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Nair D, Liu CK, Raslan R, McAdams-DeMarco M, Hall RK. Frailty in Kidney Disease: A Comprehensive Review to Advance Its Clinical and Research Applications. Am J Kidney Dis 2024:S0272-6386(24)00836-9. [PMID: 38906506 DOI: 10.1053/j.ajkd.2024.04.018] [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: 01/27/2024] [Revised: 04/05/2024] [Accepted: 04/20/2024] [Indexed: 06/23/2024]
Abstract
Frailty is a multi-system syndrome of decreased physiologic reserve that has been shown to strongly and independently predict morbidity and mortality. Frailty is prevalent in patients living with kidney disease and occurs earlier in individuals with kidney disease as compared to the general population. In this comprehensive review, we aim to advance the clinical and research applications of frailty in kidney disease populations. Specifically, we clarify the definition of frailty and address its common misconceptions; review the mechanisms and epidemiology of frailty in kidney disease; discuss challenges and limitations in frailty measurement; and provide updated evidence related to risk factors for frailty, its associated adverse outcomes, and interventions. We further add to the literature in this topic by highlighting potential applications of frailty measurement in care of patients with kidney disease and conclude with our recommendations for future research related to this important syndrome.
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Affiliation(s)
- Devika Nair
- Vanderbilt University Medical Center, Division of Nephrology and Hypertension - Nashville, Tennessee; Vanderbilt Center for Health Services Research - Nashville, Tennessee; Tennessee Valley Veterans Affairs Healthcare System - Nashville, Tennessee
| | - Christine K Liu
- Geriatric Research and Education Clinical Center, Veteran Affairs Palo Alto Health Care System, Palo Alto, California; Section of Geriatric Medicine, Division of Primary Care and Population Health, Stanford University School of Medicine - Stanford, California
| | - Rasha Raslan
- Department of Medicine, Duke University School of Medicine - Durham, North Carolina
| | - Mara McAdams-DeMarco
- Department of Surgery, New York University Langone Health and Grossman School of Medicine - New York, New York; Department of Population Health, New York University Langone Health and Grossman School of Medicine - New York, New York
| | - Rasheeda K Hall
- Department of Medicine, Duke University School of Medicine - Durham, North Carolina; Durham Veterans Affairs Medical Center - Durham, North Carolina.
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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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Hannan M, Chen J, Hsu J, Zhang X, Saunders MR, Brown J, McAdams-DeMarco M, Mohanty MJ, Vyas R, Hajjiri Z, Carmona-Powell E, Meza N, Porter AC, Ricardo AC, Lash JP. Frailty and Cardiovascular Outcomes in Adults With CKD: Findings From the Chronic Renal Insufficiency Cohort (CRIC) Study. Am J Kidney Dis 2024; 83:208-215. [PMID: 37741609 PMCID: PMC10810341 DOI: 10.1053/j.ajkd.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 06/13/2023] [Accepted: 06/23/2023] [Indexed: 09/25/2023]
Abstract
RATIONALE & OBJECTIVE Frailty is common in individuals with chronic kidney disease (CKD) and increases the risk of adverse outcomes in adults with kidney failure requiring dialysis. However, this relationship has not been thoroughly evaluated among those with non-dialysis-dependent CKD. STUDY DESIGN Prospective cohort study. SETTING & PARTICIPANTS 2,539 adults in the Chronic Renal Insufficiency Cohort Study. EXPOSURE Frailty status assessed using 5 criteria: slow gait speed, muscle weakness, low physical activity, exhaustion, and unintentional weight loss. OUTCOME Atherosclerotic events, incident heart failure, all-cause death, and cardiovascular death. ANALYTICAL APPROACH Cause-specific hazards models. RESULTS At study entry, the participants' mean age was 62 years, 46% were female, the mean estimated glomerular filtration rate was 45.4mL/min/1.73m2, and the median urine protein was 0.2mg/day. Frailty status was as follows: 12% frail, 51% prefrail, and 37% nonfrail. Over a median follow-up of 11.4 years, there were 393 atherosclerotic events, 413 heart failure events, 497 deaths, and 132 cardiovascular deaths. In multivariable regression analyses, compared with nonfrailty, both frailty and prefrailty status were each associated with higher risk of an atherosclerotic event (HR, 2.03 [95% CI, 1.41-2.91] and 1.77 [95% CI, 1.35-2.31], respectively) and incident heart failure (HR, 2.22 [95% CI, 1.59-3.10] and 1.39 [95% CI, 1.07-1.82], respectively), as well as higher risk of all-cause death (HR, 2.52 [95% CI, 1.84-3.45] and 1.76 [95% CI, 1.37-2.24], respectively) and cardiovascular death (HR, 3.01 [95% CI, 1.62-5.62] and 1.78 [95% 1.06-2.99], respectively). LIMITATIONS Self-report of aspects of the frailty assessment and comorbidities, which may have led to bias in some estimates. CONCLUSIONS In adults with CKD, frailty status was associated with higher risk of cardiovascular events and mortality. Future studies are needed to evaluate the impact of interventions to reduce frailty on cardiovascular outcomes in this population. PLAIN-LANGUAGE SUMMARY Frailty is common in individuals with chronic kidney disease (CKD) and increases the risk of adverse outcomes. We sought to evaluate the association of frailty status with cardiovascular events and death in adults with CKD. Frailty was assessed according to the 5 phenotypic criteria detailed by Fried and colleagues. Among 2,539 participants in the CRIC Study, we found that 12% were frail, 51% were prefrail, and 37% were nonfrail. Frailty status was associated with an increased risk of atherosclerotic events, incident heart failure, and death.
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Affiliation(s)
- Mary Hannan
- Department of Biobehavioral Nursing Science, College of Nursing, University of Illinois Chicago, Chicago, Illinois.
| | - Jinsong Chen
- Department of Medicine, College of Medicine, University of Illinois Chicago, Chicago, Illinois; School of Public Health, University of Nevada, Reno, Reno, Nevada
| | - Jesse Hsu
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Xiaoming Zhang
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Milda R Saunders
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Julia Brown
- Department of Medicine, College of Medicine, University of Illinois Chicago, Chicago, Illinois
| | - Mara McAdams-DeMarco
- Department of Surgery, New York University Grossman School of Medicine, New York, New York
| | - Madhumita Jena Mohanty
- Department of Internal Medicine, School of Medicine, Wayne State University, Detroit, Michigan
| | - Rahul Vyas
- Department of Internal Medicine, School of Medicine, Wayne State University, Detroit, Michigan
| | - Zahraa Hajjiri
- Department of Medicine, College of Medicine, University of Illinois Chicago, Chicago, Illinois
| | - Eunice Carmona-Powell
- Department of Medicine, College of Medicine, University of Illinois Chicago, Chicago, Illinois
| | - Natalie Meza
- Department of Medicine, College of Medicine, University of Illinois Chicago, Chicago, Illinois
| | - Anna C Porter
- Department of Medicine, College of Medicine, University of Illinois Chicago, Chicago, Illinois; Jesse Brown VA Hospital, Chicago, Illinois
| | - Ana C Ricardo
- Department of Medicine, College of Medicine, University of Illinois Chicago, Chicago, Illinois
| | - James P Lash
- Department of Medicine, College of Medicine, University of Illinois Chicago, Chicago, Illinois
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Xu EJ, Kyriazis P, Pawar A, Pavlakis M, Aala A. Frailty and Kidney Transplant Waitlisting: A Single-Center Experience. Transplant Proc 2024; 56:37-43. [PMID: 38195285 DOI: 10.1016/j.transproceed.2023.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 09/28/2023] [Accepted: 10/22/2023] [Indexed: 01/11/2024]
Abstract
BACKGROUND Frailty is widely prevalent among kidney transplant (KT) candidates and is associated with poor peri and post-transplant outcomes. Whether frailty is a modifiable risk factor in KT candidates is unknown. Efforts to intervene in frailty have been hindered by a lack of a standardized approach to testing and treating frailty in clinical practice. METHODS Patients undergoing evaluation for kidney transplantation underwent frailty testing during their clinical visits using a combination of the Short Physical Performance Battery (SPPB) and Groningen Frailty Indicator (GFI) instruments. Scores from the SPPB and GFI were combined to stratify patients into 4 risk groups. Patients in the highest-risk groups were referred to physical therapy (PT) and returned for repeat frailty testing. Pre- and post-PT scores were compared with assessment for improvement. RESULTS Forty patients met the criteria for PT, of which 16 (40%) completed PT and returned for repeat frailty testing. The mean SPPB score improved from 5.88 to 8.94 after PT (P < .01). The mean GFI score improved from 5.25 to 4.06 after PT but was not statistically significant (P = .081). CONCLUSIONS Our unique approach of using 2 validated scores, SPPB and GFI, together addressed many components of frailty evaluation, including physical, cognitive, and psychosocial components. We used PT as a targeted intervention for addressing both the physical and non-physical impairments among frail KT candidates. Physical therapy was noted to have a positive impact on each of these components.
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Affiliation(s)
- Eric J Xu
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Periklis Kyriazis
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Aditya Pawar
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Martha Pavlakis
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Amtul Aala
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
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Castle EM, Billany RE, Lightfoot CJ, Annema C, De Smet S, Graham-Brown MP, Greenwood SA. Exercise as a therapeutic intervention in chronic kidney disease: are we nearly there yet? Curr Opin Nephrol Hypertens 2023; 32:502-508. [PMID: 37622530 PMCID: PMC10552838 DOI: 10.1097/mnh.0000000000000923] [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] [Indexed: 08/26/2023]
Abstract
PURPOSE OF REVIEW The opportunity to review the more recent evidence for prescribing exercise-based physical rehabilitation for people living with chronic kidney disease (CKD) is timely. There has been a recent global focus evaluating how physical activity interventions might improve health-related quality of life and outcomes for people living with chronic health conditions in a post-COVID era. There is finally a long overdue commitment from the kidney research and clinical community to deliver pragmatic interventions to help people living with CKD to be able to live well with their condition. RECENT FINDINGS This article reviews recent research, and discusses the challenges and potential solutions, for providing exercise-based therapeutic options for people living with CKD; including predialysis self-management interventions, options for both prehabilitation and posttransplant rehabilitation, pragmatic considerations for delivery of exercise therapy for people receiving haemodialysis treatment and the role of virtual kidney-specific rehabilitation. SUMMARY Whilst there remains a need for further research in this area of patient care, there is now a body of evidence and kidney-specific guidelines that firmly support a rollout of pragmatic and scalable exercise-based interventions for people living with CKD. We are indeed nearly there now.
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Affiliation(s)
- Ellen M. Castle
- Physiotherapy, Department of Health Sciences, College of Health, Medicine, and life Sciences, Brunel University, London, UK
| | - Roseanne E. Billany
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Courtney J. Lightfoot
- Leicester Kidney Lifestyle Team, Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - Coby Annema
- Section of Nursing Science, Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Stefan De Smet
- Group Rehabilitation for Internal Disorders, Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
- Nephrology and Renal Transplantation, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Laboratory of Abdominal Transplantation, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | | | - Sharlene A. Greenwood
- Renal Therapies, King's College Hospital NHS Trust, London, UK
- Faculty of Life Sciences & Medicine, King's College London, London, UK
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Lorenz EC, Hickson LJ, Hogan MC, Kennedy CC. Examining the safety and effectiveness of a 4-week supervised exercise intervention in the treatment of frailty in patients with chronic kidney disease. Clin Kidney J 2023; 16:2003-2010. [PMID: 37915911 PMCID: PMC10616430 DOI: 10.1093/ckj/sfad192] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Indexed: 11/03/2023] Open
Abstract
Background The optimal duration of antifrailty interventions and how best to deliver them to patients with chronic kidney disease (CKD) is unknown. The aim of this study was to examine the safety, feasibility and preliminary efficacy of a 4-week supervised exercise intervention on frailty in patients with CKD. Methods We conducted a prospective feasibility study involving patients with ≥stage 3 CKD (1 patient with stage 3 CKD, 7 patients with stage 4 CKD and 17 patients with stage 5 CKD) who were either frail or prefrail according to the physical frailty phenotype and/or had a Short Physical Performance Battery (SPPB) score ≤10. The exercise intervention consisted of two supervised outpatient sessions per week for 4 weeks (eight total sessions). Frailty and other study measures were assessed at baseline and after 4 weeks of exercise. Results Of the 34 participants who completed the baseline assessment and were included in the analyses, 25 (73.5%) completed the 4-week assessment. Overall, 64.0% of patients were on dialysis and 64.0% had diabetes mellitus. After 4 weeks of exercise, frailty prevalence, total SPPB scores and energy/fatigue scores improved. No adverse study-related outcomes were reported. Conclusions The 4 weeks of supervised exercise was safe, was associated with an excellent completion rate and improved frailty parameters in CKD patients with CKD. This study provides important preliminary data for a future larger prospective randomized study. Clinical Trialgov registration: NCT03535584.
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Affiliation(s)
| | - LaTonya J Hickson
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, FL, USA
| | - Marie C Hogan
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Cassie C Kennedy
- Division of Pulmonary, Critical Care, and Sleep Medicine, Mayo Clinic, Rochester, MN, USA
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Drewniok N, Kiselev J, Daum N, Mörgeli R, Spies C, Schaller SJ. Concepts for exercise therapy in prehabilitation for elderly people with frailty or pre-frailty prior to elective surgery. A scoping review. J Bodyw Mov Ther 2023; 36:74-82. [PMID: 37949603 DOI: 10.1016/j.jbmt.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 03/19/2023] [Accepted: 05/01/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Frailty is a state of reduced functional capacities in older people that can be reversed through multimodal therapy concepts. The effect of preoperative prehabilitation on frailty has been examined, but the heterogeneity of exercise regimens has prevented conclusive evidence. This scoping review analyses prehabilitation interventions, particularly exercise methods, published in trials for prefrail and frail elderly patients. METHOD We identified studies evaluating prehabilitation for frail elderly using the framework of Arksey and O'Malley. Five scientific databases were searched until March 2022. Articles were screened by two independent reviewers. Data extraction included, but was not limited to, study design, intervention protocol of the prehabilitation including exercise therapy and additional interventions, and safety of the reported exercise concepts. RESULTS Nineteen studies were included, offering an insight into the utilized prehabilitation concepts for exercise. All study interventions were based around exercise programs, potentially with complementary interventions. Twelve studies based their exercise programs on a combination of endurance and strength training. Breathing exercises were prescribed in five studies, flexibility routines in five, and one study included balance training. Further interventions included nutritional counselling/supplementation in nine studies, smoking/alcohol cessation in five, in addition to two physiological and three medical/pharmaceutical interventions. DISCUSSION Prehabilitation for the frail elderly is safe and feasible. The general concept of prehabiliation for frail patients is promising. An exercise program should focus on improving the patient's endurance and strength, considering the positive effects that can be provided by breathing exercises and other additional interventions, such as nutritional support or lifestyle counselling.
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Affiliation(s)
- Nils Drewniok
- Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin, Germany
| | - Jörn Kiselev
- Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin, Germany
| | - Nils Daum
- Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin, Germany
| | - Rudolf Mörgeli
- Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin, Germany
| | - Claudia Spies
- Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin, Germany
| | - Stefan J Schaller
- Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin, Germany.
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Quint EE, Haanstra AJ, van der Veen Y, Maring H, Berger SP, Ranchor A, Bakker SJL, Finnema E, Pol RA, Annema C. PREhabilitation of CAndidates for REnal Transplantation (PreCareTx) study: protocol for a hybrid type I, mixed method, randomised controlled trial. BMJ Open 2023; 13:e072805. [PMID: 37500274 PMCID: PMC10387712 DOI: 10.1136/bmjopen-2023-072805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/29/2023] Open
Abstract
INTRODUCTION Kidney transplant candidates (KTCs) need to be in optimal physical and psychological condition prior to surgery. However, KTCs often experience compromised functional capacity which can be characterised as frailty. Prehabilitation, the enhancement of a person's functional capacity, may be an effective intervention to improve the health status of KTCs. The PREhabilitation of CAndidates for REnal Transplantation (PreCareTx) study aims to examine the effectiveness of a multimodal prehabilitation programme on the health status of KTCs, and to explore the potential of implementation of prehabilitation in daily clinical practice. METHODS AND ANALYSIS This study uses a single centre, effectiveness-implementation hybrid type I study design, comprised of a randomised controlled trial and a mixed-methods study. Adult patients who are currently on the transplant waiting list or are waitlisted during the study period, at a university medical centre in The Netherlands, will be randomly assigned to either prehabilitation (n=64) or care as usual (n=64) groups. The prehabilitation group will undergo a 12-week home-based, tailored prehabilitation programme consisting of physical and/or nutritional and/or psychosocial interventions depending on the participant's deficits. This programme will be followed by a 12-week maintenance programme in order to enhance the incorporation of the interventions into daily life. The primary endpoint of this study is a change in frailty status as a proxy for health status. Secondary endpoints include changes in physical fitness, nutritional status, psychological well-being, quality of life and clinical outcomes. Tertiary endpoints include the safety, feasibility and acceptability of the prehabilitation programme, and the barriers and facilitators for further implementation. ETHICS AND DISSEMINATION Medical ethical approval was granted by the Medical Ethics Committee Groningen, Netherlands (M22.421). Written informed consent will be obtained from all participants. The results will be disseminated at international conferences and in peer-reviewed journals. TRIAL REGISTRATION NUMBER ClinicalTrials.gov, NCT05489432.
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Affiliation(s)
- Evelien E Quint
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Avril J Haanstra
- Department of Health Sciences, Section of Nursing Science, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Yvonne van der Veen
- Department of Health Sciences, Section of Nursing Science, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Internal Medicine, Department of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Heleen Maring
- Department of Health Sciences, Section of Nursing Science, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Physical Therapy, University Medical Center Groningen, Groningen, The Netherlands
| | - Stefan P Berger
- Internal Medicine, Department of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Adelita Ranchor
- Department of Health Sciences, Section of Health Psychology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Stephan J L Bakker
- Internal Medicine, Department of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Evelyn Finnema
- Department of Health Sciences, Section of Nursing Science, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Robert A Pol
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Coby Annema
- Department of Health Sciences, Section of Nursing Science, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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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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10
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Annema C, De Smet S, Castle EM, Overloop Y, Klaase JM, Janaudis-Ferreira T, Mathur S, Kouidi E, Perez Saez MJ, Matthys C, Dobbels F, Ferrari P, Gołębiewska J, Mrzljak A, Girman P, Perch M, Lopez-Lopez V, White C, Koval D, Greenwood S, Monbaliu D. European Society of Organ Transplantation (ESOT) Consensus Statement on Prehabilitation for Solid Organ Transplantation Candidates. Transpl Int 2023; 36:11564. [PMID: 37547750 PMCID: PMC10401602 DOI: 10.3389/ti.2023.11564] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 06/15/2023] [Indexed: 08/08/2023]
Abstract
There is increasingly growing evidence and awareness that prehabilitation in waitlisted solid organ transplant candidates may benefit clinical transplant outcomes and improve the patient's overall health and quality of life. Lifestyle changes, consisting of physical training, dietary management, and psychosocial interventions, aim to optimize the patient's physical and mental health before undergoing surgery, so as to enhance their ability to overcome procedure-associated stress, reduce complications, and accelerate post-operative recovery. Clinical data are promising but few, and evidence-based recommendations are scarce. To address the need for clinical guidelines, The European Society of Organ Transplantation (ESOT) convened a dedicated Working Group "Prehabilitation in Solid Organ Transplant Candidates," comprising experts in physical exercise, nutrition and psychosocial interventions, to review the literature on prehabilitation in this population, and develop recommendations. These were discussed and voted upon during the Consensus Conference in Prague, 13-15 November 2022. A high degree of consensus existed amongst all stakeholders including transplant recipients and their representatives. Ten recommendations were formulated that are a balanced representation of current published evidence and real-world practice. The findings and recommendations of the Working Group on Prehabilitation for solid organ transplant candidates are presented in this article.
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Affiliation(s)
- Coby Annema
- Section of Nursing Science, Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Stefan De Smet
- Group Rehabilitation for Internal Disorders, Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
- Nephrology and Renal Transplantation, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Laboratory of Abdominal Transplantation, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Ellen M. Castle
- Physiotherapy, Department of Health Sciences, College of Health, Medicine and Life Sciences, Brunel University London, London, United Kingdom
| | - Yasna Overloop
- Department of Endocrinology, University Hospitals Leuven, Leuven, Belgium
| | - Joost M. Klaase
- Section of Hepatobiliary Surgery & Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Tania Janaudis-Ferreira
- Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, Research Institute of McGill University Health Centre, Montreal, QC, Canada
- School of Physical and Occupational Therapy, McGill University, Montreal, QC, Canada
| | - Sunita Mathur
- School of Rehabilitation Therapy, Queen’s University, Kingston, ON, Canada
| | - Evangelia Kouidi
- Laboratory of Sports Medicine, Department of Physical Education and Sports Science, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Christophe Matthys
- Department of Endocrinology, University Hospitals Leuven, Leuven, Belgium
- Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Fabienne Dobbels
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium
| | - Pisana Ferrari
- Associazione Italiana Ipertensione Polmonare (AIPI), Bologna, Italy
| | - Justyna Gołębiewska
- Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Anna Mrzljak
- Liver Transplant Center, University Hospital Center Zagreb, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Peter Girman
- Diabetes Center, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Michael Perch
- Section of Lung Transplantation, Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Victor Lopez-Lopez
- Department of General, Visceral and Transplant Surgery, Hospital Clínico y Universitario Virgen de La Arrixaca, Murcia, Spain
| | - Colin White
- Representative of the European Kidney Patients’ Federation, Dublin, Ireland
| | - Dmytro Koval
- Ukrainian Transplant Coordination Center, Specialized State Institution, Kiev, Ukraine
| | - Sharlene Greenwood
- Renal Medicine and Therapies, King’s College Hospital NHS Trust, London, United Kingdom
- Centre for Nephrology, Urology and Transplantation, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Diethard Monbaliu
- Laboratory of Abdominal Transplantation, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Transplantoux Foundation, Leuven, Belgium
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11
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Karnabi P, Massicotte-Azarniouch D, Ritchie LJ, Marshall S, Knoll GA. Physical Frailty and Functional Status in Patients With Advanced Chronic Kidney Disease: A Systematic Review. Can J Kidney Health Dis 2023; 10:20543581231181026. [PMID: 37377480 PMCID: PMC10291542 DOI: 10.1177/20543581231181026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 05/04/2023] [Indexed: 06/29/2023] Open
Abstract
Background With an aging population and growing number of patients with chronic kidney disease (CKD), integrating the latest risk factors when deciding on a treatment plan can result in better patient care. Frailty remains a prevalent syndrome in CKD resulting in adverse health outcomes. However, measures of frailty and functional status remain excluded from clinical decision making. Objective To examine the degree to which different measures of frailty and functional status are associated with mortality, hospitalization, and other clinical outcomes in patients with advanced CKD. Design Systematic review. Setting Observation studies including cohort study, case-control study, or cross-sectional study examining frailty and functional status on clinical outcomes. There were no restrictions on type of setting or country of origin. Patients Adults with advanced CKD, including both types of dialysis patients. Measurements Data including demographic information (e.g., sample size, follow-up time, age, country), assessments of frailty or functional status and their domains, and outcomes including mortality, hospitalization, cardiovascular events, kidney function, and composite outcomes were extracted. Methods A search was conducted using databases Medline, Embase, and Cochrane Central Register for Controlled Trials. Studies were included from inception to March 17, 2021. The eligibility of studies was screened by 2 independent reviewers. Data were presented by instrument and clinical outcome. Point estimates and 95% confidence intervals from the fully adjusted statistical model were reported or calculated from the raw data. Results A total of 117 unique instruments were found among 140 studies. The median sample size of studies was 319 (interquartile range, 161-893). Most studies focused on incident and chronic dialysis patient populations, with only 15% of studies examining non-dialysis CKD patients. Frailty and lower functional status were associated with an increased risk for adverse clinical outcomes such as mortality and hospitalization. The 5 individual domains of frailty were also found to be associated with poor health outcomes. Limitations Meta-analysis could not be performed due to significant heterogeneity between studies and methods used to measure frailty and functional status. Many studies had issues with methodological rigor. Selection bias and the validity of data collection could not be ascertained for some studies. Conclusion Frailty and functional status measures should be integrated to help guide clinical care decision making for a comprehensive assessment of risk for adverse outcomes among patients with advanced CKD. Registration PROSPERO CRD42016045251.
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Affiliation(s)
- Priscilla Karnabi
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, ON, Canada
| | - David Massicotte-Azarniouch
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, ON, Canada
- Department of Medicine, University of Ottawa, ON, Canada
- Division of Nephrology, Kidney Research Centre, The Ottawa Hospital Research Institute, ON, Canada
| | - Lindsay J. Ritchie
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, ON, Canada
| | - Shawn Marshall
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, ON, Canada
- Department of Medicine, University of Ottawa, ON, Canada
| | - Greg A. Knoll
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, ON, Canada
- Department of Medicine, University of Ottawa, ON, Canada
- Division of Nephrology, Kidney Research Centre, The Ottawa Hospital Research Institute, ON, Canada
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12
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Lorenz EC, Hickson LJ, Khairallah P, Najafi B, Kennedy CC. Cellular Senescence and Frailty in Transplantation. CURRENT TRANSPLANTATION REPORTS 2023; 10:51-59. [PMID: 37576589 PMCID: PMC10414789 DOI: 10.1007/s40472-023-00393-6] [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] [Accepted: 02/16/2023] [Indexed: 03/28/2023]
Abstract
Purpose of review To summarizes the literature on cellular senescence and frailty in solid-organ transplantation and highlight the emerging role of senotherapeutics as a treatment for cellular senescence. Recent findings Solid-organ transplant patients are aging. Many factors contribute to aging acceleration in this population, including cellular senescence. Senescent cells accumulate in tissues and secrete proinflammatory and profibrotic proteins which result in tissue damage. Cellular senescence contributes to age-related diseases and frailty. Our understanding of the role cellular senescence plays in transplant-specific complications such as allograft immunogenicity and infections is expanding. Promising treatments, including senolytics, senomorphics, cell-based regenerative therapies, and behavioral interventions, may reduce cellular senescence abundance and frailty in patients with solid-organ transplants. Summary Cellular senescence and frailty contribute to adverse outcomes in solid-organ transplantation. Continued pursuit of understanding the role cellular senescence plays in transplantation may lead to improved senotherapeutic approaches and better graft and patient outcomes.
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Affiliation(s)
| | - LaTonya J. Hickson
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, Florida
| | | | - Bijan Najafi
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, Texas
| | - Cassie C. Kennedy
- Division of Pulmonary, Critical Care, and Sleep Medicine, Mayo Clinic, Rochester, Minnesota
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13
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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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14
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Li G, Guo QF, Zhao SP, Wang MW, Zhang X, Wang A, Gui CF, Tan QL, Gao Q. Investigation of preoperative physical activity level in kidney transplant recipients and its impact on early postoperative recovery: A retrospective cohort study. Front Surg 2023; 9:1062652. [PMID: 36684240 PMCID: PMC9852711 DOI: 10.3389/fsurg.2022.1062652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 11/21/2022] [Indexed: 01/07/2023] Open
Abstract
Objective To retrospectively investigate the preoperative physical activity (PA) level in kidney transplant recipients (KTRs) and its impact on early postoperative recovery. Methods A total of 113 patients who received kidney transplantation at West China Hospital of Sichuan University were enrolled in this retrospective cohort study. According to the PA level measured by the Chinese version of the International Physical Activity Questionnaire-Long Version, the patients were allocated into the low PA level group (Group L, n = 55) and medium to high PA level group (Group MH, n = 58). The kidney function recovery indicators, including estimated glomerular filtration rate (eGFR), postoperative complications, postoperative length of stay (LOS), and unscheduled readmission within three months of discharge, were evaluated and documented. A association analysis was applied to analyze and compare the association between indicators. Results The median PA levels of the KTRs were 1701.0 MTEs * min/week. Regarding the postoperative recovery indicators, the KTRs spent a mean time of 19.63 h to achieve transfer out of bed after the operation (Group L: 19.67 h; Group MH: 19.53 h; P = 0.952) and reached a mean distance of 183.10 m as the best ambulatory training score within two days after the operation (Group L: 134.91 m; Group MH: 228.79 m; P < 0.001). The preoperative PA level showed a moderate positive association with early postoperative ambulation distance (ρ = 0.497, P < 0.001). However, no significant between-group difference in eGFR on postoperative days 1, 3, and 5 (P = 0.913, 0.335, and 0.524) or postoperative complications, including DGF (P = 0.436), infection (P = 0.479), postoperative LOS (P = 0.103), and unscheduled readmission (P = 0.698), was found. Conclusions The preoperative PA level of KTRs is lower than that of the general population. KTRs with moderate or high preoperative PA levels showed higher ambulatory function in the early postoperative period than those with low preoperative PA levels, but no between-group differences in other early recovery indicators were observed.
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Affiliation(s)
- Guo Li
- Department of Rehabilitation Medicine, West China Hospital, Sichuan University, Chengdu, People's Rublic of China,Key Laboratory of Rehabilitation Medicine in Sichuan Province, West China Hospital, Sichuan University, Chengdu, China
| | - Qi-fan Guo
- Department of Rehabilitation Medicine, West China Hospital, Sichuan University, Chengdu, People's Rublic of China,Key Laboratory of Rehabilitation Medicine in Sichuan Province, West China Hospital, Sichuan University, Chengdu, China
| | - Shang-ping Zhao
- Centre of Kidney Transplantation, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Miao-wei Wang
- Department of Rehabilitation Medicine, West China Hospital, Sichuan University, Chengdu, People's Rublic of China,Key Laboratory of Rehabilitation Medicine in Sichuan Province, West China Hospital, Sichuan University, Chengdu, China
| | - Xia Zhang
- Department of Rehabilitation Medicine, West China Hospital, Sichuan University, Chengdu, People's Rublic of China,Key Laboratory of Rehabilitation Medicine in Sichuan Province, West China Hospital, Sichuan University, Chengdu, China
| | - Ao Wang
- Department of Rehabilitation Medicine, West China Hospital, Sichuan University, Chengdu, People's Rublic of China,Key Laboratory of Rehabilitation Medicine in Sichuan Province, West China Hospital, Sichuan University, Chengdu, China
| | - Chen-fan Gui
- Department of Rehabilitation Medicine, West China Hospital, Sichuan University, Chengdu, People's Rublic of China,Key Laboratory of Rehabilitation Medicine in Sichuan Province, West China Hospital, Sichuan University, Chengdu, China
| | - Qi-ling Tan
- Centre of Kidney Transplantation, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Qiang Gao
- Department of Rehabilitation Medicine, West China Hospital, Sichuan University, Chengdu, People's Rublic of China,Key Laboratory of Rehabilitation Medicine in Sichuan Province, West China Hospital, Sichuan University, Chengdu, China,Correspondence: Qiang Gao
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15
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Quint EE, Ferreira M, van Munster BC, Nieuwenhuijs-Moeke G, te Velde-Keyzer C, Bakker SJL, Annema C, Mathur S, Pol RA. Prehabilitation in Adult Solid Organ Transplant Candidates. CURRENT TRANSPLANTATION REPORTS 2023; 10:70-82. [PMID: 37124070 PMCID: PMC10039771 DOI: 10.1007/s40472-023-00395-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2023] [Indexed: 05/02/2023]
Abstract
Purpose of Review To highlight the importance of biological age in the context of prehabilitation and to present relevant research regarding prehabilitation prior to solid organ transplantation. Recent Findings Studies on the effect of prehabilitation have been performed in kidney-, lung-, liver-, and heart transplant patient populations. Prior to kidney transplantation, exercise interventions have been shown to improve cardiopulmonary- and physical fitness and result in a decreased length of hospital stay postoperatively. Among lung transplant candidates, various methods of prehabilitation have been studied including home-based, outpatient and in-patient programs, consisting of physical training, psychological support, education, and nutritional interventions. Overall, prehabilitation seems to improve or maintain quality of life and exercise capacity in this patient population. Patients undergoing liver transplantation seem to benefit from prehabilitation as well. Not only does it seem safe and feasible, but significant improvements in aerobic and functional capacity have also been found. Regarding heart transplant candidates, both inpatient and outpatient, supervised prehabilitation programs show promising results with improvements in exercise capacities and quality of life. Summary Prehabilitation is an effective and safe intervention for improving functional outcomes of solid organ transplant patients. Future studies should evaluate whether prehabilitation translates into improved pre- and post-transplant clinical outcomes.
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Affiliation(s)
- Evelien E. Quint
- Division of Transplantation Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, P.O. Box 30 001, 9700 RB Groningen, The Netherlands
| | - Manoela Ferreira
- Department of Physical Therapy, University of Toronto, Toronto, ON Canada
| | - Barbara C. van Munster
- Division of Geriatric Medicine, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Gertrude Nieuwenhuijs-Moeke
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Charlotte te Velde-Keyzer
- Division of Nephrology, Department of Internal Medicine, 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
| | - Coby Annema
- Division of Nursing Science, Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Sunita Mathur
- School of Rehabilitation Therapy, Queen’s University, Kingston Ontario, Canada
| | - Robert A. Pol
- Division of Transplantation Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, P.O. Box 30 001, 9700 RB Groningen, The Netherlands
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16
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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: 8] [Impact Index Per Article: 4.0] [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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17
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Shrestha P, Van Pilsum Rasmussen SE, Fazal M, Chu NM, Garonzik-Wang JM, Gordon EJ, McAdams-DeMarco M, Humbyrd CJ. Patient Perspectives on the Use of Frailty, Cognitive Function, and Age in Kidney Transplant Evaluation. AJOB Empir Bioeth 2022; 13:263-274. [PMID: 35802563 DOI: 10.1080/23294515.2022.2090460] [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] [Indexed: 01/29/2023]
Abstract
BACKGROUND The allocation of scarce deceased donor kidneys is a complex process. Transplant providers are increasingly relying on constructs such as frailty and cognitive function to guide kidney transplant (KT) candidate selection. Patient views of the ethical issues surrounding the use of such constructs are unclear. We sought to assess KT candidates' attitudes and beliefs about the use of frailty and cognitive function to guide waitlist selection. METHODS KT candidates were randomly recruited from an ongoing single-center cohort study of frailty and cognitive function. Semi-structured interviews were conducted, and thematic analysis was performed. Inductively derived themes were mapped onto bioethics principles. RESULTS Twenty interviews were conducted (65% contact rate, 100% participation rate) (60% male; 70% White). With respect to the use of frailty and cognitive function in waitlisting decisions, four themes emerged in which participants: (1) valued maximizing a scarce resource (utility); (2) prioritized equal access to all patients (equity); (3) appreciated a proportional approach to the use of equity and utility (precautionary utility); and (4) sought to weigh utility- and equity-based concerns regarding social support. While some participants believed frailty and cognitive function were useful constructs to maximize utility, others believed their use would jeopardize equity. Patients were uncomfortable with using single factors such as frailty or cognitive impairment to deny someone access to transplantation; participants instead encouraged using the constructs to identify opportunities for intervention to improve frailty and cognitive function prior to KT. CONCLUSIONS KT candidates' values mirrored the current allocation strategy, seeking to balance equity and utility in a just manner, albeit with conflicting viewpoints on the appropriate use of frailty and cognitive impairment in waitlisting decisions.
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Affiliation(s)
- Prakriti Shrestha
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Maria Fazal
- Johns Hopkins, University School of Medicine, Baltimore, MD, USA
| | - 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
| | | | - Elisa J Gordon
- Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Casey Jo Humbyrd
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
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18
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Ma X, Zhang Z, Peng M, Yao B, Jiang H, Ji X, You Y. Face-to-Face Mentoring, Remotely Supervised Home Exercise Prehabilitation to Improve Physical Function in Patients Awaiting Kidney Transplantation: A Randomized Clinical Trial. Front Psychol 2022; 13:831445. [PMID: 35783746 PMCID: PMC9245540 DOI: 10.3389/fpsyg.2022.831445] [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: 12/09/2021] [Accepted: 04/19/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveThis study aims to explore the feasibility, safety, and effectiveness of home exercise prehabilitation on a new social platform for remote guidance to optimize the physical function of patients with end-stage renal disease awaiting kidney transplantation and provide scientific guidance on home prehabilitation exercises for patients awaiting kidney transplantation.MethodsThe subjects of this randomized clinical trial were randomly divided into the test and control groups. The control group maintained their exercise habits, while the trial group was given a 12-week personalized home prehabilitation exercise prescription (aerobic exercise + functional resistance exercise + flexibility exercise) on a new social platform with remote guidance. The participants’ physical and cardiorespiratory fitness, quality of life, and psychological functioning were assessed before and after the intervention. The 6-min walk test (6MWT) walking distance and its percentage of attainment, the handgrip, the 5 repetition-sit-to-stand test, and the 4-m gait speed were used as primary outcome indicators, while the Short Form Health Survey SF-36 (health survey summary table) and the Hospital Anxiety and Depression scale were used as the secondary outcome indicators.ResultsAfter 12 weeks of intervention, the changes in the 6MWT measured distance (+ 44.9 ± 40.2, P = 0.001) and the percentage of 6MWT measured distance achieved (+ 6.8 ± 5.7, P = 0.001), the handgrip (+ 2.7 ± 4.3, P = 0.028), the 5-sit-to-stand test (−1.1 ± 1.4, P = 0.005), and the 4-m walking speed (−0.3 ± 0.4, P < 0.001) of the test group (n = 21) improved significantly. In the control group (n = 16), the changes in the 6MWT measured distance (−13.1 ± 57.2), the 6MWT measured distance attainment percentage (−2.1 ± 9.1), the handgrip (−0.1 ± 2.5), the 5-sit-to-stand test value (0.6 ± 2.2), and the 4-m walking speed (0.2 ± 0.5) showed no significant difference. No significant improvement in anxiety, depression, and SF-36 was noted in both the test and control groups.ConclusionThe remote coaching of home exercise pre-habilitation on a new social platform significantly improves the physical and cardiopulmonary fitness of patients with end-stage renal disease awaiting kidney transplantation. This treatment is safe and feasible in this population.
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Affiliation(s)
- Xiaojie Ma
- Department of Rehabilitation Medicine, The Second Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Zaozhang Zhang
- Department of General Practice, The Second Hospital of Hainan Medical University, Haikou, China
| | - Mengsi Peng
- Department of Rehabilitation Medicine, The Second Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Bonuan Yao
- Department of Rehabilitation Medicine, The Second Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Hongtao Jiang
- Department of Organ Transplantation, The Second Affiliated Hospital of Hainan Medical University, Haikou, China
- *Correspondence: Yong You,
| | - Xuanfu Ji
- Department of Rehabilitation Therapy Program, Hainan Medical University, Haikou, China
| | - Yong You
- Department of Neurology, The Second Hospital of Hainan Medical University, Haikou, China
- *Correspondence: Yong You,
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19
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Chan GCK, Ng JKC, Chow KM, Kwong VWK, Pang WF, Cheng PMS, Law MC, Leung CB, Li PKT, Szeto CC. Impact of frailty and its inter-relationship with lean tissue wasting and malnutrition on kidney transplant waitlist candidacy and delisting. Clin Nutr 2021; 40:5620-5629. [PMID: 34656960 DOI: 10.1016/j.clnu.2021.09.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 08/18/2021] [Accepted: 09/11/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND & AIMS Frailty and body composition contribute to adverse pre-transplant outcomes including hospitalization and waitlist mortality, but the interaction between frailty and body composition remains uncertain. METHODS Frailty was diagnosed by Clinical Frailty Scale (CFS) and a standard Frailty Questionnaire (FQ). Nutrition was evaluated by serum albumin level, subjective global assessment (SGA) and comprehensive malnutrition-inflammation score (MIS). Body composition was assessed by bioimpedance spectroscopy. All patients were followed up for three years. Primary outcome measure was a composite of death and permanent removal from waitlist. Secondary outcomes were emergency room attendance and hospitalization. RESULTS 432 prevalent peritoneal dialysis (PD) patients were recruited. 148 (34.3%) were listed on transplant waitlist. Frailty, age and comorbidity load predicted waitlisting. With time, 47 patients were delisted. Frailty by FQ (p = 0.028), serum albumin level (p = 0.005) and waist circumference (p = 0.010) predicted delisting after adjustment for confounders. Frailty significantly interacted with lean tissue wasting (FQ: p = 0.002, CFS: p = 0.048), and MIS (FQ: p = 0.004; CFS: p = 0.014) on delisting. Lean tissue wasting caused 2.56 times risk of delisting among frail individuals identified by FQ (p = 0.016), while serum albumin and the presence of diabetes mellitus predicted the risk of delisting among non-frail individuals. Lean tissue wasted and frail subjects had a higher all-cause and infection-related hospitalization. CONCLUSION Frailty predicted both kidney transplant waitlisting and subsequent delisting. Frailty interacted with body composition on transplant waitlist delisting. Lean tissue wasting and malnutrition independently predicted delisting in frail and non-frail listed subjects respectively.
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Affiliation(s)
- Gordon Chun-Kau Chan
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong, China.
| | - Jack Kit-Chung Ng
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Kai-Ming Chow
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Vickie Wai-Ki Kwong
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Wing-Fai Pang
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Phyllis Mei-Shan Cheng
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Man-Ching Law
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Chi-Bon Leung
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Philip Kam-Tao Li
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Cheuk-Chun Szeto
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong, China
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Lorenz EC, Kennedy CC, Rule AD, LeBrasseur NK, Kirkland JL, Hickson LJ. Frailty in CKD and Transplantation. Kidney Int Rep 2021; 6:2270-2280. [PMID: 34514190 PMCID: PMC8418946 DOI: 10.1016/j.ekir.2021.05.025] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 05/18/2021] [Accepted: 05/24/2021] [Indexed: 12/20/2022] Open
Abstract
The population is aging. Although older adults have higher rates of comorbidities and adverse health events, they represent a heterogeneous group with different health trajectories. Frailty, a clinical syndrome of decreased physiological reserve and increased susceptibility to illness and death, has emerged as a potential risk stratification tool in older patients with chronic kidney disease (CKD). Frailty is commonly observed in patients with CKD and associated with numerous adverse outcomes, including falls, decreased quality of life, hospitalizations, and death. Multiple pathologic factors contribute to the development of frailty in patients with CKD, including biological mechanisms of aging and physiological dysregulation. Current interventions to reduce frailty are promising, but additional investigations are needed to determine whether optimizing frailty measures improves renal and overall health outcomes. This review of frailty in CKD examines frailty definitions, the impact of frailty on health outcomes across the CKD spectrum, mechanisms of frailty, and antifrailty interventions (e.g., exercise or senescent cell clearance) tested in CKD patients. In addition, existing knowledge gaps, limitations of current frailty definitions in CKD, and challenges surrounding effective antifrailty strategies in CKD are considered.
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Affiliation(s)
- Elizabeth C Lorenz
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA.,William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
| | - Cassie C Kennedy
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA.,Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew D Rule
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Nathan K LeBrasseur
- Robert and Arlene Kogod Center on Aging, Mayo Clinic, Rochester, Minnesota, USA
| | - James L Kirkland
- Robert and Arlene Kogod Center on Aging, Mayo Clinic, Rochester, Minnesota, USA
| | - LaTonya J Hickson
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, Florida, USA
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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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Kang SH, Do JY, Kim JC. The relationship between disability and clinical outcomes in maintenance dialysis patients. Yeungnam Univ J Med 2020; 38:127-135. [PMID: 33053615 PMCID: PMC8016623 DOI: 10.12701/yujm.2020.00346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 09/11/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGRUOUND Dialysis patients are prone to having disabilities. We aimed to evaluate the association between disability and various clinical outcomes in Korean dialysis patients. METHODS This study consisted of 1,615 dialysis patients from 27 centers. We evaluated disability by using four questions on the activities of daily living (ADLs) concerning whether help was needed for feeding, dressing/undressing, getting in/out of bed, or taking a bath/shower. We divided the patients into three groups: no disability (Non-D, none of the four ADL domains required help; n=1,312), mild disability (Mild-D, one ADL domain required some/full help; n=163), or moderate to severe disability (MS-D, two or more ADL domains required some/full help; n=140). We evaluated falls, frailty, health-related quality of life (HRQoL), mortality, and hospitalization. RESULTS The numbers of participants with a fall during the last 1 year were 199 (15.2%), 42 (25.8%), and 44 (31.4%) in the Non-D, Mild-D, and MS-D groups, respectively (p<0.001). The numbers of participants with frailty in the Non-D, Mild-D, and MS-D groups were 381 (29.0%), 84 (51.5%), and 93 (66.4%), respectively (p<0.001). In both univariate and multivariate analyses, the physical component scale and mental component scale scores decreased as the grade of disability increased (p<0.001 for both scores). Hospitalization-free survival rate at 500 days was 64.2%, 56.7%, and 51.1% in the Non-D, Mild-D, and MS-D, respectively (p=0.001 for trend). Patient survival rate at 500 days was 95.3%, 89.5%, and 92.3% in the Non-D, Mild-D, and MS-D, respectively (p=0.005 for trend). CONCLUSION Disability was associated with falls, frailty, HRQoL scales, and survival trends in Korean dialysis patients.
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Affiliation(s)
- Seok Hui Kang
- Division of Nephrology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Jun Young Do
- Division of Nephrology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Jun Chul Kim
- Division of Nephrology, Department of Internal Medicine, CHA Gumi Medical Center, CHA University, Gumi, Korea
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