Frailty Severity and Hospitalization After Dialysis Initiation

Abstract

Background: Frailty is associated with hospitalization and mortality among dialysis patients. To now, few studies have considered the degree of frailty as a predictor of hospitalization. Objective: We evaluated whether frailty severity was associated with hospitalization after dialysis initiation. Design: Retrolective cohort study. Setting: Nova Scotia, Canada. Patients: Consecutive adult, chronic dialysis patients who initiated dialysis from January 1, 2009 to June 30, 2014, (last follow-up June, 2015). Methods: Frailty Severity, as determined by the 7-point Clinical Frailty Scale (CFS, ranging from 1 = very fit to 7 = severely frail), was measured at dialysis initiation and treated as continuous and in categories (CFS scores of 1-3, 4/5, and 6/7). Hospitalization was characterized by cumulative time admitted to hospital (proportion of days admitted/time at risk) and by the joint risk of hospitalization and death. Time at risk included time in hospital after dialysis initiation and patients were followed until transplantation or death. Results: Of 647 patients (mean age: 62 ± 15), 564 (87%) had CFS scores. The mean CFS score was 4 (“corresponding to “vulnerable”) ± 2 (“well” to “moderately frail”). In an adjusted negative binomial regression model, moderate-severely frail patients (CFS 6/7) had a >2-fold increased risk of cumulative time admitted to hospital compared to the lowest CFS category (IRR = 2.18, 95% confidence interval [CI] = 1.31-3.63). In the joint model, moderate-severely frail patients had a 61% increase in the relative hazard for hospitalization (hazard ratio [HR] = 1.61, 95% CI = 1.29-2.02) and a 93% increase in the relative hazard for death compared to the lowest CFS category (HR = 1.93, 95% CI = 1.16-3.22). Limitations: Potential unknown confounders may have affected the association between frailty severity and hospitalization given observational study design. The CFS is subjective and different clinicians may grade frailty severity differently or misclassify patients on the basis of limited availability. Conclusions: Among incident dialysis patients, a higher frailty severity as defined by the CFS is associated with both an increased risk of cumulative time admitted to hospital and joint risk of hospitalization and death.

Is It Time to Integrate Frailty Assessment in Onconephrology?

“…Therefore, other tools that may be more pragmatic have been developed. The clinical frailty scale (CFS) is a categorical tool that rates individuals from a score of 1 “very fit” to 8 “very severely frail” and studies have shown that the CFS has value in outcome prediction as a more comprehensive tool [ 34 , 35 , 36 ]. However, while pragmatic tools based on clinical impression (such as the CFS) allow more efficiency and easier incorporation into clinical care, they are subjective.…”

Prescribing Immunosuppressive Treatment for Older People with Glomerular Diseases: Time to Assess Frailty?

“…7 In chronic dialysis, frailty has been associated with mortality, hospitalization, and other health outcomes. [8][9][10][11][12] Finally, people categorized as frail during wait-listing are less likely to survive to transplant. 13,14 A growing body of evidence describes the association between frailty and outcomes after kidney transplantation.…”

Frailty in chronic kidney disease: challenges in nephrology practice. A review of current literature

“…Among incident dialysis populations, degree of frailty associates with infection, bleeding and cardiac complications in a dose-dependent manner. 33 Severity of frailty predicts dialysis difficulties and vascular access complications (HR 2.63; 95% CI: 1.03-6.71) 34 indicating that frailty should prompt a re-evaluation of vascular access models. Frailty among dialysis patients increases odds of dialysis withdrawal as primary cause of death.…”

“…These data suggest a pathogenic process, leading some authors to speculate that dialysis accelerates frailty through inflammatory and haemodynamic mechanisms. Among incident dialysis populations, degree of frailty associates with infection, bleeding and cardiac complications in a dose‐dependent manner 33 . Severity of frailty predicts dialysis difficulties and vascular access complications (HR 2.63; 95% CI: 1.03–6.71) 34 indicating that frailty should prompt a re‐evaluation of vascular access models.…”