Background and Aims Frailty and comorbidity have been shown to predict mortality in end stage renal failure patients. This knowledge can help inform patients and clinicians when undertaking the joint decision-making process regarding the management of advanced renal disease. This project sets out to record the serial and net frailty scores of patients with stage 4 and 5 kidney disease and study the change of frailty score in association with mortality and patient’s preferred modality of renal replacement therapy (RRT). Method All patients followed up in Low Clearance Clinic with eGFR <30ml/min/1.73m2 were identified from West of Scotland Electronic Renal Patient Record (SERPR). Biochemical data, patient’s preferred modality of RRT, clinic/admission records were extracted from SERPR and Clinical Portal. Rockwood Clinical Frailty Scale (CFS) was used to determine patients’ degree of frailty (1 being fittest and 9 being frailest). Patient’s CFS was reviewed by our Low Clearance Nurse Specialists at 4-monthly interval over a 12-month period. Frailty score was not repeated once patient commenced RRT. Results 125 patients with CKD stage 4 and 5 had a baseline CFS in April 2018. 54.4% were female and median age was 66 years old. 40.8% patients had a diagnosis of diabetes. Table 1 shows the demographics for patients with baseline CFS 1-3 (not frail), 4-5 (mild frailty) and 6-9 (moderate – severe frailty) respectively. RRT was planned for 82.8% of patients with CFS1-3 (63.3% HD, 36.7 PD), 52.1% of patients with CFS 4-5 (96.0% HD, 4.0% PD) and 36.8% patients with CFS 6-9 (100% HD, 0% PD). 29.2% of patients with CFS 4-5 and 47.4% of patients with CFS 6-9 were for conservative care. 1-year mortality for patients with CFS 1-3, 4-5 and 6-9 was 1.7%, 18.8% and 26.3% respectively. A total of 362 CFS were recorded over the 12-month period (125 at month 0, 88 at month 4, 80 at month 8 and 69 at month 12). 49 changes in CFS were noted in 37 patients. 34 patients had a net deterioration of CFS by the end of month 12. Figure 1 shows the changes in patients’ CFS at 4-monthly interval and the net changes by the end of 12-month follow up. Four patients changed their RRT planning from dialysis to conservative care and they all had a deterioration of CFS. Comparing the patients with deterioration of CFS against those without, they had similar number of hospital admissions and clinic appointments and appear to have no association with having the diagnosis of diabetes. However, patients with deterioration of CFS had higher rate of death (14.3% vs 4.7%) and higher likelihood to change their preferred modality of RRT (8.6% vs 4.7%). Conclusion Frailty is common among patients with advanced CKD and is associated with significant mortality rate. Serial assessment of frailty score is helpful in monitoring patients’ physical and functional status. Consistently high or deteriorating frailty score may correlate with higher mortality and this should trigger a review of their suitability for RRT, and consideration of anticipatory care planning.
Diabetes is the leading cause of chronic kidney disease worldwide and associated with significant morbidity and mortality. Despite advances in treatment options for diabetic kidney disease, a substantial proportion of patients still progress to end‐stage renal disease. While not without its own risk and complications, transplantation remains the best modality of renal replacement therapy in terms of patient outcome and cost‐effectiveness when compared to dialysis. This article reviews diabetic kidney disease with a focus on options for transplantation including kidney, pancreas and islet cell transplantation. Copyright © 2021 John Wiley & Sons.
Background and Aims Current guidelines recommend the pursuit of arteriovenous (AV) access over central venous catheter (CVC) access in haemodialysis (HD) populations. The limitations of this approach are increasingly recognised, and are particularly relevant when considering frail patients with relatively high levels of comorbidity and limited life expectancy. In such patients AV access may incur more invasive procedures, whereas CVC access may incur heightened risks of infection. This study aimed to evaluate the association between HD access modality and access complications, hospitalisation and mortality in a cohort of HD patients with frailty. Method We performed a retrospective analysis of prospectively recorded data from the Strathclyde Electronic Renal Patient Record concerning HD patients from 01/10/2017 to 21/09/2019. HD patients with a Rockwood clinical frailty scale (CFS) ≥6 were identified with baseline demographic data being recorded from date of first CFS ≥6 to census date 21/09/19 or death. We recorded the first vascular access modality at study inception and the modality at the time of census or death. Episodes of TCVC associated sepsis were determined using both clinical diagnosis in patient case records and positive blood cultures. Episodes were regarded as separate where positive blood cultures occurred ≥14 days apart. An inpatient admission was regarded as a discharge date ≥24 hours following admission. These were then further categorised as unscheduled or elective. Results 139 patients were identified with CFS ≥6. Median age was 72 years and 51% were female. Median follow-up was 1.1 years with total 50861 observed HD days. 52.3% patients were deceased at census. Table 1 illustrates vascular access modality at initial CFS. CVC accounted for the greatest proportion of dialysis access days (50.3%) compared to AVF (40.7%) and AVG (8.9 %). There was no significant difference in mortality between vascular access modalities over the follow-up period (50.7% CVC; 55% AVF; 54.5% AVG, p=0.18). In total, 5244 HD exposed days (10.3%) were spent as an inpatient during follow-up, of which 5120 (98%) were unscheduled and 119 (2%) were elective. The AVG group had the highest rate of inpatient bed days (138/1000 HD days) when compared to CVC (107/1000 HD days) and AVF (94/1000 HD days). Both AVG and CVC were associated with more inpatient bed days than AVF (p<0.0001 for each). Patients who started with CVC and transitioned to AV access had a rate of 86/1000 HD days. This was significantly lower than those who remained CVC throughout (p=0.0001). There were 24 recorded events of CVC associated sepsis during follow-up, occurring at a rate of 0.8 per 1000 HD days. Rates of CVC associated sepsis were similar between CFS 6 (0.6 per 1000 HD days) and CFS 7 (1.1 per 1000 HD days), p=0.21. The CVC associated staphylococcus aureus bacteraemia (SAB) rate for the overall population was 0.2 per 1000 HD days. AVG sepsis occurred at a rate of 0.2 per 1000 HD days and there were no incidences of AVF sepsis in those who continued with AVF throughout the follow-up period. Conclusion CVC was the most prevalent access modality in this frail HD population. Rates of CVC associated sepsis and SAB were similar to published bloodstream infection rates and existing local data (Murray et al QJM 2014). Although absolute events were low, increasing frailty from CFS 6 “moderately frail” to CFS 7 “severely frail” did not appear to influence rate of CVC associated sepsis. Patients with CVC and AVG had greater inpatient bed days than those with AVF. Transitioning from CVC to AV access reduced inpatient bed days. However, the choice of vascular access modality did not influence mortality overall.
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