Frailty and Mortality in Dialysis

Alfaadhel, Talal; Soroka, Steven D.; Kiberd, Bryce A.; Landry, David; Moorhouse, Paige; Tennankore, Karthik

doi:10.2215/cjn.07760814

Cited by 169 publications

(192 citation statements)

References 41 publications

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“…All four studies found a positive association of the presence of frailty with adverse health outcomes. Frailty at dialysis initiation was associated with a higher risk of mortality (45)(46)(47)(48) and hospitalization (45,46,48), independent of age and other possible risk factors for poor outcome. In the largest study in 2275 patients on incident dialysis of all ages, frailty as measured using a modification of Fried criteria for frailty was associated with higher risk of death within 1 year in a fully adjusted model (adjusted HR, 2.24; 95% CI, 1.60 to 3.15) (45).…”

Section: Association Of Functional or Cognitive Impairment And Frailtmentioning

confidence: 96%

“…Four studies assessed frailty and reported a high prevalence of frailty among patients on incident dialysis ranging from 32% to 79% (45)(46)(47)(48). Frailty was measured using different instruments, including two studies using (modified) Fried criteria for frailty (45,46), one using the Clinical Frailty Scale (47), and one using the Groningen Frailty Indicator (48).…”

Section: Association Of Functional or Cognitive Impairment And Frailtmentioning

confidence: 99%

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Functional and Cognitive Impairment, Frailty, and Adverse Health Outcomes in Older Patients Reaching ESRD—A Systematic Review

Kallenberg¹,

Kleinveld²,

Dekker

et al. 2016

CJASN

155

124

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Background and objectives Older patients reaching ESRD have a higher risk of adverse health outcomes. We aimed to determine the association of functional and cognitive impairment and frailty with adverse health outcomes in patients reaching ESRD. Understanding these associations could ultimately lead to prediction models to guide tailored treatment decisions or preventive interventions.Design, setting, participants, & measurements We searched MEDLINE, Embase, Web of Science, CENTRAL, CINAHL, PsycINFO, and COCHRANE for original studies published until February 8, 2016 reporting on the association of functional or cognitive impairment or frailty with adverse health outcome after follow-up in patients reaching ESRD either with or without RRT.Results Of 7451 identified citations, we included 30 articles that reported on 35 associations. Mean age was .60 years old in 73% of the studies, and geriatric conditions were highly prevalent. Twenty-four studies (80%) reported on functional impairment, seven (23%) reported on cognitive impairment, and four (13%) reported on frailty. Mortality was the main outcome measure in 29 studies (97%), and one study assessed functional status trajectory. In 34 of 35 (97%) associations reported, functional or cognitive impairment or frailty was significantly and independently associated with adverse health outcomes. The majority of studies (83%) were conducted in selected patient populations, mainly patients on incident dialysis.Conclusions Functional and cognitive impairment and frailty in patients reaching ESRD are highly prevalent and strongly and independently associated with adverse health outcomes, and they may, therefore, be useful for risk stratification. More research into their prognostic value is needed.

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Section: Association Of Functional or Cognitive Impairment And Frailtmentioning

confidence: 96%

Section: Association Of Functional or Cognitive Impairment And Frailtmentioning

confidence: 99%

Functional and Cognitive Impairment, Frailty, and Adverse Health Outcomes in Older Patients Reaching ESRD—A Systematic Review

Kallenberg¹,

Kleinveld²,

Dekker

et al. 2016

CJASN

155

124

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“…Other risk factors for morality in this population were age and being on dialysis. This is consistent with previous literature, which finds frailty is associated with mortality in both pre-dialysis and dialysis patients with CKD (17,28,29,40,44,46,52). The association between FI and mortality was also comparable to previous literature in study populations other than CKD.…”

Section: Discussionsupporting

confidence: 92%

“…However, once this analysis was adjusted for frailty, the relationship between the early dialysis initiation and mortality became non-significant (17). A study by Alfaadel et al further highlighted that frailty at dialysis initiation was independently associated with an increased risk of mortality (52). This indicates that the patient's frailty is the more important predicator of poor outcome from dialysis rather than the time when dialysis is initiated.…”

Section: Implications For Policy and Practicementioning

confidence: 99%

Frailty in chronic kidney disease

Chowdhury¹

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Frailty is regarded as the most problematic consequence of aging. Whilst there is no precise definition for frailty, most clinicians agree that patients who are frail are vulnerable to poor health.Frailty can be conceptualised as a syndrome with a set of symptoms and signs that are measured to give a categorical classification of frailty as described by Fried and colleagues. Alternatively, frailty can be considered as a state, where deficits in health across multiple organ systems accumulate over time. These deficits are summated to give a continuous measure of frailty called the frailty index (FI).Patients with chronic kidney disease (CKD) are at risk of frailty. CKD has effects in multiple systems and it leads to accelerated manifestation of frailty, especially in those who are on dialysis.The Fried approach to frailty assessment has been applied in numerous settings of patients with CKD. However, there are limitations of the Fried approach especially when the prevalence of frailty is high, and a more precise measure is needed of the severity of frailty in an individual.The thesis begins with a systematic review of frailty in patients with CKD. It focuses on how frailty is assessed, including the Fried approach and other assessment methods; differences in frailty between dialysis and pre-dialysis patients; and how frailty changes across the spectrum of severity in kidney function. The systematic review yielded 37 articles encompassing 53,000 patients with CKD. The most common method of frailty assessment was the Fried approach (n=27 articles, 73%).The prevalence of frailty ranged between 7% in a population of pre-dialysis patients with CKD to 73% in patients on dialysis. There was considerable heterogeneity in how the studies defined the Fried phenotype and this impacted on the reported prevalence of frailty. Regardless of the method of assessment, frailty was associated with an increased risk of mortality and hospitalization.The systematic review highlighted gaps in the current evidence, especially in better delineating risk amongst patients on dialysis where the prevalence of frailty may be high. This leads to the next chapter of the thesis, a prospective study of the Frailty Index in CKD (FI-CKD). The aim of the study was to investigate the frailty index (FI) in outpatients with pre-dialysis and dialysis dependent CKD. Associations between FI and kidney function were explored as well as the relationship between FI and change in kidney function, mortality and hospitalization after twelve months of follow up. Amongst 314 patients, the mean FI was 0.29 (SD 0.13) corresponding to a clinical description of mild to moderate frailty. FI was associated with an increased risk of mortality (OR:1.8; 95% CI 1.77 -2.44) and hospitalization (OR 1.3 95% CI 1.06-1.5). Patients with a higher CKD stage were significantly more likely to have a higher FI. However, there was no significant 2 differences in the average FI between dialysis and pre-dialysis patients, perhaps due to the limited number of patients on dialysi...

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“…The agreement between the two reviewers in this paper was .95% for all aspects. The quality of three of 27 studies was good according to all of the established quality criteria (17,22); the remainder of studies was (somewhat) compromised. In 15 studies (56%), the representativeness of the exposed cohort was (somewhat) compromised, because the population proved to be either selected (not black or white race [41] or not $2 years Medicare follow-up before entering the study) or highly selected (exclusion of elderly patients [30], early deaths [43], and one study included 17% prevalent patients who were on chronic hemodialysis before peritoneal dialysis was initiated [24]).…”

Section: Quality Assessmentmentioning

confidence: 99%

The Relevance of Geriatric Impairments in Patients Starting Dialysis: A Systematic Review

Loon

Wouters²,

Boereboom

et al. 2016

CJASN

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Background and objectives With aging of the general population, patients who enter dialysis therapy will more frequently have geriatric impairments and a considerable comorbidity burden. The most vulnerable among these patients might benefit from conservative therapy. Whether assessment of geriatric impairments would contribute to the decision-making process of dialysis initiation is unknown.Design, setting, participants, & measurements A systematic Medline and Embase search was performed on December 1, 2015 to identify studies assessing the association between risk of mortality or hospitalization and one or more geriatric impairments at the start of dialysis therapy, including impairment of cognitive function, mood, performance status or (instrumental) activities of daily living, mobility (including falls), social environment, or nutritional status.Results Twenty-seven studies were identified that assessed one or more geriatric impairments with respect to prognosis. The quality of most studies was moderate. Only seven studies carried out an analysis of elderly patients ($70 years old). Malnutrition and frailty were systematically assessed, and their relation with mortality was clear. In addition, cognitive impairment and functional outcomes at the initiation of dialysis were related to an increased mortality in most studies. However, not all studies applied systematic assessment tools, thereby potentially missing relevant impairment. None of the studies applied a geriatric assessment across multiple domains.Conclusions Geriatric impairment across multiple domains at dialysis initiation is related to poor outcome. However, information in the elderly is sparse, and a systematic approach of multiple domains with respect to poor outcome has not been performed. Because a geriatric assessment has proved useful in predicting outcome in other medical fields, its potential role in the ESRD population should be the subject of future research.

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Frailty and Mortality in Dialysis

Abstract: A higher severity of frailty (as defined by the CFS) at dialysis initiation is associated with higher mortality.

Cited by 169 publications

References 41 publications

Functional and Cognitive Impairment, Frailty, and Adverse Health Outcomes in Older Patients Reaching ESRD—A Systematic Review

Functional and Cognitive Impairment, Frailty, and Adverse Health Outcomes in Older Patients Reaching ESRD—A Systematic Review

Frailty in chronic kidney disease

The Relevance of Geriatric Impairments in Patients Starting Dialysis: A Systematic Review

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