visual and spatial processing ability. Although other domains, such as language [r = 0.38] and naming [r = 0.096] [Table 9], exhibited mild positive trends, they were not statistically significant, emphasizing the need for further research with larger sample sizes. The duration of dialysis was also associated with cognitive decline in certain areas, with a statistically significant negative correlation found in the language domain [r = -0.4859, p = 0.018] [Table 9], suggesting that an extended duration of dialysis could negatively affect verbal abilities. Other domains, such as visuospatial [r = -0.2912, p = 0.167] and abstraction [r = -0.0951, p = 0.551] [Table 9], showed weak and non-significant associations. Overall, these findings suggest that long-term hypertension and prolonged dialysis treatment may affect specific cognitive domains, particularly visuospatial and language function. The duration of diabetes did not emerge as a significant factor in domain-specific cognitive decline within this sample, highlighting the complex and multifactorial nature of cognitive impairment in patients with chronic kidney disease. 4. Discussion This study highlights the significant burden of cognitive impairment among patients undergoing long-term dialysis, as evaluated by the Montreal Cognitive Assessment [MoCA]. Patients were categorized into four cognitive levels: normal, mild, moderate, and severe, with most showing some cognitive decline, particularly in attention, delayed recall, and abstraction [Figure 2 ] [ 47 ]. A notable negative correlation between age and MoCA scores [p = 0.022] [Table 8] emphasized the influence of aging on cognitive abilities in this group [Figure 2 ]. These results are consistent with earlier studies that associate age-related neurovascular and metabolic changes in chronic kidney disease [CKD] with cognitive decline [ 8 , 10 , 13 , 20 , 40 , 51 ]. Furthermore, the duration of dialysis and pulse rate showed a directionality towards significant correlations [although not statistically significant with the current statistical power], indicating that prolonged dialysis exposure and autonomic instability may contribute to subtle cognitive impairment. Extended dialysis is associated with repeated cerebral hypoperfusion and inflammatory processes that gradually impair brain function [ 3 , 26 , 27 , 30 , 33 , 34 ]. In addition to vascular and metabolic contributors, anemia has been linked to cognitive decline in patients with CKD due to reduced oxygen delivery and cerebral hypoxia [ 36 ]. Among the comorbidities, diabetes mellitus was identified as a potential factor for cognitive impairment, with patients having lower average MoCA scores [p = 0.094] [Table 3 ]. Although not statistically significant, this trend aligns with the existing literature connecting chronic hyperglycemia and insulin resistance to neurovascular damage in CKD [ 9 – 10 , 28 , 39 ]. Experimental and clinical studies have demonstrated that diabetes exacerbates neurodegeneration via blood-brain barrier disruption, microvascular injury, and synaptic dysfunction [ 38 , 45 ], mechanisms that are likely to be amplified in CKD. Conversely, hypertension did not show a significant relationship with cognitive scores in this study, although its role in microvascular injury and cerebral autoregulation remains clinically relevant. [ 1 , 20 , 23 ]. Analysis of MoCA subdomains showed that delayed recall and attention were the most affected in patients with cognitive deficits, consistent with previous findings that identified these areas as early indicators of uremia-related cognitive decline [ 12 – 14 , 16 – 17 ]. Meanwhile, orientation and naming abilities were relatively preserved, supporting the idea that basic language and spatiotemporal awareness often remain intact in the early stages of cognitive impairment. [ 12 , 15 , 17 ]. The brain regions and circuits involved in delayed recall and attention are intricate and well defined. The hippocampus and associated structures within the medial temporal lobe are crucial for encoding, consolidating, and retrieving episodic memories, which are central to delayed recall [ 17 ]. Conversely, attention is managed by a network of areas, including the prefrontal cortex, anterior cingulate cortex, parietal lobes, and subcortical structures such as the thalamus and basal ganglia [ 9 , 17 , 54 ]. In individuals with chronic kidney disease [CKD] and those undergoing dialysis, these brain regions are particularly susceptible to damage by uremic toxins, such as indoxyl sulfate, p-cresyl sulfate, and guanidino compounds [ 32 ]. These toxins can penetrate the blood-brain barrier, leading to neurotoxic and proinflammatory effects [ 31 , 49 ]. Recent evidence suggests that CKD-related cognitive impairment arises from a combination of blood-brain barrier disruption, oxidative stress, and microglial activation, which collectively accelerate neurodegeneration [ 41 ]. They interfere with synaptic signaling, hinder neurogenesis in the hippocampus, and decrease cerebral blood flow, especially during or after hemodialysis, owing to repeated episodes of intradialytic hypotension and cerebral hypoperfusion [ 30 , 33 ]. Furthermore, chronic inflammation, oxidative stress, and endothelial dysfunction associated with CKD further weakens the neurovascular unit, affecting attention regulation and memory consolidation [ 9 , 17 ]. The combined effect of these factors results in specific cognitive deficits in patients undergoing dialysis, particularly in delayed recall and attention [ 1 – 2 ]. Nutritional factors may also contribute to this phenomenon. Patients with severe cognitive impairment often have a lower average weight, possibly indicating malnutrition or protein-energy wasting, conditions frequently found in the dialysis population that are known to affect cognitive health [ 11 , 50 ]. Additionally, patients involved in cognitively demanding jobs tend to perform better, possibly because of the protective effect of the cognitive reserve. This supports the idea that mentally stimulating environments can help mitigate cognitive decline among older adults. [ 6 , 25 , 29 ]. However, given the lack of detailed data on education and socioeconomic status, these findings should be interpreted with caution. In summary, this study underscores the multifaceted nature of cognitive impairment in patients undergoing dialysis, influenced by aging, vascular comorbidities, frailty [ 44 ], dialysis exposure, autonomic parameters, and nutritional status of the patients. The observed patterns, many of which align with previous research, support the need for routine cognitive screening and personalized risk assessments in clinical nephrology. These efforts are crucial for the early detection and targeted intervention in this vulnerable group of patients. 5. Recommendations for clinicians Given the high prevalence of cognitive impairment in patients undergoing long-term dialysis, this study underscores the importance of implementing key clinical strategies. It is crucial to integrate regular cognitive assessments using standardized tools, such as the Montreal Cognitive Assessment [MoCA], into dialysis care routines, particularly for older adults, those with diabetes, and individuals with prolonged dialysis histories, as these groups tend to experience more severe cognitive deficits. Regularly conducting these evaluations can help in the early detection of cognitive changes and enable timely intervention. In addition to general cognitive assessments, specific deficits in areas such as attention, delayed recall, abstraction, and visuospatial skills highlight the need for tailored cognitive rehabilitation programs that focus on improving executive functioning and memory. Given the association between prolonged dialysis and cognitive decline, it is essential to optimize dialysis practices, including session duration and fluid management, to prevent cerebral hypoperfusion and neurovascular damage in patients undergoing hemodialysis. Routine care should also include nutritional assessments, as lower body weight in severely impaired patients may signal malnutrition or protein-energy wasting, both of which can affect cognitive functions. A multidisciplinary approach involving nephrologists, psychologists, nutritionists, and social workers is recommended to address the complex nature of cognitive impairment in this patient population. Additionally, encouraging patients to engage in mentally stimulating activities may help preserve their cognitive reserve, especially in those with a history of cognitively demanding work. Notably, the nearly significant correlation between pulse rate and MoCA scores suggests that autonomic indicators, such as resting pulse, could offer additional insights into cerebral perfusion status and merit further investigation in future studies. Finally, educating and supporting patients and caregivers about cognitive decline and its potential impact on treatment adherence and quality of life are essential components of comprehensive care. 6. Limitations This study had several limitations. First, the small sample size [n = 32] restricts both the statistical power and generalizability of the results. Second, the single-center design of the study might have led to selection bias. Third, the lack of follow-up data prevented the assessment of cognitive changes over time in this study. Moreover, the absence of neuroimaging or biomarkers limits the depth of clinical correlation. Finally, this study did not account for socioeconomic status or educational attainment, both of which are known to significantly affect cognitive outcomes, leaving a gap in understanding potential confounding factors. Despite these limitations, the study's findings could lay the groundwork for future, larger-scale, and more representative studies aimed at better understanding the factors contributing to cognitive decline in patients undergoing dialysis. Declarations Ethics approval and consent to participate The study was reviewed and approved by the Research Ethics Committee of Symbiosis International [Deemed University] [Approval Code: SIU/IEC/486]. All participants provided in-person informed consent before accessing the questionnaire, ensuring adherence to the principles of the Helsinki Declaration [autonomy, justice, beneficence] and current national regulations. Funding: The authors received no funding for the study Clinical trial number: Not Applicable. Competing Interests: The authors declare no competing interests. Consent of Publish Declaration: All authors have provided their consent to publish this research paper. Data availability Availability of data and materials: All data relevant to the study are included in the article or uploaded as supplementary information files. Author Contribution A.S. drafted the manuscript (finalized version and data analysis), A.N. contributed in data collection, D.F contributed in data analysis & manuscript writing, K.D. contributed in data analysis , S.J. reviewed the final manuscript. References Angermann S, Baumann M, Dörr M, Nauck M, Völzke H, Felix SB, et al. Pulse-wave velocity is associated with cognitive impairment in hemodialysis patients. Clin Sci [Lond] . 2017 Jul 1;131[13]:1483–92. doi:10.1042/CS20170079. Foster R, Walker S, Brar R, Hiebert B, Komenda P, Rigatto C, Storsley L, Prasad B, Bohm C, Tangri N. Cognitive Impairment in Advanced Chronic Kidney Disease: The Canadian Frailty Observation and Interventions Trial. Am J Nephrol . 2016 Nov 1;44[6]:473–80. doi:10.1159/000450837. Iyasere O, Okai D, Brown E. Cognitive function and advanced kidney disease: longitudinal trends and impact on decision-making‑. Clin Kidney J . 2017;10[1]:89–96. doi:10.1093/ckj/sfw128. Lambert K, Mullan J, Mansfield K, Lonergan M. Comparison of the extent and pattern of cognitive impairment among predialysis, dialysis and transplant patients: a cross‑sectional study from Australia. Nephrology [Carlton] . 2016;21[7]. Nikić P, Andrić B, Stojimirović B, Popović M, Mitrović D, Bojić B, et al. Habitual coffee consumption enhances attention and vigilance in patients undergoing hemodialysis Biomed Res Int. 2014;2014:707460. doi:10.1155/2014/707460. Gupta A, Mahnken JD, Johnson DK, Thomas TS, Subramaniam D, Polshak T, Gani I, Chen GJ, Burns JM, Sarnak MJ. Prevalence and correlates of cognitive impairment in kidney transplant recipients. BMC Nephrol. 2017 May 12;18:158. doi:10.1186/s12882-017-0570-1. [bmcnephrol.biomedcentral.com] Gupta A, Thomas TS, Klein JA, Montgomery RN, Mahnken JD, Johnson DK, Drew DA, Sarnak MJ, Burns JM. Discrepancies between Perceived and Measured Cognition in Kidney Transplant Recipients: Implications for Clinical Management. Nephron. 2018 Jan;138[1]:22–28. doi:10.1159/000481182. Sarnak MJ, Tighiouart H, Scott TM, Lou KV, Sorensen EP, Giang LM, et al. Frequency and risk factors for poor cognitive performance in hemodialysis patients. Kidney Int . 2013 Mar;83[3]:436–42. doi:10.1038/ki.2012.40. Drew DA, Weiner DE, Sarnak MJ. Cognitive Impairment in CKD: Pathophysiology, Management, and Prevention. Am J Kidney Dis . 2019 Apr;73[4]:529–537. doi:10.1053/j.ajkd.2018.10.014 Murray AM, Knopman DS, Tupper DE, Gilbertson DT, Pederson SL, Li S, et al. Cognitive impairment is common in patients undergoing hemodialysis. J Am Soc Nephrol . 2006 Jul;17[7]:2030–7. doi:10.1681/ASN.2005111206 Kalantar-Zadeh K, Ikizler TA, Block G, Avram MM, Kopple JD. Malnutrition-inflammation complex syndrome in dialysis patients: causes and consequences. Am J Kidney Dis . 2003 Nov;42[5]:864–81. doi:10.1016/j.ajkd.2003.07.016 Griva K, Stygall J, Hankins M, Davenport A, Harrison M, Newman SP. Cognitive impairment and 7-year mortality in dialysis patients. Am J Kidney Dis . 2004;44[4]:556–565. doi:10.1053/j.ajkd.2004.06.023 Kurella Tamura M, Larive B, Unruh ML, Stokes JB, Nissenson A, Mehta RL, et al. Prevalence and correlates of cognitive impairment in hemodialysis patients: the Frequent Hemodialysis Network trials. Clin J Am Soc Nephrol . 2008;3[6]:1733–1740. doi:10.2215/CJN.00140108 Seidel UK, Gronewold J, Volsek M, Todica O, Kribben A, Bald M, et al. Physical, cognitive, and emotional factors contributing to quality of life, functional health, and participation in community dwelling in chronic kidney disease. PLoS One . 2014;9[3]:e91176. doi:10.1371/journal.pone.0091176 Berger I, Wu S, Masson P, Kelly PJ, Duthie FA, Whiteley W, et al. Cognition in chronic kidney disease: a systematic review and meta-analysis. BMC Nephrol . 2016;17[1]:48. doi:10.1186/s12882-016-0256-6 Kalirao P, Pederson S, Foley RN, Kolste A, Tupper D, Zaun D, et al. Cognitive impairment in peritoneal dialysis patients. Am J Kidney Dis . 2011;57[4]:612–620. doi:10.1053/j.ajkd.2010.10.047 Bugnicourt JM, Godefroy O, Chillon JM, Choukroun G, Massy ZA. Cognitive disorders and dementia in CKD: the neglected kidney-brain axis. Am J Kidney Dis . 2013 Mar;61[3]:466–76. doi:10.1053/j.ajkd.2012.08.036 Griva K, Stygall J, Hankins M, Davenport A, Harrison M, Newman SP. Cognitive impairment and 7-year mortality in dialysis patients. Am J Kidney Dis . 2004 Oct;44[4]:556–65. doi:10.1053/j.ajkd.2004.06.023 Kalirao P, Pederson S, Foley RN, Kolste A, Tupper D, Zaun D, et al. Cognitive impairment in peritoneal dialysis patients. Am J Kidney Dis . 2011 Apr;57[4]:612–20. doi:10.1053/j.ajkd.2010.10.04 Etgen T, Chonchol M, Förstl H, Sander D. Chronic kidney disease and cognitive impairment: a systematic review and meta-analysis. Am J Nephrol . 2012;35[5]:474–82. doi:10.1159/000336000. Murray AM. Cognitive impairment in the aging dialysis and chronic kidney disease populations: an occult burden. Adv Chronic Kidney Dis . 2008;15[2]:123–32. doi:10.1053/j.ackd.2008.01.011. Abdel-Kader K, Unruh ML, Weisbord SD. Symptom burden, depression, and quality of life in chronic and end-stage kidney disease. Clin J Am Soc Nephrol . 2009;4[6]:1057–64. doi:10.2215/CJN.00430109. Seliger SL, Longstreth WT Jr, Katz R, Manolio T, Fried LF, Shlipak MG, et al. Cystatin C and subclinical brain infarction. J Am Soc Nephrol . 2005;16[12]:3721–7. doi:10.1681/ASN.2005020126. Kurella M, Chertow GM, Luan J, Yaffe K. Cognitive impairment in chronic kidney disease. J Am Geriatr Soc . 2004;52[11]:1863–9. doi:10.1111/j.1532-5415.2004.52510.x. Stern Y. Cognitive reserve in ageing and Alzheimer’s disease. Lancet Neurol . 2012;11[11]:1006–12. doi:10.1016/S1474-4422[12]70191-6. Pereira AA, Weiner DE, Scott T, Sarnak MJ. Cognitive function in dialysis patients. Am J Kidney Dis . 2005;45[3]:448–62. doi:10.1053/j.ajkd.2004.11.014. Findlay MD, Dawson J, MacIsaac R, Jardine AG, Wigmore SJ, MacLeod MJ. Investigating the relationship between cerebral blood flow and cognitive function in hemodialysis patients. J Am Soc Nephrol . 2019;30[1]:147–58. doi:10.1681/ASN.2018030295. Biessels GJ, Deary IJ, Ryan CM. Cognition and diabetes: A lifespan perspective. Lancet Neurol . 2008;7[2]:184–90. doi:10.1016/S1474-4422[08]70021-8. Opdebeeck C, Martyr A, Clare L. Cognitive reserve and cognitive function in healthy older people: a meta-analysis. Neuropsychol Dev Cogn B Aging Neuropsychol Cogn . 2016;23[1]:40–60. doi:10.1080/13825585.2015.1041450. McIntyre CW. Cerebral ischemia: a forgotten component of intradialytic hypotension. Clin J Am Soc Nephrol . 2013;8[3]:543–8. doi:10.2215/CJN.00710112. Vanholder R, Schepers E, Pletinck A, Nagler EV, Glorieux G. The uremic toxicity of indoxyl sulfate and p-cresyl sulfate: a systematic review. J Am Soc Nephrol . 2014;25[9]:1897–907. doi:10.1681/ASN.2013101062. Hill NR, Fatoba ST, Oke JL, Hirst JA, O'Callaghan CA, Lasserson DS, et al. Global prevalence of chronic kidney disease: a systematic review and meta-analysis. PLoS One . 2016;11[7]:e0158765. doi:10.1371/journal.pone.0158765. Prohovnik I, Post J, Uribarri J, Lee H, Sandu O, Lesser M. Cerebrovascular effects of hemodialysis in chronic kidney disease. J Cereb Blood Flow Metab . 2007;27[11]:1861–9. doi:10.1038/sj.jcbfm.9600481. Hailpern SM, Melamed ML, Cohen HW, Hostetter TH. Moderate chronic kidney disease and cognitive function in adults 20 to 59 years of age: Third National Health and Nutrition Examination Survey [NHANES III]. J Am Soc Nephrol . 2007;18[7]:2205–13. doi:10.1681/ASN.2006101155. Isoyama N, Qureshi AR, Avesani CM, Lindholm B, Bárány P, Heimbürger O, et al. Comparative associations of muscle mass and muscle strength with mortality in dialysis patients. Clin J Am Soc Nephrol . 2014;9[10]:1720–8. doi:10.2215/CJN.10201013. Agganis BT, Weiner DE, Giang LM, Scott T, Tighiouart H, Griffith JL, et al. Cognitive function in patients undergoing maintenance hemodialysis: the relation to depression, fatigue, and sleep disturbances. Am J Kidney Dis . 2010;56[3]:516–26. doi:10.1053/j.ajkd.2010.03.017. Mu J, Ma L, Ma S, Ding D, Li P, Ma X, Zhang M, Liu J . Neurological effects of hemodialysis on white matter microstructure in patients with end-stage renal disease Neuroimage Clin. 2021;31:102743. doi:10.1016/j.nicl.2021.102743 Nasreddine ZS, Phillips NA, Bédirian V, et al. The Montreal Cognitive Assessment (MoCA) is a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53[4]:695–9. Carson N, Leach L, Murphy KJ. A re-examination of MoCA cutoff scores. Int. J Geriatr. Psychiatry. 2018;33[2]:379–388 Kurella Tamura M et al. Anemia and risk of cognitive decline in chronic kidney disease. BMC Nephrol. 2016;17:13. Viggiano D, Wagner CA, Martino G, Nedergaard M, Zoccali C, Unwin R, et al. Mechanisms of cognitive dysfunction in CKD. Nat Rev Nephrol. 2020;16[8]:452–469. doi:10.1038/s41581-020-0266-9** Kurella Tamura M, Xie D, Yaffe K, et al. Vascular risk factors and cognitive impairment in chronic kidney disease: The Chronic Renal Insufficiency Cohort [CRIC] Study. Clin J Am Soc Nephrol. 2011;6[2]:248-256. doi:10.2215/CJN.02660310 McIntyre CW, Goldsmith DJ. Ischemic brain injury in hemodialysis patients: Which patient is at risk? Kidney Int. 2015;87[1]:50–57. doi:10.1038/ki.2014.282 Kurella Tamura M, Unruh ML, Nissenson AR, et al. Effect of more frequent hemodialysis on cognitive function in the Frequent Hemodialysis Network trials. Am J Kidney Dis. 2013;61[2]:228-237 Biessels GJ, Despa F. Cognitive decline and dementia in diabetes mellitus: Mechanisms and clinical implications. Nat Rev Endocrinol. 2018;14[10]:591–604. doi:10.1038/s41574-018-0048-7** Rawlings AM, Sharrett AR, Albert MS, Coresh J, Windham BG, Power MC, et al. The association of late-life diabetes status and hyperglycemia with incident mild cognitive impairment and dementia: The ARIC Study. Diabetes Care. 2019;42[7]:1248–1254. doi:10.2337/dc19-0120** Tiffin-Richards FE, Costa AS, Holschbach B, Frank RD, Vassiliadou A, Krüger T, et al. The Montreal Cognitive Assessment [MoCA] in CKD: Diagnostic accuracy for cognitive impairment. Nephrol. Dial. Transplant 2014;29[12]:2297–2304. doi:10.1093/ndt/gfu229 Khatri M, Nickolas T, Moon YP, et al. CKD associates with cognitive decline. J Am Soc Nephrol. 2009;20[11]:2427-2432. Weiner DE, Bartolomei K, Scott T, et al. Albuminuria, cognitive functioning, and white matter hyperintensities in homebound elders. Am J Kidney Dis. 2009;53[3]:438-447. Kang EW, Abdel-Kader K, Yabes J, et al. Association of sleep-disordered breathing with cognitive dysfunction in CKD stages 4-5. Am J Kidney Dis. 2012;60[6]:949-958. McAdams-DeMarco MA, Law A, Tan J, et al. Frailty and Cognitive Function in Incident Hemodialysis Patients. Clin J Am Soc Nephrol. 2015;10[12]:2181-2189. Bossola M, Antocicco M, Di Stasio E, et al. Mini-Mental State Examination over time in chronic hemodialysis patients. J Psychosom Res. 2011;71[1]:50-54. Hailpern SM, Melamed ML, Cohen HW, Hostetter TH. Moderate CKD and cognitive function in adults 20-59 years: NHANES III. Am J Kidney Dis. 2007;50[1]:18-27. Mu J, et al. Neurological effects of hemodialysis on white matter microstructure. Neuroimage Clin. 2021;31:102743. GBD 2019 Chronic Kidney Disease Collaborators. Global, regional, and national burden of CKD from 1990 to 2019. Lancet. 2020;395[10225]:709–733. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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10:47:28","extension":"png","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":9169,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinegroupimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8228712/v1/ed93e03a59181f1eaff383c9.png"},{"id":97689721,"identity":"1fabe6ee-0235-405e-a544-24313e6a0333","added_by":"auto","created_at":"2025-12-08 10:47:28","extension":"xml","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":204925,"visible":true,"origin":"","legend":"","description":"","filename":"f3a79d72b5db43bd92981cae7958291e1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8228712/v1/3d316be2c0f3060da4e514b6.xml"},{"id":97893829,"identity":"1ff6b06b-8ef1-4b07-b7ae-398f3f85dcd9","added_by":"auto","created_at":"2025-12-10 15:31:18","extension":"html","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":217607,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8228712/v1/5f1757fe19e89aa69f4f9346.html"},{"id":97689706,"identity":"9c1e7034-4c6e-4c6c-a0ed-51d07248a54b","added_by":"auto","created_at":"2025-12-08 10:47:28","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":39034,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA] Pie diagram depicting the percentage of cognitively afflicted [68.75%] and normal individuals [31.25%]. B] Percentage of mild, moderate, and severe categories based on MoCA of the total number of cognitively impaired individuals [N =22].\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8228712/v1/c4d5ce70f592ceee63d46d86.png"},{"id":97689715,"identity":"6886d6a9-07e3-4621-abc4-90cd272ac6fb","added_by":"auto","created_at":"2025-12-08 10:47:28","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":79306,"visible":true,"origin":"","legend":"\u003cp\u003eOverview of study findings [CI: Cognitive Impairments]\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8228712/v1/80fb043f43803818d3d88596.png"},{"id":98420896,"identity":"0b27b5f7-a427-4275-a6ab-652e7fde0f49","added_by":"auto","created_at":"2025-12-17 16:18:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2088539,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8228712/v1/a6f12616-95df-43d9-a7f0-31f91ff568d6.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A cross-sectional assessment of key cognitive domains affected in Chronic dialysis patients with associated co-morbidities: A pilot study","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eCognitive impairment [CI] refers to difficulties in mental processes, such as thinking, memory, and attention, which can range from mild to severe. These difficulties can affect decision-making, problem-solving, and daily self-management tasks [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e] and are increasingly acknowledged as prevalent and clinically significant complications at all stages of chronic kidney disease [CKD] [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. CKD is a progressive illness in which the kidneys gradually lose their ability to function. When kidney function falls below 15% [GFR is less than 15 mL/min/1.73 m\u0026sup2;] [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e], the patient enters end-stage renal disease [ESRD], leading to the buildup of harmful levels of waste, fluids, and electrolytes in the body. Dialysis is essential for artificially carrying out kidney functions, helping patients prevent complications such as fluid overload, electrolyte imbalance, and uremic toxicity [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Numerous studies have shown that individuals with CKD have higher rates of cognitive dysfunction than those without CKD [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The prevalence rates vary widely from 28.9% to over 70%, depending on the CKD stage and the methods used for cognitive evaluation and assessment [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e], with vascular risk factors such as hypertension and diabetes significantly exacerbating cognitive decline [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. The impact of cognitive impairment [CI] is particularly severe in patients with end-stage renal disease [ESRD], especially in those undergoing hemodialysis [HD]. Angermann et al. [2017] [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] found that 60.2% of HD patients scored pathologically on the Montreal Cognitive Assessment [MoCA], indicating cognitive impairment. They also identified, for the first time, a connection between cognitive decline and arterial stiffness [pulse wave velocity [PWV]], suggesting that vascular factors may contribute to cognitive impairment in patients undergoing dialysis [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Foster et al. [2016] [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] conducted a study assessing cognitive dysfunction in a diverse group of Canadian patients with stage G4\u0026ndash;G5 CKD who were not yet on dialysis. The findings revealed that 61% of these patients exhibited cognitive impairments, particularly affecting their attention, memory, and executive function. This suggests that cognitive problems can manifest before the initiation of dialysis [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], even in the early stages of CKD, and are not exclusive to patients undergoing dialysis [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. A longitudinal study by Iyasere et al. [2017] [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e] indicated that patients with CKD on dialysis experience faster cognitive decline than those not on dialysis. Among those on dialysis, patients receiving hemodialysis showed a more significant decline in cognitive abilities, especially executive function, than those undergoing peritoneal dialysis [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Furthermore, cognitive outcomes following kidney transplantation are complex and not completely understood. Although transplantation is generally believed to enhance cognitive function by eliminating uremia, studies have indicated that many transplant recipients continue to suffer from cognitive impairment [CI] years after the procedure. Gupta et al. [2017] [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] discovered that 58% of stable transplant patients had cognitive impairments. This study highlights the need for objective screening of CI incidence and severity in CKD and chronic dialysis populations. Gupta et al. [2018] [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] demonstrated that relying solely on clinical judgment often leads to inaccurate assessments of CI prevalence, suggesting that regular cognitive assessments, such as the MoCA, should be conducted for dialysis and transplant patients [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The link between cognitive impairment in CKD and various outcomes, such as diminished quality of life, impaired decision-making, lower treatment adherence, and increased mortality [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] is well documented. However, there is a lack of studies measuring cognitive impairment in the dialysis population in India and its surrounding regions. Given the significant clinical and psychosocial impacts of cognitive impairment in CKD, this study aimed to explore the incidence of CI, identify affected domains, and highlight the demographic and clinically modifiable factors influencing CI among patients with CKD.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Study Design\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThis study utilized a single-center, cross-sectional observational design, concentrating on 32 adults diagnosed with chronic kidney disease [CKD] at stages 3\u0026ndash;5. CKD stages were classified based on the estimated glomerular filtration rate [eGFR], which assesses kidney function. Stage 3 CKD is identified by an eGFR ranging from 30 to 59 mL/min/1.73 m\u0026sup2; and is further divided into stages 3a [eGFR 45\u0026ndash;59] and 3b [eGFR 30\u0026ndash;44]. Stage 4 is characterized by an eGFR between 15 and 29 mL/min/1.73 m\u0026sup2;, signifying a significant reduction in kidney function. Stage 5 CKD, also known as end-stage renal disease [ESRD], is diagnosed when the eGFR drops below 15 mL/min/1.73 m\u0026sup2;, at which point patients generally need renal replacement therapy, such as dialysis, to manage uremic complications and maintain their lives. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Location \u0026amp; Timelines of Study\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIndividuals were recruited from a single dialysis center at a Tertiary Care Hospital in Pune. The research and data gathering were conducted between April and May 2023.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Inclusion \u0026amp; Exclusion Criteria of Studied Population\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eTo be eligible, participants needed to have a CKD diagnosis, be at least 18 years old, and possess an eGFR of less than 60 ml/min/1.73 m\u0026sup2;. The criteria for exclusion included being under 18, having neurological disorders like stroke, multiple sclerosis, or epilepsy, undergoing dialysis for a minimum of six months, experiencing severe visual or auditory impairments, being unable to give informed consent, suffering from uncontrolled severe psychiatric conditions such as untreated psychosis, having received a kidney transplant, and starting dialysis less than three months prior to the study.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.4 Cognitive Screening Strategy\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eCognitive abilities were evaluated using the Montreal Cognitive Assessment [MoCA], a validated 30-point screening instrument sensitive to mild cognitive impairment, particularly executive dysfunction, which is frequently observed in patients with CKD [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e2.5 Statistical Analysis\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eAll statistical analyses were performed using IBM SPSS Statistics version 27.0 and Prism 5 software. Descriptive statistics were used to summarize the data collected. All continuous variables are reported as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation [SD] and median with interquartile range [Q1\u0026ndash;Q3]. Inferential statistical tests were applied based on the data type and distribution. We used the Mann\u0026ndash;Whitney U test to compare the means of two groups for non-normally distributed data. The Kruskal\u0026ndash;Wallis test was applied to compare the means between multiple groups, followed by a post-hoc analysis with pairwise comparison of means. Pearson\u0026rsquo;s correlation was used for bivariate correlations. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e2.6 Ethical considerations\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe study protocol was reviewed and approved by the Research Ethics Committee of Symbiosis International [Deemed University] [Approval Code: SIU/IEC/486]. All participants provided in-person informed consent before accessing the questionnaire, ensuring adherence to the principles of the Helsinki Declaration [autonomy, justice, beneficence] and current national regulations.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eClinical and Demographic Characteristics of the Study Participants [N\u0026thinsp;=\u0026thinsp;32]\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePATIENTS CHARACTERISTICS\u003c/p\u003e\u003cp\u003e[N\u0026thinsp;=\u0026thinsp;32]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMEAN\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRange\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMEDIAN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e[Q1-Q3]\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge [yrs]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e47.8\u0026thinsp;\u0026plusmn;\u0026thinsp;15.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e[21\u0026ndash;75]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e49.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e[34.5\u0026ndash;61.5]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBP Systolic [mm/Hg]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e143.4\u0026thinsp;\u0026plusmn;\u0026thinsp;30.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e[92\u0026ndash;212]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e142.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e[120.5- 158.5]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBP diastolic [mm/Hg]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e90.8\u0026thinsp;\u0026plusmn;\u0026thinsp;21.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e[45\u0026ndash;147]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e[78.5\u0026ndash;101]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePulse [bpm]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e75.8\u0026thinsp;\u0026plusmn;\u0026thinsp;10.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e[42\u0026ndash;90]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e[69- 84.5]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWeight [Kg]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e61.8\u0026thinsp;\u0026plusmn;\u0026thinsp;12.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e[40\u0026ndash;95]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e60.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e[55\u0026ndash;70]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHypertension/Duration [yrs]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e3.9\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e[0\u0026ndash;15]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e[1.75\u0026ndash;4.5]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiabetes Mellitus /Duration [yrs]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e9.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e[0\u0026ndash;15]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e[4 \u0026minus;\u0026thinsp;15]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedication/Duration [yrs]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e4.8\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e[0\u0026ndash;15]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e[1.75\u0026ndash;6.5]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDialysis/Duration [yrs]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e2.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e[0.6\u0026ndash;11]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e[1.5\u0026ndash;2.5]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn our study, the average age of the participants was 47.8 years, with a standard deviation of 15.1 years [Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e]. The mean systolic blood pressure recorded was 143.4 mmHg with a standard deviation of 30.3, whereas the diastolic pressure averaged 90.8 mmHg with a standard deviation of 21.9 [Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e]. Participants had an average pulse rate of 75.8 beats per minute, with a standard deviation of 10.6 [Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e], and their mean weight was 61.8 kg, with a standard deviation of 12.4 [Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e]. Among the participants, nine were diagnosed with diabetes and 25 with hypertension. The average duration of hypertension was [mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD] 3.9\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8 years [Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e], while diabetes had been present for an average of 9.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.6 years [Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e]. The mean duration of medication use was 4.8\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5 years [Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e], and dialysis treatment was ongoing for an average of 2.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9 years [Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e]. These statistics provide insights into the health and clinical history of the study population. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes the baseline characteristics of the participants.\u003c/p\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Cognitive Impairment Assessment\u003c/h2\u003e\u003cp\u003eThe MoCA test revealed a high prevalence of cognitive impairment, affecting 22 of the 32 patients [68.75%] [Figure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA]. Of these 22 patients, 7 [31.81%] had mild impairment, 9 [40.9%] had moderate impairment, and 6 [27.27%] had severe impairment [Figure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB]. When considering this statistic Among the total chronic dialysis population [N =32], 21.88% had mild impairment, 28.13% had moderate impairment, and 18.75% were classified as severely impaired [Fig \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA]. These results underscore the significant burden of cognitive decline in the chronic dialysis population.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWe aimed to identify the MoCA domains that were most affected in our sample. To achieve this, we analyzed the data, finding a visuospatial mean of [2.7\u0026thinsp;\u0026plusmn;\u0026thinsp;9.2] out of 5, a naming mean of [2.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7] out of 3, an attention mean of [3.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3] out of 2, a language average of [1.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8] out of 2, an abstraction average of [1.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8] out of 2, a delayed recall mean of [1.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3] out of 5, and an orientation average of [5.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2] out of 6 [Table\u0026nbsp;2]. These findings imply that while certain cognitive domains are relatively intact, others\u0026mdash;especially those associated with memory and abstract reasoning\u0026mdash;are more susceptible in this group of patients than in healthy individuals.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e3.2 Table\u0026nbsp;2: Cognitive Domain Scores of Dialysis patients\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDomain [Total Score]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRange\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMedian\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e[Q1-Q3]\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVisuospatial [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e2.7\u0026thinsp;\u0026plusmn;\u0026thinsp;9.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e[0\u0026ndash;5]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e[0.5-4]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNaming [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e2.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e[\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAttention [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e3.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e[0\u0026ndash;6]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e[1.5-6]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLanguage [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e1.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e[0\u0026ndash;3]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAbstraction [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e1.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e[0\u0026ndash;2]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDelayed Recall [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e1.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e[0\u0026ndash;4]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e[0\u0026ndash;2]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOrientation [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e5.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e[\u003cspan additionalcitationids=\"CR3 CR4 CR5\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTo better understand the specific cognitive domains affected among patients undergoing dialysis, Table\u0026nbsp;2 summarizes their performance across the various components of the Montreal Cognitive Assessment [MoCA]. The results revealed considerable variability in cognitive functioning across the domains. Orientation had the highest average score [mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD: 5.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2 out of 6] [Table\u0026nbsp;2], with a median of 6, indicating relatively preserved awareness of time and place among most participants. Similarly, naming was largely intact [mean: 2.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7 out of 3], with a narrow range [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] and high median [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] [Table\u0026nbsp;2], suggesting minimal deficits in object recognition and verbal labelling. In contrast, delayed recall showed the lowest performance [mean: 1.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3 out of 5; median: 0] [Table\u0026nbsp;2], reflecting significant impairments in short-term memory retention. Visuospatial abilities also demonstrated marked variability [mean: 2.7\u0026thinsp;\u0026plusmn;\u0026thinsp;9.2 out of 5] [Table\u0026nbsp;2], likely influenced by outliers or possible recording errors, as the standard deviation exceeded the domain's maximum score. Domains such as attention [mean: 3.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3 out of 6], language [1.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8 out of 3], and abstraction [1.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8 out of 2] showed moderate deficits, with median scores falling near the midpoints of their respective scales. Overall, the data suggest that while certain cognitive faculties remain relatively preserved in this population, memory, abstraction, and visuospatial processing may be particularly vulnerable in patients undergoing dialysis.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Subgroup analysis of MoCA Scores\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMean MoCA Scores Across Patient Subgroups Based on Clinical and Demographic Characteristic\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"+\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOption\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMEAN [CI] +_ STD.DEVITATION\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMedian [Q1-Q3]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMean Rank\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eMann Whitney U\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003ep VALUE\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiabetes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes [N\u0026thinsp;=\u0026thinsp;9]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"+\" colname=\"c3\"\u003e\u003cp\u003e14.5 [8.9\u0026ndash;20.2]\u0026thinsp;+\u0026thinsp;7.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11 [8.5\u0026ndash;24]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.094\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo [N\u0026thinsp;=\u0026thinsp;23]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"+\" colname=\"c3\"\u003e\u003cp\u003e19.4 [16.9\u0026ndash;22]\u0026thinsp;+\u0026thinsp;5.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e19 [\u003cspan additionalcitationids=\"CR17 CR18 CR19 CR20 CR21 CR22 CR23\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e18.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHypertension\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes [N\u0026thinsp;=\u0026thinsp;7]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"+\" colname=\"c3\"\u003e\u003cp\u003e17.08 [14.3\u0026ndash;19.8]\u0026thinsp;+\u0026thinsp;6.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17 [10.5\u0026ndash;24]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e15.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e54.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.135\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo [N\u0026thinsp;=\u0026thinsp;25]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"+\" colname=\"c3\"\u003e\u003cp\u003e21.7[17.2\u0026ndash;26.2]\u0026thinsp;+\u0026thinsp;4.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e21 [\u003cspan additionalcitationids=\"CR19 CR20 CR21 CR22 CR23 CR24 CR25 CR26 CR27\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e21.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMed. Duration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes [N\u0026thinsp;=\u0026thinsp;8]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"+\" colname=\"c3\"\u003e\u003cp\u003e17.3 [14.2\u0026ndash;20.3]\u0026thinsp;+\u0026thinsp;7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e19 [\u003cspan additionalcitationids=\"CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23 CR24\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e15.61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.409\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo [N\u0026thinsp;=\u0026thinsp;24]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"+\" colname=\"c3\"\u003e\u003cp\u003e20.2 [16.3\u0026ndash;24.2]\u0026thinsp;+\u0026thinsp;5.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20 [6.2\u0026ndash;24]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e18.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;45 [N\u0026thinsp;=\u0026thinsp;15]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"+\" colname=\"c3\"\u003e\u003cp\u003e15 [11.6\u0026ndash;18.4]\u0026thinsp;+\u0026thinsp;6.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15 [8.5\u0026ndash;21.5]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.585\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;45 [N\u0026thinsp;=\u0026thinsp;17]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"+\" colname=\"c3\"\u003e\u003cp\u003e21.4 [19.2\u0026ndash;24]\u0026thinsp;+\u0026thinsp;4.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e22 [\u003cspan additionalcitationids=\"CR18 CR19 CR20 CR21 CR22 CR23 CR24\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e14.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGendre\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale [N\u0026thinsp;=\u0026thinsp;23]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"+\" colname=\"c3\"\u003e\u003cp\u003e19.6 [17\u0026ndash;22.2]\u0026thinsp;+\u0026thinsp;6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e19 [10.5\u0026ndash;20.75]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e10.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.729\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale [N\u0026thinsp;=\u0026thinsp;9]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"+\" colname=\"c3\"\u003e\u003cp\u003e14.2 [9\u0026ndash;19.4]\u0026thinsp;+\u0026thinsp;6.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14 [12\u0026ndash;23.5]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e15.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOccupation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBlue [N\u0026thinsp;=\u0026thinsp;25]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"+\" colname=\"c3\"\u003e\u003cp\u003e16.6 [13.9\u0026ndash;19.3]\u0026thinsp;+\u0026thinsp;6.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16.5[\u003cspan additionalcitationids=\"CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.398\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWhite [N\u0026thinsp;=\u0026thinsp;7]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"+\" colname=\"c3\"\u003e\u003cp\u003e22.6 [18.6\u0026ndash;26.7]\u0026thinsp;+\u0026thinsp;4.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24.5[\u003cspan additionalcitationids=\"CR19 CR20 CR21 CR22 CR23 CR24\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e16.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSystolic BP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNormal [N\u0026thinsp;=\u0026thinsp;19]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"+\" colname=\"c3\"\u003e\u003cp\u003e18.2 [11.4\u0026ndash;22]\u0026thinsp;+\u0026thinsp;6.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17 [\u003cspan additionalcitationids=\"CR18 CR19 CR20 CR21 CR22 CR23 CR24\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e16.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.639\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAbnormal [N\u0026thinsp;=\u0026thinsp;13]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"+\" colname=\"c3\"\u003e\u003cp\u003e18 [14.7\u0026ndash;21.4]\u0026thinsp;+\u0026thinsp;7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e19 [9.5\u0026ndash;19]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiastolic BP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNormal [N\u0026thinsp;=\u0026thinsp;29]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"+\" colname=\"c3\"\u003e\u003cp\u003e18 [15.4\u0026ndash;20.6]\u0026thinsp;+\u0026thinsp;6.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e19[\u003cspan additionalcitationids=\"CR19 CR20 CR21 CR22 CR23 CR24\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e16.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.351\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAbnormal [N\u0026thinsp;=\u0026thinsp;3]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"+\" colname=\"c3\"\u003e\u003cp\u003e18.7 [8.3\u0026ndash;29]\u0026thinsp;+\u0026thinsp;4.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20 [8.5\u0026ndash;20]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePulse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNormal [N\u0026thinsp;=\u0026thinsp;24]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"+\" colname=\"c3\"\u003e\u003cp\u003e18.2 [15.1\u0026ndash;21.2]\u0026thinsp;+\u0026thinsp;7.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18.5 [\u003cspan additionalcitationids=\"CR19 CR20 CR21 CR22 CR23 CR24\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e16.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.889\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAbnormal [N\u0026thinsp;=\u0026thinsp;8]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"+\" colname=\"c3\"\u003e\u003cp\u003e17.9 [13.9\u0026ndash;21.9]\u0026thinsp;+\u0026thinsp;4.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e19 [9\u0026ndash;19.5]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eNext, we aimed to identify whether certain demographic and clinical variables influenced the cognitive capacity of patients undergoing dialysis. Patients with diabetes had a lower average MoCA score [14.56\u0026thinsp;\u0026plusmn;\u0026thinsp;7.35] [Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e] than those without diabetes [19.47\u0026thinsp;\u0026plusmn;\u0026thinsp;5.84] [Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e]. Although this difference was not statistically significant [p\u0026thinsp;=\u0026thinsp;0.094] [Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e], it was close to the threshold, indicating a potential association between diabetes and decreased cognitive function. Conversely, hypertension did not show a statistically significant effect [p\u0026thinsp;=\u0026thinsp;0.138] [Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e], even though individuals without hypertension had slightly higher scores [19.87] than those with hypertension [17.08] [Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e]. A similar trend was observed for medication use: individuals on prescribed medications scored higher [21.71] than those not on medication [17.27] [Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e], but this difference was not statistically significant [p\u0026thinsp;=\u0026thinsp;0.409] [Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e]. Age also had no significant effect. Individuals aged\u0026thinsp;\u0026ge;\u0026thinsp;45 years had cognitive scores similar to those aged\u0026thinsp;\u0026lt;\u0026thinsp;45 years [p\u0026thinsp;=\u0026thinsp;0.585] [Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e]. Sex had minimal influence, with nearly identical scores between men and women [p\u0026thinsp;=\u0026thinsp;0.883] [Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e]. Occupational status followed the same pattern, although white-collar workers scored slightly higher [22.63] than blue-collar workers [16.58] [Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e], the difference was not statistically significant [p\u0026thinsp;=\u0026thinsp;0.738] [Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e]. Other clinical factors, such as systolic [p\u0026thinsp;=\u0026thinsp;0.639] and diastolic blood pressure [p\u0026thinsp;=\u0026thinsp;0.351] and pulse rate [p\u0026thinsp;=\u0026thinsp;0.889] [Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e], classified as normal or abnormal, also showed no significant relationship with cognitive performance, with all p-values above [0.05].\u003c/p\u003e\u003cp\u003e\u003cb\u003e3.4 Table\u0026nbsp;4: Comparison of Clinical and Demographic Variables Between Cognitively Normal and Impaired Haemodialysis Patients\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e\u003ccolgroup cols=\"10\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003ePatient's Characteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e\u003cp\u003eNormal [N\u0026thinsp;=\u0026thinsp;10]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e\u003cp\u003eImpaired [N\u0026thinsp;=\u0026thinsp;22]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003emean\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003emedian\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e[Q1-Q3]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003emean\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003emedian\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003e[Q1-Q3]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAge [yrs]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e41.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e38.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e[32.5-51.75]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e50.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e[35-64.25]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.1159\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eBP systolic [mmhg]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e142.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e146.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e[132.5-156.3]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e143.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e140\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e[113-172.5]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.7718\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eBP diastolic [mmhg]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e95.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e97.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e[88-100.5]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e88.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e[70-109.3]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.1787\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003epulse [bpm]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e81.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e84.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e[78.75-86]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e73.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e72.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e[67.25-82]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.0331*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eweight [kg]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e[56\u0026ndash;71]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e60.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e60.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e[51.5\u0026ndash;70]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.4048\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003ehypertension duration [years]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e[1.5\u0026ndash;6.25]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e[0.4-3]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.2594\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003ediabetes duration [years]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e[0-12.75]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e[0-0.82]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.6488\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003emedication duration [years]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e[1.125\u0026ndash;12.75]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e[0-3.25]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.1442\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003edialysis duration [years]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e[2-3.875]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.0329*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"10\"\u003eTo further elucidate the clinical correlates of cognitive impairment, a subgroup analysis was conducted comparing patients with normal cognition to those with any degree of cognitive impairment. A comparative analysis between cognitively normal and impaired patients revealed several clinical and demographic trends that aligned with known contributors to cognitive dysfunction in the dialysis population. The mean age of cognitively impaired individuals was notably higher [50.9 years] compared to the normal group [41.1 years] [Table\u0026nbsp;4], supporting the well-documented association between advancing age and cognitive decline in chronic kidney disease [CKD] populations, however it wasn\u0026rsquo;t significant [p\u0026thinsp;=\u0026thinsp;0.1159]\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe hemodynamic variables showed mixed patterns. Systolic blood pressure was slightly elevated in the impaired group [mean: 143.8 mmHg vs. 142.5 mmHg] [p\u0026thinsp;=\u0026thinsp;0.7718], whereas diastolic pressure was notably lower [88.6 mmHg vs. 95.8 mmHg] [p\u0026thinsp;=\u0026thinsp;0.1787] [Table\u0026nbsp;4]. This drop in diastolic pressure may reflect impaired vascular compliance or autonomic dysregulation, both of which have been linked to cerebral hypoperfusion and cognitive impairment in previous studies. The pulse rate was also lower in the impaired group [73.2 bpm vs. 81.7 bpm] [Table\u0026nbsp;4], a finding that could suggest autonomic dysfunction, deconditioning, or medication effects, with a P value of [p\u0026thinsp;=\u0026thinsp;0.0331], suggesting a significant link between pulse and cognitive health.\u003c/p\u003e\u003cp\u003eWeight differences were minimal between the two groups. However, the impaired group had shorter durations of hypertension [2.6 vs. 4 years] [p\u0026thinsp;=\u0026thinsp;0.2549], diabetes mellitus [1.86 vs. 4.2 years] [p\u0026thinsp;=\u0026thinsp;0.4048], and overall medication use [2.6 vs. 5.7 years] [p\u0026thinsp;=\u0026thinsp;0.1442] [Table\u0026nbsp;4]. While this may appear counterintuitive, it could reflect more recent diagnoses or underreporting, or it may suggest that the cumulative burden over a longer duration contributes more significantly to cognitive preservation than the presence of comorbidities alone.\u003c/p\u003e\u003cp\u003eDialysis duration was substantially longer in the cognitively normal group [mean: 3.41 years] than in the impaired group [1.8 years] [Table\u0026nbsp;4] [p\u0026thinsp;=\u0026thinsp;0.0329], which may be due to an adaptation effect or survivorship bias, wherein patients with better baseline cognitive reserve or health are more likely to remain on dialysis longer. These patterns collectively underscore the complex and multifactorial nature of cognitive impairment in CKD, which is shaped by age, vascular dynamics, disease duration, and dialysis exposure.\u003c/p\u003e\u003cp\u003e\u003cb\u003e3.5 Table\u0026nbsp;5: Compares between clinical and demographic variables of patients segregated into mild, moderate and severe cognitive impairment\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabc\" border=\"1\"\u003e\u003ccolgroup cols=\"16\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c15\" colnum=\"15\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c16\" colnum=\"16\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003ePATIENTS CHARACTERISTICS\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003eNORMAL [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eMILD [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u003cp\u003eMODERATE [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c15\" namest=\"c13\"\u003e\u003cp\u003eSEVERE [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c16\"\u003e\u003cp\u003ep value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMEAN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMEDIAN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e[Q1-Q3]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eMEAN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eMEDIAN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003e[Q1-Q3]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u003cp\u003eMEAN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c11\"\u003e\u003cp\u003eMEDIAN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c12\"\u003e\u003cp\u003e[Q1-Q3]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c13\"\u003e\u003cp\u003eMEAN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c14\"\u003e\u003cp\u003eMEDIAN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c15\"\u003e\u003cp\u003e[Q1-Q3]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eAGE\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e[yrs]\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e41.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e38.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e[32.5-51.75]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e49.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e46.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e[34\u0026ndash;64]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e45.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e[33-56.5]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e60.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e60.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e[55\u0026ndash;65]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e0.091\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBP SYSTOLIC\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e[mm Hg]\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e142.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e146.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e[132.5-156.3]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e153.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e148.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e[126\u0026ndash;189]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e124.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e120.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e[110-132.5]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e156.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e160\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e[140\u0026ndash;187]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e0.158\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBP DIASTOLIC\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e[mm Hg]\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e95.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e97.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e[88-100.5]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e83.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e[64.5-116.5]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e81.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e[71\u0026ndash;95]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e97.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e[80\u0026ndash;118]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e0.094\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e\u003cb\u003ePULSE\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e[BPM]\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e81.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e84.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e[78.75-86]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e73.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e[66-83.5]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e71.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e72.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e[67.5\u0026ndash;82.5]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e74.83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e78.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e[70\u0026ndash;80]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e0.387\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e\u003cb\u003eWEIGHT [kg]\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e[56\u0026ndash;71]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e59.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e[46.5\u0026ndash;67]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e67.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e[60-74.5]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e57.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e53.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e[52\u0026ndash;61]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e0.236\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHYPERTENSION DURATION [YRS]\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e[1.5\u0026ndash;6.25]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.825\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e[0-1.45]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e3.58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e2.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e[1.05\u0026ndash;3.5]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e3.83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e2.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e[\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" 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colname=\"c9\"\u003e\u003cp\u003e[0\u0026ndash;0]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e2.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e[0\u0026ndash;3]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e3.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e[0\u0026ndash;8]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e0.254\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMEDICATION DURATION [YRS]\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e[1.125\u0026ndash;12.75]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.825\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-1.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e2.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e2.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e[1.05\u0026ndash;3.5]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e4.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e3.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e[\u003cspan additionalcitationids=\"CR3 CR4 CR5 CR6 CR7\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e0.121\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDIALYSIS DURATION [YRS]\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e[2-3.875]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.675\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e[0.85-2]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e1.91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e1.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e[1.1\u0026ndash;2.5]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e1.83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e0.442\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTo better understand the clinical context of cognitive impairment in this cohort, Table\u0026nbsp;5 compares the key demographic and clinical parameters across varying levels of cognitive impairment severity. Table\u0026nbsp;5 presents a comparative analysis of key demographic and clinical variables across the categories of cognitive function, namely, normal, mild, moderate, and severe impairment. Although none of the differences reached statistical significance [p\u0026thinsp;\u0026gt;\u0026thinsp;0.05], several notable patterns emerged that aligned with established pathophysiological pathways associated with cognitive decline in chronic kidney disease [CKD] populations.\u003c/p\u003e\u003cp\u003eMost prominently, age showed a progressive increase across the cognitive spectrum, rising from a mean of 41.1 years in the cognitively normal group to 60.17 years in the severely impaired group [p\u0026thinsp;=\u0026thinsp;0.091] [Table\u0026nbsp;5]. This trend supports the existing literature suggesting that advancing age is a critical risk factor for cognitive dysfunction, particularly in patients with underlying comorbidities such as CKD.\u003c/p\u003e\u003cp\u003eMoreover, systolic and diastolic blood pressure values were elevated in patients with severe cognitive impairment [SBP, 156.33 mmHg; DBP, 97.5 mmHg], indicating a potential link between chronic hemodynamic stress and cerebrovascular dysregulation [Table\u0026nbsp;5]. These hemodynamic changes may contribute to cumulative vascular injury, cerebral hypoperfusion, and structural brain alterations, all of which are known to contribute to cognitive impairment. Additionally, patients with severe impairment also demonstrated longer durations of hypertension and diabetes mellitus, further reinforcing the role of sustained metabolic and vascular insults, particularly microvascular damage and prolonged hyperglycemia, in the pathogenesis of cognitive deterioration. Although dialysis duration, pulse rate, and body weight did not show a consistent trend across cognitive categories, the observed patterns suggest a complex interplay of cardiovascular, metabolic, and age-related factors that may jointly influence neurocognitive outcomes in patients undergoing dialysis.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e3.6 MoCA Domain Scores by Cognitive Impairment Category\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eTo gain deeper insight into how specific cognitive domains are affected at varying levels of impairment, Table\u0026nbsp;6 offers a stratified analysis of MoCA subdomain performance across cognitive severity categories, focusing on specific ones. In patients with severe impairment, the most significantly affected areas were visuospatial skills [p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001], attention [p\u0026thinsp;=\u0026thinsp;0.0003], and orientation [p\u0026thinsp;=\u0026thinsp;0.0005] [Table\u0026nbsp;6], which exhibited the most pronounced declines. This emphasizes the susceptibility of these domains to vascular cognitive dysfunction, which is often observed in patients with advanced CKD. These impairments are likely due to cerebrovascular disease and the neurotoxic impact of accumulated uremic toxins, which particularly affect executive and visuospatial processing abilities. Notably, deficits in abstraction and delayed recall were already apparent in patients with mild-to-moderate impairment, suggesting that these domains may serve as early indicators of cognitive decline. Conversely, naming and language skills remained relatively intact at most cognitive-severity levels. This stability may indicate the robustness of the core verbal functions. The orientation domain, which includes awareness of time and place, was largely unaffected until the most severe impairment stage, suggesting that basic temporal and spatial orientation is maintained for a longer period, even when other cognitive functions deteriorate. Overall, these domain-specific trends highlight the limitations of relying solely on global MoCA scores. Subtle yet significant impairments, particularly in executive, memory, and visuospatial functions, may be overlooked without domain-specific screening. These findings underscore the need for more detailed cognitive assessments in patients with CKD.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e3.8 Table\u0026nbsp;6: Distribution of Montreal Cognitive Assessment [MoCA] Domain Scores by Cognitive Impairment Category\u003c/b\u003e\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabd\" border=\"1\"\u003e\u003ccolgroup cols=\"16\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c15\" colnum=\"15\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c16\" colnum=\"16\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNormal\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eMild\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c14\"\u003e\u003cp\u003eSevere\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c16\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMEAN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMEDIAN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e[Q1-Q3]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eMEAN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eMEDIAN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003e[Q1-Q3]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u003cp\u003eMEAN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c11\"\u003e\u003cp\u003eMEDIAN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c12\"\u003e\u003cp\u003e[Q1-Q3]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c13\"\u003e\u003cp\u003eMEAN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c14\"\u003e\u003cp\u003eMEDIAN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c15\"\u003e\u003cp\u003e[Q1-Q3]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eVisuospatial [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e3.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e[2.5-4]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e1.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e[0.5-3]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e0.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e[0\u0026ndash;0]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001***\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eNAMING [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2.625\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e[2.5-3]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e2.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e2.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e[1.5-3]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e2.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e2.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e0.024*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eATTENTION [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e4.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e[4-5.5]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e2.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e[1.5-4]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e0.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e[0\u0026ndash;1]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e0.0003***\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eLANGUAGE [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e2.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e2.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e[1.5\u0026ndash;3.5]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e0.0018**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eABSTRACTION [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.125\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e[1-1.5]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e0.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e[0\u0026ndash;0]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e0.0023**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eDELAYED RECALL [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e[\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.625\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e[0\u0026ndash;1]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e[0-0.5]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e0.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e[0\u0026ndash;0]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e0.0077**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eOREINTATION [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e5.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e[5.5-6]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e[5.5-6]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e[\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e0.0005***\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e5.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e3.9 Table\u0026nbsp;7: Multiple Comparisons of MoCA Cognitive Domains Between Severity Groups\u003c/b\u003e\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabe\" border=\"1\"\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOverall\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMild vs. Normal\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNormal vs. Moderate\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSevere vs. Normal\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eModerate vs. Mild\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eModerate vs. severe\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eMild vs. Severe\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVisuospatial\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001****\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.0983\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.2761\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ens\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001****\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.0106*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.9587\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNaming\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.0409*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ens\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.1146\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.862\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ens\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003ens\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003ens\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAttention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.0001***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ens\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.0244*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.0002***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.6342\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.8381\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.0176*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLanguage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.0033**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ens\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.0522\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.0102*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.334\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003ens\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.0813\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAbstraction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.0031**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.3021\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.1178\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.0019**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ens\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.9903\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.5139\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDelayed Recall\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.0098**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.1415\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.0258*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.043*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ens\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003ens\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003ens\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOrientation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.0002***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ens\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ens\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.0002***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ens\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.0113*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.0021**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eNext, we wanted to dig deeper, so we started comparing MoCA domains between severity groups to discover the notable differences that were observed in certain cognitive categories when comparing MoCA cognitive domains across groups, underscoring the progressive nature of the impairment. The visuospatial domain exhibited a highly significant difference between the moderate and mild groups [p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001] and between the moderate and severe groups [p\u0026thinsp;=\u0026thinsp;0.0106] [Table\u0026nbsp;7], indicating a marked decline in visuospatial abilities at the moderate stage. Similarly, attention showed statistically significant differences in several comparisons: severe vs. normal [p\u0026thinsp;=\u0026thinsp;0.0002], mild vs. severe [p\u0026thinsp;=\u0026thinsp;0.0176], and normal vs. moderate [p\u0026thinsp;=\u0026thinsp;0.0244] [Table\u0026nbsp;7], suggesting that attention is one of the earliest and most progressively affected domains. Orientation also demonstrated strong significance in comparisons such as moderate vs. severe [p\u0026thinsp;=\u0026thinsp;0.0113], severe vs. normal [p\u0026thinsp;=\u0026thinsp;0.0002], and mild vs. severe [p\u0026thinsp;=\u0026thinsp;0.0021] [Table\u0026nbsp;7], highlighting disorientation as a key indicator of advanced cognitive decline. Other domains, such as language, abstraction, and delayed recall, showed significant differences, mainly between the severe and normal groups, further supporting the cumulative burden of cognitive dysfunction in more severe stages. Notably, naming only showed significance in the overall comparison [p\u0026thinsp;=\u0026thinsp;0.0409] [Table\u0026nbsp;7], but not between specific pairs, indicating a relatively preserved naming ability across earlier categories. Overall, the statistical analysis highlighted that cognitive decline in patients undergoing dialysis may disproportionately affect specific domains, with attention, orientation, and visuospatial abilities showing the most consistent and significant differences across stages of impairment.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e3.10 Table\u0026nbsp;8: Correlation coefficient and p-value of variables with MoCA scores\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabf\" border=\"1\"\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCorrelation Coefficient [r]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ep value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.022*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePulse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.057\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWeight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.112\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.543\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHypertension Duration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.077\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.713\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiastolic BP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.171\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.351\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedication duration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.088\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.631\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSystolic BP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.849\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDialysis duration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.3473\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.051\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTo examine the potential predictors of cognitive performance, Table\u0026nbsp;8 presents the correlation analysis between key clinical variables and MoCA scores. In this table, we present the correlation coefficients and associated p-values for a range of clinical variables related to cognitive performance. Notably, age [p\u0026thinsp;=\u0026thinsp;0.022] and duration of dialysis [p\u0026thinsp;=\u0026thinsp;0.051] [Table\u0026nbsp;8] were identified as significant factors. This outcome aligns with expectations, as advancing age and extended dialysis duration are both recognized to have detrimental effects on cognitive function. Interestingly, the pulse rate [p\u0026thinsp;=\u0026thinsp;0.057] [Table\u0026nbsp;8] showed a trend towards significance. Although it did not reach the conventional threshold, its proximity to statistical relevance, coupled with the constraints of a small sample size, suggests that it could be a factor worth investigating further. Notably, the pulse rate has not been identified as a significant variable in any of the studies referenced in this paper, making it a potentially new area of research. All other variables analyzed were found to be statistically insignificant. These results underscore the importance of age and dialysis duration as key contributors to cognitive decline, while highlighting the pulse rate as an emerging variable that may merit further study in larger cohorts.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003e3.11 Table\u0026nbsp;9: Correlation of MoCA test domains with diabetes/hypertension/Dialysis Duration\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabg\" border=\"1\"\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiabetes duration\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003er value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ep value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHypertension duration\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003er value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eDialysis duration\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003er values\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003ep\u003c/p\u003e\u003cp\u003evalue\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVisuospatial\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.197\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.694\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eVisuospatial\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.02439\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.3611\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eVisuospatial\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-0.2912\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.167\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNaming\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.2621\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.694\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNaming\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.3139\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.096\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eNaming\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-0.1107\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.883\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAttention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.295\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.681\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAttention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.3506\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.501\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eAttention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.2458\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.82\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLanguage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.542\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.355\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLanguage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.362\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eLanguage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-0.4859\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.018*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDelayed Recall\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.749\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDelayed Recall\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.1328\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.913\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eDelayed Recall\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-0.1459\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.673\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOrientation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.6495\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.381\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eOrientation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.07918\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.709\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eOrientation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.2297\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.617\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAbstraction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.124\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.816\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAbstraction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.05075\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.814\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eAbstraction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-0.09515\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.551\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTo further explore how chronic clinical conditions may differentially impact cognitive function, Table\u0026nbsp;9 presents domain-specific correlations between the MoCA scores and the duration of diabetes, hypertension, and dialysis. The analysis of cognitive performance across different domains in relation to the duration of diabetes, hypertension, and dialysis highlighted several significant trends. The duration of diabetes did not show any statistically significant links with any of the MoCA domains, and the correlation coefficients varied in both direction and strength, indicating no consistent pattern. For instance, weak correlations were found in the visuospatial [r = -0.197, p\u0026thinsp;=\u0026thinsp;0.694], naming [r\u0026thinsp;=\u0026thinsp;0.2621, p\u0026thinsp;=\u0026thinsp;0.694], and language [r = -0.542, p\u0026thinsp;=\u0026thinsp;0.355] domains [Table\u0026nbsp;9], suggesting that the duration of time a patient had diabetes did not independently influence domain-specific cognitive abilities in this group. Conversely, the duration of hypertension was significantly negatively correlated with visuospatial performance [r = -0.3611, p\u0026thinsp;=\u0026thinsp;0.024] [Table\u0026nbsp;9], indicating that prolonged high blood pressure may impair visual and spatial processing ability. Although other domains, such as language [r\u0026thinsp;=\u0026thinsp;0.38] and naming [r\u0026thinsp;=\u0026thinsp;0.096] [Table\u0026nbsp;9], exhibited mild positive trends, they were not statistically significant, emphasizing the need for further research with larger sample sizes. The duration of dialysis was also associated with cognitive decline in certain areas, with a statistically significant negative correlation found in the language domain [r = -0.4859, p\u0026thinsp;=\u0026thinsp;0.018] [Table\u0026nbsp;9], suggesting that an extended duration of dialysis could negatively affect verbal abilities. Other domains, such as visuospatial [r = -0.2912, p\u0026thinsp;=\u0026thinsp;0.167] and abstraction [r = -0.0951, p\u0026thinsp;=\u0026thinsp;0.551] [Table\u0026nbsp;9], showed weak and non-significant associations. Overall, these findings suggest that long-term hypertension and prolonged dialysis treatment may affect specific cognitive domains, particularly visuospatial and language function. The duration of diabetes did not emerge as a significant factor in domain-specific cognitive decline within this sample, highlighting the complex and multifactorial nature of cognitive impairment in patients with chronic kidney disease.\u003c/p\u003e\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study highlights the significant burden of cognitive impairment among patients undergoing long-term dialysis, as evaluated by the Montreal Cognitive Assessment [MoCA]. Patients were categorized into four cognitive levels: normal, mild, moderate, and severe, with most showing some cognitive decline, particularly in attention, delayed recall, and abstraction [Figure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e] [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. A notable negative correlation between age and MoCA scores [p\u0026thinsp;=\u0026thinsp;0.022] [Table\u0026nbsp;8] emphasized the influence of aging on cognitive abilities in this group [Figure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e]. These results are consistent with earlier studies that associate age-related neurovascular and metabolic changes in chronic kidney disease [CKD] with cognitive decline [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. Furthermore, the duration of dialysis and pulse rate showed a directionality towards significant correlations [although not statistically significant with the current statistical power], indicating that prolonged dialysis exposure and autonomic instability may contribute to subtle cognitive impairment. Extended dialysis is associated with repeated cerebral hypoperfusion and inflammatory processes that gradually impair brain function [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. In addition to vascular and metabolic contributors, anemia has been linked to cognitive decline in patients with CKD due to reduced oxygen delivery and cerebral hypoxia [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Among the comorbidities, diabetes mellitus was identified as a potential factor for cognitive impairment, with patients having lower average MoCA scores [p\u0026thinsp;=\u0026thinsp;0.094] [Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e]. Although not statistically significant, this trend aligns with the existing literature connecting chronic hyperglycemia and insulin resistance to neurovascular damage in CKD [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Experimental and clinical studies have demonstrated that diabetes exacerbates neurodegeneration via blood-brain barrier disruption, microvascular injury, and synaptic dysfunction [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e], mechanisms that are likely to be amplified in CKD. Conversely, hypertension did not show a significant relationship with cognitive scores in this study, although its role in microvascular injury and cerebral autoregulation remains clinically relevant. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAnalysis of MoCA subdomains showed that delayed recall and attention were the most affected in patients with cognitive deficits, consistent with previous findings that identified these areas as early indicators of uremia-related cognitive decline [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Meanwhile, orientation and naming abilities were relatively preserved, supporting the idea that basic language and spatiotemporal awareness often remain intact in the early stages of cognitive impairment. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The brain regions and circuits involved in delayed recall and attention are intricate and well defined. The hippocampus and associated structures within the medial temporal lobe are crucial for encoding, consolidating, and retrieving episodic memories, which are central to delayed recall [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Conversely, attention is managed by a network of areas, including the prefrontal cortex, anterior cingulate cortex, parietal lobes, and subcortical structures such as the thalamus and basal ganglia [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. In individuals with chronic kidney disease [CKD] and those undergoing dialysis, these brain regions are particularly susceptible to damage by uremic toxins, such as indoxyl sulfate, p-cresyl sulfate, and guanidino compounds [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. These toxins can penetrate the blood-brain barrier, leading to neurotoxic and proinflammatory effects [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eRecent evidence suggests that CKD-related cognitive impairment arises from a combination of blood-brain barrier disruption, oxidative stress, and microglial activation, which collectively accelerate neurodegeneration [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. They interfere with synaptic signaling, hinder neurogenesis in the hippocampus, and decrease cerebral blood flow, especially during or after hemodialysis, owing to repeated episodes of intradialytic hypotension and cerebral hypoperfusion [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Furthermore, chronic inflammation, oxidative stress, and endothelial dysfunction associated with CKD further weakens the neurovascular unit, affecting attention regulation and memory consolidation [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The combined effect of these factors results in specific cognitive deficits in patients undergoing dialysis, particularly in delayed recall and attention [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Nutritional factors may also contribute to this phenomenon. Patients with severe cognitive impairment often have a lower average weight, possibly indicating malnutrition or protein-energy wasting, conditions frequently found in the dialysis population that are known to affect cognitive health [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Additionally, patients involved in cognitively demanding jobs tend to perform better, possibly because of the protective effect of the cognitive reserve. This supports the idea that mentally stimulating environments can help mitigate cognitive decline among older adults. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. However, given the lack of detailed data on education and socioeconomic status, these findings should be interpreted with caution. In summary, this study underscores the multifaceted nature of cognitive impairment in patients undergoing dialysis, influenced by aging, vascular comorbidities, frailty [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e], dialysis exposure, autonomic parameters, and nutritional status of the patients. The observed patterns, many of which align with previous research, support the need for routine cognitive screening and personalized risk assessments in clinical nephrology. These efforts are crucial for the early detection and targeted intervention in this vulnerable group of patients.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"5. Recommendations for clinicians","content":"\u003cp\u003eGiven the high prevalence of cognitive impairment in patients undergoing long-term dialysis, this study underscores the importance of implementing key clinical strategies. It is crucial to integrate regular cognitive assessments using standardized tools, such as the Montreal Cognitive Assessment [MoCA], into dialysis care routines, particularly for older adults, those with diabetes, and individuals with prolonged dialysis histories, as these groups tend to experience more severe cognitive deficits. Regularly conducting these evaluations can help in the early detection of cognitive changes and enable timely intervention. In addition to general cognitive assessments, specific deficits in areas such as attention, delayed recall, abstraction, and visuospatial skills highlight the need for tailored cognitive rehabilitation programs that focus on improving executive functioning and memory. Given the association between prolonged dialysis and cognitive decline, it is essential to optimize dialysis practices, including session duration and fluid management, to prevent cerebral hypoperfusion and neurovascular damage in patients undergoing hemodialysis. Routine care should also include nutritional assessments, as lower body weight in severely impaired patients may signal malnutrition or protein-energy wasting, both of which can affect cognitive functions. A multidisciplinary approach involving nephrologists, psychologists, nutritionists, and social workers is recommended to address the complex nature of cognitive impairment in this patient population. Additionally, encouraging patients to engage in mentally stimulating activities may help preserve their cognitive reserve, especially in those with a history of cognitively demanding work. Notably, the nearly significant correlation between pulse rate and MoCA scores suggests that autonomic indicators, such as resting pulse, could offer additional insights into cerebral perfusion status and merit further investigation in future studies. Finally, educating and supporting patients and caregivers about cognitive decline and its potential impact on treatment adherence and quality of life are essential components of comprehensive care.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"6. Limitations","content":"\u003cp\u003eThis study had several limitations. First, the small sample size [n\u0026thinsp;=\u0026thinsp;32] restricts both the statistical power and generalizability of the results. Second, the single-center design of the study might have led to selection bias. Third, the lack of follow-up data prevented the assessment of cognitive changes over time in this study. Moreover, the absence of neuroimaging or biomarkers limits the depth of clinical correlation. Finally, this study did not account for socioeconomic status or educational attainment, both of which are known to significantly affect cognitive outcomes, leaving a gap in understanding potential confounding factors. Despite these limitations, the study's findings could lay the groundwork for future, larger-scale, and more representative studies aimed at better understanding the factors contributing to cognitive decline in patients undergoing dialysis.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was reviewed and approved by the Research Ethics Committee of Symbiosis International [Deemed University] [Approval Code: SIU/IEC/486]. All participants provided in-person informed consent before accessing the questionnaire, ensuring adherence to the principles of the Helsinki Declaration [autonomy, justice, beneficence] and current national regulations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e The authors received no funding for the study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u003c/strong\u003e Not Applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u003c/strong\u003e The authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent of Publish Declaration:\u003c/strong\u003e All authors have provided their consent to publish this research paper.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e All data relevant to the study are included in the article or uploaded as supplementary information files.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eA.S. drafted the manuscript (finalized version and data analysis), A.N. contributed in data collection, D.F contributed in data analysis \u0026amp; manuscript writing, K.D. contributed in data analysis , S.J. reviewed the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003e\u003cstrong\u003eAngermann S, Baumann M, D\u0026ouml;rr M, Nauck M, V\u0026ouml;lzke H, Felix SB, et al.\u003c/strong\u003e Pulse-wave velocity is associated with cognitive impairment in hemodialysis patients. \u003cem\u003eClin Sci [Lond]\u003c/em\u003e. 2017 Jul 1;131[13]:1483\u0026ndash;92. doi:10.1042/CS20170079.\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eFoster R, Walker S, Brar R, Hiebert B, Komenda P, Rigatto C, Storsley L, Prasad B, Bohm C, Tangri N.\u003c/strong\u003e Cognitive Impairment in Advanced Chronic Kidney Disease: The Canadian Frailty Observation and Interventions Trial. \u003cem\u003eAm J Nephrol\u003c/em\u003e. 2016 Nov 1;44[6]:473\u0026ndash;80. doi:10.1159/000450837.\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eIyasere O, Okai D, Brown E.\u003c/strong\u003e Cognitive function and advanced kidney disease: longitudinal trends and impact on decision-making‑. \u003cem\u003eClin Kidney J\u003c/em\u003e. 2017;10[1]:89\u0026ndash;96. doi:10.1093/ckj/sfw128.\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eLambert K, Mullan J, Mansfield K, Lonergan M.\u003c/strong\u003e Comparison of the extent and pattern of cognitive impairment among predialysis, dialysis and transplant patients: a cross‑sectional study from Australia. \u003cem\u003eNephrology [Carlton]\u003c/em\u003e. 2016;21[7].\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eNikić P, Andrić B, Stojimirović B, Popović M, Mitrović D, Bojić B, et al.\u003c/strong\u003e Habitual coffee consumption enhances attention and vigilance in patients undergoing hemodialysis \u003cem\u003eBiomed Res Int.\u003c/em\u003e 2014;2014:707460. doi:10.1155/2014/707460.\u003c/li\u003e\n\u003cli\u003eGupta A, Mahnken JD, Johnson DK, Thomas TS, Subramaniam D, Polshak T, Gani I, Chen GJ, Burns JM, Sarnak MJ. Prevalence and correlates of cognitive impairment in kidney transplant recipients. \u003cem\u003eBMC Nephrol.\u003c/em\u003e 2017 May 12;18:158. doi:10.1186/s12882-017-0570-1. [bmcnephrol.biomedcentral.com]\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eGupta A, Thomas TS, Klein JA, Montgomery RN, Mahnken JD, Johnson DK, Drew DA, Sarnak MJ, Burns JM.\u003c/strong\u003e Discrepancies between Perceived and Measured Cognition in Kidney Transplant Recipients: Implications for Clinical Management. \u003cem\u003eNephron.\u003c/em\u003e 2018 Jan;138[1]:22\u0026ndash;28. doi:10.1159/000481182.\u003c/li\u003e\n\u003cli\u003eSarnak MJ, Tighiouart H, Scott TM, Lou KV, Sorensen EP, Giang LM, et al. Frequency and risk factors for poor cognitive performance in hemodialysis patients. \u003cem\u003eKidney Int\u003c/em\u003e. 2013 Mar;83[3]:436\u0026ndash;42. doi:10.1038/ki.2012.40.\u003c/li\u003e\n\u003cli\u003eDrew DA, Weiner DE, Sarnak MJ. Cognitive Impairment in CKD: Pathophysiology, Management, and Prevention. \u003cem\u003eAm J Kidney Dis\u003c/em\u003e. 2019 Apr;73[4]:529\u0026ndash;537. doi:10.1053/j.ajkd.2018.10.014\u003c/li\u003e\n\u003cli\u003eMurray AM, Knopman DS, Tupper DE, Gilbertson DT, Pederson SL, Li S, et al. Cognitive impairment is common in patients undergoing hemodialysis. \u003cem\u003eJ Am Soc Nephrol\u003c/em\u003e. 2006 Jul;17[7]:2030\u0026ndash;7. doi:10.1681/ASN.2005111206\u003c/li\u003e\n\u003cli\u003eKalantar-Zadeh K, Ikizler TA, Block G, Avram MM, Kopple JD. Malnutrition-inflammation complex syndrome in dialysis patients: causes and consequences. \u003cem\u003eAm J Kidney Dis\u003c/em\u003e. 2003 Nov;42[5]:864\u0026ndash;81. doi:10.1016/j.ajkd.2003.07.016\u003c/li\u003e\n\u003cli\u003eGriva K, Stygall J, Hankins M, Davenport A, Harrison M, Newman SP. Cognitive impairment and 7-year mortality in dialysis patients. \u003cem\u003eAm J Kidney Dis\u003c/em\u003e. 2004;44[4]:556\u0026ndash;565. doi:10.1053/j.ajkd.2004.06.023\u003c/li\u003e\n\u003cli\u003eKurella Tamura M, Larive B, Unruh ML, Stokes JB, Nissenson A, Mehta RL, et al. Prevalence and correlates of cognitive impairment in hemodialysis patients: the Frequent Hemodialysis Network trials. \u003cem\u003eClin J Am Soc Nephrol\u003c/em\u003e. 2008;3[6]:1733\u0026ndash;1740. doi:10.2215/CJN.00140108\u003c/li\u003e\n\u003cli\u003eSeidel UK, Gronewold J, Volsek M, Todica O, Kribben A, Bald M, et al. Physical, cognitive, and emotional factors contributing to quality of life, functional health, and participation in community dwelling in chronic kidney disease. \u003cem\u003ePLoS One\u003c/em\u003e. 2014;9[3]:e91176. doi:10.1371/journal.pone.0091176\u003c/li\u003e\n\u003cli\u003eBerger I, Wu S, Masson P, Kelly PJ, Duthie FA, Whiteley W, et al. Cognition in chronic kidney disease: a systematic review and meta-analysis. \u003cem\u003eBMC Nephrol\u003c/em\u003e. 2016;17[1]:48. doi:10.1186/s12882-016-0256-6\u003c/li\u003e\n\u003cli\u003eKalirao P, Pederson S, Foley RN, Kolste A, Tupper D, Zaun D, et al. Cognitive impairment in peritoneal dialysis patients. \u003cem\u003eAm J Kidney Dis\u003c/em\u003e. 2011;57[4]:612\u0026ndash;620. doi:10.1053/j.ajkd.2010.10.047\u003c/li\u003e\n\u003cli\u003eBugnicourt JM, Godefroy O, Chillon JM, Choukroun G, Massy ZA. Cognitive disorders and dementia in CKD: the neglected kidney-brain axis. \u003cem\u003eAm J Kidney Dis\u003c/em\u003e. 2013 Mar;61[3]:466\u0026ndash;76. doi:10.1053/j.ajkd.2012.08.036\u003c/li\u003e\n\u003cli\u003eGriva K, Stygall J, Hankins M, Davenport A, Harrison M, Newman SP. Cognitive impairment and 7-year mortality in dialysis patients. \u003cem\u003eAm J Kidney Dis\u003c/em\u003e. 2004 Oct;44[4]:556\u0026ndash;65. doi:10.1053/j.ajkd.2004.06.023\u003c/li\u003e\n\u003cli\u003eKalirao P, Pederson S, Foley RN, Kolste A, Tupper D, Zaun D, et al. Cognitive impairment in peritoneal dialysis patients. \u003cem\u003eAm J Kidney Dis\u003c/em\u003e. 2011 Apr;57[4]:612\u0026ndash;20. doi:10.1053/j.ajkd.2010.10.04\u003c/li\u003e\n\u003cli\u003eEtgen T, Chonchol M, F\u0026ouml;rstl H, Sander D. Chronic kidney disease and cognitive impairment: a systematic review and meta-analysis. \u003cem\u003eAm J Nephrol\u003c/em\u003e. 2012;35[5]:474\u0026ndash;82. doi:10.1159/000336000.\u003c/li\u003e\n\u003cli\u003eMurray AM. Cognitive impairment in the aging dialysis and chronic kidney disease populations: an occult burden. \u003cem\u003eAdv Chronic Kidney Dis\u003c/em\u003e. 2008;15[2]:123\u0026ndash;32. doi:10.1053/j.ackd.2008.01.011.\u003c/li\u003e\n\u003cli\u003eAbdel-Kader K, Unruh ML, Weisbord SD. Symptom burden, depression, and quality of life in chronic and end-stage kidney disease. \u003cem\u003eClin J Am Soc Nephrol\u003c/em\u003e. 2009;4[6]:1057\u0026ndash;64. doi:10.2215/CJN.00430109.\u003c/li\u003e\n\u003cli\u003eSeliger SL, Longstreth WT Jr, Katz R, Manolio T, Fried LF, Shlipak MG, et al. Cystatin C and subclinical brain infarction. \u003cem\u003eJ Am Soc Nephrol\u003c/em\u003e. 2005;16[12]:3721\u0026ndash;7. doi:10.1681/ASN.2005020126.\u003c/li\u003e\n\u003cli\u003eKurella M, Chertow GM, Luan J, Yaffe K. Cognitive impairment in chronic kidney disease. \u003cem\u003eJ Am Geriatr Soc\u003c/em\u003e. 2004;52[11]:1863\u0026ndash;9. doi:10.1111/j.1532-5415.2004.52510.x.\u003c/li\u003e\n\u003cli\u003eStern Y. Cognitive reserve in ageing and Alzheimer\u0026rsquo;s disease. \u003cem\u003eLancet Neurol\u003c/em\u003e. 2012;11[11]:1006\u0026ndash;12. doi:10.1016/S1474-4422[12]70191-6.\u003c/li\u003e\n\u003cli\u003ePereira AA, Weiner DE, Scott T, Sarnak MJ. Cognitive function in dialysis patients. \u003cem\u003eAm J Kidney Dis\u003c/em\u003e. 2005;45[3]:448\u0026ndash;62. doi:10.1053/j.ajkd.2004.11.014.\u003c/li\u003e\n\u003cli\u003eFindlay MD, Dawson J, MacIsaac R, Jardine AG, Wigmore SJ, MacLeod MJ. Investigating the relationship between cerebral blood flow and cognitive function in hemodialysis patients. \u003cem\u003eJ Am Soc Nephrol\u003c/em\u003e. 2019;30[1]:147\u0026ndash;58. doi:10.1681/ASN.2018030295.\u003c/li\u003e\n\u003cli\u003eBiessels GJ, Deary IJ, Ryan CM. Cognition and diabetes: A lifespan perspective. \u003cem\u003eLancet Neurol\u003c/em\u003e. 2008;7[2]:184\u0026ndash;90. doi:10.1016/S1474-4422[08]70021-8.\u003c/li\u003e\n\u003cli\u003eOpdebeeck C, Martyr A, Clare L. Cognitive reserve and cognitive function in healthy older people: a meta-analysis. \u003cem\u003eNeuropsychol Dev Cogn B Aging Neuropsychol Cogn\u003c/em\u003e. 2016;23[1]:40\u0026ndash;60. doi:10.1080/13825585.2015.1041450.\u003c/li\u003e\n\u003cli\u003eMcIntyre CW. Cerebral ischemia: a forgotten component of intradialytic hypotension. \u003cem\u003eClin J Am Soc Nephrol\u003c/em\u003e. 2013;8[3]:543\u0026ndash;8. doi:10.2215/CJN.00710112.\u003c/li\u003e\n\u003cli\u003eVanholder R, Schepers E, Pletinck A, Nagler EV, Glorieux G. The uremic toxicity of indoxyl sulfate and p-cresyl sulfate: a systematic review. \u003cem\u003eJ Am Soc Nephrol\u003c/em\u003e. 2014;25[9]:1897\u0026ndash;907. doi:10.1681/ASN.2013101062.\u003c/li\u003e\n\u003cli\u003eHill NR, Fatoba ST, Oke JL, Hirst JA, O\u0026apos;Callaghan CA, Lasserson DS, et al. Global prevalence of chronic kidney disease: a systematic review and meta-analysis. \u003cem\u003ePLoS One\u003c/em\u003e. 2016;11[7]:e0158765. doi:10.1371/journal.pone.0158765.\u003c/li\u003e\n\u003cli\u003eProhovnik I, Post J, Uribarri J, Lee H, Sandu O, Lesser M. Cerebrovascular effects of hemodialysis in chronic kidney disease. \u003cem\u003eJ Cereb Blood Flow Metab\u003c/em\u003e. 2007;27[11]:1861\u0026ndash;9. doi:10.1038/sj.jcbfm.9600481.\u003c/li\u003e\n\u003cli\u003eHailpern SM, Melamed ML, Cohen HW, Hostetter TH. Moderate chronic kidney disease and cognitive function in adults 20 to 59 years of age: Third National Health and Nutrition Examination Survey [NHANES III]. \u003cem\u003eJ Am Soc Nephrol\u003c/em\u003e. 2007;18[7]:2205\u0026ndash;13. doi:10.1681/ASN.2006101155.\u003c/li\u003e\n\u003cli\u003eIsoyama N, Qureshi AR, Avesani CM, Lindholm B, B\u0026aacute;r\u0026aacute;ny P, Heimb\u0026uuml;rger O, et al. Comparative associations of muscle mass and muscle strength with mortality in dialysis patients. \u003cem\u003eClin J Am Soc Nephrol\u003c/em\u003e. 2014;9[10]:1720\u0026ndash;8. doi:10.2215/CJN.10201013.\u003c/li\u003e\n\u003cli\u003eAgganis BT, Weiner DE, Giang LM, Scott T, Tighiouart H, Griffith JL, et al. Cognitive function in patients undergoing maintenance hemodialysis: the relation to depression, fatigue, and sleep disturbances. \u003cem\u003eAm J Kidney Dis\u003c/em\u003e. 2010;56[3]:516\u0026ndash;26. doi:10.1053/j.ajkd.2010.03.017.\u003c/li\u003e\n\u003cli\u003eMu J, Ma L, Ma S, Ding D, Li P, Ma X, Zhang M, Liu J\u003cstrong\u003e.\u003c/strong\u003e Neurological effects of hemodialysis on white matter microstructure in patients with end-stage renal disease \u003cem\u003eNeuroimage Clin.\u003c/em\u003e 2021;31:102743. doi:10.1016/j.nicl.2021.102743\u003c/li\u003e\n\u003cli\u003eNasreddine ZS, Phillips NA, B\u0026eacute;dirian V, et al. \u003cem\u003eThe Montreal Cognitive Assessment (MoCA) is a brief screening tool for mild cognitive impairment.\u003c/em\u003e J Am Geriatr Soc. 2005;53[4]:695\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eCarson N, Leach L, Murphy KJ. \u003cem\u003eA re-examination of MoCA cutoff scores.\u003c/em\u003e Int. J Geriatr. Psychiatry. 2018;33[2]:379\u0026ndash;388\u003c/li\u003e\n\u003cli\u003eKurella Tamura M et al. \u003cem\u003eAnemia and risk of cognitive decline in chronic kidney disease.\u003c/em\u003e BMC Nephrol. 2016;17:13.\u003c/li\u003e\n\u003cli\u003eViggiano D, Wagner CA, Martino G, Nedergaard M, Zoccali C, Unwin R, et al. Mechanisms of cognitive dysfunction in CKD. Nat Rev Nephrol. 2020;16[8]:452\u0026ndash;469. doi:10.1038/s41581-020-0266-9**\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eKurella Tamura M, Xie D, Yaffe K, et al.\u003c/strong\u003e Vascular risk factors and cognitive impairment in chronic kidney disease: The Chronic Renal Insufficiency Cohort [CRIC] Study. \u003cem\u003eClin J Am Soc Nephrol.\u003c/em\u003e 2011;6[2]:248-256. doi:10.2215/CJN.02660310\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eMcIntyre CW, Goldsmith DJ.\u003c/strong\u003e Ischemic brain injury in hemodialysis patients: Which patient is at risk? \u003cem\u003eKidney Int.\u003c/em\u003e 2015;87[1]:50\u0026ndash;57. doi:10.1038/ki.2014.282\u003c/li\u003e\n\u003cli\u003eKurella Tamura M, Unruh ML, Nissenson AR, et al. Effect of more frequent hemodialysis on cognitive function in the Frequent Hemodialysis Network trials. Am J Kidney Dis. 2013;61[2]:228-237\u003c/li\u003e\n\u003cli\u003eBiessels GJ, Despa F. Cognitive decline and dementia in diabetes mellitus: Mechanisms and clinical implications. Nat Rev Endocrinol. 2018;14[10]:591\u0026ndash;604. doi:10.1038/s41574-018-0048-7**\u003c/li\u003e\n\u003cli\u003eRawlings AM, Sharrett AR, Albert MS, Coresh J, Windham BG, Power MC, et al. The association of late-life diabetes status and hyperglycemia with incident mild cognitive impairment and dementia: The ARIC Study. Diabetes Care. 2019;42[7]:1248\u0026ndash;1254. doi:10.2337/dc19-0120**\u003c/li\u003e\n\u003cli\u003eTiffin-Richards FE, Costa AS, Holschbach B, Frank RD, Vassiliadou A, Kr\u0026uuml;ger T, et al. The Montreal Cognitive Assessment [MoCA] in CKD: Diagnostic accuracy for cognitive impairment. Nephrol. Dial. Transplant 2014;29[12]:2297\u0026ndash;2304. doi:10.1093/ndt/gfu229\u003c/li\u003e\n\u003cli\u003eKhatri M, Nickolas T, Moon YP, et al. CKD associates with cognitive decline. J Am Soc Nephrol. 2009;20[11]:2427-2432.\u003c/li\u003e\n\u003cli\u003eWeiner DE, Bartolomei K, Scott T, et al. Albuminuria, cognitive functioning, and white matter hyperintensities in homebound elders. Am J Kidney Dis. 2009;53[3]:438-447.\u003c/li\u003e\n\u003cli\u003eKang EW, Abdel-Kader K, Yabes J, et al. Association of sleep-disordered breathing with cognitive dysfunction in CKD stages 4-5. Am J Kidney Dis. 2012;60[6]:949-958.\u003c/li\u003e\n\u003cli\u003eMcAdams-DeMarco MA, Law A, Tan J, et al. Frailty and Cognitive Function in Incident Hemodialysis Patients. Clin J Am Soc Nephrol. 2015;10[12]:2181-2189.\u003c/li\u003e\n\u003cli\u003eBossola M, Antocicco M, Di Stasio E, et al. Mini-Mental State Examination over time in chronic hemodialysis patients. J Psychosom Res. 2011;71[1]:50-54.\u003c/li\u003e\n\u003cli\u003eHailpern SM, Melamed ML, Cohen HW, Hostetter TH. Moderate CKD and cognitive function in adults 20-59 years: NHANES III. Am J Kidney Dis. 2007;50[1]:18-27.\u003c/li\u003e\n\u003cli\u003eMu J, et al. Neurological effects of hemodialysis on white matter microstructure. Neuroimage Clin. 2021;31:102743.\u003c/li\u003e\n\u003cli\u003eGBD 2019 Chronic Kidney Disease Collaborators. Global, regional, and national burden of CKD from 1990 to 2019. Lancet. 2020;395[10225]:709\u0026ndash;733.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8228712/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8228712/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eCognitive impairment is a common but under-recognized complication in patients undergoing dialysis, with limited data available from India. This cross-sectional study assessed the cognitive abilities of 32 patients undergoing chronic dialysis using the Montreal Cognitive Assessment [MoCA].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethodology\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA single-center cross-sectional design was used to evaluate 32 adults with CKD stages 3-5. Cognitive function was assessed using the 30-point MoCA tool. Descriptive statistics and non-parametric tests [Mann-Whitney U and Kruskal-Wallis tests] were applied, with significance set at p \u0026lt; 0.05. Ethical approval was obtained from the Institutional Ethics Committee.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003cbr\u003e\n\u003c/strong\u003eMoCA scores classified 10 patients as normal, 7 with mild impairment, 9 with moderate impairment, and 6 with severe impairment of cognitive function. The most affected domains were delayed recall [1.0 ± 1.3/5], attention [3.8 ± 2.3/6], and abstraction [1.1 ± 0.8/2]. Patients with diabetes showed a trend toward poorer cognitive scores [14.5 ± 7.3] than non-diabetics [19.4 ± 5.8] [p = 0.094]. Individuals with cognitive impairment had significantly lower pulse rates [p = 0.0331] and shorter dialysis durations [p = 0.0329]. Age [r = –0.4122, p = 0.022] and dialysis duration [r = 0.3473, p = 0.051] showed notable associations with MoCA scores, whereas blood pressure, sex, and occupation were not significantly related.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003cbr\u003e\n\u003c/strong\u003eMost participants demonstrated cognitive impairment, highlighting the importance of routine cognitive screening in long-term dialysis care. Rehabilitation strategies should consider age, dialysis duration, and comorbidities, such as diabetes and hypertension. The findings suggest a link between autonomic function, dialysis adaptation, and cognitive status, underscoring the need for evidence-based cognitive rehabilitation programs to support patients undergoing chronic dialysis.\u003c/p\u003e","manuscriptTitle":"A cross-sectional assessment of key cognitive domains affected in Chronic dialysis patients with associated co-morbidities: A pilot study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-08 10:47:23","doi":"10.21203/rs.3.rs-8228712/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f1cc63bb-3c77-4058-84a1-e9cd43537367","owner":[],"postedDate":"December 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-08T10:47:26+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-08 10:47:23","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8228712","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8228712","identity":"rs-8228712","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}