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Pérez-Sáez MJ, Pascual J. Unmet Questions About Frailty in Kidney Transplant Candidates. Transplantation 2024:00007890-990000000-00795. [PMID: 38886883 DOI: 10.1097/tp.0000000000005093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Abstract
Frailty occurs frequently among patients with advanced chronic kidney disease, especially among women. Assessing frailty in kidney transplant (KT) candidates is crucial for informing them about associated risks. However, there is poor agreement between frailty scales and research on their correlation with transplant outcomes. Being prefrail significantly impacts both graft and patient survival, often beginning with just 1 Fried criterion. Rather than viewing frailty as a categorical state, it should be regarded as a spectrum ranging from 1 to 5 criteria, with the risk of adverse outcomes escalating as frailty worsens. Frailty status fluctuates during the waiting period for KT; hence, a 1-time frailty evaluation is insufficient to determine risks and implement strategies for improving functional status. Further research should investigate the components of frailty that most frequently change during this waiting period and establish strategies to prevent or reverse frailty. Although careful evaluation of frail KT candidates is necessary to prevent early complications and mortality, exclusion based solely on a frailty score is unwarranted. Instead, efforts should focus on timely interventions to enhance their condition before transplantation. Although evidence is limited, exercise programs appear feasible and yield positive results. A pretransplant clinical framework encompassing multimodal prehabilitation-comprising physical therapy, nutritional measures, and psychological support-during the waiting list period may help alleviate the effects of frailty and poor fitness after KT, ultimately improving key outcomes. Despite logistical challenges, there is a pressing need for interventional trials in this area.
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Affiliation(s)
- María José Pérez-Sáez
- Nephrology Department, Hospital del Mar, Barcelona, Spain
- Nephropathies Research Group, Hospital del Mar Research Institute, Barcelona, Spain
| | - Julio Pascual
- Nephropathies Research Group, Hospital del Mar Research Institute, Barcelona, Spain
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
- Institute for Research i+12, Madrid, Spain
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2
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Fergie R, Maxwell AP, Cunningham EL. Latest advances in frailty in kidney transplantation: A narrative review. Transplant Rev (Orlando) 2024; 38:100833. [PMID: 38309184 DOI: 10.1016/j.trre.2024.100833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 01/19/2024] [Accepted: 01/20/2024] [Indexed: 02/05/2024]
Abstract
Frailty is a clinical syndrome that is characterised by decline in multiple systems with associated decreased physiological reserve and ability to respond to stressor events. It is associated with greater healthcare burden. It is common in patients with end-stage renal disease (ESRD). Kidney transplantation is considered the optimal form of renal replacement therapy for suitable patients with ESRD. However, surgery and immunosuppression are physiological stresses that can disproportionately affect frail individuals. Frailty is emerging as a potentially important risk factor in patients waitlisted for kidney transplantation. Most of the published research to date in this area comes from a single transplant centre in the USA. Frailty, as measured using the Physical Frailty Phenotype (FP), is prevalent in waitlisted patients and has been associated with early hospital re-admission, prolonged length of stay, delayed graft function and increased mortality after kidney transplantation. However, although kidney transplantation is a substantial physiological stress to a patient's reserve, by restoring kidney function, kidney transplantation has also been shown to improve a patient's frailty status. The FP is the most studied tool in patients waitlisted for transplantation, but it has not been able to distinguish those whose frailty is improved by kidney transplantation. In summary, there remain significant gaps in knowledge and uncertainties as to how to effectively use existing frailty measures to inform decision-making around kidney transplantation. Further research is needed to address these important gaps in the literature.
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Affiliation(s)
- Ruth Fergie
- Centre for Public Health, Queen's University of Belfast, Belfast BT12 6AB, UK; Regional Nephrology Unit, Belfast City Hospital, Lisburn Road, BT9 7BA Belfast, UK.
| | - Alexander P Maxwell
- Centre for Public Health, Queen's University of Belfast, Belfast BT12 6AB, UK.
| | - Emma L Cunningham
- Centre for Public Health, Queen's University of Belfast, Belfast BT12 6AB, UK.
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3
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Kennard AL, Glasgow NJ, Rainsford SE, Talaulikar GS. Narrative Review: Clinical Implications and Assessment of Frailty in Patients With Advanced CKD. Kidney Int Rep 2024; 9:791-806. [PMID: 38765572 PMCID: PMC11101734 DOI: 10.1016/j.ekir.2023.12.022] [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: 09/14/2023] [Revised: 12/12/2023] [Accepted: 12/21/2023] [Indexed: 05/22/2024] Open
Abstract
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.
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Affiliation(s)
- Alice L. Kennard
- Department of Renal Medicine, Canberra Health Services, Australian Capital Territory, Australia
- Australian National University, Canberra, Australian Capital Territory, Australia
| | - Nicholas J. Glasgow
- Australian National University, Canberra, Australian Capital Territory, Australia
| | - Suzanne E. Rainsford
- Australian National University, Canberra, Australian Capital Territory, Australia
| | - Girish S. Talaulikar
- Department of Renal Medicine, Canberra Health Services, Australian Capital Territory, Australia
- Australian National University, Canberra, Australian Capital Territory, Australia
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4
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Chen X, Chu NM, Thompson V, Quint EE, Alasfar S, Xue QL, Brennan DC, Norman SP, Lonze BE, Walston JD, Segev DL, McAdams-DeMarco MA. Development and Validation of an Abridged Physical Frailty Phenotype for Clinical Use: A Cohort Study Among Kidney Transplant Candidates. J Gerontol A Biol Sci Med Sci 2024; 79:glad173. [PMID: 37466327 PMCID: PMC10733181 DOI: 10.1093/gerona/glad173] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Frailty is associated with poor outcomes in surgical patients including kidney transplant (KT) recipients. Transplant centers that measure frailty have better pre- and postoperative outcomes. However, clinical utility of existing tools is low due to time constraints. To address this major barrier to implementation in the preoperative evaluation of patients, we developed an abridged frailty phenotype. METHODS The abridged frailty phenotype was developed by simplifying the 5 physical frailty phenotype (PFP) components in a two-center prospective cohort of 3 220 KT candidates and tested for efficiency (time to completion) in 20 candidates evaluation (January 2009 to March 2020). We examined area under curve (AUC) and Cohen's kappa agreement to compare the abridged assessment with the PFP. We compared waitlist mortality risk (competing risks models) by frailty using the PFP and abridged assessment, respectively. Model discrimination was assessed using Harrell's C-statistic. RESULTS Of 3 220 candidates, the PFP and abridged assessment identified 23.8% and 27.4% candidates as frail, respectively. The abridged frailty phenotype had substantial agreement (kappa = 0.69, 95% CI: 0.66-0.71) and excellent discrimination (AUC = 0.861). Among 20 patients at evaluation, abridged assessment took 5-7 minutes to complete. The PFP and abridged assessment had similar associations with waitlist mortality (subdistribution hazard ratio [SHR] = 1.62, 95% CI: 1.26-2.08 vs SHR = 1.70, 95% CI: 1.33-2.16) and comparable mortality discrimination (p = .51). CONCLUSIONS The abridged assessment is an efficient and valid way to identify frailty. It predicts waitlist mortality without sacrificing discrimination. Surgical departments should consider utilizing the abridged assessment to evaluate frailty in patients when time is limited.
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Affiliation(s)
- Xiaomeng Chen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nadia M Chu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Valerie Thompson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Evelien E Quint
- Division of Transplant Surgery, Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Sami Alasfar
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Qian-Li Xue
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Daniel C Brennan
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Silas P Norman
- Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Bonnie E Lonze
- Department of Surgery, NYU Grossman School of Medicine and NYU Langone Health, New York, New York, USA
| | - Jeremy D Walston
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Surgery, NYU Grossman School of Medicine and NYU Langone Health, New York, New York, USA
| | - Mara A McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Surgery, NYU Grossman School of Medicine and NYU Langone Health, New York, New York, USA
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Weerasekera S, Reid N, Young A, Homes R, Sia A, Giddens F, Francis RS, Hubbard RE, Gordon EH. Putting Guidelines Into Practice: Is Frailty Measurement at the Time of Kidney Transplant Eligibility Assessment Valid, Feasible, and Acceptable to Patients? Transplant Direct 2023; 9:e1548. [PMID: 37854024 PMCID: PMC10581598 DOI: 10.1097/txd.0000000000001548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 08/22/2023] [Accepted: 09/08/2023] [Indexed: 10/20/2023] Open
Abstract
Background Clinical Practice Guidelines suggest that frailty be measured during kidney transplant eligibility assessments. Yet it is not known how frailty is best assessed in this setting or whether its assessment is acceptable to patients. We aimed to examine the construct validity and feasibility of Frailty Index (FI) assessment among patients attending a kidney transplant assessment clinic and to explore patients' perspectives on frailty and the acceptability of its routine assessment. Methods A 58-item FI was calculated for 147 clinic patients. Semistructured interviews were conducted with a subgroup of 29 patients. The FI was validated against normative FI characteristics (mean, distribution, limit), age, and the Estimated Post-Transplant Survival Score. Feasibility was assessed using descriptive statistics. Qualitative data were analyzed using reflexive thematic analysis. Results The mean FI was 0.23 (±0.10, normal distribution, limit 0.53). FI increased with age and Estimated Post-Transplant Survival score. The FI was completed for 62.8% of eligible patients (147/234). The median completion time was 10 min, and completion rate (with no missing data) was 100%. Four themes were identified: perceptions of frailty, acceptability, perceived benefits, and risks of frailty measurement. Patients linked frailty with age and adverse outcomes, and most did not consider themselves frail. Patients reported that the FI was quick, simple, and efficient. They felt that frailty assessment is relevant to transplant eligibility and should be used to address potentially reversible factors. Conclusions The FI demonstrated construct validity and was feasible and acceptable in this clinic setting. The challenge is ensuring that routine assessments lead to better care.
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Affiliation(s)
- Shavini Weerasekera
- Geriatrics and Rehabilitation Unit, Princess Alexandra Hospital, Metro South Hospital & Health Service, Brisbane, Australia
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
- School of Medicine and Dentistry, Griffith University, Gold Coast, Australia
| | - Natasha Reid
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
| | - Adrienne Young
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
| | - Ryan Homes
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Aaron Sia
- Geriatrics and Rehabilitation Unit, Princess Alexandra Hospital, Metro South Hospital & Health Service, Brisbane, Australia
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
| | - Fiona Giddens
- Department of Nephrology, Princess Alexandra Hospital, Metro South Hospital & Health Service, Brisbane, Australia
| | - Ross S. Francis
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
- Department of Nephrology, Princess Alexandra Hospital, Metro South Hospital & Health Service, Brisbane, Australia
| | - Ruth E. Hubbard
- Geriatrics and Rehabilitation Unit, Princess Alexandra Hospital, Metro South Hospital & Health Service, Brisbane, Australia
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
| | - Emily H. Gordon
- Geriatrics and Rehabilitation Unit, Princess Alexandra Hospital, Metro South Hospital & Health Service, Brisbane, Australia
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
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Zheng J, Cao Y, Wang Z, Nian Y, Guo L, Song W. Frailty and prognosis of patients with kidney transplantation: a meta-analysis. BMC Nephrol 2023; 24:303. [PMID: 37833650 PMCID: PMC10576274 DOI: 10.1186/s12882-023-03358-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 10/03/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND The prevalence of frailty among candidates and recipients of kidney transplantation (KT) is well-established, yet the impact of frailty on clinical outcomes following KT remains uncertain. To address this knowledge gap, we conducted a systematic meta-analysis to comprehensively assess the aforementioned relationship. METHODS The present study conducted a comprehensive search of PubMed, Embase, and Cochrane Library databases to identify relevant observational studies that compared mortality risk and other clinical outcomes of KT recipients with and without frailty. Two authors independently conducted data collection, literature searching, and statistical analysis. The results were synthesized using a heterogeneity-incorporating random-effects model. RESULTS In this meta-analysis, 6279 patients from 13 cohort studies were included, and 1435 patients (22.9%) were with frailty before KT. There were higher mortality rates among frail patients at admission, compared to those without frailty (risk ratio [RR]: 1.97, 95% confidence interval [CI]: 1.57 to 2.47, p < 0.001; I2 = 19%). Subgroup analysis suggested the association between frailty and high mortality risk after KT was consistent in studies of frailty assessed via Physical Frailty Phenotype or other methods, and in studies of follow-up duration < or ≥ 5 years. In addition, frailty was associated with higher incidence of delayed graft function (RR: 1.78, 95% CI: 1.21 to 2.61, p = 0.003; I2 = 0%), postoperative complications (RR: 1.88, 95% CI: 1.15 to 3.08, p = 0.01; I2 = 0%), and longer hospitalization (RR: 1.55, 95% CI: 1.22 to 1.97, p < 0.001; I2 = 0%). CONCLUSION Following KT, frail patients are at higher risks for all-cause mortality, delayed graft function, postoperative complications, and longer hospital stays.
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Affiliation(s)
- Jianming Zheng
- Department of Kidney and Pancreas Transplantation, Tianjin First Central Hospital, Nankai District, Tianjin, 300192, China
| | - Yu Cao
- Department of Kidney and Pancreas Transplantation, Tianjin First Central Hospital, Nankai District, Tianjin, 300192, China
| | - Zhen Wang
- Department of Kidney and Pancreas Transplantation, Tianjin First Central Hospital, Nankai District, Tianjin, 300192, China
| | - Yeqi Nian
- Department of Kidney and Pancreas Transplantation, Tianjin First Central Hospital, Nankai District, Tianjin, 300192, China
| | - Liping Guo
- Department of Kidney and Pancreas Transplantation, Tianjin First Central Hospital, Nankai District, Tianjin, 300192, China
| | - Wenli Song
- Department of Kidney and Pancreas Transplantation, Tianjin First Central Hospital, Nankai District, Tianjin, 300192, China.
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7
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Kennard AL, Rainsford S, Glasgow NJ, Talaulikar GS. Use of frailty assessment instruments in nephrology populations: a scoping review. BMC Geriatr 2023; 23:449. [PMID: 37479978 PMCID: PMC10360289 DOI: 10.1186/s12877-023-04101-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 06/09/2023] [Indexed: 07/23/2023] Open
Abstract
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.
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Affiliation(s)
- Alice L Kennard
- Department of Renal Medicine, The Canberra Hospital, Canberra Health Services, Building 15, Yamba Drive, Garran, ACT 2605, Australia.
- Australian National University, Canberra, ACT, Australia.
| | | | | | - Girish S Talaulikar
- Department of Renal Medicine, The Canberra Hospital, Canberra Health Services, Building 15, Yamba Drive, Garran, ACT 2605, Australia
- Australian National University, Canberra, ACT, Australia
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8
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Katz DA, Ten Eyck P, Binns G, Manay P, Sanders ML, Hornickel JL, Vu A, Swee M, Kalil R. Walking Ability and Brain Natriuretic Peptide Are Highly Predictive of Kidney Transplant Waiting List Removal. Transplant Direct 2023; 9:e1483. [PMID: 37197015 PMCID: PMC10184993 DOI: 10.1097/txd.0000000000001483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 02/15/2023] [Indexed: 05/19/2023] Open
Abstract
Kidney transplant waitlist management is complex because waiting time is long, and the patients have significant comorbidities. Identification of patients at highest risk for waiting list removal for death and medical complications could allow better outcomes and allocation of resources. Methods Demographics, functional and frailty assessment' and biochemical data were retrospectively analyzed on 313 consecutive patients listed for kidney transplant. Troponin, brain natriuretic peptide, components of the Fried frailty metrics, pedometer activity, and treadmill ability were measured at the time of transplant evaluation and at subsequent re-evaluations. Cox proportional hazards models were used to identify factors associated with death or waiting list removal for medical reasons. Multivariate models were created to identify significant predictor sets. Results Among 249 patients removed while waitlisted, 19 (6.1%) died and 51 (16.3%) were removed for medical reasons. Mean follow-up duration was 2.3 y (±1.5 y). 417 sets of measurements were collected. Significant (P < 0.05) non-time-dependent variables associated with the composite outcome identified on univariate analysis included N-terminal probrain natriuretic peptide (BNP), treadmill ability, pedometer activity, diagnosis of diabetes and the Center of Epidemiological Studies Depression Scale question asking how many days per week could you not get going. Significant time-dependent factors included BNP, treadmill ability, Up and Go, pedometer activity, handgrip, 30 s chair sit-stand test, and age. The optimal time-dependent predictor set included BNP, treadmill ability, and patient age. Conclusions Changes in functional and biochemical markers are predictive of kidney waitlist removal for death and medical reasons. BNP and measures of walking ability were of particular importance.
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Affiliation(s)
- Daniel A. Katz
- Department of Surgery, Organ Transplant Center, University of Iowa Hospitals and Clinics, Iowa City, IA
- Transplant Department, Veterans Affairs Medical Center, Iowa City, IA
| | - Patrick Ten Eyck
- Institute for Clinical and Translational Science, University of Iowa, Iowa City, IA
| | - Grace Binns
- Transplant Department, Veterans Affairs Medical Center, Iowa City, IA
| | - Priyadarshini Manay
- Department of Surgery, Organ Transplant Center, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - M. Lee Sanders
- Transplant Department, Veterans Affairs Medical Center, Iowa City, IA
- Division of Nephrology, Organ Transplant Center, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA
| | | | - An Vu
- Transplant Department, Veterans Affairs Medical Center, Iowa City, IA
| | - Melissa Swee
- Transplant Department, Veterans Affairs Medical Center, Iowa City, IA
- Division of Nephrology, Organ Transplant Center, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Roberto Kalil
- Department of Medicine, University of Maryland Medical Center and Veterans Affairs Medical Center, Baltimore, MD
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McAdams-DeMarco MA, Thind AK, Nixon AC, Woywodt A. Frailty assessment as part of transplant listing: yes, no or maybe? Clin Kidney J 2023; 16:809-816. [PMID: 37151416 PMCID: PMC10157764 DOI: 10.1093/ckj/sfac277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Indexed: 12/31/2022] Open
Abstract
Frailty, characterized by a decreased physiological reserve and an increased vulnerability to stressors, is common among kidney transplant (KT) candidates and recipients. In this review, we present and summarize the key arguments for and against the assessment of frailty as part of KT evaluation. The key arguments for including frailty were: (i) sheer prevalence and far-reaching consequences of frailty on KT, and (ii) the ability to conduct a more holistic and objective evaluation of candidates, removing the inaccuracy associated with 'eye-ball' assessments of transplant fitness. The key argument against were: (i) lack of agreement on the definition of frailty and which tools should be used in renal populations, (ii) a lack of clarity on how, by whom and how often frailty assessments should be performed, and (iii) a poor understanding of how acute stressors affect frailty. However, it is the overwhelming opinion that the time has come for frailty assessments to be incorporated into KT listing. Although ongoing areas of uncertainty exist and further evidence development is needed, the well-established impact of frailty on clinical and experiential outcomes, the invaluable information obtained from frailty assessments, and the potential for intervention outweigh these limitations. Proactive and early identification of frailty allows for individualized and improved risk assessment, communication and optimization of candidates.
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Affiliation(s)
- Mara A McAdams-DeMarco
- Department of Surgery, NYU Grossman School of Medicine and NYU Langone Health, New York, USA
- Department of Population Health, NYU Grossman School of Medicine, New York, USA
| | - Amarpreet K Thind
- Division of Immunology and Inflammation, Department of Medicine, Centre for Inflammatory Disease, Imperial College London, London, UK
- Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, Manchester, UK
| | - Andrew C Nixon
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
- Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
| | - Alexander Woywodt
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
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10
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Fulinara CP, Huynh A, Goldwater D, Abdalla B, Schaenman J. Frailty and Age-Associated Assessments Associated with Chronic Kidney Disease and Transplantation Outcomes. J Transplant 2023; 2023:1510259. [PMID: 37038595 PMCID: PMC10082678 DOI: 10.1155/2023/1510259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 01/03/2023] [Accepted: 02/06/2023] [Indexed: 04/04/2023] Open
Abstract
Background. Frailty is often defined as a decrease in physiological reserve and has been shown to be correlated with adverse health outcomes and mortality in the general population. This condition is highly prevalent in the chronic kidney disease (CKD) patient population as well as in kidney transplant (KT) recipients. Other age-associated changes include sarcopenia, nutrition, cognition, and depression. In assessing the contributions of these components to patient outcomes and their prevalence in the CKD and KT patient population, it can be determined how such variables may be associated with frailty and the extent to which they may impact the adverse outcomes an individual may experience. Objectives. We sought to perform a systematic literature review to review published data on frailty and associated age-associated syndromes in CKD and KT patients. Results. Over 80 references pertinent to frailty, sarcopenia, nutrition, cognition, or depression in patients with CKD or KT were identified. Systematic review was performed to evaluate the data supporting the use of the following approaches: Fried Frailty, Short Physical Performance Battery, Frailty Index, Sarcopenia Index, CT scan quantification of muscle mass, health-related quality of life, and assessment tools for nutrition, cognition, and depression. Conclusion. This report represents a comprehensive review of previously published research articles on this topic. The intersectionality between all these components in contributing to the patient’s clinical status suggests a need for a multifaceted approach to developing comprehensive care and treatment for the CKD and KT population to improve outcomes before and after transplantation.
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Affiliation(s)
- Christian P. Fulinara
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Alina Huynh
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Deena Goldwater
- Divisions of Geriatrics and Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Basmah Abdalla
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Joanna Schaenman
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
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11
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Parsons RF, Tantisattamo E, Cheungpasitporn W, Basu A, Lu Y, Lentine KL, Woodside KJ, Singh N, Scalea J, Alhamad T, Dunn TB, Rivera FHC, Parajuli S, Pavlakis M, Cooper M. Comprehensive review: Frailty in pancreas transplant candidates and recipients. Clin Transplant 2023; 37:e14899. [PMID: 36591953 DOI: 10.1111/ctr.14899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 12/22/2022] [Accepted: 12/29/2022] [Indexed: 01/03/2023]
Abstract
Well-selected patients with kidney disease and diabetes mellitus who undergo simultaneous kidney-pancreas transplantation often experience dramatic improvements in quality of life and long-term survival compared to those who remain on medical therapy. Over the past several years the importance of frailty in the pancreas transplant candidate and recipient populations has grown. More patients with advanced age have entered the waitlist, and complications from prolonged diabetes, even in younger patients, have created increased evidence of risk for frailty. Given these concerns, and the broad challenges facing pancreas transplantation volumes overall, we generated this review to help establish the impact and implications. We summarize the interplay of immunological factors, aging, environmental factors, diabetes mellitus, and chronic kidney disease that put these patients at risk for frailty. We discuss its measurement and recommend a combination of two instruments (both well-validated and one entirely objective). We describe the outcomes for patients before and after pancreas transplantation who may have frailty, and what interventions can be taken to mitigate its effects. Broader investigation into frailty in the pancreas transplant population is needed to better understand how to select patients for pancreas transplantation and to how manage its consequences thereafter.
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Affiliation(s)
| | | | | | | | - Yee Lu
- University of Michigan, Ann Arbor, Michigan, USA
| | | | | | - Neeraj Singh
- John C. McDonald Regional Transplant Center, Shreveport, Los Angeles, USA
| | - Joseph Scalea
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Tarek Alhamad
- Washington University School of Medicine, St. Louis, Missouri, USA
| | - Ty B Dunn
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | - Martha Pavlakis
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Matthew Cooper
- Medstar Georgetown Transplant Institute, Washington DC, USA
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12
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Parajuli S, Astor BC, Lorden HM, O'Toole KA, Wallschlaeger RE, Breyer IC, Dodin B, Aziz F, Garonzik-Wang J, Mandelbrot DA. Analysis of individual components of frailty: Pre-transplant grip strength is the strongest predictor of post kidney transplant outcomes. Clin Transplant 2022; 36:e14827. [PMID: 36166355 DOI: 10.1111/ctr.14827] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/28/2022] [Accepted: 09/21/2022] [Indexed: 12/27/2022]
Abstract
Frailty is commonly assessed during kidney transplant recipient (KTR) evaluation. However, individual frailty components may have varying impact on post-transplant outcomes. In this single-center study of 825 KTRs, we determined the association between the individual components of a modified Fried frailty score and delayed graft function (DGF), early hospital readmission (EHR), cardiovascular (CV) events, acute rejection (AR), death censored graft failure (DCGF), and death. Sum frailty ≥3 was significantly associated with EHR (aOR = 3.62; 95% CI: 1.21-10.80). Among individual components, only grip strength was significantly associated with EHR (aOR = 1.54; 95% CI: 1.03-2.31). The addition of grip strength to a model with the other four components resulted in Net Reclassification Improvement (NRI) of 20.51% (p = .01). Similarly, only grip strength was significantly associated with CV events (aOR = 1.79; 95% CI: 1.12-2.86). The addition of grip strength to a model with the other four components resulted in NRI of 27.37% (p = .006). No other frailty components were associated with the outcomes of interest. Based on our findings, handgrip strength may be an important tool while assessing frailty, mainly predicting early readmission and cardiovascular events post-transplant.
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Affiliation(s)
- Sandesh Parajuli
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Brad C Astor
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Heather M Lorden
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Kristan A O'Toole
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Rebecca E Wallschlaeger
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Isabel C Breyer
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Ban Dodin
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Fahad Aziz
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Jacqueline Garonzik-Wang
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Didier A Mandelbrot
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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13
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Dos Santos Mantovani M, Coelho de Carvalho N, Ferreira Minicucci M, Gustavo Modelli de Andrade L, de Souza Cavalcante R, Berg de Almeida G, Aline Costa N, de Fátima da Silva J, Augusto Monteiro de Barros Almeida R. Transitions in frailty state 12 months after kidney transplantation: a prospective cohort study. J Nephrol 2022; 35:2341-2349. [PMID: 36048368 DOI: 10.1007/s40620-022-01436-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/08/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Frailty is associated with several unfavorable outcomes after kidney transplantation (KTx). However, limited information is available regarding the transitions in frailty state and its components after KTx. This study aimed to evaluate the transitions in physical frailty phenotype and its components over a period of 12 months after KTx. METHODS In this prospective single-center cohort study, we measured physical frailty phenotype (PFP) and its components at the time of admission for KTx and 12 months after KTx. The evaluation includes five components: weakness (grip strength analysed by sex and body mass index quartiles), physical activity (kcals/week based on the Minnesota Leisure Time Physical Activity questionnaire), exhaustion (self-report using the Center for Epidemiological Studies Depression Scale), gait speed (time taken to walk 15 feet based on sex and height-specific cutoff), and unintentional weight loss (self-report of unintentional weight loss > 10 lbs in the last year). The exhaustion and physical activity components are validated in the Brazilian population. Each component is scored as 0 or 1 according to its presence or absence, and a PFP score of 3-5 defines frailty, 2 is intermediate, and 0-1 is rated as non-frail. We used the McNemar and Wilcoxon test to compare physical frailty phenotype and its components between the two periods. RESULTS Among 87 patients included in the study, 16.1% were classified as frail, 20.7% as intermediately frail, and 63.2% as non-frail. Sixty-four patients were included in the analysis to evaluate transitions in frailty. At the time of admission for KTx, 15.6% of patients were defined as frail compared to 4.7% of patients at 12 months after KTx (p = 0.023). Among the physical frailty phenotype components, the proportion of patients who scored in the weight loss category 12 months after KTx was significantly lower than that at the time of KTx (6.3% vs 34.4%, p < 0.001). CONCLUSIONS There was a 69.9% reduction in the prevalence of frail patients at the end of the 12-month follow-up after KTx. Among the components of frailty, weight loss showed a significant improvement.
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Affiliation(s)
| | | | - Marcos Ferreira Minicucci
- Internal Medicine Department, São Paulo State University (Unesp), Medical School, Botucatu, São Paulo, Brazil
| | | | - Ricardo de Souza Cavalcante
- Department of Infectious Diseases, Dermatology, Imaging Diagnosis, and Radiotherapy, São Paulo State University (Unesp), Medical School, Botucatu, São Paulo, Brazil
| | - Gabriel Berg de Almeida
- Department of Infectious Diseases, Dermatology, Imaging Diagnosis, and Radiotherapy, São Paulo State University (Unesp), Medical School, Botucatu, São Paulo, Brazil
| | - Nara Aline Costa
- Faculty of Nutrition, Universidade Federal de Goiás (UFG), Goiânia, Brazil
| | - Julhiany de Fátima da Silva
- Department of Infectious Diseases, Dermatology, Imaging Diagnosis, and Radiotherapy, São Paulo State University (Unesp), Medical School, Botucatu, São Paulo, Brazil
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14
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Kao J, Reid N, Hubbard RE, Homes R, Hanjani LS, Pearson E, Logan B, King S, Fox S, Gordon EH. Frailty and solid-organ transplant candidates: a scoping review. BMC Geriatr 2022; 22:864. [PMCID: PMC9667636 DOI: 10.1186/s12877-022-03485-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 09/14/2022] [Indexed: 11/17/2022] Open
Abstract
Abstract
Background
There is currently no consensus as to a standardized tool for frailty measurement in any patient population. In the solid-organ transplantation population, routinely identifying and quantifying frailty in potential transplant candidates would support patients and the multidisciplinary team to make well-informed, individualized, management decisions. The aim of this scoping review was to synthesise the literature regarding frailty measurement in solid-organ transplant (SOT) candidates.
Methods
A search of four databases (Cochrane, Pubmed, EMBASE and CINAHL) yielded 3124 studies. 101 studies (including heart, kidney, liver, and lung transplant candidate populations) met the inclusion criteria.
Results
We found that studies used a wide range of frailty tools (N = 22), including four ‘established’ frailty tools. The most commonly used tools were the Fried Frailty Phenotype and the Liver Frailty Index. Frailty prevalence estimates for this middle-aged, predominantly male, population varied between 2.7% and 100%. In the SOT candidate population, frailty was found to be associated with a range of adverse outcomes, with most evidence for increased mortality (including post-transplant and wait-list mortality), post-operative complications and prolonged hospitalisation. There is currently insufficient data to compare the predictive validity of frailty tools in the SOT population.
Conclusion
Overall, there is great variability in the approach to frailty measurement in this population. Preferably, a validated frailty measurement tool would be incorporated into SOT eligibility assessments internationally with a view to facilitating comparisons between patient sub-groups and national and international transplant services with the ultimate goal of improved patient care.
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15
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Brotherton A, Evison F, Gallier S, Sharif A. Pre-operative Waterlow score and outcomes after kidney transplantation. BMC Nephrol 2022; 23:273. [PMID: 35927670 PMCID: PMC9351155 DOI: 10.1186/s12882-022-02902-8] [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: 03/12/2022] [Accepted: 07/28/2022] [Indexed: 11/24/2022] Open
Abstract
Background Waterlow scoring was introduced in the 1980s as a nursing tool to risk stratify for development of decubitus ulcers (pressure sores) and is commonly used in UK hospitals. Recent interest has focussed on its value as a pre-op surrogate marker for adverse surgical outcomes, but utility after kidney transplantation has never been explored. Methods In this single-centre observational study, data was extracted from hospital informatics systems for all kidney allograft recipients transplanted between 1st January 2007 and 30th June 2020. Waterlow scores were categorised as per national standards; 0–9 (low risk), 10–14 (at risk), 15–19 (high risk) and ≥ 20 (very high risk). Multiple imputation was used to replace missing data with substituted values. Primary outcomes of interest were post-operative length of stay, emergency re-admission within 90-days and mortality analysed by linear, logistic or Cox regression models respectively. Results Data was available for 2,041 kidney transplant patients, with baseline demographics significantly different across Waterlow categories. As a continuous variable, the median Waterlow score across the study cohort was 10 (interquartile range 8–13). As a categorical variable, Waterlow scores pre-operatively were classified as low risk (n = 557), at risk (n = 543), high risk (n = 120), very high risk (n = 27) and a large proportion of missing data (n = 794). Median length of stay in days varied significantly with pre-op Waterlow category scores, progressively getting longer with increasing severity of Waterlow category. However, no difference was observed in risk for emergency readmission within 90-days of surgery with severity of Waterlow category. Patients with ‘very high risk’ Waterlow scores had increased risk for mortality at 41.9% versus high risk (23.7%), at risk (17.4%) and low risk (13.4%). In adjusted analyses, ‘very high risk’ Waterlow group (as a categorical variable) or Waterlow score (as a continuous variable) had an independent association with increase length of stay after transplant surgery only. No association was observed between any Waterlow risk group/score with emergency 90-day readmission rates or post-transplant mortality after adjustment. Conclusions Pre-operative Waterlow scoring is a poor surrogate marker to identify kidney transplant patients at risk of emergency readmission or death and should not be utilised outside its intended use. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-022-02902-8.
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Affiliation(s)
- Anna Brotherton
- Department of Nephrology and Transplantation, University Hospitals Birmingham, Queen Elizabeth Hospital, Edgbaston, Birmingham, B15 2WB, UK
| | - Felicity Evison
- Research Informatics, Research Development and Innovation, University Hospitals Birmingham, Queen Elizabeth Hospital, Birmingham, UK
| | - Suzy Gallier
- Research Informatics, Research Development and Innovation, University Hospitals Birmingham, Queen Elizabeth Hospital, Birmingham, UK.,PIONEER - HDR-UK Health Data Hub in Acute Care, University of Birmingham, Birmingham, UK
| | - Adnan Sharif
- Department of Nephrology and Transplantation, University Hospitals Birmingham, Queen Elizabeth Hospital, Edgbaston, Birmingham, B15 2WB, UK. .,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.
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16
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Chu NM, Ruck J, Chen X, Xue QL, Norman SP, Segev DL, McAdams-DeMarco MA. Long-Term Trajectories of Frailty and Its Components After Kidney Transplantation. J Gerontol A Biol Sci Med Sci 2022; 77:2474-2481. [PMID: 35184167 PMCID: PMC9799205 DOI: 10.1093/gerona/glac051] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Frailty is common and associated with poor outcomes among kidney transplant (KT) recipients. While frailty improves in the first 3 months post-KT with restored kidney function, longer-term trajectories are likely to plateau/decline due to aging and other stressors (eg, immunosuppression). We evaluated longer-term post-KT trajectories of the physical frailty phenotype (PFP) and its components in adult patients at 2 centers. METHODS PFP components were measured at admission, 1, 3, 6 months, 1 year, and annually thereafter post-KT. We used adjusted mixed-effects models to describe repeated measures of continuous components (weight, gait speed, grip strength, activity) and generalized estimating equations to quantify longitudinal, binomial response patterns (PFP; exhaustion). RESULTS Among 1 336 recipients (mean age = 53) followed for a median of 1.9 years (interquartile range [IQR] = 0.1-3.2), likelihood of frailty declined in the first 2.5 years post-KT (adjusted odds ratio [aOR] = 0.96, 95% confidence interval [CI]: 0.95, 0.98), but increased after 2.5 years post-KT (aOR = 1.03, 95% CI: 1.00, 1.05). In the first 2.5 years post-KT, recipients demonstrated increases in weight (0.4 lbs/month, 95% CI: 0.3, 0.5), grip strength (0.2 kg/month, 95% CI: 0.1, 0.2), and activity (23.9 kcal/month, 95% CI: 17.5, 30.2); gait speed remained stable (-0.01 s/month, 95% CI: 0.01, 0.003). Additionally, likelihood of becoming exhausted declined post-KT (OR = 0.99, 95% CI: 0.98, 1.00). After 2.5 years post-KT, recipients demonstrated decreased grip strength (-0.07 kg/month, 95% CI: -0.12, -0.01) and activity (-20 kcal/month, 95% CI: -32.3, -8.2); they had stable weight (-0.003 lbs/month, 95% CI: -0.17, 0.16), gait speed (-0.003 s/month, 95% CI: -0.02, 0.01), and likelihood of becoming exhausted (OR = 1.01, 95% CI: 0.99, 1.02). CONCLUSION Despite frailty improvements in the first 2.5 years, recipients' frailty worsened after 2.5 years post-KT. Specifically, they experienced gains in strength, activity, and exhaustion in the first 2.5 years post-KT, but declined in strength and activity after 2.5 years post-KT while experiencing persistent slowness. Clinicians should consider monitoring recipients for worsening frailty after 2.5 years despite shorter-term improvements.
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Affiliation(s)
| | | | - Xiaomeng Chen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Qian-Li Xue
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA,Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Silas P Norman
- Department of Internal Medicine, Division of Nephrology, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Mara A McAdams-DeMarco
- Address correspondence to: Mara A. McAdams-DeMarco, PhD, Departments of Surgery and Epidemiology, Johns Hopkins School of Medicine, 2000 E. Monument St., Baltimore, MD 21205, USA. E-mail:
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17
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Chen X, Liu Y, Thompson V, Chu NM, King EA, Walston JD, Kobashigawa JA, Dadhania DM, Segev DL, McAdams-DeMarco MA. Transplant centers that assess frailty as part of clinical practice have better outcomes. BMC Geriatr 2022; 22:82. [PMID: 35086480 PMCID: PMC8793239 DOI: 10.1186/s12877-022-02777-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 01/17/2022] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Frailty predicts adverse post-kidney transplant (KT) outcomes, yet the impact of frailty assessment on center-level outcomes remains unclear. We sought to test whether transplant centers assessing frailty as part of clinical practice have better pre- and post-KT outcomes in all adult patients (≥18 years) and older patients (≥65 years). METHODS In a survey of US transplant centers (11/2017-4/2018), 132 (response rate = 65.3%) centers reported their frailty assessment practices (frequency and specific tool) at KT evaluation and admission. Assessment frequency was categorized as never, sometime, and always; type of assessment tool was categorized as none, validated (for post-KT risk prediction), and any other tool. Center characteristics and clinical outcomes for adult patients during 2017-2019 were gleaned from the transplant national registry (Scientific Registry of Transplant Recipients). Poisson regression was used to estimate incidence rate ratios (IRRs) of waitlist outcomes (waitlist mortality, transplantation) in candidates and IRRs of post-KT outcomes (all-cause mortality, death-censored graft loss) in recipients by frailty assessment frequency. We also estimated IRRs of waitlist outcomes by type of assessment tool at evaluation. All models were adjusted for case mix and center characteristics. RESULTS Assessing frailty at evaluation was associated with lower waitlist mortality rate (always IRR = 0.91,95%CI:0.84-0.99; sometimes = 0.89,95%CI:0.83-0.96) and KT rate (always = 0.94,95%CI:0.91-0.97; sometimes = 0.88,95%CI:0.85-0.90); the associations with waitlist mortality rate (always = 0.86,95%CI:0.74-0.99; sometimes = 0.83,95%CI:0.73-0.94) and KT rate (always = 0.82,95%CI:0.77-0.88; sometimes = 0.92,95%CI:0.87-0.98) were stronger in older patients. Furthermore, using validated (IRR = 0.90,95%CI:0.88-0.92) or any other tool (IRR = 0.90,95%CI:0.87-0.93) at evaluation was associated lower KT rate, while only using a validated tool was associated with lower waitlist mortality rate (IRR = 0.89,95%CI:0.83-0.96), especially in older patients (IRR = 0.82,95%CI:0.72-0.93). At admission for KT, always assessing frailty was associated with a lower graft loss rate (IRR = 0.71,95%CI:0.54-0.92) but not with mortality (IRR = 0.93,95%CI:0.76-1.13). CONCLUSIONS Assessing frailty at evaluation is associated with lower KT rate, while only using a validated frailty assessment tool is associated with better survival, particularly in older candidates. Centers always assessing frailty at admission are likely to have better graft survival rates. Transplant centers may utilize validated frailty assessment tools to secure KT access for appropriate candidates and to better allocate health care resources for patients identified as frail, particularly for older patients.
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Affiliation(s)
- Xiaomeng Chen
- Department of Surgery, Johns Hopkins University School of Medicine, 2000 E Monument Street, Baltimore, MD, 21205, USA
| | - Yi Liu
- Department of Surgery, Johns Hopkins University School of Medicine, 2000 E Monument Street, Baltimore, MD, 21205, USA
| | - Valerie Thompson
- Department of Surgery, Johns Hopkins University School of Medicine, 2000 E Monument Street, Baltimore, MD, 21205, USA
| | - Nadia M Chu
- Department of Surgery, Johns Hopkins University School of Medicine, 2000 E Monument Street, Baltimore, MD, 21205, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Elizabeth A King
- Department of Surgery, Johns Hopkins University School of Medicine, 2000 E Monument Street, Baltimore, MD, 21205, USA
| | - Jeremy D Walston
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Jon A Kobashigawa
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Darshana M Dadhania
- Division of Nephrology and Hypertension, Weill Cornell Medicine, New York, NY, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, 2000 E Monument Street, Baltimore, MD, 21205, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Mara A McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, 2000 E Monument Street, Baltimore, MD, 21205, USA. .,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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18
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Pérez-Sáez MJ, Arias-Cabrales CE, Dávalos-Yerovi V, Redondo D, Faura A, Vera M, Bach A, Pedreira G, Junyent E, Crespo M, Marco E, Rodríguez-Mañas L, Pascual J. Frailty among chronic kidney disease patients on the kidney transplant waiting list: the sex–frailty paradox. Clin Kidney J 2022; 15:109-118. [PMID: 35035941 PMCID: PMC8757431 DOI: 10.1093/ckj/sfab133] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Indexed: 01/04/2023] Open
Abstract
Background Frailty is defined as decreased physiologic reserve and resistance to stressors that predisposes patients towards poor health results. Its prevalence in chronic kidney disease (CKD) patients who are kidney transplant (KT) candidates is high. Frailty is associated with a higher rate of complications and mortality after transplant. It is unknown whether frailty phenotype differs depending on sex in this population. Methods This was a prospective longitudinal study of 455 KT candidates evaluated for frailty by physical frailty phenotype at the time of inclusion on the KT waiting list. Pre-frailty was defined as the presence of two criteria and frailty as three or more criteria. Univariate and multivariate analyses searched for associations of frailty status, frailty components and gender differences. Results Thirty percent of the total cohort resulted to be pre-frail (20%) or frail (10.3%), but disparities were observed between sexes, with 22.5% of men and 47.2% of women falling into one of these categories. Among frailty criteria, women presented with a higher percentage of exhaustion (39.6% versus 17%) and slowness (22.2% versus 9.6%) compared with men. Comorbidity burden was higher among frail men, whereas social factors were poorer between frail women. Disability was common among those patients who were frail, both men and women. Conclusions Frailty is twice as frequent in advanced CKD women as men. Frailty criteria distribution and phenotype seem to differ among sexes, which might have implications in terms of specific and individualized interventions to improve their status before transplantation.
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Affiliation(s)
| | | | - Vanesa Dávalos-Yerovi
- Physical Medicine and Rehabilitation Department, Parc de Salut Mar (Hospital del Mar-Hospital de l’Esperança), Rehabilitation Research Group, Hospital del Mar Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Anna Faura
- Nephrology Department, Hospital del Mar, Barcelona, Spain
| | - María Vera
- Nephrology Department, Hospital del Mar, Barcelona, Spain
| | - Anna Bach
- Nephrology Department, Hospital del Mar, Barcelona, Spain
| | | | | | - Marta Crespo
- Nephrology Department, Hospital del Mar, Barcelona, Spain
| | - Ester Marco
- Physical Medicine and Rehabilitation Department, Parc de Salut Mar (Hospital del Mar-Hospital de l’Esperança), Rehabilitation Research Group, Hospital del Mar Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
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19
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Frailty in kidney transplant candidates: a comparison between physical frailty phenotype and FRAIL scales. J Nephrol 2022; 35:1841-1849. [PMID: 34978704 DOI: 10.1007/s40620-021-01234-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 12/16/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Frailty is common among advanced chronic kidney disease (CKD) patients who are kidney transplant (KT) candidates, and predisposes to poor outcomes after transplantation. However, frailty is not routinely measured during pretransplant work-up and it is unknown which metric should be used in this specific population. Our aim was to establish frailty prevalence in KT candidates according to different frailty scales. METHODS Prospective longitudinal study of 451 KT candidates evaluated for frailty by both Physical Frailty Phenotype (PFP) and FRAIL scale at the time of inclusion on the KT waiting list. Clinical and functional characteristics including sociodemographics, comorbidities, disability and nutritional status were recorded. Agreement between PFP and FRAIL scales as well as dissonant patients were analyzed. RESULTS Mean age was 60.9 years and 31.7% were female. Comorbidity burden among patients was high, with 36.9% and 16.2% presenting with diabetes and ischemic coronary disease, respectively. Disabilities were also frequent. More than 70% of patients presented with ≥ 1 PFP criteria while this percentage for ≥ 1 FRAIL criteria was 45.4%. Agreement between PFP and FRAIL was not good (kappa index 0.317). There were 132 patients who were pre-frail or frail according to PFP but non-frail according to the FRAIL scale and they presented with fewer comorbidities and less disability. CONCLUSIONS Frailty is frequent in advanced CKD patients, although its prevalence may vary according to different scales. Agreement between PFP and FRAIL scale is not good, and FRAIL scale might misclassify as robust patients those frail/prefrail patients who are in better health conditions.
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20
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Chan GCK, Ng JKC, Chow KM, Cheng PMS, Law MC, Leung CB, Li PKT, Szeto CC. Polypharmacy Predicts Onset and Transition of Frailty, Malnutrition, and Adverse Outcomes in Peritoneal Dialysis Patient. J Nutr Health Aging 2022; 26:1054-1060. [PMID: 36519768 DOI: 10.1007/s12603-022-1859-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Polypharmacy, frailty and malnutrition are known predictors of adverse outcomes in dialysis patients. Little has reported about their interaction and composite prognostic values. We aimed to describe the interaction between polypharmacy, frailty, nutrition, hospitalization, and survival in peritoneal dialysis patients. METHODS In this prospective cohort study, we recruited 573 peritoneal dialysis patients. Drug burden was measured by medication number and daily pill load. Frailty and nutrition were assessed by the validated Frailty Score (FQ) and Subjective Global Assessment (SGA) respectively. All patients were followed for two years. Primary outcome was all-cause mortality. Secondary outcomes were fall and fracture episodes, hospitalization, change in FQ and SGA. RESULTS At baseline, each patient took 7.5 ± 2.6 medications with 15.5 ± 8.5 tablets per day. Medication number, but not daily pill load predicted baseline FQ (p = 0.004) and SGA (p = 0.03). Over 2 years, there were 69 fall and 1,606 hospitalization episodes. In addition, 148 (25.8%) patients died, while FQ and SGA changed by 0.73 ± 4.23 and -0.07 ± 1.06 respectively in survivors. Medication number (hospitalization: p = 0.02, survival: p = 0.005), FQ (hospitalization: p < 0.001; survival: p = 0.01) predicted hospitalization and survival. Medication number also predicted fall episodes (p = 0.02) and frailty progression (p = 0.002). Daily pill load did not predict any of these outcomes. CONCLUSIONS Drug burden is high in peritoneal dialysis patients, and it carries important prognostic implication. Medication number but not pill load significantly predicted onset and progression of frailty, malnutrition, fall, hospitalization, and mortality.
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Affiliation(s)
- G C-K Chan
- Dr. Gordon CK Chan, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong, China. Tel: (852) 3505-1729; Fax: (852) 2637-3852; E-mail:
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21
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Alsaad R, Chen X, McAdams-DeMarco M. The clinical application of frailty in nephrology and transplantation. Curr Opin Nephrol Hypertens 2021; 30:593-599. [PMID: 34483298 PMCID: PMC8490315 DOI: 10.1097/mnh.0000000000000743] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW Clinicians treating end-stage kidney disease (ESKD) and kidney transplant patients face unique challenges in their care because of the high burden of frailty in these patients. Frailty has gained significant attention by medical and surgical specialties for risk stratification in the past decades. This review highlights the importance of measuring frailty in kidney transplant candidates and recipients. RECENT FINDINGS Emerging data support that frailty is present even at younger ages among patients undergoing dialysis, transplant evaluation, or transplantation. It is estimated that 18.8% of younger (18-64 years) candidates, 25.2% of older (≥65 years) candidates, 14.3% of younger recipients, and 20.8% of older recipients are frail. Additionally, frailty is dynamic and subject to change pretransplantation and posttransplantation. Although many patients and clinicians are aware of the importance of measuring frailty, further studies addressing the need for interventions to reduce frailty burden are needed. SUMMARY Frailty is independently associated with many adverse outcomes in ESKD and kidney transplant populations. Given the growing number of ESKD and kidney transplant patients, it is pivotal to expand the utility of frailty measurement in clinical practice, recognize the burden of frailty, and identify appropriate interventions to mitigate the adverse effects of frailty.
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Affiliation(s)
- Ranim Alsaad
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Xiaomeng Chen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Mara McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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22
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Cobacho-Salmoral O, Parra-Martos L, Laguna-Castro M, Crespo-Montero R. Factores asociados a la fragilidad en el paciente en tratamiento renal sustitutivo con diálisis. Una revisión sistemática. ENFERMERÍA NEFROLÓGICA 2021. [DOI: 10.37551/s2254-28842021021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Introducción: La fragilidad es un síndrome multidimensional caracterizado por una disminución de reservas fisiológicas, de masa corporal magra, debilidad y disminución de resistencia al ejercicio físico. Sitúa a la persona en una situación de mayor vulnerabilidad ante factores externos, además existe una estrecha relación entre la fragilidad y las enfermedades crónicas, como es el caso de la enfermedad renal crónica. Objetivo: El objetivo principal de esta revisión fue sintetizar y conocer la evidencia científica sobre los factores asociados a la fragilidad de los pacientes con enfermedad renal crónica en tratamiento renal sustitutivo en diálisis. Material y Método: Se llevó a cabo una revisión sistemática a través de las bases de datos de Pubmed y Proquest. Se incluyeron artículos originales en inglés y español publicados entre 2015 y 2020, y se analizaron los artículos que trataban sobre fragilidad en el paciente con enfermedad renal en tratamiento sustitutivo. Se excluyeron aquellos artículos que no presentaron resultados. Resultados: Se incluyeron 26 artículos de diseño observacional. Los hallazgos se enfocan a la prevalencia, mortalidad, tasa de hospitalización, discapacidad, deterioro cognitivo, síntomas depresivos, obesidad, comorbilidades, caídas o fracturas y actividad y rendimiento físico. Conclusiones: Se ha encontrado una elevada prevalencia de fragilidad en el enfermo renal crónico en tratamiento renal sustitutivo con diálisis, sin diferencias entre diálisis peritoneal y hemodiálisis. La fragilidad en estos pacientes está asociada a mayor mortalidad, tasa de hospitalización, discapacidad, deterioro cognitivo, síntomas depresivos y comorbilidades. La actividad y rendimiento físico, parecen ser factores que disminuyen la fragilidad.
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Affiliation(s)
- Olga Cobacho-Salmoral
- Departamento de Enfermería. Facultad de Medicina y Enfermería. Universidad de Córdoba. España
| | - Lucía Parra-Martos
- Departamento de Enfermería. Facultad de Medicina y Enfermería. Universidad de Córdoba. España
| | - Marta Laguna-Castro
- Departamento de Enfermería. Facultad de Medicina y Enfermería. Universidad de Córdoba. España
| | - Rodolfo Crespo-Montero
- Departamento de Enfermería. Facultad de Medicina y Enfermería. Universidad de Córdoba. España. Servicio de Nefrología. Hospital Universitario Reina Sofía de Córdoba. España. Instituto Maimónides de Investigación Biomédica de Córdoba. España
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23
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Huckaby LV, Hickey G, Sultan I, Kilic A. Improvements in Functional Status Among Survivors of Orthotopic Heart Transplantation Following High-risk Bridging Modalities. Transplantation 2021; 105:2097-2103. [PMID: 33988350 PMCID: PMC8991387 DOI: 10.1097/tp.0000000000003602] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The 2018 heart allocation change has resulted in greater frequency of high-risk bridging to orthotopic heart transplantation (OHT). Although survival has been studied in these patients, functional status outcomes are less established. This study evaluated changes in functional status of OHT survivors based on bridging strategy. METHODS Adults (≥18 y) undergoing OHT between January 2015 and March 2020 were stratified by bridging modality: no bridging, inotropes only, intra-aortic balloon pump (IABP), temporary ventricular assist device (VAD), durable VAD, and extracorporeal membrane oxygenation (ECMO). Using paired analysis, the Karnofsky performance scale (0-100) was utilized to compare differences in function at listing, transplant, and follow-up. RESULTS In total, 13 142 patients underwent OHT. At the time of both listing and transplant, patients requiring IABP, temporary VAD, and ECMO displayed the lowest functional status (each median 20) compared with other groups (P < 0.001). Among survivors, the median performance status at follow-up was ≥80 for all groups, indicating total functional independence with no assistance required. Substantial improvement in Karnofsky score occurred from transplant to follow-up in survivors bridged with IABP (40), temporary VADs (60), and ECMO (50) (each P < 0.001). Among survivors with at least 90-day follow-up, the median Karnofsky score was 90 regardless of bridging modality. CONCLUSIONS Despite a higher mortality risk, critically ill patients who survive OHT after bridging with high-risk modalities experience acceptable functional status outcomes. These findings are important to place in the context of the impact that the 2018 allocation change has had on the landscape of OHT in the United States.
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Affiliation(s)
- Lauren V. Huckaby
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Gavin Hickey
- Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Ibrahim Sultan
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Arman Kilic
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
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24
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Chu NM, Chen X, Bae S, Brennan DC, Segev DL, McAdams-DeMarco MA. Changes in Functional Status Among Kidney Transplant Recipients: Data From the Scientific Registry of Transplant Recipients. Transplantation 2021; 105:2104-2111. [PMID: 33449609 PMCID: PMC8273213 DOI: 10.1097/tp.0000000000003608] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND With stressors of dialysis prekidney transplantation (KT) and restoration of kidney function post-KT, it is likely that KT recipients experience a decline in functional status while on the waitlist and improvements post-KT. METHODS We leveraged 224 832 KT recipients from the national registry (SRTR, February 1990-May 2019) with measured Karnofsky Performance Status (KPS, 0%-100%) at listing, KT admission, and post-KT. We quantified the change in KPS from listing to KT using generalized linear models. We described post-KT KPS trajectories using adjusted mixed-effects models and tested whether those trajectories differed by age, sex, race, and diabetes status using a Wald test among all KT recipients. We then quantified risk adverse post-KT outcomes (mortality and all-cause graft loss [ACGL]) by preoperative KPS and time-varying KPS. RESULTS Mean KPS declined from listing (83.7%) to admission (78.9%) (mean = 4.76%, 95% confidence interval [CI]: -4.82, -4.70). After adjustment, mean KPS improved post-KT (slope = 0.89%/y, 95% CI: 0.87, 0.91); younger, female, non-Black, and diabetic recipients experienced greater post-KT improvements (Pinteractions < 0.001). Lower KPS (per 10% decrease) at admission was associated with greater mortality (adjusted hazard ratio [aHR] = 1.11, 95% CI: 1.10, 1.11) and ACGL (aHR = 1.08, 95% CI: 1.08, 1.09) risk. Lower post-KT KPS (per 10% decrease; time-varying) were more strongly associated with mortality (aHR = 1.93, 95% CI: 1.92, 1.94) and ACGL (aHR = 1.84, 95% CI: 1.83, 1.85). CONCLUSIONS Functional status declines pre-KT and improves post-KT in the national registry. Despite post-KT improvements, poorer functional status at KT and post-KT are associated with greater mortality and ACGL risk. Because of its dynamic nature, clinicians should repeatedly screen for lower functional status pre-KT to refer vulnerable patients to prehabilitation in hopes of reducing risk of adverse post-KT outcomes.
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Affiliation(s)
- Nadia M Chu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Xiaomeng Chen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sunjae Bae
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Daniel C Brennan
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Mara A McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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25
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Abstract
PURPOSE OF REVIEW Kidney and/or pancreas transplantation candidacy criteria have evolved significantly over time reflecting improved pre and post-transplant management. With improvement in medical care, potential candidates for transplant not only are older but also have complex medical issues. This review focuses on the latest trends regarding candidacy for kidney and/or pancreas transplantation along with advances in pretransplant cardiac testing. RECENT FINDINGS More candidates are now eligible for kidney and/or pancreas transplantation owing to less stringent candidacy criteria especially in regards to age, obesity, frailty and history of prior malignancy. Pretransplant cardiovascular assessment has also come a long way with a focus on less invasive strategies to assess for coronary artery disease. SUMMARY Criteria for kidney and/or pancreas transplantation are expanding. Patients who in the past might have been declined because of numerous factors are now finding that transplant centers are more open minded to their candidacy, which could lead to better access to organ transplant wait list.
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26
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Haugen CE, Gross A, Chu NM, Norman SP, Brennan DC, Xue QL, Walston J, Segev DL, McAdams-DeMarco M. Development and Validation of an Inflammatory-Frailty Index for Kidney Transplantation. J Gerontol A Biol Sci Med Sci 2021; 76:470-477. [PMID: 32619229 DOI: 10.1093/gerona/glaa167] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Physical frailty phenotype is characterized by decreased physiologic reserve to stressors and associated with poor outcomes, such as delirium and mortality, that may result from post-kidney transplant (KT) inflammation. Despite a hypothesized underlying pro-inflammatory state, conventional measures of frailty typically do not incorporate inflammatory biomarkers directly. Among KT candidates and recipients, we evaluated the inclusion of inflammatory biomarkers with traditional physical frailty phenotype components. METHODS Among 1154 KT candidates and recipients with measures of physical frailty phenotype and inflammation (interleukin 6 [IL6], tumor necrosis factor alpha [TNFα], C-reactive protein [CRP]) at 2 transplant centers (2009-2017), we evaluated construct validity of inflammatory-frailty using latent class analysis. Inflammatory-frailty measures combined 5 physical frailty phenotype components plus the addition of an individual inflammatory biomarkers, separately (highest tertiles) as a sixth component. We then used Kaplan-Meier methods and adjusted Cox proportional hazards to assess post-KT mortality risk by inflammatory-frailty (n = 378); Harrell's C-statistics assessed risk prediction (discrimination). RESULTS Based on fit criteria, a 2-class solution (frail vs nonfrail) for inflammatory-frailty was the best-fitting model. Five-year survival (frail vs nonfrail) was: 81% versus 93% (IL6-frailty), 87% versus 89% (CRP-frailty), and 83% versus 91% (TNFα-frailty). Mortality was 2.07-fold higher for IL6-frail recipients (95% CI: 1.03-4.19, p = .04); there were no associations between the mortality and the other inflammatory-frailty indices (TNFα-frail: 1.88, 95% CI: 0.95-3.74, p = .07; CRP-frail: 1.02, 95% CI: 0.52-2.03, p = .95). However, none of the frailty-inflammatory indices (all C-statistics = 0.71) improved post-KT mortality risk prediction over the physical frailty phenotype (C-statistics = 0.70). CONCLUSIONS Measurement of IL6-frailty at transplantation can inform which patients should be targeted for pre-KT interventions. However, the traditional physical frailty phenotype is sufficient for post-KT mortality risk prediction.
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Affiliation(s)
- Christine E Haugen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alden Gross
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Nadia M Chu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Silas P Norman
- Department of Medicine, Division of Nephrology, University of Michigan, Ann Arbor
| | - Daniel C Brennan
- Department of Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Qian-Li Xue
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Department of Medicine, Division of Geriatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jeremy Walston
- Department of Medicine, Division of Geriatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Mara McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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27
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Quint EE, Zogaj D, Banning LB, Benjamens S, Annema C, Bakker SJ, Nieuwenhuijs-Moeke GJ, Segev DL, McAdams-DeMarco MA, Pol RA. Frailty and Kidney Transplantation: A Systematic Review and Meta-analysis. Transplant Direct 2021; 7:e701. [PMID: 34036171 PMCID: PMC8133203 DOI: 10.1097/txd.0000000000001156] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 03/22/2021] [Indexed: 11/25/2022] Open
Abstract
Frailty is a multidimensional condition and is the result of the body's age-associated decline in physical, cognitive, physiological, and immune reserves. The aim of this systematic review is to assess the quality of evidence of the included studies, determine the prevalence of frailty among kidney transplant candidates, and evaluate the relationship between frailty and associated patient characteristics and outcomes after kidney transplantation. METHODS A systematic search was performed for relevant literature on frailty and kidney transplantation. This was followed by a meta-analysis for patient characteristics and outcomes reported by a minimum of 2 studies including mean age, gender, mean body mass index, type of kidney transplantation, dialysis, previous kidney transplantation, comorbidities, hypertension, race, preemptive kidney transplantation, delayed graft function, and length of stay. RESULTS A total of 18 studies were included in the systematic review and 14 of those studies were suitable for meta-analysis. The overall pooled prevalence of frailty before transplantation was estimated at 17.1% (95% confidence interval [CI], 15.4-18.7). Frailty was significantly associated with higher age (mean difference, 3.6; 95% CI, 1.4-5.9), lower rate of preemptive transplantation (relative risk, 0.60; 95% CI, 0.4-0.9), longer duration of delayed graft function (relative risk, 1.80; 95% CI, 1.1-3.0), and length of stay longer than 2 wk (odds ratio, 1.64; 95% CI, 1.2-2.3). CONCLUSIONS One in 6 kidney transplant recipients is frail before transplantation. The presence of frailty is associated with lower rates of preemptive transplantation, older recipient age, higher rates of delayed graft function, and longer length of stay. Future research is required to explore the association of frailty with other adverse outcomes after kidney transplantation and the effects of intervention programs to improve the different frailty domains.
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Affiliation(s)
- Evelien E. Quint
- Division of Transplantation Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Donika Zogaj
- Division of Transplantation Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Louise B.D. Banning
- Division of Transplantation Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Stan Benjamens
- Division of Transplantation Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Coby Annema
- Division of Nursing Science, Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Stephan J.L. Bakker
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Dorry L. Segev
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | | | - Robert A. Pol
- Division of Transplantation Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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28
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Spiers GF, Kunonga TP, Hall A, Beyer F, Boulton E, Parker S, Bower P, Craig D, Todd C, Hanratty B. Measuring frailty in younger populations: a rapid review of evidence. BMJ Open 2021; 11:e047051. [PMID: 33753447 PMCID: PMC7986767 DOI: 10.1136/bmjopen-2020-047051] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 02/11/2021] [Accepted: 03/03/2021] [Indexed: 12/16/2022] Open
Abstract
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.
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Affiliation(s)
- Gemma F Spiers
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Tafadzwa Patience Kunonga
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Alex Hall
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Fiona Beyer
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Elisabeth Boulton
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Stuart Parker
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Peter Bower
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Dawn Craig
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Chris Todd
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Barbara Hanratty
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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29
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Nutrition-Based Management of Inflammaging in CKD and Renal Replacement Therapies. Nutrients 2021; 13:nu13010267. [PMID: 33477671 PMCID: PMC7831904 DOI: 10.3390/nu13010267] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/15/2021] [Accepted: 01/15/2021] [Indexed: 12/12/2022] Open
Abstract
Access to renal transplantation guarantees a substantial improvement in the clinical condition and quality of life (QoL) for end-stage renal disease (ESRD) patients. In recent years, a greater number of older patients starting renal replacement therapies (RRT) have shown the long-term impact of conservative therapies for advanced CKD and the consequences of the uremic milieu, with a frail clinical condition that impacts not only their survival but also limits their access to transplantation. This process, referred to as “inflammaging,” might be reversible with a tailored approach, such as RRT accompanied by specific nutritional support. In this review, we summarize the evidence demonstrating the presence of several proinflammatory substances in the Western diet (WD) and the positive effect of unprocessed food consumption and increased fruit and vegetable intake, suggesting a new approach to reduce inflammaging with the improvement of ESRD clinical status. We conclude that the Mediterranean diet (MD), because of its modulative effects on microbiota and its anti-inflammaging properties, may be a cornerstone in a more precise nutritional support for patients on the waiting list for kidney transplantation.
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30
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Leng SX, Kittleson MM. Beyond the eyeball test: Impact and potential mechanisms of frailty in heart transplant candidates. J Heart Lung Transplant 2021; 40:95-98. [PMID: 33419640 DOI: 10.1016/j.healun.2020.12.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 12/11/2020] [Indexed: 12/20/2022] Open
Affiliation(s)
- Sean X Leng
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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31
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Harhay MN, Rao MK, Woodside KJ, Johansen KL, Lentine KL, Tullius SG, Parsons RF, Alhamad T, Berger J, Cheng XS, Lappin J, Lynch R, Parajuli S, Tan JC, Segev DL, Kaplan B, Kobashigawa J, Dadhania DM, McAdams-DeMarco MA. An overview of frailty in kidney transplantation: measurement, management and future considerations. Nephrol Dial Transplant 2020; 35:1099-1112. [PMID: 32191296 DOI: 10.1093/ndt/gfaa016] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Indexed: 02/07/2023] Open
Abstract
The construct of frailty was first developed in gerontology to help identify older adults with increased vulnerability when confronted with a health stressor. This article is a review of studies in which frailty has been applied to pre- and post-kidney transplantation (KT) populations. Although KT is the optimal treatment for end-stage kidney disease (ESKD), KT candidates often must overcome numerous health challenges associated with ESKD before receiving KT. After KT, the impacts of surgery and immunosuppression represent additional health stressors that disproportionately impact individuals with frailty. Frailty metrics could improve the ability to identify KT candidates and recipients at risk for adverse health outcomes and those who could potentially benefit from interventions to improve their frail status. The Physical Frailty Phenotype (PFP) is the most commonly used frailty metric in ESKD research, and KT recipients who are frail at KT (~20% of recipients) are twice as likely to die as nonfrail recipients. In addition to the PFP, many other metrics are currently used to assess pre- and post-KT vulnerability in research and clinical practice, underscoring the need for a disease-specific frailty metric that can be used to monitor KT candidates and recipients. Although frailty is an independent risk factor for post-transplant adverse outcomes, it is not factored into the current transplant program risk-adjustment equations. Future studies are needed to explore pre- and post-KT interventions to improve or prevent frailty.
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Affiliation(s)
- Meera N Harhay
- Department of Medicine, Division of Nephrology, Drexel University College of Medicine, Philadelphia, PA, USA.,Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, PA, USA.,Tower Health Transplant Institute, Tower Health System, West Reading, PA, USA
| | - Maya K Rao
- Division of Nephrology, Columbia University Vagelos College of Physicians & Surgeons, New York, NY, USA
| | | | | | - Krista L Lentine
- Center for Abdominal Transplantation, St Louis University School of Medicine, St Louis, MO, USA
| | - Stefan G Tullius
- Department of Surgery, Division of Transplant Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ronald F Parsons
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Tarek Alhamad
- Division of Nephrology, Washington University School of Medicine, St Louis, MO, USA
| | - Joseph Berger
- Department of Internal Medicine, Division of Nephrology, UT Southwestern Medical Center, Dallas, TX, USA
| | - XingXing S Cheng
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA
| | | | - Raymond Lynch
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Sandesh Parajuli
- Department of Medicine, Division of Nephrology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Jane C Tan
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, 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
| | - Bruce Kaplan
- Vice President System Office, Baylor Scott and White Health, Temple, TX, USA
| | - Jon Kobashigawa
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Darshana M Dadhania
- Department of Transplantation Medicine, New York Presbyterian Hospital - Weill Cornell Medical Center, New York, NY, USA
| | - Mara A 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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32
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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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Wu HH, Woywodt A, Nixon AC. Frailty and the Potential Kidney Transplant Recipient: Time for a More Holistic Assessment? KIDNEY360 2020; 1:685-690. [PMID: 35372945 PMCID: PMC8815542 DOI: 10.34067/kid.0001822020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 05/22/2020] [Indexed: 06/14/2023]
Affiliation(s)
- Henry H.L. Wu
- Department of Renal Medicine, Lancashire Teaching Hospitals National Health Service Foundation Trust, Royal Preston Hospital, Preston, United Kingdom
- Faculty of Medical and Human Sciences, University of Manchester, Manchester, United Kingdom
| | - Alexander Woywodt
- Department of Renal Medicine, Lancashire Teaching Hospitals National Health Service Foundation Trust, Royal Preston Hospital, Preston, United Kingdom
- Faculty of Medical and Human Sciences, University of Manchester, Manchester, United Kingdom
| | - Andrew C. Nixon
- Department of Renal Medicine, Lancashire Teaching Hospitals National Health Service Foundation Trust, Royal Preston Hospital, Preston, United Kingdom
- Division of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
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Chu NM, Chen X, Norman SP, Fitzpatrick J, Sozio SM, Jaar BG, Frey A, Estrella MM, Xue QL, Parekh RS, Segev DL, McAdams-DeMarco MA. Frailty Prevalence in Younger End-Stage Kidney Disease Patients Undergoing Dialysis and Transplantation. Am J Nephrol 2020; 51:501-510. [PMID: 32640462 DOI: 10.1159/000508576] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 05/09/2020] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- Nadia M Chu
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Xiaomeng Chen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Silas P Norman
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jessica Fitzpatrick
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Stephen M Sozio
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Baltimore, Maryland, USA
| | - Bernard G Jaar
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Baltimore, Maryland, USA
| | - Alena Frey
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Michelle M Estrella
- Kidney Health Research Collaborative, Department of Medicine, University of California, San Francisco and Department of Medicine, San Francisco VA Medical Center, San Francisco, California, USA
| | - Qian-Li Xue
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Rulan S Parekh
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Nephrology, Department of Pediatrics and Medicine, The Hospital for Sick Children, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Dorry L Segev
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mara A McAdams-DeMarco
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA,
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA,
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35
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Cheng XS, Myers J, Han J, Stedman MR, Watford DJ, Lee J, Discipulo KV, Chan KN, Chertow GM, Tan JC. Physical Performance Testing in Kidney Transplant Candidates at the Top of the Waitlist. Am J Kidney Dis 2020; 76:815-825. [PMID: 32512039 DOI: 10.1053/j.ajkd.2020.04.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 04/08/2020] [Indexed: 02/08/2023]
Abstract
RATIONALE & OBJECTIVE Frailty and poor physical function are associated with adverse kidney transplant outcomes, but how to incorporate this knowledge into clinical practice is uncertain. We studied the association between measured physical performance and clinical outcomes among patients on kidney transplant waitlists. STUDY DESIGN Prospective observational cohort study. SETTING & PARTICIPANTS We studied consecutive patients evaluated in our Transplant Readiness Assessment Clinic, a top-of-the-waitlist management program, from May 2017 through December 2018 (N=305). We incorporated physical performance testing, including the 6-minute walk test (6MWT) and the sit-to-stand (STS) test, into routine clinical assessments. EXPOSURES 6MWT and STS test results. OUTCOMES The primary outcome was time to adverse waitlist outcomes (removal from waitlist or death); secondary outcomes were time to transplantation and time to death. ANALYTICAL APPROACH We used linear regression to examine the relationship between clinical characteristics and physical performance test results. We used subdistribution hazards models to examine the association between physical performance test results and outcomes. RESULTS Median 6MWT and STS results were 393 (IQR, 305-455) m and 17 (IQR, 12-21) repetitions, respectively. Clinical characteristics and Estimated Post-Transplant Survival scores accounted for only 14% to 21% of the variance in 6MWT/STS results. Physical performance test results were associated with adverse waitlist outcomes (adjusted subdistribution hazard ratio [sHR] of 1.42 [95% CI, 1.30-1.56] per 50-m lower 6MWT test result and 1.53 [95% CI, 1.33-1.75] per 5-repetition lower STS test result) and with transplantation (adjusted sHR of 0.80 [95% CI, 0.72-0.88] per 50-m lower 6MWT test result and 0.80 [95% CI, 0.71-0.89] per 5-repetition lower STS test result). Addition of either STS or 6MWT to survival models containing clinical characteristics enhanced fit (likelihood ratio test P<0.001). LIMITATIONS Single-center observational study. Other measures of global health status (eg, Fried Frailty Index or Short Physical Performance Battery) were not examined. CONCLUSIONS Among waitlisted kidney transplant candidates with high kidney allocation scores, standardized and easily performed physical performance test results are associated with waitlist outcomes and contain information beyond what is currently routinely collected in clinical practice.
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Affiliation(s)
- Xingxing S Cheng
- Division of Nephrology, Department of Medicine, Stanford University Medical Center, Palo Alto, CA
| | - Jonathan Myers
- Veterans Administration Palo Alto Health Care System/Stanford University, Palo Alto, CA
| | - Jialin Han
- Division of Nephrology, Department of Medicine, Stanford University Medical Center, Palo Alto, CA
| | - Margaret R Stedman
- Division of Nephrology, Department of Medicine, Stanford University Medical Center, Palo Alto, CA
| | - Daniel J Watford
- Division of Nephrology, Department of Medicine, Stanford University Medical Center, Palo Alto, CA
| | - Jenny Lee
- Stanford Hospital and Clinics, Palo Alto, CA
| | | | - Khin N Chan
- Veterans Administration Palo Alto Health Care System/Stanford University, Palo Alto, CA
| | - Glenn M Chertow
- Division of Nephrology, Department of Medicine, Stanford University Medical Center, Palo Alto, CA
| | - Jane C Tan
- Division of Nephrology, Department of Medicine, Stanford University Medical Center, Palo Alto, CA.
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de Kok MJ, Schaapherder AF, Mensink JW, de Vries AP, Reinders ME, Konijn C, Bemelman FJ, van de Wetering J, van Zuilen AD, Christiaans MH, Baas MC, Nurmohamed AS, Berger SP, Ploeg RJ, Alwayn IP, Lindeman JH. A nationwide evaluation of deceased donor kidney transplantation indicates detrimental consequences of early graft loss. Kidney Int 2020; 97:1243-1252. [DOI: 10.1016/j.kint.2020.01.043] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 01/10/2020] [Accepted: 01/31/2020] [Indexed: 11/28/2022]
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37
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An interdisciplinary approach to the older transplant patient: strategies for improving clinical outcomes. Curr Opin Organ Transplant 2020; 24:504-510. [PMID: 31219840 DOI: 10.1097/mot.0000000000000662] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE OF REVIEW To describe the latest investigations into the role of frailty and assessment of other aging-related issues in the solid organ transplant candidate and recipient. This information is relevant for all involved in the care of transplant patients, but is especially relevant in infectious diseases, given the increased burden of infection seen in older and frailer patients. RECENT FINDINGS The Fried Frailty Phenotype (FFP) and Short Performance Physical Battery (SPPB) are well validated tools for measuring frailty in older adults. Recently, these frailty tools have also been used to predict a range of clinical outcomes in adults with endstage organ disease undergoing advanced therapies including mechanical circulatory device (MCSD) or transplantation including death on the waiting list, length of hospital stay, need for readmission, infection, and death. Frailty may also be estimated by chart review and comorbidity assessment. Other aging-related evaluations of interest are cognitive function, sarcopenia, and nutritional status. The strength of association for each tool varies by the type of end organ disease, although there are many findings in common across organ types. SUMMARY As trends in the aging of the population continue to impact transplant and MCSD candidates and recipients, it is increasingly important for providers to be cognizant of the methods for assessment of aging-associated dysfunction including frailty and sarcopenia.
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38
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Haugen CE, Thomas AG, Chu NM, Shaffer AA, Norman SP, Bingaman AW, Segev DL, McAdams-DeMarco M. Prevalence of frailty among kidney transplant candidates and recipients in the United States: Estimates from a National Registry and Multicenter Cohort Study. Am J Transplant 2020; 20:1170-1180. [PMID: 31733176 PMCID: PMC7103511 DOI: 10.1111/ajt.15709] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 09/27/2019] [Accepted: 10/30/2019] [Indexed: 01/25/2023]
Abstract
Frailty, a measure of physiologic reserve, is associated with poor outcomes and mortality among kidney transplant (KT) candidates and recipients. There are no national estimates of frailty in this population, which may help patient counseling and resource allocation at transplant centers. We studied 4616 KT candidates and 1763 recipients in our multicenter prospective cohort of frailty from 2008-2018 with Fried frailty measurements. Using Scientific Registry of Transplant Recipients (SRTR) data (KT candidates = 560 143 and recipients = 243 508), we projected the national prevalence of frailty (for KT candidates and recipients separately) using standardization through inverse probability weighting, accounting for candidate/recipient, donor, and transplant factors. In our multicenter cohort, 13.3% of KT candidates were frail at evaluation; 8.2% of LDKT recipients and 17.8% of DDKT recipients were frail at transplantation. Projected nationally, our modeling strategy estimated 91 738 KT candidates or 16.4% (95% confidence interval [CI] 14.4%-18.4%) of all KT candidates during the study period were frail, and that 34 822 KT recipients or 14.3% (95% CI 12.3%-16.3%) of all KT recipients were frail (LDKT = 8.2%; DDKT = 17.8%). Given the estimated national prevalence of frailty, transplant programs should consider assessing the condition during KT evaluation to improve patient counseling and resource allocation along with identification of recipients at risk for poor outcomes.
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Affiliation(s)
- Christine E. Haugen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alvin G. Thomas
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nadia M. Chu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Ashton A. Shaffer
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Silas P. Norman
- Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Adam W. Bingaman
- Department of Surgery, Methodist Specialty and Transplant Hospital, San Antonio, Texas
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Mara McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
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McAdams-DeMarco MA, Van Pilsum Rasmussen SE, Chu NM, Agoons D, Parsons RF, Alhamad T, Johansen KL, Tullius SG, Lynch R, Harhay MN, Rao MK, Berger J, Cooper M, Tan JC, Cheng XS, Woodside KJ, Parajuli S, Lentine KL, Kaplan B, Segev DL, Kobashigawa JA, Dadhania D. Perceptions and Practices Regarding Frailty in Kidney Transplantation: Results of a National Survey. Transplantation 2020; 104:349-356. [PMID: 31343576 PMCID: PMC6834867 DOI: 10.1097/tp.0000000000002779] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Given the potential utility of frailty, a clinical phenotype of decreased physiologic reserve and resistance to stressors, to predict postkidney transplant (KT) outcomes, we sought to understand the perceptions and practices regarding frailty measurement in US KT programs. METHODS Surveys were emailed to American Society of Transplantation Kidney/Pancreas Community of Practice members and 202 US transplant programs (November 2017 to April 2018). Program characteristics were gleaned from Scientific Registry of Transplant Recipients. RESULTS The 133 responding programs (response rate = 66%) represented 77% of adult KTs and 79% of adult KT candidates in the United States. Respondents considered frailty to be a useful concept in evaluating candidacy (99%) and endorsed a need to develop a frailty measurement specific to KT (92%). Frailty measurement was more common during candidacy evaluation (69%) than during KT admission (28%). Of the 202 programs, 38% performed frailty assessments in all candidates while 23% performed assessments only for older candidates. There was heterogeneity in the frailty assessment method; 18 different tools were utilized to measure frailty. The most common tool was a timed walk test (19%); 67% reported performing >1 tool. Among programs that measure frailty, 53% reported being less likely to list frail patients for KT. CONCLUSIONS Among US KT programs, frailty is recognized as a clinically relevant construct and is commonly measured at evaluation. However, there is considerable heterogeneity in the tools used to measure frailty. Efforts to identify optimal measurement of frailty using either an existing or a novel tool and subsequent standardization of its measurement and application across KT programs should be considered.
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Affiliation(s)
- Mara A McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | - Nadia M Chu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Dayawa Agoons
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ronald F Parsons
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Tarek Alhamad
- Division of Nephrology, Washington University in St. Louis, St. Louis, MO
| | | | - Stefan G Tullius
- Department of Surgery, Division of Transplant Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Raymond Lynch
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Meera N Harhay
- Department of Medicine, Division of Nephrology, Drexel University College of Medicine, Philadelphia, PA
- Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, PA
| | - Maya K Rao
- Division of Nephrology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Joseph Berger
- Division of Nephrology, University of Texas Southwestern Medical School, Dallas, TX
| | - Matthew Cooper
- Department of Surgery, Georgetown University School of Medicine, Washington, DC
| | - Jane C Tan
- Department of Medicine, Division of Nephrology, Stanford University, Stanford, CA
| | - XingXing S Cheng
- Department of Medicine, Division of Nephrology, Stanford University, Stanford, CA
| | - Kenneth J Woodside
- Department of Surgery, Medical School, University of Michigan, Ann Arbor, MI
| | - Sandesh Parajuli
- Department of Medicine, Division of Nephrology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Krista L Lentine
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, MO
| | | | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Jon A Kobashigawa
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Darshana Dadhania
- Division of Nephrology and Hypertension, Weill Cornell Medicine, New York, NY
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40
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Haugen CE, Agoons D, Chu NM, Liyanage L, Long J, Desai NM, Norman SP, Brennan DC, Segev DL, McAdams-DeMarco M. Physical Impairment and Access to Kidney Transplantation. Transplantation 2020; 104:367-373. [PMID: 31033648 PMCID: PMC6814511 DOI: 10.1097/tp.0000000000002778] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND The short physical performance battery (SPPB) test is an objective measurement of lower extremity function (walk speed, balance, chair stands). SPPB impairment is associated with longer length of stay and increased mortality in kidney transplant (KT) recipients. Furthermore, the SPPB test may represent an objective quantification of the "foot of the bed test" utilized by clinicians; therefore, impairment may translate with decreased access to KT. METHODS We studied 3255 participants (2009-2018) at 2 KT centers. SPPB impairment was defined as a score of ≤10. We estimated time to listing, waitlist mortality, and transplant rate by SPPB impairment status using Cox proportional hazards, competing risks, and Poisson regression. RESULTS The mean age was 54 years (SD = 14; range 18-89) and 54% had SPPB impairment. Impaired participants were less likely to be listed for KT (adjusted hazard ratio: 0.70, 95% CI: 0.64-0.77, P < 0.001). Also, once listed, impaired candidates had a 1.6-fold increased risk of waitlist mortality (adjusted subhazard ratio: 1.56, 95% CI: 1.18-2.06, P = 0.002). Furthermore, impaired candidates were transplanted 16% less frequently (adjusted incidence rate ratio: 0.84, 95% CI: 0.73-0.98, P = 0.02). CONCLUSIONS SPPB impairment was highly prevalent in KT candidates. Impaired candidates had decreased chance of listing, increased risk of waitlist mortality, and decreased rate of KT. Identification of robust KT candidates and improvement in lower extremity function are potential ways to improve survival on the waitlist and access to KT.
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Affiliation(s)
- Christine E Haugen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dayawa Agoons
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nadia M Chu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Luckimini Liyanage
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jane Long
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Niraj M Desai
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Silas P Norman
- Department of Medicine, Division of Nephrology, University of Michigan, Ann Arbor, MI
| | - Daniel C Brennan
- Department of Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Mara McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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41
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Gandolfini I, Regolisti G, Bazzocchi A, Maggiore U, Palmisano A, Piotti G, Fiaccadori E, Sabatino A. Frailty and Sarcopenia in Older Patients Receiving Kidney Transplantation. Front Nutr 2019; 6:169. [PMID: 31781571 PMCID: PMC6861371 DOI: 10.3389/fnut.2019.00169] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 10/23/2019] [Indexed: 12/14/2022] Open
Abstract
Kidney transplantation is the treatment of choice for most of the patients with end-stage renal disease (ESRD). It improves quality of life, life expectancy, and has a lower financial burden to the healthcare system in comparison to dialysis. Every year more and more older patients are included in the kidney transplant waitlist. Within this patient population, transplanted subjects have better survival and quality of life as compared to those on dialysis. It is therefore crucial to select older patients who may benefit from renal transplantation, as well as those particularly at risk for post-transplant complications. Sarcopenia and frailty are frequently neglected in the evaluation of kidney transplant candidates. Both conditions are interrelated complex geriatric syndromes that are linked to disability, aging, comorbidities, increased mortality, and graft failure post-transplantation. Chronic kidney disease (CKD) and more importantly ESRD are characterized by multiple metabolic complications that contribute for the development of sarcopenia and frailty. In particular, anorexia, metabolic acidosis and chronic low-grade inflammation are the main contributors to the development of sarcopenia, a key component in frail transplant candidates and recipients. Both frailty and sarcopenia are considered to be reversible. Frail patients respond well to multiprofessional interventions that focus on the patients' positive frailty criteria, while physical rehabilitation and oral supplementation may improve sarcopenia. Prospective studies are still needed to evaluate the utility of formally measuring frailty and sarcopenia in the older candidates to renal transplantation as part of the transplant evaluation process.
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Affiliation(s)
- Ilaria Gandolfini
- UO Nefrologia, Azienda Ospedaliero-Universitaria di Parma & Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
- Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Giuseppe Regolisti
- UO Nefrologia, Azienda Ospedaliero-Universitaria di Parma & Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
- Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Alberto Bazzocchi
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Umberto Maggiore
- UO Nefrologia, Azienda Ospedaliero-Universitaria di Parma & Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
- Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Alessandra Palmisano
- UO Nefrologia, Azienda Ospedaliero-Universitaria di Parma & Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Giovanni Piotti
- UO Nefrologia, Azienda Ospedaliero-Universitaria di Parma & Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Enrico Fiaccadori
- UO Nefrologia, Azienda Ospedaliero-Universitaria di Parma & Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
- Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Alice Sabatino
- Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
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Wu PY, Chao CT, Chan DC, Huang JW, Hung KY. Contributors, risk associates, and complications of frailty in patients with chronic kidney disease: a scoping review. Ther Adv Chronic Dis 2019; 10:2040622319880382. [PMID: 31632625 PMCID: PMC6778996 DOI: 10.1177/2040622319880382] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 09/11/2019] [Indexed: 12/23/2022] Open
Abstract
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.
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Affiliation(s)
| | - Chia-Ter Chao
- Department of Medicine, National Taiwan University Hospital BeiHu Branch, College of Medicine, National Taiwan University, Taipei, Geriatric and Community Medicine Research Center, National Taiwan University Hospital BeiHu Branch, Taipei, Graduate Institute of Toxicology, National Taiwan University, NO.87, Nei-Jiang Street, WanHua District, 108 Taipei, Taiwan
| | - Ding-Cheng Chan
- Department of Medicine, National Taiwan University Hospital ChuTung Branch, Hsin-Chu County
- Department of Geriatrics and Gerontology, National Taiwan University Hospital, Taipei
| | - Jenq-Wen Huang
- Nephrology Division, Department of Internal Medicine, National Taiwan University Hospital, Taipei
| | - Kuan-Yu Hung
- Nephrology Division, Department of Internal Medicine, National Taiwan University Hospital, Taipei
- Department of Internal Medicine, National Taiwan University Hospital HsinChu branch, HsinChu County
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43
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Changes in Frailty Status: Some Better, Some Worse. Transplantation 2019; 103:1540-1541. [PMID: 30753176 DOI: 10.1097/tp.0000000000002564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Cheng XS, Lentine KL, Koraishy FM, Myers J, Tan JC. Implications of Frailty for Peritransplant Outcomes in Kidney Transplant Recipients. CURRENT TRANSPLANTATION REPORTS 2019; 6:16-25. [PMID: 31131186 DOI: 10.1007/s40472-019-0227-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Purpose of Review Research over the past few decades points to the importance of frailty, or the lack of physiologic reserve, in the natural history of chronic diseases and in modifying the impact of potential interventions. End-stage kidney disease (ESKD) and the intervention of kidney transplantation are no exception. We review the recent epidemiologic and cohort-based evidence on the association between frailty and kidney transplant outcomes and provide a framework of questions with which to approach future research endeavors and clinical practice. Recent Findings Frailty in kidney transplant candidates can be measured in numerous ways, including descriptive phenotype, description scores, functional testing, and surrogate measures. Regardless of the metric, the presence of frailty is strongly associated with inferior pre- and posttransplant outcomes compared to the absence of frailty. However, some frail patients with ESKD can benefit from transplant over chronic dialysis. Evidence-based approaches for identifying frail ESKD patients who can benefit from transplant over dialysis, with acceptable posttransplant outcomes, are lacking. Interventional trials to improve frailty and physical function before transplant (prehabilitation) and after transplant (rehabilitation) are also lacking. Conclusion Frailty is increasingly recognized as highly relevant to peritransplant outcomes, but more work is needed to: 1) tailor management to the unique needs of frail patients, both pre- and posttransplant; 2) define phenotypes of frail patients who are expected to benefit from transplant over dialysis; and 3) develop interventions to reverse frailty, both pre- and post-transplant.
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Affiliation(s)
- Xingxing S Cheng
- Department of Medicine, Division of Nephrology, Stanford University, Stanford CA
| | - Krista L Lentine
- Department of Medicine, Division of Nephrology, Saint Louis University, St. Louis MO
| | - Farrukh M Koraishy
- Department of Medicine, Division of Nephrology, Saint Louis University, St. Louis MO
| | - Jonathan Myers
- Department of Medicine, Division of Cardiology, Palo Alto VA Hospital and Stanford University, Palo Alto CA
| | - Jane C Tan
- Department of Medicine, Division of Nephrology, Stanford University, Stanford CA
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