Frailty, physical function and affective status in elderly patients on hemodialysis
Introduction
Frailty is a progressive age-related decline in physiological systems that results in a decreased reserve of intrinsic capacity, confering extreme vulnerability to stressors and increasing the risk of a range of adverse health outcomes (Rodríguez-Laso et al., 2019). Frailty is part of the functional continuum in older adults and is considered as a predisability condition as a bridge between maximal intrinsic capacity and the begining of low disability in activities of daily living (Rodriguez-Mañas, 2016; World Health Organization, 2015). Frailty is actually considered the cornerstone of Geriatric Medicine (Abizanda & Rodríguez-Mañas, 2017), clearly situated over multimorbidity as the main risk factor for health-related adverse outcomes in older adults (Abizanda, Romero, & Sánchez-Jurado, 2014).
Frailty is very common in older adults with chronic kidney disease (CKD) with prevalences greater than 60 % in dialysis dependent patients (Bao, Dalrymple, & Chertow, 2012; Johansen, Chertow, & Jin, 2007), although the relationship between these two conditions is not completely understood (Chowdhury, Peel, Krosch, & Hubbard, 2017). A negative correlation between glomerular filtration rates and both prevalent and incident frailty has been stablished (Dalrymple, Katz, & Rifkin, 2013). Furthermore, the progressive aging of the population, the progressive increase in the number of older adults with high intrinsic capacity, and the progressive improvement in nephrologic treatments, make highly probable that this figures continue to increase (Nixon, Bampouras, & Pendleton, 2018; Rodriguez-Mañas, 2016; World Health Organization, 2015).
Frailty in older adults with CKD on dialysis treatment is associated with an increased risk of adverse health-related outcomes like mortality (Bao et al., 2012; Kallenberg, Kleinveld, & Dekker, 2016; McAdams-Demarco, Law, & Salter, 2013; Roshanravan, Khatri, & Robinson-Cohen, 2012), hospitalization (Bao et al., 2012; Kallenberg et al., 2016; McAdams-Demarco et al., 2013), falls (McAdams-DeMarco, Suresh, & Law, 2013), and bad quality of life (Lee, Son, & Shin, 2015; Mansur, Colugnati, & Grincenkov, 2014). However, the relationship between frailty and other important health outcomes for older adults like physical function, depression and cognitive status has not yet been well determined.
Recently, the guideline on the management of older adults with CKD stage 3b or higher, published by the European Renal Best Practice (ERBP) Working Group, highlights the relevance of assessing function in these populations (Farrington, Covic, & Aucella, 2016). Given the clear relationship between frailty, CKD and health outcomes, nephrologists and geriatricians need to work together in the decission-making process in order to achieve a healthy aging in these patients. For all these reasons, there is a clear necessity of studies that help understand the implications of frailty on CKD patients as a first stage for decission-making strategies. Our study aims at looking on the relationship between frailty and physical function, depression and cognitive status in CKD older adults.
Section snippets
Study design, participants and setting
Ongoing cohort study of patients that were at least 70 years old at the begining of an hemodialysis program. The inclussion period was from 2012 to 2016 (5 years). Participants were recruited if they were in CKD stage 5 and they had never received renal replacement therapy before. They had to give informed consent before the baseline visit. The only exclussion criteria were any acute or chronic infectious active disease or known active cancer at entry. We included in the study all the patients
Results
Table 1 presents the basal characteristics of the complete sample, and regarding frailty status at baseline and mortality at 12-month follow-up. Mean age was 78.1 years (SD 4.1, range 70–86 years), 63.2 % male. CKD etiology was: undetermined in 28.8 %, chronic tubulo-interstitial nephropathy in 22.9 %, vascular nephropathy in 19.5 % and diabetes nephropathy in 15.4 %. On hemodialysis entry, 63 participants were frail (53.8 %). Frail participants were more frequently female, presented a
Discussion
Our study confirms previous results that frailty is an independent factor for poor healthcare outcomes in older adults with CKD beginning hemodialysis (Bao et al., 2012; Johansen et al., 2007; Kallenberg et al., 2016; McAdams-Demarco et al., 2013; Roshanravan et al., 2012). However, our study adds to previous knowledge that in the subgroup of frail older adults that survive for the first 12 months, physical function and affective status improve compared to the non frail ones, and that this
Conclusions and implications
Frailty is an independent mortality-risk factor in older adults that begin haemodialysis. However, in those frail older adults surviving after 12 months in haemodialysis, physical function and affective status improve compared to the non frail ones. This improvement is associated with an increase in haemoglobin values and with a decrease in CRP values during follow-up, suggesting a better hemodialysis-related inflammatory profile.
Age by itself should not be a limiting condition for hemodialysis
Declaration of Competing Interest
There are no conflicts of interest of any of the authors.
Acknowledgements
This work was supported by CIBERFES (CB16/10/00408), Instituto de Salud Carlos III, Ministerio de Economía y Competitividad, España. Ayuda cofinanciada por el Fondo Europeo de Desarrollo Regional FEDER Una Manera de hacer Europa.
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