Association of Self-Reported Frailty with Falls and Fractures among Patients New to Dialysis

Abstract

Background: Although frailty has been linked to higher risk of falls and fracture in the general population, only few studies have examined the extent to which frailty is associated with these outcomes among patients with end-stage renal disease, who are at particularly high risk for these events. Methods: A total of 1,646 patients who were beginning maintenance hemodialysis in 297 dialysis units throughout the United States from September 2005 to June 2007 were enrolled in the Comprehensive Dialysis Study, and 1,053 Medicare beneficiaries were included in this study. Self-reported frailty was defined by the patients endorsing 2 or more of the following: poor physical functioning, exhaustion or low physical activity. Falls and fractures requiring medical attention were identified through Medicare claims data. We examined the association between frailty and the time to first fall or fracture using the Fine-Gray modification of Cox proportional hazards regression, adjusted for demographics, Quételet's body mass index, diabetes mellitus, heart failure and atherosclerosis. Results: Seventy-seven percent of patients were frail by self-report. The median length of follow-up was 2.5 (1.0-3.9) years. Crude rates of first medically urgent falls or fractures were 66 and 126 per 1,000 person-years in non-frail and self-reported frail participants, respectively. After accounting for demographic factors, comorbidities and the competing risk of death, self-reported frailty was associated with a higher risk of falls or fractures requiring medical attention (hazards ratio 1.60, 95% CI 1.16-2.20). Conclusion: Participants reporting frailty experienced nearly twice the risk of medically urgent falls or fractures compared to those who did not report frailty.

Fractures in patients with CKD—diagnosis, treatment, and prevention: a review by members of the European Calcified Tissue Society and the European Renal Association of Nephrology Dialysis and Transplantation

“…Table 1 summarizes several longitudinal studies reporting the incidence of fractures. 4,[7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25] Most of them found the fracture incidence to progressively increase by 15.0, 20.5, 24.2, 31.2, and 46.3 per 1000 person-years for CKD stages 1 to 2, 3a, 3b, Patients with CKD and older than 65 years of age exhibit a particularly high rate of fractures, with 1 in 10 women and 1 in 20 men experiencing at least 1 fracture in the subsequent 3 years of follow-up. 27 In a recent Dialysis Outcomes and Practice Patterns Study (DOPPS) report, the incidence of fractures was significantly higher for patients receiving hemodialysis therapy than in the general population, with a 3.7-fold increase in the unadjusted relative risk of death.…”

Association between the risk of falls and osteoporotic fractures in patients with type 2 diabetes mellitus

“…The anterior, central, and posterior heights of each of the 13 vertebral bodies from T4 to L4 were measured. A vertebral fracture was diagnosed if at least one of three height measurements along the length of the same vertebra had decreased by Moreover, because the risk of falls is associated with frailty [10], it is important to define what factors are associated with the risk of falls in patients with DM. Several studies have previously shown that diabetic microangiopathies, such as neuropathy and retinopathy, increase the risk of falls [11].…”

Risk of falls in chronic kidney disease

“…Low levels of active vitamin D lead to impaired binding in the vitamin D receptor (VDR). The loss of VDR in the parathyroid glands is causing resistance to the action of calcictriol 37 . CKD is also characterized by lower calcidiol, with reduced sun exposure, reduced skin production and loss of vitamin D binding protein (DBP) being the main reasons for these changes 37 .…”

“…The loss of VDR in the parathyroid glands is causing resistance to the action of calcictriol 37 . CKD is also characterized by lower calcidiol, with reduced sun exposure, reduced skin production and loss of vitamin D binding protein (DBP) being the main reasons for these changes 37 . Vitamin D deficiency is defined as a serum 25(OH) D level <20 ng/ml and insufficiency as between 21-29 ng/ ml 38 .…”