Use of the FRAIL Questionnaire in Patients With End-Stage Kidney Disease

Abstract

Background: Frailty is a clinical phenotype of decreased physiologic reserve that is associated with increased morbidity and mortality. The most meaningful way to assess frailty in patients with end-stage kidney disease (ESKD) is unknown. Objective: To assess the prevalence of frailty in ESKD patients using the easy-to-administer FRAIL scale and, to determine its association with mortality, transplantation, and hospitalization. Design: A cohort study was used. Setting: The Ottawa Hospital, Ottawa, Ontario, Canada, was the setting of this study. Patients: All eligible adult ESKD patients treated with dialysis from August to November 2017 at The Ottawa Hospital were invited to participate. Measurements: The FRAIL scale. Methods: Eligible patients completed an exercise survey with FRAIL questions embedded within the instrument. Number of comorbid illnesses was determined from the electronic medical record and weight loss was calculated from target weight in the patients’ dialysis prescription. Mortality, transplant status, and hospitalizations were ascertained from the electronic medical record 18 months later; differences by frailty status were evaluated using descriptive statistics. Kaplan-Meier and Cox regression models were used to examine the association between frailty and transplant. Results: Of 476 ESKD patients screened, 261 participated; 101 receiving peritoneal dialysis, 135 intermittent hemodialysis, and 25 home hemodialysis. Thirty-nine, 145, and 77 were frail, pre-frail, and not frail, respectively. Employment status, ethnicity, and comorbid illnesses differed significantly by frailty status, but mortality did not. In univariate analysis, frail patients were less likely to be listed for ( P = .05) and to receive a kidney transplant ( P = .02). However, after adjusting for age and modality, frailty was not statistically associated with a decreased likelihood of transplant (Hazard Ratio: 0.15; confidence interval [CI], 0.02-1.15; P = .068). The results were similar when accounting for the competing risk of death ( P = .060). Frail patients were more likely to be hospitalized ( P = .01) and spend more time in the hospital ( P = .04). Limitations: Single-center design with a relatively short follow-up and small sample size limiting the number of variables that could be assessed in analysis. We also excluded patients who were unable to communicate in English or French and those patients with physical limitations such as amputations, potentially affecting generalizability. Conclusions: Frail ESKD patients as identified by the FRAIL scale are less likely to receive a renal transplant; this association diminished statistically after adjusting for age and modality and when accounting for the competing risk of death. Frail patients were at increased risk of hospitalization. Further study with larger patient numbers and longer follow-up is needed to determine the usefulness of the FRAIL scale in predicting adverse outcomes. Trial registration: Not required as this was an observational study.

Comparison between FRAIL Scale and Clinical Frailty Scale in predicting hospitalization in hemodialysis patients

“…In a small cohort of rural Chinese subjects undergoing chronic dialysis, the FRAIL scale demonstrated a good correlation with several clinical parameters, such as age, presence of comorbidities, and dialysis complications, better than the other six types of established self-report questionnaires (Strawbridge questionnaire, Edmonton Frail Scale, simple FRAIL scale, Groningen Frail Indicator, G8 questionnaire, and Tilburg Frail Indicator), although outcomes such as mortality or hospitalization were not assessed [ 16 ]. Additionally, another observational study [ 23 ] showed that frailty identified by the FRAIL scale was associated with an increased risk of hospitalization in adults treated with any dialysis modality (peritoneal dialysis, intermittent HD, or home HD). Also, the risk of death did not differ by frailty status, as observed in our study.…”

“…The CFS has been extensively used to detect frailty and its association with diverse outcomes among dialysis patients [ 13 , 23 – 27 ]. The available studies with CFS are heterogeneous regarding study design, type of dialysis (peritoneal or HD), ethnicity, follow-up time, time of dialysis start, and patients’ age.…”

Frailty Severity and Hospitalization After Dialysis Initiation

“…Supporting the generalizability of our study findings to current day patients is the continued pattern of hospitalization in patients identified as frail in studies involving more contemporary cohorts. 31 , 32 Despite attempts to include all patients who started chronic dialysis as an inpatient (in addition to the outpatient setting), it is possible that some patients may have died before being captured for electronic database entry and assigned a CFS score, introducing risk for selection bias. Finally, the CFS is subjective and different clinicians may grade severity differently or misclassify patients on the basis of limited availability.…”

Use of frailty assessment instruments in nephrology populations: a scoping review

“…Three studies reported frailty predicted increased likelihood of in-centre HD modality choice (71,74,81). Eight studies reported frailty was associated with reduced likelihood of transplant referral and waitlisting, removal from waitlist or death on waitlist (42,55,(82)(83)(84)(85)(86)(87) while four studies reported an association with post-transplant complications (34,58,88,89).…”