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Verrelli D, Sharma A, Alexiuk J, Tays Q, Rossum K, Sharma M, Ford E, Iansavitchene A, Al-Jaishi AA, Whitlock R, McIntyre CW, Garg AX, Bohm C. Effect of Intradialytic Exercise on Cardiovascular Outcomes in Maintenance Hemodialysis: A Systematic Review and Meta-Analysis. KIDNEY360 2024; 5:390-413. [PMID: 38306116 PMCID: PMC11000728 DOI: 10.34067/kid.0000000000000361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 01/11/2024] [Indexed: 02/03/2024]
Abstract
Key Points Individuals receiving hemodialysis have high rates of cardiovascular disease not explained by traditional cardiovascular risk factors. Intradialytic exercise improves cardiovascular outcomes, including arterial resistance, BP, and heart rate variability. Clinicians should consider including intradialytic aerobic exercise programs in hemodialysis care to supplement broader treatment plans. Background Cardiovascular disease is the leading cause of death among people with kidney failure on hemodialysis, for whom improving cardiovascular health is a research priority. Intradialytic myocardial stunning is common and associated with adverse cardiovascular events. Intradialytic exercise may mitigate intradialytic myocardial stunning and improve cardiovascular structure and function. This systematic review investigated the effect of intradialytic exercise on cardiovascular outcomes in adults undergoing maintenance hemodialysis (PROSPERO CRD42018103118). Methods Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we systematically searched MEDLINE, Embase, Cochrane CENTRAL, SportDiscus, and PEDro databases from 1960 until June 2022, for randomized and nonrandomized studies investigating the effect of intradialytic exercise programs on objective cardiovascular outcomes, prespecified as primary or secondary outcomes. The primary outcome was arterial resistance. Results Of 10,837 references identified, 32 met eligibility criteria. These studies investigated the effect of intradialytic exercise on arterial resistance (eight studies), BP (20 studies), myocardial structure and function (seven studies), endothelial function (two studies), sympathetic overactivity (nine studies), biomarkers of cardiac injury (three studies), and cardiovascular hospitalization and mortality (two studies). Most studies used aerobic exercise as the intervention and usual care (no exercise) controls. Meta-analysis of intradialytic exercise versus usual care resulted in a statistically significant reduction in arterial resistance measured by pulse wave velocity with mean difference −1.63 m/s (95% confidence interval, −2.51 to −0.75). Meta-analyses for diastolic BP, left ventricular ejection fraction, and low-frequency/high-frequency ratio measure of heart rate variability also showed statistically significant improvements with exercise. There was no significant difference in change in systolic BP, augmentation index, and left ventricular mass index between groups. Conclusions Intradialytic exercise programming resulted in a clinically meaningful improvement to pulse wave velocity, a component of arterial resistance. Improvements in several physiologic measures of cardiovascular health, including diastolic BP, left ventricular ejection fraction, and heart rate variability measured by the low-frequency/high-frequency ratio were also observed. The effects of intradialytic exercise on major adverse cardiovascular events remains uncertain.
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Affiliation(s)
- Davide Verrelli
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ajaya Sharma
- Institute for Clinical Evaluative Sciences, University of Western Ontario, London, Ontario, Canada
| | - Jamie Alexiuk
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Quinn Tays
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Krista Rossum
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Monica Sharma
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Emilie Ford
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada
| | - Alla Iansavitchene
- Corporate Academics, Health Sciences Library, London Health Sciences Centre, London, Ontario, Canada
| | - Ahmed A. Al-Jaishi
- Institute for Clinical Evaluative Sciences, University of Western Ontario, London, Ontario, Canada
| | - Reid Whitlock
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada
| | - Christopher W. McIntyre
- Institute for Clinical Evaluative Sciences, University of Western Ontario, London, Ontario, Canada
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Amit X. Garg
- Institute for Clinical Evaluative Sciences, University of Western Ontario, London, Ontario, Canada
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Clara Bohm
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada
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Li J, Wang Z, Zhang Q, Zhang H, Shen Y, Zhang Q, Jian G, Cheng D, Wang N. Association between disability in activities of daily living and phase angle in hemodialysis patients. BMC Nephrol 2023; 24:350. [PMID: 38031052 PMCID: PMC10688067 DOI: 10.1186/s12882-023-03400-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 11/15/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Disability in activities of daily living (ADL) significantly increases the risk of mortality among patients undergoing hemodialysis. Malnutrition and decreased exercise capacity are closely correlated with ADL disability. Phase angle (PhA) has been proposed as a measure of nutritional status and exercise capacity. This study aims to investigate the prevalence of ADL disability in hemodialysis patients and its association with PhA. METHODS A prospective, observational study was conducted, involving hemodialysis patients treated between November 2019 and January 2020 in an affiliated hospital of Chinese university. ADL was measured using both basic ADL (BADL) scales and instrumental ADL (IADL) scales. PhA measurements were obtained using a BIA device while the patients were in the supine position after dialysis. RESULTS A total of 237 hemodialysis patients with a mean age of 60.01 ± 13.55 years were included in this study. The prevalence of disability in ADL was 43.5%. Multivariable analysis results showed a robust association between low PhA and disability in both BADL and IADL (for each unit decrease in PhA: odds ratio 4.83 [95% CI: 2.56-9.0], and 3.57 [95% CI: 2.14-5.95], respectively). The optimal cut-off values of PhA for disability in BADL and IADL were 4.8 and 5.4, with the area under the ROC curve (AUC) were 0.783 (0.727, 0.835) and 0.799 (0.743, 0.848), respectively. CONCLUSIONS Low PhA is strongly associated with disability in ADL in hemodialysis patients. These findings suggest that PhA may serve as a potentially objective measure of ADL disability in hemodialysis patients.
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Affiliation(s)
- Junhui Li
- Department of Nephrology, Putuo People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Zhi Wang
- Department of Nephrology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, 200233, P.R. China
| | - Qiannan Zhang
- Department of Nephrology, Putuo People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Huiping Zhang
- Department of Nephrology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, 200233, P.R. China
| | - Yuxin Shen
- Department of Nephrology, Putuo People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Qi Zhang
- Tian Lin Community Health Center, Xuhui District, Shanghai, China
| | - Guihua Jian
- Department of Nephrology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, 200233, P.R. China.
| | - Dongsheng Cheng
- Department of Nephrology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, 200233, P.R. China.
| | - Niansong Wang
- Department of Nephrology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, 200233, P.R. China
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3
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Bossola M, Pepe G, Antocicco M, di Stasio E. Mini-Mental State Examination predicts mortality in patients on chronic hemodialysis. Semin Dial 2023; 36:37-42. [PMID: 35119128 DOI: 10.1111/sdi.13057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 11/24/2021] [Accepted: 01/18/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND No available and easy to administer cognitive test has been evaluated for the prediction of mortality in prevalent patients on chronic hemodialysis. The aim of the present study was to determine if the Mini-Mental State Examination (MMSE) was predictor of mortality in patients on chronic hemodialysis. METHODS One hundred twenty-seven prevalent patients on chronic hemodialysis were studied. All patients underwent assessment of cognitive function through the MMSE. The MMSE was administered during a midweek hemodialysis session, avoiding the beginning and the end of each treatment to minimize the effects of fluctuations in uremic syndrome or blood pressure in accordance with a previous study. An MMSE score ≤23 was used as indicative of cognitive impairment. Demographic, clinical, and laboratory parameters were recorded for each patient. RESULTS Mean (SD) MMSE was 23.2 ± 4.1. Median MMSE was 24 (min-max: 2-30). MMSE was ≤23 in 72 patients and >23 in 55. With data updated in March 2021, after a mean follow-up of 58.8 ± 41 months (range: 2-156 months), 75 patients died, and 17 were transplanted. None was lost to follow-up or was transferred to another unit. Dead participants, as compared with alive ones, were significantly older, had a higher Charlson Index score, had lower Activities daily living and Instrumental activities daily living, and had a lower MMSE score and lower serum albumin levels. Kaplan-Meier analysis showed that survival was significantly lower in patients with MMSE ≤23 than in those with MMSE >23 (log-rank χ2 : 8.825, p = 0.003). According to Cox regression analysis, mortality was associated with age and inversely associated with MMSE. CONCLUSION We show that the MMSE predicts mortality in prevalent patients on chronic hemodialysis.
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Affiliation(s)
- Maurizio Bossola
- Servizio Emodialisi, Università Cattolica del Sacro Cuore, Rome, Italy.,Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Gilda Pepe
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Dipartimento di Scienze mediche e chirurgiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Manuela Antocicco
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Dipartimento di Geriatria, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Enrico di Stasio
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Dipartimento di Scienze biotecnologiche di base, cliniche intensivologiche e perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
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Clinical frailty assessment might be associated with mortality in incident dialysis patients. Sci Rep 2022; 12:17651. [PMID: 36271111 PMCID: PMC9587224 DOI: 10.1038/s41598-022-22483-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 10/14/2022] [Indexed: 01/18/2023] Open
Abstract
Frailty is associated with mortality in maintenance dialysis patients. For incident dialysis patients, we used the clinical frailty scale (CFS) to investigate frailty as related to mortality or hospitalization within 2 years. We retrospectively reviewed the medical records of patients initiating hemodialysis or peritoneal dialysis during 2016-2018. Based on those records, two dialysis nurses independently used a 9-point CFS (1 = "Very fit" to 9 = "Terminally ill") to assess each patient's frailty at dialysis initiation. Patients with a mean CFS value of 5 or higher were classified into the frail group. The 2-year survival rates or hospitalization-free rates after the initiation of dialysis were compared between the frail (mean CFS score ≥ 5) and non-frail (mean CFS score < 5) groups. The analysis included 155 incident dialysis patients with mean age of 66.7 ± 14.1 (71% male). Frailty was inferred for 39 (25%) patients at dialysis initiation. Kaplan-Meier analyses showed that the survival rate and hospitalization-free rate within 2 years were significantly lower in the frail group than in the non-frail group (p < 0.01). Cox proportional hazards regression analyses revealed the CFS score as associated with the occurrence of a composite outcome, independently of age (hazard ratio 1.34, 95% confidence interval 1.04-1.72). Frailty assessment based on clinical judgment using CFS might predict adverse outcomes in dialysis-initiated patients.
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5
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Sato K, Konta Y, Furuta K, Kamizato K, Furukawa A, Ono A, Ogawa R, Sato R, Endo K, Yamamoto T. Prognostic factors for acute ischemic stroke in patients undergoing hemodialysis. Clin Exp Nephrol 2021; 26:286-293. [PMID: 34767098 PMCID: PMC8847285 DOI: 10.1007/s10157-021-02146-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 09/28/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Acute ischemic stroke (AIS) is a critical complication in patients undergoing dialysis. Although the improvement of AIS management is an urgent requirement, few studies have evaluated the prognostic factors of AIS in these patients. This study aimed to assess the relationship between clinical factors in patients undergoing dialysis and the prognosis of AIS. METHODS Among 1267 patients who were hospitalized for AIS in Sendai City Hospital from January 2015 to June 2020, 81 patients undergoing hemodialysis were retrospectively enrolled. Multivariate analysis was performed to evaluate the effect of baseline characteristics, dialysis factors, and neurological severity of patients at admission [National Institutes of Health Stroke Scale (NIHSS) score] on in-hospital mortality, physical disability, and the need for rehabilitation transfer. RESULTS A higher NIHSS score was a critical risk factor for each outcome and the only significant factor for in-hospital mortality [odds ratio (OR)/point 1.156, 95% confidence interval (CI) 1.054-1.267]. The risk factors of physical disability were NIHSS score (OR/point 1.458, 95% CI 1.064-1.998), older age (OR/year 1.141, 95% CI 1.022-1.274), diabetic nephropathy (OR 7.096, 95% CI 1.066-47.218), and higher premorbid modified Rankin scale (mRS) score (OR/grade 2.144, 95% CI 1.155-3.978); while those of rehabilitation transfer were a higher NIHSS score (OR/point 1.253, 95% CI 1.080-1.455), dialysis vintage (OR/year 1.175, 95% CI 1.024-1.349), and intradialytic hypotension before onset (OR 5.430, 95% CI 1.320-22.338). CONCLUSIONS Along with neurological severity, dialysis vintage, intradialytic hypotension, and diabetic nephropathy could worsen the prognosis of patients with AIS undergoing hemodialysis.
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Affiliation(s)
- Koji Sato
- Division of Internal Medicine, Sendai City Hospital, 1-1-1 Asutonagamachi, Taihaku-ku, Sendai, Miyagi, 982-8502, Japan
| | - Yusuke Konta
- Division of Internal Medicine, Sendai City Hospital, 1-1-1 Asutonagamachi, Taihaku-ku, Sendai, Miyagi, 982-8502, Japan
| | - Kyohei Furuta
- Division of Internal Medicine, Sendai City Hospital, 1-1-1 Asutonagamachi, Taihaku-ku, Sendai, Miyagi, 982-8502, Japan
| | - Kenyu Kamizato
- Division of Internal Medicine, Sendai City Hospital, 1-1-1 Asutonagamachi, Taihaku-ku, Sendai, Miyagi, 982-8502, Japan
| | - Akiko Furukawa
- Division of Internal Medicine, Sendai City Hospital, 1-1-1 Asutonagamachi, Taihaku-ku, Sendai, Miyagi, 982-8502, Japan
| | - Akiyuki Ono
- Division of Neurology, Sendai City Hospital, 1-1-1 Asutonagamachi, Taihaku-ku, Sendai, Miyagi, 982-8502, Japan
| | - Ryo Ogawa
- Division of Neurology, Sendai City Hospital, 1-1-1 Asutonagamachi, Taihaku-ku, Sendai, Miyagi, 982-8502, Japan
| | - Ryosuke Sato
- Department of Clinical Engineering, Sendai City Hospital, 1-1-1 Asutonagamachi, Taihaku-ku, Sendai, Miyagi, 982-8502, Japan
| | - Kaoru Endo
- Division of Neurology, Sendai City Hospital, 1-1-1 Asutonagamachi, Taihaku-ku, Sendai, Miyagi, 982-8502, Japan
| | - Tae Yamamoto
- Division of Internal Medicine, Sendai City Hospital, 1-1-1 Asutonagamachi, Taihaku-ku, Sendai, Miyagi, 982-8502, Japan.
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6
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Chu NM, Sison S, Muzaale AD, Haugen CE, Garonzik-Wang JM, Brennan DC, Norman SP, Segev DL, McAdams-DeMarco M. Functional independence, access to kidney transplantation and waitlist mortality. Nephrol Dial Transplant 2020; 35:870-877. [PMID: 31860087 DOI: 10.1093/ndt/gfz265] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 11/01/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Approximately half of the patients who progress to end-stage kidney disease (ESKD) and undergo dialysis develop difficulties carrying out essential self-care activities, leading to institutionalization and mortality. It is unclear what percentage of kidney transplant (KT) candidates, a group of ESKD patients selected to be healthy enough to withstand transplantation, are functionally independent and whether independence is associated with better access to KT and reduced waitlist mortality. METHODS We studied a prospective cohort of 3168 ESKD participants (January 2009 to June 2018) who self-reported functional independence in more basic self-care Activities of Daily Living (ADL) (needing help with eating, dressing, walking, grooming, toileting and bathing) and more complex instrumental ADL (IADL) (needing help using a phone, shopping, cooking, housework, washing, using transportation, managing medications and managing money). We estimated adjusted associations between functional independence (separately) and listing (Cox), waitlist mortality (competing risks) and transplant rates (Poisson). RESULTS At KT evaluation, 92.4% were independent in ADLs, but only 68.5% were independent in IADLs. Functionally independent participants had a higher chance of listing for KT [ADL: adjusted hazard ratio (aHR) = 1.55, 95% confidence interval (CI) 1.30-1.87; IADL: aHR = 1.39, 95% CI 1.26-1.52]. Among KT candidates, ADL independence was associated with lower waitlist mortality risk [adjusted subdistribution HR (aSHR) = 0.66, 95% CI 0.44-0.98] and higher rate of KT [adjusted incidence rate ratio (aIRR) = 1.58, 95% CI 1.12-2.22]; the same was not observed for IADL independence (aSHR = 0.86, 95% CI 0.65-1.12; aIRR = 1.01, 95% CI 0.97-1.19). CONCLUSIONS Functional independence in more basic self-care ADL was associated with better KT access and lower waitlist mortality. Nephrologists, geriatricians and transplant surgeons should screen KT candidates for ADLs, and identify interventions to promote independence and improve waitlist outcomes.
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Affiliation(s)
- Nadia M Chu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Stephanie Sison
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Abimereki D Muzaale
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christine E Haugen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Daniel C Brennan
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Silas P Norman
- Department of Medicine, University of Michigan School of Medicine, Baltimore, MD, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Mara McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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7
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Moorman D, Mallick R, Rhodes E, Bieber B, Nesrallah G, Davis J, Suri R, Perl J, Tanuseputro P, Pisoni R, Robinson B, Sood MM. Facility Variation and Predictors of Do Not Resuscitate Orders of Hemodialysis Patients in Canada: DOPPS. Can J Kidney Health Dis 2019; 6:2054358119879777. [PMID: 31632682 PMCID: PMC6778991 DOI: 10.1177/2054358119879777] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 07/22/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Life expectancy in patients with end-stage kidney disease treated with hemodialysis (HD) is limited, and as such, the presence of an advanced care directive (ACD) may improve the quality of death as experienced for patients and families. Strategies to discuss and implement ACDs are limited with little being known about the status of Do Not Resuscitate (DNR) orders in the Canadian HD population. OBJECTIVES Using data from the Dialysis Outcomes and Practice Patterns Study (DOPPS), we set out to (1) examine the variability in DNR orders across Canada and its largest province, Ontario and (2) identify clinical and functional status measures associated with a DNR order. DESIGN We conducted a retrospective cohort study using data from the DOPPS Canada Phase 4 to 6 from 2009 to 2017. SETTING DOPPS facilities in Canada. PATIENTS All adults (>18 years) who initiated chronic HD with a documented ACD were included. MEASUREMENTS ACD and DNR orders. METHODS Descriptive statistics were compared for baseline characteristics (demographics, comorbidities, medications, facility characteristics, and patient functional status) and DNR status. The crude proportion of patients per facility with a DNR order was calculated across Canada and Ontario. Functional status was determined by activities of daily living and components of the Kidney Disease Quality of Life (KDQOL)-validated questionnaire. We used generalized estimating equations (GEEs) to create sequential multivariable models (demographics, comorbidities, and functional status) of variables associated with DNR status. RESULTS A total of 1556 (96% of total) patients treated with HD had a documented ACD and were included. A total of 10% of patients had a DNR order. The crude variation of DNR status differed considerably across facilities within Canada, between Ontario and non-Ontario, and within Ontario (interprovince variation = 6.3%-17.1%, Ontario vs non-Ontario = 8.2% vs 11.7%, intraprovincial variation [Ontario] = 1%-26%). Patients with a DNR order were more commonly older, white, with cardiac comorbidities, with less or shorter predialysis care compared with those without a DNR order. Patients with a DNR order reported lower energy, more difficulty with transfers, meal preparation, household tasks, and financial management. In a multivariate model, age, cardiac disease, stroke, dialysis duration, and intradialytic weight gain were associated with DNR status. LIMITATIONS Relatively small number of events or measures in certain categories. CONCLUSIONS A large inter- and intraprovincial (Ontario) variation was observed regarding DNR orders across Canada highlighting areas for potential quality improvement. While functional status did not appear to have a bearing on the presence of a DNR order, the presence of various comorbidities was associated with the presence of a DNR order.
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Affiliation(s)
| | | | | | - Brian Bieber
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | | | | | | | | | | | - Ronald Pisoni
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | - Bruce Robinson
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
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8
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Viecelli AK, Lok CE. Hemodialysis vascular access in the elderly-getting it right. Kidney Int 2019; 95:38-49. [PMID: 30606427 DOI: 10.1016/j.kint.2018.09.016] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 08/21/2018] [Accepted: 09/11/2018] [Indexed: 01/01/2023]
Abstract
Choosing the optimal hemodialysis vascular access for the elderly patient is best achieved by a patient-centered coordinated multidisciplinary team approach that aligns the patient's end-stage kidney disease Life-Plan, i.e., the individual treatment approach (supportive care, time-limited or long-term kidney replacement therapy, or combination thereof) and selection of dialysis modality (peritoneal dialysis versus hemodialysis) with the most suitable dialysis access. Finding the right balance between the patient's preferences, the likelihood of access function and survival, and potential complications in the context of available resources and limited patient survival can be extremely challenging. The framework for choosing the most appropriate vascular access for the elderly presented in this review considers the individual end-stage kidney disease Life-Plan, the patient life expectancy, the likelihood of access function and survival, the timing of dialysis relative to access placement, prior access history, and patient preference. This complex decision-making process should be dynamic in order to accommodate patients' changing needs and life and health circumstances. Effective and timely communication between the patient, their caregivers, and treating team is key to delivering truly patient-centered care. Delivering this care also requires overcoming the limitations of the currently available evidence that is predominantly based on observational data with its inherent risks of bias. While challenging, future randomized controlled studies exploring the risks, benefits, costs, and timing of placement of available access types in the elderly are required to help us "get it right" for our patients.
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Affiliation(s)
- Andrea K Viecelli
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia; Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Charmaine E Lok
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
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9
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Suzuki Y, Kamiya K, Tanaka S, Hoshi K, Watanabe T, Harada M, Matsuzawa R, Shimoda T, Yamamoto S, Matsunaga Y, Yoneki K, Yoshida A, Matsunaga A. Effects of electrical muscle stimulation in frail elderly patients during haemodialysis (DIAL): rationale and protocol for a crossover randomised controlled trial. BMJ Open 2019; 9:e025389. [PMID: 31122968 PMCID: PMC6537999 DOI: 10.1136/bmjopen-2018-025389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION The phenomenon of population ageing is accompanied by increases in the number of elderly haemodialysis patients worldwide. The incidence of frailty is high in the haemodialysis population and is associated with poor clinical outcome. Although several interventions have been developed for use in general haemodialysis patients, the efficacy of such rehabilitation programmes in frail elderly patients on haemodialysis has not been elucidated. Here, we examined whether electrical muscle stimulation (EMS) would show beneficial effects in frail elderly patients on haemodialysis. METHODS AND ANALYSIS This is a randomised, two-period, controlled crossover trial, which will enrol 20 patients. Haemodialysis patients aged ≥65 years and defined as frail (ie, Short Physical Performance Battery score 4-9), will be randomly assigned to either group 1 (EMS intervention beginning in treatment period I, followed by reallocation as controls in treatment period II after a 5-week washout period) or group 2 (opposite schedule) in a 1:1 ratio. The two intervention periods will last 5 weeks each with an intervening washout period of 5 weeks. In the EMS intervention group, the treatment will be applied to the skeletal muscle of the entire lower extremity for 5 weeks, three times/week for 30-40 min during haemodialysis. The primary outcome of this study is the change in quadriceps isometric strength after the interventions. The secondary outcomes are the changes in physical function, physical activity, difficulty in activities of daily living, body composition, cognitive function, depressive symptoms, quality of life, blood test results and the clinical safety and feasibility of EMS therapy. ETHICS AND DISSEMINATION This study has been approved by the institutional review board/ethics committee of Kitasato University Allied Health Sciences. This study will be reported in peer reviewed publications and at conference presentations. TRIAL REGISTRATION NUMBER UMIN000032501.
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Affiliation(s)
- Yuta Suzuki
- Rehabilitation Sciences, Kitasato University Graduate School of Medical Sciences, Sagamihara, Japan
| | - Kentaro Kamiya
- Rehabilitation, Kitasato University School of Allied Health Sciences, Sagamihara, Japan
| | - Shinya Tanaka
- Rehabilitation, Kitasato University School of Allied Health Sciences, Sagamihara, Japan
| | - Keika Hoshi
- Department of Hygiene, Kitasato University School of Medicine, Kanagawa, Japan
| | - Takaaki Watanabe
- Rehabilitation Sciences, Kitasato University Graduate School of Medical Sciences, Sagamihara, Japan
| | - Manae Harada
- Rehabilitation Sciences, Kitasato University Graduate School of Medical Sciences, Sagamihara, Japan
| | - Ryota Matsuzawa
- Department of Rehabilitation, Kitasato University Hospital, Sagamihara, Japan
| | - Takahiro Shimoda
- Rehabilitation Sciences, Kitasato University Graduate School of Medical Sciences, Sagamihara, Japan
| | - Shohei Yamamoto
- Rehabilitation Sciences, Kitasato University Graduate School of Medical Sciences, Sagamihara, Japan
| | - Yusuke Matsunaga
- Sleep Medicine, Kitasato University Graduate School of Medical Sciences, Sagamihara, Japan
| | - Kei Yoneki
- Rehabilitation Sciences, Kitasato University Graduate School of Medical Sciences, Sagamihara, Japan
| | - Atsushi Yoshida
- Haemodialysis Center, Sagami Circulatory Organ Clinic, Sagahihara, Japan
| | - Atsuhiko Matsunaga
- Rehabilitation Sciences, Kitasato University Graduate School of Medical Sciences, Sagamihara, Japan
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10
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So C, Lage DE, Slocum CS, Zafonte RD, Schneider JC. Utility of Functional Metrics Assessed During Acute Care on Hospital Outcomes: A Systematic Review. PM R 2019; 11:522-532. [PMID: 30758920 PMCID: PMC10108704 DOI: 10.1002/pmrj.12013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 11/10/2018] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Traditionally, illness severity, social factors, and comorbid conditions have been examined as predictors of hospital outcomes. However, recent research in the rehabilitation setting demonstrated that physical function outperformed comorbidity indices as a predictor of 30-day readmission. The purpose of this study was to review the literature examining the association between acute hospital physical function and various hospital outcomes and health care utilization. TYPE: Systematic review. LITERATURE SURVEY A review of the MEDLINE database was performed. Search terms included acute functional outcomes and frailty outcomes. Studies up to September 2017 were included if they were in English and examined how functional metrics collected at acute care hospitalization affected hospital outcomes. METHODOLOGY Cohort characteristics and measures of associations were extracted from the studies. Outcomes include hospital readmission, length of stay, mortality, discharge location, and physical function post acute care. The studies were assessed for potential confounders as well as selection, attrition, and detection bias. SYNTHESIS A total of 30 studies were identified (hospital readmissions: 6; discharge location: 11; length of stay: 4; mortality: 15; function: 6). Thirteen different metrics assessed function during acute care. Lower function during acute care was associated with statistically significant higher odds of hospital readmission, lower likelihood of discharge to home, longer hospital length of stay, increased mortality, and worse functional recovery when compared to patients with higher function during acute care, when adjusted for age and gender. The Barthel Index may be a useful marker for mortality in the elderly whereas the Functional Independence Measure instrument may be valuable for examining discharge location. CONCLUSIONS There is increasing evidence that function measured during acute care predicts a broad array of meaningful clinical outcomes. Further research would help direct the use of practical, yet parsimonious functional metrics that effectively screen high-need, high-cost patients to deliver optimal care. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Conan So
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA.,University of Maryland School of Medicine, Baltimore, MD
| | - Daniel E Lage
- Department of Medicine, Massachusetts General Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Chloe S Slocum
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Ross D Zafonte
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA.,Department of Medicine, Massachusetts General Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Jeffrey C Schneider
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA.,Harvard Medical School, Boston, MA
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Bossola M, Di Stasio E, Sirolli V, Ippoliti F, Cenerelli S, Monteburini T, Parodi E, Santarelli S, Nebiolo PE, Bonomini M, Picca A, Calvani R, Marzetti E. Prevalence and Severity of Postdialysis Fatigue Are Higher in Patients on Chronic Hemodialysis With Functional Disability. Ther Apher Dial 2018; 22:635-640. [DOI: 10.1111/1744-9987.12705] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 04/25/2018] [Accepted: 04/27/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Maurizio Bossola
- Hemodialysis Service, Institute of Clinical Surgery; Catholic University of the Sacred Heart; Rome Italy
| | - Enrico Di Stasio
- Department of Clinical Chemistry; Catholic University of the Sacred Heart; Rome Italy
| | - Vittorio Sirolli
- Department of Nephrology; General Hospital SS Annunziata; Chieti Italy
| | - Fabio Ippoliti
- Department of Nephrology; General Hospital Umberto; Pariniu, Aosta Italy
| | | | | | - Emanuele Parodi
- Department of Nephrology; General Hospital Umberto; Pariniu, Aosta Italy
| | | | | | - Mario Bonomini
- Department of Nephrology; General Hospital SS Annunziata; Chieti Italy
| | - Anna Picca
- Department of Geriatrics, Neurosciences and Orthopedics; Catholic University of the Sacred Heart; Rome Italy
| | - Riccardo Calvani
- Department of Geriatrics, Neurosciences and Orthopedics; Catholic University of the Sacred Heart; Rome Italy
| | - Emanuele Marzetti
- Department of Geriatrics, Neurosciences and Orthopedics; Catholic University of the Sacred Heart; Rome Italy
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12
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Yau K, Farragher JF, Kim SJ, Famure O, Jassal SV. A Longitudinal Study Examining the Change in Functional Independence Over Time in Elderly Individuals With a Functioning Kidney Transplant. Can J Kidney Health Dis 2018; 5:2054358118775099. [PMID: 29899998 PMCID: PMC5985553 DOI: 10.1177/2054358118775099] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Accepted: 02/02/2018] [Indexed: 12/17/2022] Open
Abstract
Background: Functional disability is defined as the need for assistance with self-care
tasks. Objective: To document changes in functional status over time among older prevalent
renal transplant recipients. Design: Single center, prospective, follow-up study. Setting: Single center, tertiary care transplant center. Patients: Patients, with a functioning kidney transplant, aged 65 years or older who
underwent assessment of functional status approximately 12 months
previously. Measurements: Validated tools used included Barthel Index, the Lawton-Brody Scale of
Instrumental Activities of Daily Living, the Timed Up and Go test, the
Veterans Specific Activity Questionnaire, the Mini-Cog, and dynamometer
handgrip strength. Methods: Outpatient assessment by a trained observer. Results: Of the 82 patients previously studied, 64 (78%) patients participated in the
follow-up study (mean age 70.5 ± 4.4 years, 58% male, 55% diabetic). Among
those completing functional status measures, 32 (50%) had functional
disability at baseline. Over the 1-year period, 11 (17%) of these patients
experienced progressive functional decline, 6 (9%) exhibited no change, and
15 (23%) had functional recovery. Eleven patients (17%) initially
independent, developed new-onset disability. One of the strongest predictors
of progressive functional decline was having 1 or more falls in the previous
year. Limitations: Assessments were performed only on 2 occasions separated by approximately 1
year. Conclusions: Fluctuations in disability states are common among older adults living with
renal transplants. Episodes of functional disability may place individuals
at higher risk of persistent and/or progressive disability.
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Affiliation(s)
- Kevin Yau
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada
| | - Janine F Farragher
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada
| | - S Joseph Kim
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada
| | - Olusegun Famure
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada
| | - Sarbjit V Jassal
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada
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Abstract
PURPOSE OF REVIEW Frailty is highly prevalent in the dialysis population and is associated with mortality. Recent studies have suggested that other dialysis outcomes are compromised in frail individuals. While we do not yet have a consensus as to the best measure of frailty, identification of these poor outcomes and their magnitude of association with frailty will help improve prognostication, allow for earlier interventions, and improve provider-to-patient communication. RECENT FINDINGS The most widely used assessment of frailty is Fried's physical performance criteria. However, regardless of assessment method, frailty remains highly associated with mortality. More recently, frailty has been associated with falls, fractures, cognitive impairment, vascular access failure, and poor quality of life. Recent large cohort studies provide strong evidence that frailty assessment can provide important prognostic information for providers and patients both before and after initiation of dialysis. Trials aimed at improving frailty are limited and show the promise of augmenting quality of life, although more studies are needed to firmly establish mortality benefits. SUMMARY We underscore the importance of frailty as a prognostic indicator and identify other recently established consequences of frailty. Widespread adoption of frailty assessment remains limited and researchers continue to find ways of simplifying the data collection process. Timely and regular assessment of frailty may allow for interventions that can mitigate the onset of poor outcomes and identify actionable targets for dialysis providers.
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Park HS, Lee KT, Kim TW. Role of physical activity in mortality prediction in elderly hospice patients. J Exerc Rehabil 2017; 13:250-254. [PMID: 28503542 PMCID: PMC5412503 DOI: 10.12965/jer.1734950.475] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Accepted: 03/31/2017] [Indexed: 11/22/2022] Open
Abstract
The prediction of life-expectancy in terminally ill patients is important both for medical and social reasons but it is widely recognized as being inaccurate. The aim of this study was to investigate the mortality predictors and indicators of life extension among elderly patients in a hospice service center. In order to determine the mortality predictors, we investigated the relationship between patients’ cognitive status using the Korean-Mini Mental State Examination & Global Deterioration Scale (K-MMSE & GDS), the patient’s physical function using the instrumental Activities of Daily Living (ADL) score, and the patient’s blood component values. The subjects included 43 men and 57 women with a mean age of 82.4±8.4 years, and a mean nursing period of 11.1±12.2 months. These terminally ill patients were enrolled in a cross-sectional study. All data were collected from paper and electronic charts, and patient interviews. A simple correlation analysis was performed to determine the relationship between the variables and to satisfy the normal distribution (P<0.01). The results revealed that the time of death negatively correlated with ADL score (r=−0.273, P=0.006). However, the K-MMSE & GDS, and the values of blood component such as albumin, gamma-glutamic transpeptidase, blood urea nitrogen, and creatinine were not correlated with the time of death. Consequently, the ADL score might be an important predictor of mortality and life extension in elderly patients. Therefore, in order to improve ADL score, physical exercise and overall fitness may be potential non-pharmacologic methods useful in preventing mortality in elderly people.
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Affiliation(s)
- Hye-Sang Park
- Department of Physiology, College of Medicine, Kyung Hee University, Seoul, Korea
| | | | - Tae-Woon Kim
- Department of Physiology, College of Medicine, Kyung Hee University, Seoul, Korea
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15
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Bossola M, Di Stasio E, Antocicco M, Pepe G, Tazza L, Zuccalà G, Laudisio A. Functional impairment is associated with an increased risk of mortality in patients on chronic hemodialysis. BMC Nephrol 2016; 17:72. [PMID: 27391964 PMCID: PMC4938936 DOI: 10.1186/s12882-016-0302-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 07/01/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Functional impairment is associated with adverse outcomes in older people, as well as in patients on chronic hemodialysis. The aim of the present study was to determine the characteristics associated with functional impairment in chronic hemodialysis, and to evaluate if functional impairment represents a risk factor for reduced survival in chronic hemodialysis. METHODS All 132 chronic hemodialysis referring to the Hemodialysis Service of the Catholic University, Rome, Italy between November 2007 and May 2015 were included. All patients underwent comprehensive geriatric assessment; functional ability was estimated using two questionnaires exploring independency in bathing, dressing, toileting, transferring, continence, feeding (ADLs), and independency in using the telephone, shopping, food preparation, housekeeping, laundering, traveling, taking medications, and handling finances (IADLs). Functional impairment was diagnosed in presence of dependence in one or more ADLs/IADLs. Mood was assessed using the 30-item Geriatric Depression Scale. Logistic regression was used to evaluate factors associated with functional impairment. The association between functional impairment and survival was assessed by Cox regression. RESULTS ADLs impairment was present in 34 (26 %) participants, while IADLs impairment was detected in 64 (48 %) subjects. After a follow up of 90 months, 55 (42 %) patients died. In logistic regression, depressive symptoms were associated with ADLs and IADLs impairment (OR 1.12; 95 % CI = 1.02-1.23; OR 1.16; 95 % CI = 1.02-1.33; respectively). In Cox regression, ADLs impairment was associated with mortality (HR 2.47; 95 % CI-1.07-5.67) while IADLs impairment was not associated with reduced survival (HR .80; 95 % CI-.36-1.76). CONCLUSIONS Functional impairment is associated with depressive symptoms; also, impairment in the ADLs represents a risk factor of reduced survival in chronic hemodialysis. These associations and their potential implication should be assessed in dedicated studies.
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Affiliation(s)
- Maurizio Bossola
- Department of Surgery, Hemodialysis Service, Catholic University of the Sacred Hearth, Largo A. Gemelli, 8 - 00168, Rome, Italy.
| | - Enrico Di Stasio
- Department of Clinical Chemistry, Catholic University of the Sacred Hearth, Largo A. Gemelli, 8 - 00168, Rome, Italy
| | - Manuela Antocicco
- Department of Gerontology, Geriatrics and Psychiatry, Catholic University of the Sacred Hearth, Largo A. Gemelli, 8 - 00168, Rome, Italy
| | - Gilda Pepe
- Department of Surgery, Hemodialysis Service, Catholic University of the Sacred Hearth, Largo A. Gemelli, 8 - 00168, Rome, Italy
| | - Luigi Tazza
- Department of Surgery, Hemodialysis Service, Catholic University of the Sacred Hearth, Largo A. Gemelli, 8 - 00168, Rome, Italy
| | - Giuseppe Zuccalà
- Department of Gerontology, Geriatrics and Psychiatry, Catholic University of the Sacred Hearth, Largo A. Gemelli, 8 - 00168, Rome, Italy
| | - Alice Laudisio
- Department of Medicine, Unit of Geriatrics, Campus Bio-Medico di Roma University, Rome, Italy
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16
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Saby A, Miller LS. Functional Assessment in End-Stage Renal Disease: Enhancing Quality of Life. Semin Dial 2016; 29:170-2. [DOI: 10.1111/sdi.12466] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Adam Saby
- Department of Physical Medicine & Rehabilitation; Greater Los Angeles Veterans Administration Health Care System; David Geffen School of Medicine-UCLA; Los Angeles California
| | - Lawrence S. Miller
- Department of Medicine; David Geffen School of Medicine-UCLA; Los Angeles California
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17
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Berger JR, Jaikaransingh V, Hedayati SS. End-Stage Kidney Disease in the Elderly: Approach to Dialysis Initiation, Choosing Modality, and Predicting Outcomes. Adv Chronic Kidney Dis 2016; 23:36-43. [PMID: 26709061 DOI: 10.1053/j.ackd.2015.08.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 07/15/2015] [Accepted: 08/20/2015] [Indexed: 01/25/2023]
Abstract
The number of patients with end-stage kidney disease 65 years and older is growing, and this growth is expected to continue. The presence of medical comorbidities, limited life expectancy, frailty, and poor functional status in these patients poses substantial challenges in clinical decision-making and provision of optimal care. Frailty is more common in elderly patients with CKD than without and is associated with poor outcomes. Several prognostic tools were developed to estimate the rate of CKD progression among elderly, and risk of mortality after dialysis initiation. Risk factors for CKD progression among elderly include low estimated glomerular filtration rate, high baseline proteinuria, acute kidney injury, low serum albumin, and presence of congestive heart failure. The decision to initiate dialysis in the elderly should take into consideration life expectancy, risks and benefits of each dialysis modality, quality of life, and patient and caregiver preferences. This article discusses common issues in the elderly with end-stage kidney disease, with particular emphasis on the impact of frailty and functional status, choice of dialysis modality and vascular access, and prognosis after dialysis initiation, to assist the nephrologist in making decisions regarding optimal care for this complex group of patients.
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18
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Jassal SV, Karaboyas A, Comment LA, Bieber BA, Morgenstern H, Sen A, Gillespie BW, De Sequera P, Marshall MR, Fukuhara S, Robinson BM, Pisoni RL, Tentori F. Functional Dependence and Mortality in the International Dialysis Outcomes and Practice Patterns Study (DOPPS). Am J Kidney Dis 2015; 67:283-92. [PMID: 26612280 DOI: 10.1053/j.ajkd.2015.09.024] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Accepted: 09/21/2015] [Indexed: 11/11/2022]
Abstract
BACKGROUND Patients receiving long-term dialysis have among the highest mortality and hospitalization rates. In the nonrenal literature, functional dependence is recognized as a contributor to subsequent disability, recurrent hospitalization, and increased mortality. A higher burden of functional dependence with progressive worsening of kidney function has been observed in several studies, suggesting that functional dependence may contribute to both morbidity and mortality in dialysis patients. STUDY DESIGN Prospective cohort study. SETTING & PARTICIPANTS 7,226 hemodialysis patients from 12 countries in the DOPPS (Dialysis Outcomes and Practice Patterns Study) phase 4 (2009-2011) with self-reported data for functional status. PREDICTOR Patients' ability to perform 13 basic and instrumental activities of daily living was summarized to create an overall functional status score (range, 1.25 [most dependent] to 13 [functionally independent]). OUTCOME Cox regression was used to estimate the association between functional status and all-cause mortality, adjusting for several demographic and clinical risk factors for mortality. Median follow-up was 17.2 months. RESULTS The proportion of patients who could perform each activity of daily living task without assistance ranged from 97% (eating) to 47% (doing housework). 36% of patients could perform all 13 tasks without assistance (functional status = 13), and 14% of patients had high functional dependence (functional status < 8). Functionally independent patients were younger and had many indicators of better health status, including higher quality of life. Compared with functionally independent patients, the adjusted HR for mortality was 2.37 (95% CI, 1.92-2.94) for patients with functional status < 8. LIMITATIONS Possible nonresponse bias and residual confounding. CONCLUSIONS We found a high burden of functional dependence across all age groups and across all DOPPS countries. When adjusting for several known mortality risk factors, including age, access type, cachexia, and multimorbidity, functional dependence was a strong consistent predictor of mortality.
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Affiliation(s)
- S Vanita Jassal
- Division of Nephrology, University Health Network, Toronto, Canada
| | | | - Leah A Comment
- Arbor Research Collaborative for Health, Ann Arbor, MI; University of Michigan, Ann Arbor, MI
| | | | - Hal Morgenstern
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI; Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MI; Department of Urology, Medical School, University of Michigan, Ann Arbor, MI
| | | | - Brenda W Gillespie
- Arbor Research Collaborative for Health, Ann Arbor, MI; University of Michigan, Ann Arbor, MI
| | | | - Mark R Marshall
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Department of Renal Medicine, Counties Manukau Health, Auckland, New Zealand; Baxter Healthcare (Asia Pacific), Shanghai, People's Republic of China
| | - Shunichi Fukuhara
- Kyoto University, Sakyo-ku, Kyoto, Japan; Center for Innovative Research in Community and Clinical Excellence, Fukushima Medical University, Fukushima, Japan
| | - Bruce M Robinson
- Arbor Research Collaborative for Health, Ann Arbor, MI; University of Michigan, Ann Arbor, MI
| | | | - Francesca Tentori
- Arbor Research Collaborative for Health, Ann Arbor, MI; Vanderbilt University Medical Center, Nashville, TN.
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Le Corvoisier P, Bastuji-Garin S, Renaud B, Mahé I, Bergmann JF, Perchet H, Paillaud E, Mottier D, Montagne O. Functional status and co-morbidities are associated with in-hospital mortality among older patients with acute decompensated heart failure: a multicentre prospective cohort study. Age Ageing 2015; 44:225-31. [PMID: 25313242 DOI: 10.1093/ageing/afu144] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Among patients admitted for acute decompensated heart failure (ADHF), half are aged 75 years or over. The high prevalence of co-morbidities and functional impairments in this age group may affect patient outcomes. OBJECTIVE To assess the association between co-morbidities, functional status and in-hospital mortality in patients with ADHF aged ≥75 years. DESIGN A prospective, multicentre cohort study. SETTING Five French hospitals. SUBJECTS Five hundred and fifty-five patients aged ≥75 years admitted to the emergency department with ADHF. METHODS Baseline clinical data and co-morbidities were recorded at admission. Functional status and cognition were assessed using the Katz index and Mini-Mental Status Examination score, respectively. The primary outcome was in-hospital mortality. RESULTS We found high prevalences of co-morbidities and functional impairments including hypertension (74.0%), atrial fibrillation (40.2%), prior acute coronary syndrome (32.3%) and diabetes (18.2%). The average creatinine clearance was 56.3 ml/min/1.73 m(2) (interquartile range, 39.2-77.0). In-hospital mortality was 67/555 (12.1%; 95% confidence interval, 9.4-14.8). In multivariate analysis, in-hospital mortality showed a statistically positive association with prior loss of self-sufficiency (Odds ratio [OR]: 5.85 [2.25-12.19]), hyperglycaemia (OR: 1.80 [1.26-2.54] per 1 SD increase), prior cerebral ischaemic event (OR: 3.56 [1.51-8.44]) and troponin I elevation above upper limit of normal (OR: 2.81 [1.37-5.77]). In addition, systolic blood pressure (OR: 0.98 [0.97-0.99] per 1 mmHg increase) and creatinine clearance (OR: 0.72 [0.51-1.00] per 1 SD increase) were negatively associated with in-hospital mortality. CONCLUSION Co-morbidities and functional impairments are associated with a worse short-term prognosis in patients aged ≥75 years admitted for ADHF. Assessing these parameters at admission may improve patient management.
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Affiliation(s)
- Philippe Le Corvoisier
- Inserm, Clinical Investigation Centre 1430, APHP, Henri Mondor Hospital, F-94010 Creteil, France
| | - Sylvie Bastuji-Garin
- Paris Est University (UPE), LIC EA4393 and APHP, Henri Mondor hospital, Clinical Research Unit (URC Mondor), F-94010 Créteil, France
| | - Bertrand Renaud
- APHP, Cochin Hospital, Emergency Department, F-75014 Paris, France
| | - Isabelle Mahé
- APHP, Louis Mourier Hospital, Department of Internal Medicine and Paris 7 University, EA REMES Paris Diderot University, Sorbonne Paris Cité, F-92700 Colombes, France
| | - Jean-François Bergmann
- APHP, Lariboisière-Fernand Vidal Hospital, Department of Internal Medicine, F-75010 Paris, France
| | - Herve Perchet
- Meaux Hospital, Department of Cardiology, F-77100 Meaux, France
| | - Elena Paillaud
- APHP, Henri Mondor Hospital, Department of Geriatry, F-94010 Creteil, France
| | - Dominique Mottier
- Cavale Blanche Hospital, Department of Internal Medicine and Pneumology, EA 3878 (GETBO), F-29609 Brest, France
| | - Olivier Montagne
- Inserm, Clinical Investigation Centre 1430, APHP, Henri Mondor Hospital, F-94010 Creteil, France
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A Cross-Sectional Study Examining the Functional Independence of Elderly Individuals With a Functioning Kidney Transplant. Transplantation 2014; 98:864-70. [DOI: 10.1097/tp.0000000000000126] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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21
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Soysal P, Isik AT, Buyukaydin B, Kazancioglu R. A comparison of end-stage renal disease and Alzheimer’s disease in the elderly through a comprehensive geriatric assessment. Int Urol Nephrol 2014; 46:1627-32. [DOI: 10.1007/s11255-014-0739-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2014] [Accepted: 05/05/2014] [Indexed: 02/07/2023]
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22
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Iyasere O, Brown EA. Determinants of quality of life in advanced kidney disease: time to screen? Postgrad Med J 2014; 90:340-7. [DOI: 10.1136/postgradmedj-2013-132251] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Abstract
PURPOSE OF REVIEW Elderly patients comprise the fastest growing population initiating dialysis and also experience the worst outcomes, including increased mortality, loss of functional status, and impaired quality of life. Nephrologists are often challenged with how best to engage in dialysis decision-making discussions within this population. Prognostication tools can assist nephrologists in engaging in these discussions, especially in patients for whom survival benefits may be outweighed by the burdens of treatment. RECENT FINDINGS This review includes the latest research in the survival of elderly patients with and without dialysis; prognostic factors associated with renal progression and survival; and integrative prognostic models to predict both short-term and long-term prognosis. The concept of kidney illness disease trajectory is defined with important outcomes including survival, health-related quality of life, and symptoms with and without dialysis. This prognostic information will then be integrated into an individualized approach to shared decision-making regarding treatment decision-making.(Figure is included in full-text article.) SUMMARY Treatment decision-making for elderly patients with advanced kidney disease necessitates an active process between nephrologist and patient, incorporating medical information as well as patient preferences. Prognostic information and observational data can facilitate nephrologists' ability to foresee and foretell the illness trajectory both with and without dialysis, further guiding these conversations.
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24
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Routine use of an abbreviated 4-item scale to assess dependence in essential activities of daily living amongst elderly hemodialysis patients: a validation study. Int Urol Nephrol 2013; 45:259-64. [DOI: 10.1007/s11255-012-0360-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Accepted: 12/12/2012] [Indexed: 10/27/2022]
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25
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McAdams-Demarco MA, Law A, Garonzik-Wang JM, Gimenez L, Jaar BG, Walston JD, Segev DL. Activity of daily living disability and dialysis mortality: better prediction using metrics of aging. J Am Geriatr Soc 2012; 60:1981-2. [PMID: 23057455 DOI: 10.1111/j.1532-5415.2012.04161.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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