Frailty, body composition and the risk of mortality in incident hemodialysis patients: the Predictors of Arrhythmic and Cardiovascular Risk in End Stage Renal Disease study

Association between frailty and adverse outcomes in patients undergoing maintenance hemodialysis: a systematic review and meta-analysis

OBJECTIVES

The aim of this study was to determine the strength of the association between frailty and adverse outcomes in patients undergoing maintenance hemodialysis.

DESIGN

A systematic review and meta-analysis.

SETTING AND PARTICIPANTS

Patients aged ≥18 years who were undergoing maintenance hemodialysis.

METHODS

PubMed, Web of Science, Embase, the Cochrane Library, Scopus, the China Knowledge Resource Integrated Database, the Wanfang Database and the Weipu Database were searched from inception until 11 April 2024. The reviewers independently selected the studies, extracted the data and evaluated the quality of the studies. Stata 15.1 software was used to perform the meta-analysis.

RESULTS

A total of 36 articles were included in this study, including 56,867 patients. The primary outcome events in this study were mortality, hospitalization, and vascular access events. The secondary outcomes were depression, cognitive impairment, falls, fracture, sleep disturbances, and quality of life. This study suggested that frailty was associated with mortality in patients undergoing maintenance hemodialysis [hazard ratio (HR), 1.97; 95% CI, 1.62-2.40]. Frailty increased the risk of mortality in patients [odds ratio (OR), 2.33; 95% CI, 1.47-3.68]. In addition, we found that frailty was significantly associated with hospitalization in patients undergoing maintenance hemodialysis (OR, 2.47; 95% CI, 1.52-4.03). Patients who were undergoing maintenance hemodialysis and who were frail had a greater risk of hospitalization [RR, 1.47; 95% CI, 1.05-2.08] and emergency visits (RR, 2.28; 95% CI, 1.78-2.92). The results of this study also suggested that frailty was associated with a greater risk of vascular access events (HR, 1.72; 95% CI, 1.50-1.97). Finally, frailty increased the risk of depression (OR, 4.31; 95% CI, 1.83-10.18), falls and fractures, and reduced quality of life.

CONCLUSIONS

The findings of this study suggested that frailty was an important predictor of adverse outcomes in patients undergoing maintenance hemodialysis. In the future, medical staff should regularly evaluate signs of weakness, formulate individual diagnosis and treatment plans, adjust dialysis plans according to the patient's condition, and reduce the occurrence of adverse events.

REGISTRATION

The study protocol was registered on PROSPERO (https://www.crd.york.ac.uk/PROSPERO/, number: CRD42023486239).

Frailty in patients on dialysis

Frailty is a condition that is frequently observed among patients undergoing dialysis. Frailty is characterized by a decline in both physiological state and cognitive state, leading to a combination of symptoms, such as weight loss, exhaustion, low physical activity level, weakness, and slow walking speed. Frail patients not only experience a poor quality of life, but also are at higher risk of hospitalization, infection, cardiovascular events, dialysis-associated complications, and death. Frailty occurs as a result of a combination and interaction of various medical issues in patients who are on dialysis. Unfortunately, frailty has no cure. To address frailty, a multifaceted approach is necessary, involving coordinated efforts from nephrologists, geriatricians, nurses, allied health practitioners, and family members. Strategies such as optimizing nutrition and chronic kidney disease-related complications, reducing polypharmacy by deprescription, personalizing dialysis prescription, and considering home-based or assisted dialysis may help slow the decline of physical function over time in subjects with frailty. This review discusses the underlying causes of frailty in patients on dialysis and examines the methods and difficulties involved in managing frailty among this group.

Interaction of general obesity and abdominal obesity with frailty in patients with chronic kidney disease: a nationally representative analysis

Background

General and abdominal obesity are prevalent, with established associations to frailty in the elderly. However, few studies have investigated these associations in patients with chronic kidney disease (CKD), yielding inconsistent results.

Methods

This cross-sectional study analysed data from the National Health and Nutrition Examination Survey (NHANES 2003-2018). Frailty was evaluated by the 36-item frailty index. General obesity was defined as a body mass index (BMI) >30 kg/m2; abdominal obesity was identified if waist circumference (WC) reached 102 cm in men and 88 cm in women. The associations of general and abdominal obesity with frailty were analysed using weighted multivariate logistic regression and restricted cubic splines. The interaction of general and abdominal obesity with frailty was examined.

Results

A total of 5604 adult patients (median age 71 years, 42% men) with CKD were included in this analysis, with a median estimated glomerular filtration rate of 57.3 ml/min/1.73 m2. A total of 21% were frail with general obesity and 32% were frail with abdominal obesity. Neither general nor abdominal obesity alone was associated with frailty. There was an interaction between general and abdominal obesity with frailty. Compared with individuals with normal BMI and WC, those with both general and abdominal obesity, rather than either alone, exhibited significantly increased odds of frailty {odds ratio [OR] 1.53 [95% confidence interval (CI) 1.20-1.95]}. General obesity was associated with being frail only when CKD patients had abdominal obesity [OR 1.59 (95% CI 1.08-2.36)].

Conclusions

There may be an interaction between general and abdominal obesity with frailty in patients with CKD. Interventions aimed at preventing frailty should consider both aspects.

Frailty in Kidney Disease: A Comprehensive Review to Advance Its Clinical and Research Applications

Frailty is a multisystem syndrome of decreased physiologic reserve that has been shown to strongly and independently predict morbidity and mortality. Frailty is prevalent in patients living with kidney disease and occurs earlier in individuals with kidney disease as compared to the general population. In this comprehensive review, we examine clinical and research applications of frailty in kidney disease populations. Specifically, we clarify the definition of frailty and address common misconceptions, review the mechanisms and epidemiology of frailty in kidney disease, discuss challenges and limitations in frailty measurement, and provide updated evidence related to risk factors for frailty, its associated adverse outcomes, and interventions. We further add to the literature in this topic by highlighting the potential applications of frailty measurement in the care of patients with kidney disease and conclude with our recommendations for future research related to this important syndrome.

Narrative Review: Clinical Implications and Assessment of Frailty in Patients With Advanced CKD

Frailty is a multidimensional clinical syndrome characterized by low physical activity, reduced strength, accumulation of multiorgan deficits, decreased physiological reserve, and vulnerability to stressors. Frailty has key social, psychological, and cognitive implications. Frailty is accelerated by uremia, leading to a high prevalence of frailty in patients with advanced chronic kidney disease (CKD) and end-stage kidney disease (ESKD) as well as contributing to adverse outcomes in this patient population. Frailty assessment is not routine in patients with CKD; however, a number of validated clinical assessment tools can assist in prognostication. Frailty assessment in nephrology populations supports shared decision-making and advanced communication and should inform key medical transitions. Frailty screening and interventions in CKD or ESKD are a developing research priority with a rapidly expanding literature base.

Association of Frailty With Nutritional Status in Patients With Chronic Kidney Disease

OBJECTIVES

Frailty is commonly observed in patients with chronic kidney disease (CKD) and is associated with adverse outcomes. Protein-energy wasting (PEW), a state of decreased body stores of protein and energy fuels, may be associated with frailty. However, few data are available on the possible association between frailty and PEW in CKD.

METHODS

We examined the association between frailty and nutritional status assessed using anthropometric and body composition measurements, serum albumin, handgrip strength, the Malnutrition Inflammation Score (MIS), and dietary protein and calorie intake in a cross-sectional analysis of nondialysis patients with CKD stages 3-5. Body composition was assessed using multifrequency bioelectrical impedance. Frailty was defined as a Clinical Frailty Scale ≥4. We performed logistic regression with different nutrition assessment tools as the main predictors and age, sex, comorbidity, estimated glomerular filtration rate (eGFR), and hemoglobin as covariates.

RESULTS

A total of 157 patients (93 men and 64 women; mean age 64 years; diabetes prevalence 38.9%) with CKD (eGFR 24.4 ± 13.4 mL/min/1.73 m2) were included. Overall, 29.3% of patients were frail. Patients with frailty were older and had a significantly higher fat tissue index and MIS but a significantly lower lean tissue index, eGFR, hemoglobin value, serum albumin value, handgrip strength value, and dietary protein intake. In multivariate logistic regression analyses, a higher body mass index category (odds ratio [OR], 1.54; 95% confidence interval [CI], 1.03-2.31), higher fat tissue index (OR, 1.15; 95% CI, 1.03-1.28), larger waist circumference (OR, 1.05; 95% CI, 1.01-1.09), reduced handgrip strength (OR, 2.70; 95% CI, 1.17-6.21), PEW defined by MIS ≥5 (OR, 3.49; 95% CI, 1.35-9.01), and dietary protein intake ≤0.8 g/kg/day (OR, 2.70; 95% CI, 1.18-6.19) were associated with higher odds of frailty.

CONCLUSION

Frailty is associated with nutritional status in patients with CKD. A comprehensive nutrition assessment may allow the implementation of strategies to prevent or reduce frailty.

A machine learning-based assistant tool for early frailty screening of patients receiving maintenance hemodialysis

PURPOSE

To develop an assistant tool based on machine learning for early frailty screening in patients receiving maintenance hemodialysis.

METHODS

This is a single-center retrospective study. 141 participants' basic information, scale results and laboratory findings were collected and the FRAIL scale was used to assess frailty. Then participants were divided into the frailty group (n = 84) and control group (n = 57). After feature selection, data split and oversampling, ten commonly used binary machine learning methods were performed and a voting classifier was developed.

RESULTS

The grade results of Clinical Frailty Scale, age, serum magnesium, lactate dehydrogenase, comorbidity and fast blood glucose were considered to be the best feature set for early frailty screening. After abandoning models with overfitting or poor performance, the voting classifier based on Support Vector Machine, Adaptive Boosting and Naive Bayes achieved a good screening performance (sensitivity: 68.24% ± 8.40%, specificity:72.50% ± 11.81%, F1 score: 72.55% ± 4.65%, AUC:78.38% ± 6.94%).

CONCLUSION

A simple and efficient early frailty screening assistant tool for patients receiving maintenance hemodialysis based on machine learning was developed. It can provide assistance on frailty, especially pre-frailty screening and decision-making tasks.

Administrative coding of frailty: Its association with clinical outcomes and resource use in kidney transplantation

INTRODUCTION

Although not formalized into current risk assessment models, frailty has been associated with negative postoperative outcomes in many specialties. However, national analyses of the association between frailty and post-transplant outcomes following kidney transplantation (KT) are lacking.

METHODS

This was a retrospective cohort study of adults undergoing KT from 2016 to 2020 in the Nationwide Readmissions Databases. Frailty was defined using the Johns Hopkins Adjusted Clinical Groups frailty indicator.

RESULTS

Of an estimated 95 765 patients undergoing KT during the study period, 4918 (5.1%) were frail. After risk adjustment, frail patients were associated with significantly higher odds of in-hospital mortality (AOR 2.17, 95% CI: 1.33-3.57) compared to their non-frail counterparts. Our findings indicate that frail patients had an average increase in postoperative hospital stay of 1.44 days, a $2300 increase in hospitalization costs, as well as higher odds of developing a major perioperative complication as compared to their non-frail counterparts. Frailty was also associated with greater adjusted risk of non-home discharge.

CONCLUSIONS

Frailty, as identified by administrative coding, is independently associated with worse surgical outcomes, including increased mortality and resource use, in adults undergoing KT. Given the already limited donor organ pool, novel efforts are needed to ensure adequate optimization and timely post-transplantation care of the growing frail cohort undergoing KT.

Prevalence and feasibility of assessing the frailty phenotype among hemodialysis patients in a dialysis unit

BACKGROUND

Frailty increases risk of morbidity and mortality in hemodialysis patients. Frailty assessments could trigger risk reduction interventions if broadly adopted in clinical practice. We aimed to assess the clinical feasibility of frailty assessment among Veteran hemodialysis patients.

METHODS

Hemodialysis patients' ≥50 years were recruited from a single dialysis unit between 9/1/2021 and 3/31/2022.Patients who consented underwent a frailty phenotype assessment by clinical staff. Five criteria were assessed: unintentional weight loss, low grip strength, self-reported exhaustion, slow gait speed, and low physical activity. Participants were classified as frail (3-5 points), pre-frail (1-2 points) or non-frail (0 points). Feasibility was determined by the number of eligible participants completing the assessment.

RESULTS

Among 82 unique dialysis patients, 45 (52%) completed the assessment, 13 (16%) refused, 18 (23%) were not offered the assessment due to death, transfers, or switch to transplant or peritoneal dialysis, and 6 patients were excluded because they did not meet mobility criteria. Among assessed patients, 40(88%) patients were identified as pre-frail (46.6%) or frail (42.2%). Low grip strength was most common (90%). Those who refused were more likely to have peripheral vascular disease (p = 0.001), low albumin (p = 0.0187), low sodium (p = 0.0422), and ineligible for kidney transplant (p = 0.005).

CONCLUSIONS

Just over half of eligible hemodialysis patients completed the frailty assessment suggesting difficulty with broad clinical adoption expectations. Among those assessed, frailty and pre-frailty prevalence was high. Given patients who were not tested were clinically high risk, our reported prevalence likely underestimates true frailty prevalence. Providing frailty reduction interventions to all hemodialysis patients could have high impact for this group.

Prevalence and risk factors of pre-frailty and frailty in maintenance haemodialysis patients in China: A cross-sectional Study

AIMS

To examine the prevalence and risk factors of pre-frailty and frailty in maintenance haemodialysis patients in China.

DESIGN

A cross-sectional study.

METHOD

From January to July 2017, using the convenience sampling method, a total of 503 maintenance haemodialysis patients from six hospitals in Lianyungang, China, were recruited for this study. The participants' socio-demographic, lifestyle factors and health information were assessed using a general information questionnaire. Frailty was evaluated based on the Fried frailty phenotype. Multi-categorical logistic regression was performed to examine factors associated with pre-frailty and frailty in this population, including age, sex, living alone, employment, educational level, body mass index, per capita monthly household income, smoking status, exercise status, primary diagnosis, dialysis age, frequency of dialysis, vascular access, congestive heart failure, other cardiac diseases, cerebrovascular disease, peripheral blood diseases, pain, albumin level and haemoglobin level.

RESULTS

Among the 503 participants with an average age of 53.02 years (standard deviation 14.99), 178 had pre-frailty (35.3%) and were mostly young and middle-aged. The prevalence of pre-frailty among participants <60 years old was more than 40%. Regression analysis showed that lack of exercise, dialysis age ≤12 months, congestive heart failure and other cardiac diseases were positively associated with pre-frailty. Two hundred and eighteen participants were frail (43.3%), most of whom were aged ≥60. The prevalence of frailty in participants ≥60 was 71.4%. Regression analysis showed that advanced age, being female, obesity, low per capita monthly household income, lack of exercise, diabetes as the primary disease, dialysis age ≤12 months, congestive heart failure, other cardiac diseases, pain and low albumin level, were positively associated with frailty. In addition, more than half of the participants hardly exercised (64.6%), while lack of exercise was a risk factor for pre-frailty and frailty. A third of the participants had pain (33.4%), while pain was an independent risk factor for pre-frailty and frailty in these participants.

CONCLUSION

Pre-frailty and frailty are common in patients with maintenance haemodialysis. Most of the elderly maintenance haemodialysis patients are frail, and most of the young and middle-aged patients are pre-frail. Clinicians should actively screen the pre-frailty and frailty among patients with maintenance haemodialysis, especially those with dialysis age ≤12 months. Many factors affect pre-frailty and frailty in this population. Tailored intervention measures should be designed and implemented based on these factors, giving priority to exercise guidance and pain management for patients to help them prevent or reverse pre-frailty and frailty.

Use of frailty assessment instruments in nephrology populations: a scoping review

BACKGROUND

Frailty is a clinical syndrome of accelerated aging associated with adverse outcomes. Frailty is prevalent among patients with chronic kidney disease but is infrequently assessed in clinical settings, due to lack of consensus regarding frailty definitions and diagnostic tools. This study aimed to review the practice of frailty assessment in nephrology populations and evaluate the context and timing of frailty assessment.

METHODS

The search included published reports of frailty assessment in patients with chronic kidney disease, undergoing dialysis or in receipt of a kidney transplant, published between January 2000 and November 2021. Medline, CINAHL, Embase, PsychINFO, PubMed and Cochrane Library databases were examined. A total of 164 articles were included for review.

RESULTS

We found that studies were most frequently set within developed nations. Overall, 161 studies were frailty assessments conducted as part of an observational study design, and 3 within an interventional study. Studies favoured assessment of participants with chronic kidney disease (CKD) and transplant candidates. A total of 40 different frailty metrics were used. The most frequently utilised tool was the Fried frailty phenotype. Frailty prevalence varied across populations and research settings from 2.8% among participants with CKD to 82% among patients undergoing haemodialysis. Studies of frailty in conservatively managed populations were infrequent (N = 4). We verified that frailty predicts higher rates of adverse patient outcomes. There is sufficient literature to justify future meta-analyses.

CONCLUSIONS

There is increasing recognition of frailty in nephrology populations and the value of assessment in informing prognostication and decision-making during transitions in care. The Fried frailty phenotype is the most frequently utilised assessment, reflecting the feasibility of incorporating objective measures of frailty and vulnerability into nephrology clinical assessment. Further research examining frailty in low and middle income countries as well as first nations people is required. Future work should focus on interventional strategies exploring frailty rehabilitation.

Cut points of the conicity index as an indicator of abdominal obesity in individuals undergoing hemodialysis: An analysis of latent classes

OBJECTIVES

Abdominal obesity favors the involvement of cardiometabolic complications in renal patients on hemodialysis. Thus, the aim of the study was to identify the cut-points of the conicity index in individuals undergoing hemodialysis.

METHODS

This was a cross-sectional study carried out with 953 individuals undergoing hemodialysis in clinics in a metropolitan region of southeastern Brazil. The conicity index was calculated using the following mathematical equation: waist circumference/0.109 × √weight/height. The receiver operating characteristic (ROC) curve was calculated from the analysis of latent classes by cross-validation through a latent variable of abdominal obesity. This latent variable was defined using the response pattern of the observed anthropometric variables considering the presence and absence of abdominal obesity: waist circumference, waist-to-height ratio, and body shape index. The cut-points identified were elucidated by the area under the curve (AUC), Youden index, sensitivity, and specificity.

RESULTS

The cut-points for the conicity index found for both sexes were similar, resulting in a cut-point for men of 1.275 (AUC, 0.921; Youden index, 0.666), with a sensitivity and specificity of 83% and 83.6%, and a cut-point for women of 1.285 (AUC, 0.921; Youden index, 0.679), with a sensitivity and specificity of 78.6% and 89.3%, respectively.

CONCLUSIONS

The conicity index showed high discriminatory power for the identification of abdominal obesity in hemodialysis patients, therefore it can be a simple and easily accessible tool to be incorporated into clinical practice in this population.

Could sarcopenia-related mortality in end-stage renal disease be underpinned by the number of hospitalizations and cardiovascular diseases?

PURPOSE

To investigate the association between sarcopenia with the number of all-cause mortality, hospitalizations, and cardiovascular diseases in patients with end-stage renal disease (ESRD).

METHODS

247 patients with ESRD (women, n = 97) (66.6 ± 3.53 years) participated in this study. At baseline, all participants were measured with dual-energy X-ray absorptiometry and handgrip dynamometer and were prospectively followed up for 5 years. The European Working Group on Sarcopenia in Older People guidelines were utilized for Sarcopenia determination. Cox proportional hazard analysis adjusted for established risk factors was used to quantify the risk between Sarcopenia and all-cause mortality.

RESULTS

Sixty-five participants (26%) were determined to have Sarcopenia at baseline and 38 (15%) have died during the follow-up. At baseline, Participants with Sarcopenia had lower body mass index and fat-free mass index. Moreover, through the 5-year follow-up, sarcopenic patients had higher number of cardiovascular disease (56.9% vs. 12.6%) and hospitalizations (93.8% vs. 49.5%) (all P < 0.0001). Sarcopenia was associated with significantly higher risk of mortality, [Hazard ratio = 3.3, (95% CI: 1.6-6.9), P = 0.001].

CONCLUSION

Sarcopenia may be a risk factor for hospitalizations, cardiovascular diseases, and all-cause mortality in patients with ESRD. These results provide support of the relevance in assessing sarcopenia in the clinical practice of chronic kidney disease and how muscle mass and strength may negatively impact the daily life of ESRD patients undergoing hemodialysis. Greater efforts at preventing muscle wasting and malfunctioning are needed through the worldwide healthcare system.

Frailty, sarcopenia and diabetic kidney disease: where do we stand?

The aim of this narrative non-systematic review was to investigate the potential interplay among frailty syndrome, sarcopenia and diabetic kidney disease (DKD) in type 2 diabetes mellitus (T2DM) patients. Data derived from a limited number of studies underline that DKD is a significant risk factor for frailty. On the other hand, frailty syndrome poses a higher risk for end-stage renal disease (ESRD) in subjects with DKD. In addition, frailty seems to affect the cognitive function and social life of DKD individuals, whilst as DKD deteriorates, there is a higher prevalence of sarcopenia which is a fundamental frailty factor. As a result, it is shown that a bidirectional relation is established between these entities, as diabetes mellitus (DM) affects the components of frailty and sarcopenia and vice versa. This vicious cycle is created through multiple pathophysiologic mechanisms, including the anabolic role of insulin, low-grade inflammation, cytokines and endothelial function, prompting further investigation in this area. Specific nutritional and exercise interventions are imperative to be established in order to ameliorate potential adverse outcomes, concerning these entities.

Clinical frailty assessment might be associated with mortality in incident dialysis patients

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.

Associations between frailty trajectories and cardiovascular, renal, and mortality outcomes in chronic kidney disease

BACKGROUND

Frailty is characterized by the loss of biological reserves and vulnerability to adverse outcomes. In individuals with chronic kidney disease (CKD), numerous pathophysiological factors may be responsible for frailty development including inflammation, physical inactivity, reduced energy intake, and metabolic acidosis. Given that both CKD and frailty incur a significant healthcare burden, it is important to understand the relationship of CKD and frailty in real-world routine clinical practice, and how simple frailty assessment methods (e.g. frailty indexes) may be useful. We investigated the risk of frailty development in CKD and the impact of frailty status on mortality and end-stage kidney disease (ESKD).

METHODS

A retrospective cohort study using primary care records from the Clinical Practice Research Datalink linked to Hospital Episode Statistics and the UK Office for National Statistics was undertaken in 819 893 participants aged ≥40 years, of which 140 674 had CKD. Frailty was defined using an electronic frailty index, generated electronically from primary care records. Cox proportional hazard and flexible parametric survival models were used to investigate the risk of developing frailty and the effect of frailty on risk of all-cause and cardiovascular mortality, and ESKD.

RESULTS

The mean age of those with CKD was 77.5 (SD 9.7) years [61.0 (SD 12.1) years in no-CKD group]; 62.0% of the CKD group were female (compared with 53.3% in no-CKD group). The mean estimated glomerular filtration rate of those with CKD was 46.1 (SD 9.9) mL/min/1.73 m² . The majority of those with CKD (75.3%) were frail [vs. 45.4% in those without CKD (no-CKD)]. Over 3 years (median), 69.5% of those with CKD developed frailty. Compared with no-CKD, those with CKD had increased rates of developing mild (hazard ratio: 1.02; 95% confidence interval: 1.01-1.04), moderate (1.30; 1.26-1.34), and severe (1.50; 1.37-1.65) frailty. Mild (1.22; 1.19-1.24), moderate (1.60; 1.56-1.63), and severe (2.16; 2.11-2.22) frailty was associated with increased rates of all-cause and cardiovascular-related mortality (mild 1.35; 1.31-1.39; moderate 1.96; 1.90-2.02; and severe 2.91; 2.81-3.02). All stages of frailty significantly increased ESKD rates.

CONCLUSIONS

Frailty is highly prevalent and associated with adverse outcomes in people with CKD, including mortality and risk of ESKD. Preventative interventions should be initiated to mitigate the development of frailty. The use of a simple frailty index, generated electronically from health records, can predict outcomes and may aid prioritization for management of people with frailty.

Frailty in end stage renal disease: Current perspectives

Frailty is common in end stage renal disease (ESRD) and is a marker of poor outcomes. Its prevalence increases as chronic kidney disease (CKD) progresses. There are different measurement tools available to assess frailty in ESRD. The pathogenesis of frailty in ESRD is multifactorial including uraemia and dialysis related factors. In this current review, we discuss the importance of frailty, its pathogenesis, screening methods, prognostic implications and management strategies in context of ESRD.

Frailty, Age, and Postdialysis Recovery Time in a Population New to Hemodialysis

Background

Frailty, a phenotype characterized by decreased physiologic reserve and the inability to recover following confrontation with a stressor like hemodialysis, may help identify which patients on incident hemodialysis will experience longer postdialysis recovery times. Recovery time is associated with downstream outcomes, including quality of life and mortality. We characterized postdialysis recovery times among patients new to hemodialysis and quantified the association between frailty and hemodialysis recovery time.

Methods

Among 285 patients on hemodialysis enrolled in the Predictors of Arrhythmic and Cardiovascular Risk in End Stage Renal Disease (PACE) study, frailty was measured using the Fried phenotype. Self-reported recovery time was obtained by telephone interview. We estimated the association of frailty (intermediately frail and frail versus nonfrail) and postdialysis recovery time using adjusted negative binomial regression.

Results

Median time between dialysis initiation and study enrollment was 3.4 months (IQR, 2.7-4.9), and that between initiation and recovery time assessment was 11 months (IQR, 9.3-15). Mean age was 55 years, 24% were >65 years, and 73% were Black; 72% of individuals recovered in ≤1 hour, 20% recovered in 1-6 hours, 5% required 6-12 hours to recover, and <5% required >12 hours to recover. Those with intermediate frailty, frailty, and age ≤65 years had 2.56-fold (95% CI, 1.45 to 4.52), 1.72-fold (95% CI, 1.03 to 2.89), and 2.35-fold (95% CI, 1.44 to 3.85) risks, respectively, of longer recovery time independent of demographic characteristics, comorbidity, and dialysis-related factors.

Conclusions

In adults new to hemodialysis, frailty was independently associated with prolonged postdialysis recovery. Future studies should assess the effect of frailty-targeted interventions on recovery time to improve clinical outcomes.

Prevalence and Associated Factors of Frailty and Mortality in Patients with End-Stage Renal Disease Undergoing Hemodialysis: A Systematic Review and Meta-Analysis

Hemodialysis is the most common type of treatment for end-stage renal disease (ESRD). Frailty is associated with poor outcomes such as higher mortality. ESRD patients have a higher prevalence of frailty. This systematic review and meta-analysis aimed to identify the prevalence and associated factors of frailty and examine whether it is a predictor of mortality among ESRD patients undergoing hemodialysis. Five electronic databases including PubMed, Embase, CINAHL, Web of Science, and Cochrane Library were searched for relevant studies up to 30 November 2020. A total of 752 articles were found, and seven studies with 2604 participants in total were included in the final analysis. The pooled prevalence of frailty in patients with ESRD undergoing hemodialysis was 46% (95% Confidence interval (CI) 34.2−58.3%). Advanced age, female sex, and the presence of diabetes mellitus increased the risk of frailty in ESRD patients undergoing hemodialysis. Our main finding showed that patients with frailty had a greater risk of all-cause mortality compared with those without (hazard ratio (HR): 2.02, 95% CI: 1.65−2.48). To improve ESRD patient outcomes, healthcare professionals need to assess the frailty of older ESRD patients, particularly by considering gender and comorbidities. Comprehensive frailty screening tools for ESRD patients on hemodialysis need to be developed.

Measuring frailty in younger populations: a rapid review of evidence

OBJECTIVES

Frailty is typically assessed in older populations. Identifying frailty in adults aged under 60 years may also have value, if it supports the delivery of timely care. We sought to identify how frailty is measured in younger populations, including evidence of the impact on patient outcomes and care.

DESIGN

A rapid review of primary studies was conducted.

DATA SOURCES

Four databases, three sources of grey literature and reference lists of systematic reviews were searched in March 2020.

ELIGIBILITY CRITERIA

Eligible studies measured frailty in populations aged under 60 years using experimental or observational designs, published after 2000 in English.

DATA EXTRACTION AND SYNTHESIS

Records were screened against review criteria. Study data were extracted with 20% of records checked for accuracy by a second researcher. Data were synthesised using a narrative approach.

RESULTS

We identified 268 studies that measured frailty in samples that included people aged under 60 years. Of these, 85 studies reported evidence about measure validity. No measures were identified that were designed and validated to identify frailty exclusively in younger groups. However, in populations that included people aged over and under 60 years, cumulative deficit frailty indices, phenotype measures, the FRAIL Scale, the Liver Frailty Index and the Short Physical Performance Battery all demonstrated predictive validity for mortality and/or hospital admission. Evidence of criterion validity was rare. The extent to which measures possess validity across the younger adult age (18-59 years) spectrum was unclear. There was no evidence about the impact of measuring frailty in younger populations on patient outcomes and care.

CONCLUSIONS

Limited evidence suggests that frailty measures have predictive validity in younger populations. Further research is needed to clarify the validity of measures across the adult age spectrum, and explore the utility of measuring frailty in younger groups.

Validation of prognostic indices for short term mortality in an incident dialysis population of older adults >75

Rational and objective

Prognosis provides critical knowledge for shared decision making between patients and clinicians. While several prognostic indices for mortality in dialysis patients have been developed, their performance among elderly patients initiating dialysis is unknown, despite great need for reliable prognostication in that context. To assess the performance of 6 previously validated prognostic indices to predict 3 and/or 6 months mortality in a cohort of elderly incident dialysis patients.

Study design

Validation study of prognostic indices using retrospective cohort data. Indices were compared using the concordance (“c”)-statistic, i.e. area under the receiver operating characteristic curve (ROC). Calibration, sensitivity, specificity, positive and negative predictive values were also calculated.

Setting & participants

Incident elderly (age ≥75 years; n = 349) dialysis patients at a tertiary referral center.

Established predictors

Variables for six validated prognostic indices for short term (3 and 6 month) mortality prediction (Foley, NCI, REIN, updated REIN, Thamer, and Wick) were extracted from the electronic medical record. The indices were individually applied as per each index specifications to predict 3- and/or 6-month mortality.

Results

In our cohort of 349 patients, mean age was 81.5±4.4 years, 66% were male, and median survival was 351 days. The c-statistic for the risk prediction indices ranged from 0.57 to 0.73. Wick ROC 0.73 (0.68, 0.78) and Foley 0.67 (0.61, 0.73) indices performed best. The Foley index was weakly calibrated with poor overall model fit (p <0.01) and overestimated mortality risk, while the Wick index was relatively well-calibrated but underestimated mortality risk.

Limitations

Small sample size, use of secondary data, need for imputation, homogeneous population.

Conclusion

Most predictive indices for mortality performed moderately in our incident dialysis population. The Wick and Foley indices were the best performing, but had issues with under and over calibration. More accurate indices for predicting survival in older patients with kidney failure are needed.

APOL1 Risk Variants and Subclinical Cardiovascular Disease in Incident Hemodialysis Patients

Introduction

To better understand the impact of APOL1 risk variants in end-stage renal disease (ESRD) we evaluated associations of APOL1 risk variants with subclinical cardiovascular disease (CVD) and mortality among African Americans initiating hemodialysis and enrolled in the Predictors of Arrhythmic and Cardiovascular Risk in ESRD cohort study.

Methods

We modeled associations of APOL1 risk status (high = 2; low = 0/1 risk alleles) with baseline subclinical CVD (left ventricular [LV] hypertrophy; LV mass; ejection fraction; coronary artery calcification [CAC]; pulse wave velocity [PWV]) using logistic and linear regression and all-cause or cardiovascular mortality using Cox models, adjusting for age, sex, and ancestry. In sensitivity analyses, we further adjusted for systolic blood pressure and Charlson Comorbidity Index.

Results

Of 267 African American participants successfully genotyped for APOL1, 27% were high-risk carriers, 41% were women, and mean age was 53 years. At baseline, APOL1 high- versus low-risk status was independently associated with 50% and 53% lower odds of LV hypertrophy and CAC, respectively, and 10.7% lower LV mass. These associations were robust to further adjustment for comorbidities but not systolic blood pressure. APOL1 risk status was not associated with all-cause or cardiovascular mortality (mean follow-up 2.5 years).

Conclusion

Among African American patients with incident hemodialysis, APOL1 high-risk status was associated with better subclinical measures of CVD but not mortality.

Frailty as a Predictor of Negative Health Outcomes in Chronic Kidney Disease: A Systematic Review and Meta-Analysis

OBJECTIVES

To perform a comprehensive evidence synthesis to summarize the impact of frailty on health outcomes in patients with chronic kidney disease (CKD).

DESIGN

Systematic reviews and meta-analysis.

SETTING

Electronic searches in PubMed, Embase, Web of Science, CNKI, VIP, CBM, and Wanfang Database were performed. The methodological quality was evaluated using the Newcastle Ottawa Scale (NOS).

PARTICIPANTS

Patients with chronic kidney disease (CKD).

MEASUREMENTS

Potential clinical outcomes due to frailty.

RESULTS

Eighteen cohort studies incorporating a total of 22,788 participants were included. The overall risk of bias was low. The median reported prevalence of frail and prefrail individuals with CKD was 41.8% (range 2.8-81.5%) and 43.9% (range 19.1-62.7%), respectively. Prefrailty and frailty related to mortality indicated an increased hazard ratio (HR), with a pooled HR of 1.68 [95% confidence interval (CI) 1.46-1.94; P < .001] and 1.48 (95% CI 1.21-1.81; P < .001), respectively. Prefrailty and frailty related to hospitalization with the pooled HR/risk ratio (RR) of 1.56 (95% CI 1.37-1.76; P < .001) and 1.21 (95% CI 0.79-1.85; P = .38), respectively. Similarly, the pooled HR demonstrated a strong correlation between frailty and falls in patients with CKD with HR 1.83 (95% CI 1.40-2.37; P < .001) and no statistical correlation between prefrailty and falls in these patients with pooled HR 1.19 (95% CI 0.44-3.22; P = .73), respectively.

CONCLUSIONS AND IMPLICATIONS

Frailty is predictive of negative outcomes in patients with CKD, including all-cause mortality, all-cause hospitalization, and falls. Therefore, frailty should be routinely assessed among patients with CKD to prevent poor prognosis, reduce fatality rate, and provide evidence to support future targeted interventions. However, because of the limited amount of information currently in the literature, additional prospective studies are needed to explore the role of prefrailty in predicting adverse outcomes for patients with CKD.

G. JKC, Chow KM, Kwong VWK, Pang WF, Cheng PMS, Law MC, Leung CB, L. I. PKT, Szeto CC. Interaction between central obesity and frailty on the clinical outcome of peritoneal dialysis patients

BACKGROUND

Frailty and obesity contribute to the adverse clinical outcome of peritoneal dialysis (PD) patients, but the interaction between frailty and obesity remains uncertain.

OBJECTIVE

To examine the interaction between frailty and obesity on the clinical outcome of PD patients.

DESIGN

Single centre prospective observational cohort study.

PATIENTS

267 prevalent Chinese PD patients were recruited.

MEASUREMENTS

Frailty was identified by a standard score. General and central obesity were determined by body mass index (BMI) and waist-hip ratio (WHR), respectively. Body composition was assessed by bioimpedance spectroscopy. All patients were followed for two years. Outcome measures included all-cause as well as cardiovascular mortality and hospitalization.

RESULTS

Of the 267 patients, 120 (44.9%) were frail. Frail individuals were more likely to have central obesity (p < 0.001) but not general obesity. Although WHR did not predict patient survival, there was a significant interaction between WHR and frailty on patient survival and cardiovascular survival (p = 0.002 and p = 0.038, respectively). For patients without frailty, the two-year cardiovascular survival was 91.3% and 74.4% for those with and without central obesity, respectively (p = 0.002). For patients with frailty, however, the two-year cardiovascular survival was 64.6% and 66.7% for those with and without central obesity, respectively (p = 0.6). For patients without frailty, the number of hospital admission for cardiovascular disease over 2 years were 0.12 ± 0.37 and 0.34 ± 0.72 for those with and without central obesity, respectively (p = 0.03). For frail patients, however, the number of hospital admission was similar between those with and without central obesity.

CONCLUSION

There is a significant interaction between frailty and central obesity on the outcome of PD patients. The protective role of central obesity is only apparent in PD patients without frailty but not the frail ones, and there is a little prognostic value of general (non-central) obesity.

Association among kidney function, frailty, and oral function in patients with chronic kidney disease: a cross-sectional study

Background

Chronic kidney disease (CKD) involves many factors that can cause frailty and oral hypofunction. We aimed to investigate the prevalence of frailty and oral hypofunction and to examine the associations among kidney function, frailty, and oral function in adults with CKD in Japan.

Methods

This cross-sectional study was conducted at two institutions. The participants included 109 patients with CKD stages 3–5 who visited outpatient clinics or were admitted for inpatient treatment. Frailty was evaluated using the Japanese version of the Cardiovascular Health Study frailty criteria. Oral function was evaluated by assessing oral motor skills [oral diadochokinesis (ODK) rate], masticatory ability, and the repetitive saliva swallowing test. The estimated glomerular filtration rate (eGFR) was used to indicate kidney function. We examined the associations among kidney function, frailty, and oral function using binomial logistic regression analysis.

Results

In total, 31 participants (28.4%) were classified as being frail. Univariate analysis showed that age, body mass index, eGFR, and haemoglobin level were significantly associated with frailty. ODK and swallowing function were significantly associated with frailty. Multivariate analysis revealed that frailty was significantly associated with eGFR [odds ratio (OR) 0.96, 95% confidence interval (CI) 0.92–1.00, p = 0.048] and ODK rate (OR 0.68, CI 0.47–0.98, p = 0.038). However, no significant association was found between CKD severity and masticatory or swallowing function.

Conclusion

We found a high prevalence of frailty in patients with CKD and a significant association between frailty and oral motor skills, affecting the swallowing function of patients with nondialysis CKD. The high prevalence of frailty among patients with CKD suggests that routine assessment of frailty is necessary to prevent the development of severe complications. In addition, oral and kidney function should be carefully evaluated, and oral health education and interventions should be performed for patients with CKD.

Poor Outcomes in Kidney Transplant Candidates and Recipients With History of Falls

BACKGROUND

Falls occur in 28% of hemodialysis patients and increase the risk of physical impairment, morbidity, and mortality. Therefore, it is likely that kidney transplantation (KT) candidates with recurrent falls are less likely to access KT and more likely to experience adverse post-KT outcomes.

METHODS

We used a 2-center cohort study of KT candidates (n = 3666) and recipients (n = 770) (January 2009 to January 2018). Among candidates, we estimated time to listing, waitlist mortality, and transplant rate by recurrent falls (≥2 falls) before evaluation using adjusted regression. Among KT recipients, we estimated risk of mortality, graft loss, and length of stay by recurrent falls before KT using adjusted regression.

RESULTS

Candidates with recurrent falls (6.5%) had a lower chance of listing (adjusted hazard ratio [aHR] = 0.68, 95% confidence interval [CI], 0.56-0.83) but not transplant rate; waitlist mortality was 31-fold (95% CI, 11.33-85.93) higher in the first year and gradually decreased over time. Recipients with recurrent falls (5.1%) were at increased risk of mortality (aHR = 51.43, 95% CI, 16.00-165.43) and graft loss (aHR = 33.57, 95% CI, 11.25-100.21) in the first year, which declined over time, and a longer length of stay (adjusted relative ratio [aRR] = 1.13, 95% CI, 1.03-1.25). In summary, 6.5% of KT candidates and 5.1% of recipients experienced recurrent falls which were associated with adverse pre- and post-KT outcomes.

CONCLUSIONS

While recurrent falls were relatively rare in KT candidates and recipients, they were associated with adverse outcomes. Transplant centers should consider employing fall prevention strategies for high-risk candidates as part of comprehensive prehabilitation.

Frailty Prevalence in Younger End-Stage Kidney Disease Patients Undergoing Dialysis and Transplantation

BACKGROUND

Frailty, originally characterized in community-dwelling older adults, is increasingly being studied and implemented for adult patients with end-stage kidney disease (ESKD) of all ages (>18 years). Frailty prevalence and manifestation are unclear in younger adults (18-64 years) with ESKD; differences likely exist based on whether the patients are treated with hemodialysis (HD) or kidney transplantation (KT).

METHODS

We leveraged 3 cohorts: 378 adults initiating HD (2008-2012), 4,304 adult KT candidates (2009-2019), and 1,396 KT recipients (2008-2019). The frailty phenotype was measured within 6 months of dialysis initiation, at KT evaluation, and KT admission. Prevalence of frailty and its components was estimated by age (≥65 vs. <65 years). A Wald test for interactions was used to test whether risk factors for frailty differed by age.

RESULTS

In all 3 cohorts, frailty prevalence was higher among older than younger adults (HD: 71.4 vs. 47.3%; candidates: 25.4 vs. 18.8%; recipients: 20.8 vs. 14.3%). In all cohorts, older patients were more likely to have slowness and weakness but less likely to report exhaustion. Among candidates, older age (odds ratio [OR] = 1.79, 95% CI: 1.47-2.17), non-Hispanic black race (OR = 1.30, 95% CI: 1.08-1.57), and dialysis type (HD vs. no dialysis: OR = 2.06, 95% CI: 1.61-2.64; peritoneal dialysis vs. no dialysis: OR = 1.78, 95% CI: 1.28-2.48) were associated with frailty prevalence, but sex and Hispanic ethnicity were not. These associations did not differ by age (pinteractions > 0.1). Similar results were observed for recipients and HD patients.

CONCLUSIONS

Although frailty prevalence increases with age, younger patients have a high burden. Clinicians caring for this vulnerable population should recognize that younger patients may experience frailty and screen all age groups.

Kidney transplant outcomes in recipients with visual, hearing, physical and walking impairments: a prospective cohort study

BACKGROUND

Disability in general has been associated with poor outcomes in kidney transplant (KT) recipients. However, disability can be derived from various components, specifically visual, hearing, physical and walking impairments. Different impairments may compromise the patient through different mechanisms and might impact different aspects of KT outcomes.

METHODS

In our prospective cohort study (June 2013-June 2017), 465 recipients reported hearing, visual, physical and walking impairments before KT. We used hybrid registry-augmented Cox regression, adjusting for confounders using the US KT population (Scientific Registry of Transplant Recipients, N = 66 891), to assess the independent association between impairments and post-KT outcomes [death-censored graft failure (DCGF) and mortality].

RESULTS

In our cohort of 465 recipients, 31.6% reported one or more impairments (hearing 9.3%, visual 16.6%, physical 9.1%, walking 12.1%). Visual impairment was associated with a 3.36-fold [95% confidence interval (CI) 1.17-9.65] higher DCGF risk, however, hearing [2.77 (95% CI 0.78-9.82)], physical [0.67 (95% CI 0.08-3.35)] and walking [0.50 (95% CI 0.06-3.89)] impairments were not. Walking impairment was associated with a 3.13-fold (95% CI 1.32-7.48) higher mortality risk, however, visual [1.20 (95% CI 0.48-2.98)], hearing [1.01 (95% CI 0.29-3.47)] and physical [1.16 (95% CI 0.34-3.94)] impairments were not.

CONCLUSIONS

Impairments are common among KT recipients, yet only visual impairment and walking impairment are associated with adverse post-KT outcomes. Referring nephrologists and KT centers should identify recipients with visual and walking impairments who might benefit from targeted interventions pre-KT, additional supportive care and close post-KT monitoring.

Frailty predicts surgical complications after kidney transplantation. A propensity score matched study

Background and objective

Surgical complications after kidney transplantation can lead to catastrophic outcomes. Frailty has been associated with important kidney transplantation outcomes; however, there are no studies assessing this measure of physiological reserve as a specific predictor of surgical complications in this population. Such an assessment was, therefore, the objective of the present study.

Methods

A total of 87 individuals aged ≥ 18 years who underwent kidney transplantation between March 2017 and March 2018 were included. At the time of admission for kidney transplantation, demographic, clinical, and kidney transplantation data were collected, and the frailty score was calculated according to Fried et al., which comprises five components: shrinking, weakness, exhaustion, low activity, and slowed walking speed. Urological, vascular, and general surgical complications were assessed three months later, or until graft loss or death. The propensity score was used to achieve a better homogeneity of the sample, and new analyses were performed in this new, balanced sample.

Results

Of the 87 individuals included, 30 (34.5%) had surgical complications. After propensity score matching, the risk of surgical complications was significantly higher among the frail individuals (RR 2.14; 95% CI 1.01–4.54; p = 0.035); specifically, the risk of noninfectious surgical complications was significantly higher among these individuals (RR 2.50; 95% CI 1.11–5.62; p = 0.017).

Conclusion

The results showed that individuals with some degree of frailty before kidney transplantation were more subject to surgical complications. The calculation of the frailty score for transplant candidates and the implementations of measures to increase the physiological reserve of these patients at the time of kidney transplantation may possibly reduce the occurrence of surgical complications.

Frailty and mortality among patients with chronic kidney disease and end-stage renal disease: a systematic review and meta-analysis

PURPOSE

Frailty is highly prevalent among patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD). Previous studies have shown that frailty is a sensitive predictor of survival in the elderly. However, convincing evidence supporting the causality between frailty and the adverse outcome in CKD patients is still lacking.

METHODS

PubMed, Embase, MEDLINE and the Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched for identifying potentially relevant literature. Studies that investigated the association between frailty and overall mortality in patients with CKD and ESRD were included. Both unadjusted and adjusted hazard ratios (HRs) with 95% confidence intervals (95% CIs) were pooled for analysis.

RESULTS

Twelve studies involving 127, 373 participants were included for analysis. The results showed that frailty was associated with 2.28-fold increased risk of overall mortality in patients with CKD and dialysis (HR 2.28; 95% CI 1.71-3.05), while 1.95-fold increased after multivariable-adjusted (HR 1.95; 95% CI 1.50-2.53). In addition, subgroup analysis showed that compared with the non-dialysis CKD patients (HR 1.47; 95% CI 1.03-2.11), patients receiving dialysis have higher overall mortality risk (HR 2.19; 95% CI 1.82-2.64). Moreover, frailty can also significantly increase short-term mortality (follow-up < 3 years: HR 2.18, 95% CI 1.76-2.70).

CONCLUSIONS

Our results indicated that frailty significantly increased the overall mortality risk in patients with CKD and ESRD, especially in dialysis patients. Frailty can be regarded as a novel independent predictor of mortality for patients with CKD and dialysis.

Role of Physical Performance Assessments and Need for a Standardized Protocol for Selection of Older Kidney Transplant Candidates

The older adult population (65 years or older) with advanced or end-stage kidney disease is steadily growing, but rates of transplantation within this cohort have not increased in a similar fashion. Physical deconditioning, resulting in poor post-transplantation outcomes, is a primary concern among older renal patients. The assessment of physical function often holds more weight in the selection process for older candidates, despite evidence showing benefits of transplantation to this vulnerable population. Although several frailty assessment tools are being used increasingly to assess functional status, there is no standardized selection process for older candidates based on these assessment results. Also, it is unknown if timely targeted physical therapy interventions in older patients result in significant improvement of functioning capacity, translating to higher listing and transplantation rates, and improved post-transplantation outcomes. It is therefore of upmost importance not only to incorporate an effective objective functional status assessment process into selection and waitlist evaluation protocols, but also to have targeted interventions in place to maintain and improve physical conditioning among older renal patients. This paper reviews the commonly utilized assessment tools, and their applicability to older patients with renal disease. We also propose the need for definitive selection and waitlist management guidelines to formulate a streamlined assessment of functional capacity and transplant eligibility, as well as a process to maintain functional status, thereby increasing the access of older patients to renal transplantation.

The prevalence of frailty in patients on hemodialysis: a systematic review and meta-analysis

PURPOSE

Coexistence of frailty and hemodialysis is related to higher risk of hospitalization, falls and mortality. Given the potential reversibility of frailty, reaching the epidemiology of frailty in hemodialysis is of great importance. However, estimates of the prevalence of frailty in patients on hemodialysis vary widely. We tried to synthesize the existing body of literature on the prevalence of frailty in patients on hemodialysis.

METHODS

We searched Pubmed, Embase, Web of Science and Cochrane for studies of the prevalence in patients on hemodialysis. The prevalence of frailty was synthesized across eligible studies using a random-effects model. We explored potential origin of heterogeneity in the estimates by meta-regression analysis.

RESULTS

Prevalence range from 6.0 to 82.0% and the pooled prevalence of frailty in patients on dialysis was 34.3% (95% confidence interval (CI) 24.5-44.1%; z = 6.87; p = 0.00). The pooled estimates of prevalence for patients aged < 55, 55-65, and ≥ 65 were 56.0% (95% CI 28.9-83.2%; z = 4.04; p = 0.00), 32.3% (95% CI 22.9-41.7%; z = 6.74; p = 0.00), and 20.3% (95% CI 7.9-32.8%; z = 3.2; p = 0.00), respectively. There were no significant relationships between frailty in hemodialysis and factors such as years of publication, sample size (continuous), sample size(> 500 vs ≤ 500), diagnostic method (the Fried Frailty vs other), country (Europe & USA vs Asia) and duration of hemodialysis.

CONCLUSIONS

Frailty influences almost three in ten patients on hemodialysis. Understanding the underlying pathophysiology mechanisms and weakening the impacts of frailty in patients on hemodialysis are called on to action in the future work.

Contributors, risk associates, and complications of frailty in patients with chronic kidney disease: a scoping review

Frailty exhibits diverse influences on health-related outcomes and represents a surrogate of increased susceptibility to harmful injuries. Patients with chronic kidney disease (CKD) are at a higher risk of accelerated biologic aging, and, in this population, the concept of frailty emerges as an instrumental measurement of physiologic reserves. However, a comprehensive description of known independent contributors to, and risk associates of, frailty in these patients remain unavailable. In the present review, original studies up to 28 February 2019 that assessed frailty in patients with all stages of CKD were retrieved and reviewed, with results extracted and summarized. By pooling 62 original investigations, 58.1% and 49.1% used cohort and cross-sectional designs, respectively. Dialysis-dependent end-stage renal disease patients (n = 39; 62.9%) were the most commonly examined population, followed by those with nondialysis CKD (n = 12; 19.4%) and those receiving renal transplantation (n = 11; 17.7%). Contributors to frailty in CKD patients included sociodemographic factors, smoking, CKD severity, organ-specific comorbidities, depression, hypoalbuminemia, and low testosterone levels. Conversely, the development of frailty was potentially associated with the emergence of cardiometabolic, musculoskeletal, and cerebral complications; mental distress; and a higher risk of subsequent functional and quality-of-life impairment. Moreover, frailty in CKD patients increased healthcare utilization and consistently elevated mortality among affected ones. Based on the multitude of contributors to frailty and its diverse health influences, a multifaceted approach to manage CKD patients with frailty is needed, and its potential influences on outcomes besides mortality need to be considered.

Kidney Transplant Outcomes in Recipients With Cognitive Impairment: A National Registry and Prospective Cohort Study

BACKGROUND

Cognitive impairment is common in patients with end-stage renal disease and is associated with poor outcomes on dialysis. We hypothesized that cognitive impairment might be associated with an increased risk of all-cause graft loss (ACGL) in kidney transplant (KT) recipients.

METHODS

Using the Modified Mini-Mental State (3MS) examination, we measured global cognitive function at KT hospital admission in a prospective, 2-center cohort of 864 KT candidates (August 2009 to July 2016). We estimated the association between pre-KT cognitive impairment and ACGL using Cox regression, adjusting for recipient, donor, and transplant factors.

RESULTS

In living donor KT (LDKT) recipients, the prevalence was 3.3% for mild impairment (60 ≤ 3MS < 80) and 3.3% for severe impairment (3MS < 60). In deceased donor KT (DDKT) recipients, the prevalence was 9.8% for mild impairment and 2.6% for severe impairment. The LDKT recipients with cognitive impairment had substantially higher ACGL risk than unimpaired recipients (5-year ACGL: 45.5% vs 10.6%; P < 0.01; adjusted hazard ratio [aHR] any impairment, 5.40 (95% confidence interval [CI], 1.78-16.34; P < 0.01); aHR severe impairment, 5.57 (95% CI, 1.29-24.00; P = 0.02). Similarly, DDKT recipients with severe impairment had higher ACGL risk than recipients without severe impairment (5-year ACGL, 53.0% vs 24.2%; P = 0.04); aHR severe impairment, 2.92 (95% CI, 1.13-7.50; P = 0.03).

CONCLUSIONS

Given the elevated risk of ACGL among KT recipients with cognitive impairment observed in this 2-center cohort, research efforts should explore the mechanisms of graft loss and mortality associated with cognitive impairment and identify potential interventions to improve posttransplant survival.

Report from the American Society of Transplantation on frailty in solid organ transplantation

A consensus conference on frailty in kidney, liver, heart, and lung transplantation sponsored by the American Society of Transplantation (AST) and endorsed by the American Society of Nephrology (ASN), the American Society of Transplant Surgeons (ASTS), and the Canadian Society of Transplantation (CST) took place on February 11, 2018 in Phoenix, Arizona. Input from the transplant community through scheduled conference calls enabled wide discussion of current concepts in frailty, exploration of best practices for frailty risk assessment of transplant candidates and for management after transplant, and development of ideas for future research. A current understanding of frailty was compiled by each of the solid organ groups and is presented in this paper. Frailty is a common entity in patients with end-stage organ disease who are awaiting organ transplantation, and affects mortality on the waitlist and in the posttransplant period. The optimal methods by which frailty should be measured in each organ group are yet to be determined, but studies are underway. Interventions to reverse frailty vary among organ groups and appear promising. This conference achieved its intent to highlight the importance of frailty in organ transplantation and to plant the seeds for further discussion and research in this field.

Comorbidity, Frailty, and Waitlist Mortality among Kidney Transplant Candidates of All Ages

BACKGROUND

Kidney transplantation (KT) candidates often present with multiple comorbidities. These patients also have a substantial burden of frailty, which is also associated with increased mortality. However, it is unknown if frailty is merely a surrogate for comorbidity, itself an independent domain of risk, or if frailty and comorbidity have differential effects. Better understanding the interplay between these 2 constructs will improve clinical decision making in KT candidates.

OBJECTIVE

To test whether comorbidity is equally associated with waitlist mortality among frail and nonfrail KT candidates and to test whether measuring both comorbidity burden and frailty improves mortality risk prediction.

METHODS

We studied 2,086 candidates on the KT waitlist (November 2009 - October 2017) in a multicenter cohort study, in whom frailty and comorbidity were measured at evaluation. We quantified the association between Charlson comorbidity index (CCI) adapted for end-stage renal disease and waitlist mortality using an adjusted Cox proportional hazards model and tested whether this association differed between frail and nonfrail candidates.

RESULTS

At evaluation, 18.1% of KT candidates were frail and 51% had a high comorbidity burden (CCI score ≥2). Candidates with a high comorbidity burden were at 1.38-fold (95% CI 1.01-1.89) increased risk of waitlist mortality. However, this association differed by frailty status (p for interaction = 0.01): among nonfrail candidates, a high comorbidity burden was associated with a 1.66-fold (95% CI 1.17-2.35) increased mortality risk; among frail candidates, here was no statistically significant association (HR 0.75, 95% CI 0.44-1.29). Adding this interaction between comorbidity and frailty to a mortality risk estimation model significantly improved prediction, increasing the c-statistic from 0.640 to 0.656 (p < 0.001).

CONCLUSIONS

Nonfrail candidates with a high comorbidity burden at KT evaluation have an increased risk of waitlist mortality. Importantly, comorbidity is less of a concern in already high-risk patients who are frail.