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and the Cockcroft-Gault formula are tools that are considered to be useful methods&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">3</span></a> Nevertheless&#44; it should be noted that in spite of the increased use of the GFR as a screening method in clinical practice&#44; a GFR level &#60;60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> does not necessarily indicate the existence of CKD&#44; and this can lead to a false increase of this pathology&#44; especially amongst the elderly&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In addition to having a decreased GFR&#44; CKD also entails an inflammatory condition leading to physiological changes that affect other organs &#40;see the section on Ageing and the mechanisms involved in chronic kidney disease&#41;&#46; In this regard a formula has been developed that includes hematocrit&#44; urea and gender &#40;HUGE&#41; and which attempts to discern whether patients with GFR &#60;60<span class="elsevierStyleHsp" style=""></span>ml&#47;min actually have kidney disease or a GFR reduction associated with the ageing process&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">4</span></a> This formula has also been associated with long-term life expectancy forecasts in non-hospitalised elderly patients&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The current prevalence of CKD in Spain is estimated to be around 9&#46;2&#37; of the adult population&#44; with an overall prevalence of 6&#46;8&#37; in stages 3&#8211;5&#44; but this number increases to 20&#46;6&#37; in patients over age 64&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">1&#44;6</span></a> This increase is attributed to this population being older&#44; due to their having greater cardiovascular risk factors&#44; and because of earlier diagnosis&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In addition to having a higher prevalence with a forecasted increase over the coming years&#44; CKD is also associated with adverse clinical and functional events&#44; and with a significant cardiovascular morbidity&#47;mortality&#44;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">7&#8211;10</span></a> which justifies a considerable use of resources and a substantial increase in healthcare spending&#46; The annual cost for treating the most advanced stages of CKD in Spain is estimated to be over &#8364;800 million&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">11</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">All this has resulted in intense attention being focused in recent years on detecting this pathology early so that its progression can be reduced&#46; In addition to this&#44; a decision also needs to be made whether the patient would be a candidate for replacement kidney therapy or conservative treatment&#44; preparing the patient sufficiently in advance for therapeutic programmes such as the various types of dialysis and transplant&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">12&#8211;15</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Ageing and the mechanisms involved in chronic kidney disease</span><p id="par0040" class="elsevierStylePara elsevierViewall">Descriptions have been given of how after age 30 a process occurs whereby glomerulus is replaced with fibrous tissue &#40;glomerulosclerosis&#41; that increases as time progresses&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">1&#44;12&#44;16&#44;17</span></a> Meanwhile there is also an increase in mesangial tissue&#44; with predominant obliteration of the juxtamedullary nephrons&#44; accompanied by subendothelial deposits of hyaline tissue and collagen in the arterioles&#44; with thickening of the intima&#44; atrophy of the media and dysfunction of the autonomic vascular reflex&#46; On the other hand&#44; there are also changes in the tubules&#44; which undergo fat tissue degeneration with enlargement of the basal membrane&#44; with increased areas of atrophy and fibrosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">14&#44;18&#44;19</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The anatomic changes described above lead to a decrease in the elderly patient&#39;s GFR and a decrease in effective renal plasma flow &#40;ERPF&#41;&#44; with a tendency towards an increase in the filtration fraction &#40;the GFR&#47;ERPF ratio&#41;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">14&#44;18</span></a>&#44; at the expense of a disproportionate decrease of the ERPF denominator compared to the GFR&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In approximately the third decade of life&#44; the GFR reaches a peak of around 140<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#44; and from that point it begins to decrease progressively by approximately 8<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73 m<span class="elsevierStyleSup">2</span> per decade&#46; This is accompanied by a decrease in creatinine production&#44; associated with a process some refer to as &#8220;senile sarcopenia&#8221;&#44;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">15</span></a> which is the reason why plasma creatinine does not increase in spite of the progressive decrease in GFR&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">All of these physiological changes explain the decrease in sodium reabsorption&#44; which causes increased fractional sodium excretion in elderly patients&#44; and a decrease in both their kidney plasma concentration and their response to stimulus&#44; creating a state of medullary hypotonicity with a decreased urine concentration capacity&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">14&#44;18</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Here it is important to emphasise that even though a senile kidney will present a series of changes associated with a decrease in GFR&#44; this is different in many aspects from the decrease in GFR that is associated with CKD &#40;see <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">In this regard&#44; CKD per se represents a state of characteristic biochemical alterations&#46; This is associated with a chronic inflammatory state that is predicated on the premature development of alterations in the patient&#39;s cytokine catabolism &#40;IL-1 beta&#44; IL-6&#44; tumour necrosis factor-alpha &#91;TNF-alpha&#93;&#41; and growth factors &#40;insulin-like growth factor &#91;IGF-I&#93;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">7&#44;20</span></a> CKD patients experience a decrease in their IGF-I levels and an increase in their TNF-alpha&#46; They are also observed to have an increase of other catabolic hormones &#40;parathyroid hormone&#44; glucagon&#44; corticosteroids and angiotensin <span class="elsevierStyleSmallCaps">ii</span>&#41; in addition to deficiency or resistance to anabolic hormones such as insulin&#44; growth hormones&#44; testosterone and 25&#40;OH&#41; D3&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Recognising frailty&#46; How does it help management&#63;</span><p id="par0070" class="elsevierStylePara elsevierViewall">Physiological ageing has been associated with inflammation&#44; loss of bone density&#44; and the presence of vascular atherosclerosis&#46; It has been acknowledged that part of this process includes a slight decline in physical and cognitive<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">7</span></a> and metabolic functions&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">When these processes occur simultaneously&#44; physiological changes are generated that interact with each other&#46; This may explain &#8220;<span class="elsevierStyleItalic">unsuccessful ageing</span>&#8221; linked to accelerated inflammation mechanisms&#44; mineral and bone disorder&#44; and vascular disease&#44;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">7</span></a> that unleash adverse events such as falls&#44; fractures and increased mortality&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Patients progress to a frail state following physical and biochemical alterations that cause a depletion of their physiological reserves and leave them exposed&#44; &#8220;<span class="elsevierStyleItalic">frail&#8221;</span> and unable to respond to stress events appropriately&#46;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">21&#44;22</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Frailty is a <span class="elsevierStyleItalic">multidimensional syndrome</span>&#44;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">7&#44;23</span></a> characterised by a loss in skeletal muscle mass &#40;sarcopenia&#41;&#44; weakness&#44; and decreased resistance to physical exercise&#44; and this leads to decreased activity and poor stress response&#46; Reduced activity&#44; in turn&#44; makes the patient&#39;s sarcopenia and weakness worse&#44; and this entails a tendency for them to spiral down to functional deterioration&#44; increasing their risk of death&#46;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">23&#44;24</span></a><span class="elsevierStyleItalic">Fried&#39;s phenotype</span>&#44; as defined using Fried&#39;s criteria &#40;see <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#44; showed that a state prior to disability can be detected&#44; thus making it deemed to be an important predictor of adverse events&#46;<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">25&#8211;28</span></a> Cognitive function has also been added recently&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Data from the community has shown that there is currently a roughly 10&#46;7&#37; prevalence of frailty amongst patients over 65&#44; and this figure surpasses 25&#37; in patients over 85&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">8&#44;25</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">In the attempt to identify which patients are more vulnerable to suffering severe adverse health events&#44; especially disability and loss of mobility&#44; the <span class="elsevierStyleItalic">Comprehensive Geriatric Assessment</span> has become more important as a basic tool for evaluating patient frailty&#46;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">22&#44;29&#44;30</span></a> This tool provides an overall assessment of elderly patients with regard to their comprehensive condition &#40;their clinical&#44; functional&#44; cognitive and psychosocial situation&#41;&#44; with a functionality-oriented approach&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Thus a recent consensus document recommended that everyone over age 70 should be screened for frailty based on data from Frailty and Dependence in Albacete &#40;FRADEA&#41; study which showed that frailty entails a 5&#46;5 times higher adjusted risk of mortality&#44; a 2&#46;5 times higher risk of disability&#44; and a 2&#46;7 times higher risk of loss of mobility&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">8&#44;25</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Some are now proposing that frailty might offer a perspective that could be used as a tool for better classifying patients&#44;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">24&#44;31</span></a> that would inform the medical decision-making process&#44; prioritising <span class="elsevierStyleItalic">the elderly patient&#39;s functionality and quality of life</span> above all else&#46; <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the clinical criteria proposed for defining frailty&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Frailty in CKD</span><p id="par0110" class="elsevierStylePara elsevierViewall">The worst prognosis factor in elderly CKD patients has been described to be their level of dependency and comorbidity<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">28</span></a>&#58; two conditions related to the onset of frailty&#46; The potential frailty mechanisms in these patients are shown below &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Anaemia</span><p id="par0115" class="elsevierStylePara elsevierViewall">This occurs following a decrease in erythropoietin &#40;EPO&#41; production resulting from nephron loss combined with increased resistance to EPO&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">7</span></a> Anaemia is a state of deficient tissue oxygenation with symptoms of low energy&#44; impaired cognitive response and decreased physical performance&#44;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">7&#44;20</span></a> and it translates into an inability to autonomously perform the basic everyday life activities&#46; Alterations of both EPO metabolism and iron occur with CKD&#44; and they are associated with poor clinical evolution and deteriorating quality of life&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Inflammation and oxidative stress</span><p id="par0120" class="elsevierStylePara elsevierViewall">As noted above&#44; CKD is a proinflammatory state with increased C-reactive protein &#40;CRP&#41;&#44; IL-6 and elevated procoagulant markers&#44; related to an increased likelihood of frailty&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">7&#44;20</span></a> Some studies have observed that frail patients have higher blood levels of CRP&#44; factor <span class="elsevierStyleSmallCaps">viii</span> and D-dimer&#44; in addition to finding an inverse relationship between patients&#8217; physical functionality tests and their CRP and IL-6 levels&#46;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">30&#44;32</span></a> Meanwhile&#44; due to their oxidative stress&#44; these patients experience protein glycation &#40;advanced glycation end products&#58; AGEs&#41; that is particularly accelerated in diabetic nephropathy&#44;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">7</span></a> associated with deterioration of their illness&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The assumption is that if CKD worsens inflammation&#44; then it will also worsen the patient&#39;s catabolic state&#44; which would entail a loss of muscle mass and cachexia&#44;<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">25&#44;31</span></a> and this may explain the cause of the patient&#39;s frailty and the deterioration of physical function in patients who have CKD&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Comorbidity</span><p id="par0130" class="elsevierStylePara elsevierViewall">CKD may occur simultaneously with other medical conditions&#44; such as diabetes mellitus&#44; chronic hypertension or malnutrition&#44; that may play a key role in its aetiology or which may be related the physiological changes occurring in these patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">2&#44;7&#44;26&#44;28</span></a> There are also other factors&#44; such as occupational illnesses or tobacco use&#44; that may increase the risk of developing obstructive pulmonary disease and heart failure&#46; It is now clear that multi-morbidity is a major factor that significantly contributes to the onset of frailty in the CKD population&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">33</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Malnutrition and sarcopenia</span><p id="par0135" class="elsevierStylePara elsevierViewall">There are multiple factors that link malnutrition to CKD&#46; The main mechanisms whereby CKD contributes to the development of malnutrition are loss of appetite&#44; dietary restrictions&#44; a loss of nutrients &#40;in dialysis patients&#41; and inflammation associated with hormonal alterations and changes in catabolism&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">7</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">The loss of appetite is created by inflammation and the metabolic disorder&#44; and this is exacerbated in the pre-dialysis stage which usually entails extremely strict dietary restrictions that aim at slowing down the progression of the CKD&#46; This low-protein diet has been recognised as a clear factor that leads to malnutrition in these patients&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Furthermore&#44; as noted above&#44; biochemical changes and kidney failure boost patients&#8217; metabolism with a significant hormonal activation&#46; This results in a catabolic&#44; low-energy state with progressive loss of muscle mass and strength &#40;sarcopenia&#41; and cachexia&#46;<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">25&#44;34</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Though elderly patients are recommended to add 1&#46;0 to 1&#46;2<span class="elsevierStyleHsp" style=""></span>g&#47;kg to their daily protein intake to maintain their physical activity&#44; and this should be increased further if they are acutely or chronically ill or malnourished &#40;1&#46;2 to 1&#46;5<span class="elsevierStyleHsp" style=""></span>g&#47;kg&#41;&#44; this diet should nevertheless be avoided in elderly CKD patients in the pre-dialysis stage because it would hasten the advance of their kidney damage and cause them to experience uraemia secondary to retention of nitrogenous products&#46; According to the recommendations of the PROT-AGE study on the optimal protein intake in the elderly&#44;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">35</span></a> pre-dialysis CKD patients with EGF &#60;30<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> should not ingest over 0&#46;8<span class="elsevierStyleHsp" style=""></span>g&#47;kg per day&#46; Nevertheless&#44; patients undergoing dialysis may add 1&#46;2&#8211;1&#46;5<span class="elsevierStyleHsp" style=""></span>g&#47;kg of protein to their daily intake&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">With regard to nutritional tests&#44; the Geriatric Nutritional Risk Index &#40;GNRI&#41; is considered to be a useful predictor of mortality&#44; especially for patients on haemodialysis&#44; while the Subjective Global Assessment &#40;SGA&#41; is useful for pre-dialysis patients&#44; and the MNA-SF is another useful method that has been proven to be appropriate in various patient populations&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">9</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Cerebrovascular disease and cognitive impairment</span><p id="par0160" class="elsevierStylePara elsevierViewall">Physiological ageing has been associated with structural and physiological changes in the brain&#46; The neuron loss in the cortical regions is low&#44; but the neurons with elevated metabolism&#44; such as neurons in the hippocampus&#44; can be affected disproportionately by changes in synaptic function&#44; carrier proteins and mitochondrial function&#46; Cerebral ageing is also characterised by structural and functional changes in the microglia&#44;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">25</span></a> which are the cells that are responsible for the immunity of the central nervous system&#46; These cells are activated by brain damage and by local or systemic inflammation&#44; and they become hyperreactive to the slightest stimulus&#44; causing damage or even death to neurons&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Cognitive impairment is common in the various stages of CKD&#44;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">36</span></a> and even though it is caused by various factors&#44; vascular disease and specifically cerebrovascular disease clearly play a major role in the onset of CKD&#44; especially impacting executive cognitive functions&#46;<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">32&#44;36</span></a> Various studies in the literature have associated CKD patients with GFR &#60;60&#44; with an increased risk of ischaemic and haemorrhagic stroke&#46;<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">32&#44;37</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">The current evidence from various observational studies supports the association between frailty&#44; cognitive impairment and dementia&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">15&#44;16&#44;20&#44;25</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Mineral and bone disorder&#46; Metabolism of calcium and vitamin D</span><p id="par0175" class="elsevierStylePara elsevierViewall">Alterations in bone and mineral metabolism entail an abnormal bone architecture combined with the occurrence of fractures&#44; that in part may explain why CKD patients have decreased mobility&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">7</span></a> Major studies have been conducted that showed a high prevalence of hip fractures in CKD patients with GF levels under 60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">7&#44;15&#44;20</span></a> Several mechanisms involving hypocalcaemia&#44; hyperphosphataemia&#44; hyperparathyroidism&#44; vitamin D deficiency and metabolic acidosis have been implicated&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Various studies of the CKD population have shown that treatment with vitamin D decreased the incidence of falls and improved patients&#8217; postural stability&#44; thus indicating an important role in physical function and frailty&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">15</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">Other recent studies have associated the Klotho gene in the pathophysiology of CKD&#44; finding that a decrease in the gene&#39;s expression is associated with alterations in how patients metabolise calcium &#40;e&#46;g&#46;&#44; ectopic calcifications&#41;&#44; and considering it as a possible biomarker for detecting the progression of frailty or as a future target for therapy&#46;<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">32&#44;38</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Functional impairment</span><p id="par0190" class="elsevierStylePara elsevierViewall">Functional status assessments are performed by evaluating patients&#8217; basic and instrumental activities and their mobility&#46; Adequate physical and cognitive capacity are needed to perform instrumental activities&#44; and this is related to elderly patients&#8217; independence in their activities of daily living&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">15&#44;21</span></a> Aside from the factors described above &#40;anaemia&#44; malnutrition&#44; cerebrovascular disease&#44; osteoporosis&#44; among others&#41; that are related to impaired functional status&#44; it should be noted that a relationship has been established between higher plasma creatinine levels and limited physical activity&#44; with the lowest GF levels associated with dependency for at least 2 of the activities of daily living&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">21</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">CKD has also been demonstrated to have predictive value with regard to mobility limits and impaired functionality<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">15&#44;23&#44;39</span></a>&#58; conditions that are induced by the illness itself and which are more transcendent than the illness itself per se<span class="elsevierStyleInf">&#46;</span></p><p id="par0200" class="elsevierStylePara elsevierViewall">Lastly it should be noted that these multi-factor changes that present in CKD patients indicate that their treatment must be multi-disciplinary&#44; in that all the potential frailty mechanisms must be involved&#46; Effective strategies need to be found that will improve these patients&#8217; quality of life and their prognosis&#46;</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions and recommendations</span><p id="par0205" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0210" class="elsevierStylePara elsevierViewall">Recognising and characterising frailty syndrome based on functional anthropometric dimensions instead of strictly biochemical&#47;biological dimensions represents a major conceptual advance with practical repercussions for the clinical practices employed to manage ageing&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0215" class="elsevierStylePara elsevierViewall">It is clearly associated with a wide range of biological alterations &#40;vascular sclerosis&#44; a proinflammatory condition&#44; oxidative stress&#44; and others&#41;&#44; the most notable of which is CKD&#44; whose presence in frailty syndrome helped contribute to its genesis and above all to its maintenance and perpetuation via CKD-associated disorders such as anaemia&#44; mineral and bone alterations&#44; inflammation and malnutrition&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0220" class="elsevierStylePara elsevierViewall">Recognising the existence of frailty and assessing it with the proper measurements should be part of the clinical care for CKD in the elderly&#46; At the same time&#44; an awareness of the significance of CKD and the biological disorders it entails should be a key part of the clinical arsenal of general practitioners and geriatric care specialists who deal with the syndrome or condition of frailty&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0225" class="elsevierStylePara elsevierViewall">The therapeutic success&#47;failure of the steps that are taken for CKD-related disorders in elderly patients should be gauged by considering how they will affect the patient&#39;s frailty&#46;</p></li></ul></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of interest</span><p id="par0230" class="elsevierStylePara elsevierViewall">The authors declare that there are no conflicts of interest&#46;</p></span></span>"
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              "titulo" => "Comorbidity"
            ]
            3 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Malnutrition and sarcopenia"
            ]
            4 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Cerebrovascular disease and cognitive impairment"
            ]
            5 => array:2 [
              "identificador" => "sec0055"
              "titulo" => "Mineral and bone disorder&#46; Metabolism of calcium and vitamin D"
            ]
            6 => array:2 [
              "identificador" => "sec0060"
              "titulo" => "Functional impairment"
            ]
          ]
        ]
        7 => array:2 [
          "identificador" => "sec0065"
          "titulo" => "Conclusions and recommendations"
        ]
        8 => array:2 [
          "identificador" => "sec0070"
          "titulo" => "Conflicts of interest"
        ]
        9 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2015-06-24"
    "fechaAceptado" => "2016-03-28"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec801973"
          "palabras" => array:5 [
            0 => "Chronic kidney disease"
            1 => "Aged kidney"
            2 => "Frailty"
            3 => "Inflammation"
            4 => "Successful ageing"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec801972"
          "palabras" => array:5 [
            0 => "Enfermedad renal cr&#243;nica"
            1 => "Ri&#241;&#243;n senil"
            2 => "Fragilidad"
            3 => "Inflamaci&#243;n"
            4 => "Envejecimiento exitoso"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">In recent years&#44; the concept of frailty as a &#8220;state of pre-disability&#8221; has been widely accepted by those involved in the care of the elderly&#46; Its importance lies not only in its high prevalence &#8211; more than 25&#37; in people over 85 years of age &#8211; but it is also considered an independent risk factor of disability&#44; institutionalisation and mortality amongst the elderly&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The study of renal function is relevant in patients with major comorbidities&#46; Studies have shown a significant association between chronic kidney disease and the development of adverse clinical outcomes such as heart disease&#44; heart failure&#44; end-stage renal disease&#44; increased susceptibility to infections and greater functional impairment&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Frailty can be reversed&#44; which is why a study of frailty in patients with chronic kidney disease is of particular interest&#46; This article aims to describe the association between ageing&#44; frailty and chronic kidney disease in light of the most recent and relevant scientific publications&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">En los &#250;ltimos a&#241;os el concepto de fragilidad como &#171;estado de prediscapacidad&#187; se ha extendido de forma amplia en todos los que trabajamos en beneficio de la persona mayor&#46; Su importancia radica no solo en su elevada prevalencia &#8212;superior al 25&#37; en mayores de 85 a&#241;os&#8212;&#44; sino a que es considerada un factor de riesgo independiente&#44; que confiere a los ancianos que lo presentan un riesgo elevado de discapacidad&#44; institucionalizaci&#243;n y mortalidad<span class="elsevierStyleInf">&#46;</span></p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El estudio de la funci&#243;n renal es relevante en pacientes que soportan gran carga de comorbilidad&#44; habi&#233;ndose encontrado una importante asociaci&#243;n entre la enfermedad renal cr&#243;nica y el desarrollo de eventos cl&#237;nicos adversos como la enfermedad cardiovascular&#44; la insuficiencia cardiaca&#44; la enfermedad renal terminal&#44; el incremento de la susceptibilidad a infecciones y el mayor deterioro funcional&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La fragilidad puede ser una situaci&#243;n reversible&#44; por lo que su estudio en el paciente con enfermedad renal cr&#243;nica es de especial inter&#233;s&#46; Este art&#237;culo tiene por objeto describir las interrelaciones existentes entre envejecimiento&#44; fragilidad y enfermedad renal cr&#243;nica a la luz de la bibliograf&#237;a pertinente m&#225;s relevante y reciente publicada&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as&#58; Portilla Franco ME&#44; Molina FT&#44; Gregorio PG&#46; La fragilidad en el anciano con enfermedad renal cr&#243;nica&#46; Nefrolog&#237;a&#46; 2016&#59;36&#58;609&#8211;615&#46;</p>"
      ]
    ]
    "multimedia" => array:4 [
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        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Mechanisms implicated in the onset of frailty in CKD&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
            "rol" => "short"
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        "tabla" => array:1 [
          "tablatextoimagen" => array:2 [
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">GF Categories</th></tr><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Category&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">GF &#40;ml&#47;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Description&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">G1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8805;90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal or elevated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">G2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">60&#8211;89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Slightly diminished&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">G3a&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">45&#8211;59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Slightly to moderately diminished&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">G3b&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30&#8211;44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderately to severely diminished&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">G4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&#8211;29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Severely diminished&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">G5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60; 15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Renal failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1349349.png"
              ]
            ]
            1 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Albuminuria categories &#40;isolated urine sample&#41;&#44; mg&#47;g</th></tr><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Category&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Albumin&#47;creatinine ratio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Description&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">A1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal to slightly elevated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">A2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30&#8211;300&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderately elevated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">A3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;300&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Very elevated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1349348.png"
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            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">CKD classification&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
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        ]
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">GFR&#58; glomerular filtration rate&#59; PTH&#58; parathyroid hormone&#59; Vit&#46; D&#58; vitamin D&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Senile kidney&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">CKD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Proximal tubule function&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Preserved&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Diminished&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Plasma erythropoietin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal&#46; Hb normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Diminished<br>Anaemia<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Calcium &#40;Ca&#41;&#44; magnesium &#40;Mg&#41; and phosphorous &#40;P&#41; levels&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ca levels impaired&#44; Mg normal and P elevated<br>Osteopenia and osteoporosis<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PTH and Vit&#46; D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PTH elevated and Vit&#46; D impaired<br>Renal osteodystrophy and risk of falls<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Urea levels&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Elevated<br>Uraemia &#40;anorexia&#44; encephalopathy&#44; pruritus&#44; oedema&#44; bleeding&#44; polyneuropathy&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fractional sodium excretion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Relatively impaired&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Increases as GFR decreases &#40;under the influence of aldosterone&#41;<br>Lastly&#44; hyper-K which leads to cardiac arrhythmia<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Urinalysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Altered&#44; haematuria and&#47;or proteinuria &#40;&#8805;0&#46;3<span class="elsevierStyleHsp" style=""></span>g&#47;day&#41;<br>Malnutrition&#44; oedema<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Clinical symptoms related to the physiological changes in CKD&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Physiological aspects differentiated in CKD&#46;</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at3"
            "detalle" => "Table "
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        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Tool&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Author&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Measurements&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Categories&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Advantages&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Disadvantages&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Short Physical Performance Battery &#40;SPPB&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Guranik et al&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46; Walking speed<br>2&#46; Balance<br>3&#46; Getting up from a chair&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Physical function&#58;<br><span class="elsevierStyleHsp" style=""></span>Optimal &#40;9&#8211;12&#41;<br><span class="elsevierStyleHsp" style=""></span>Poor &#40;1&#8211;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Quick and easy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Does not take other areas into account&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fried&#39;s criteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fried et al&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46; Involuntary weight loss<br>2&#46; Weakness<br>3&#46; Fatigue<br>4&#46; Slowness<br>5&#46; Decreased activity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Frail&#58; &#8805; 3 criteria<br>Pre-frail&#58; 1&#8211;2<br>Nor frail&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Specific definition&#46; Multiple areas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Combines objective and subjective patient criteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Frailty index&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rockwood et al&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Quantification of clinical deficit&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Does not use a strict frailty criterion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Flexible criteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hard to standardise results&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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