Frailty, physical function and affective status in elderly patients on hemodialysis

https://doi.org/10.1016/j.archger.2019.103976Get rights and content

Highlights

  • Frail older adults that initiate hemodialysis, present higher mortality than the non-frail ones.

  • Frail older adults that initiate hemodialysis and survive at 12-months, improve depression and physical function.

  • Older adults that initiate hemodialysis with higher inflammatory profile, present higher 12-month mortality.

  • Frail older adults that initiate hemodialysis and survive at 12-months, improve the inflammatory profile when compared to the non-frail ones.

Abstract

Objetives

To analyze depression, cognition, and physical function change in older adults on hemodialysis at 12-month follow-up, depending on frailty status.

Design

Ongoing cohort study.

Participants

117 patients older than 69 years on hemodialysis; 75 men.

Measurements

Frailty was measured with the frailty phenotype, disability in basic and instrumental activities of daily living with the Barthel and Lawton index respectively, physical function with the Short Physical Performance Battery (SPPB), cognitive status with the Mini Cognitive Examination, and depression with the Yesavage´s Geriatric Depression Scale (GDS), at hemodialysis initiation and after 12-month follow-up. Inflammatory and nutrition profile was determined with C-reactive protein (CRP), albumin, and haemoglobin levels.

Results

The mean age of the participants was 78.1 years; 63 (53.8 %) were frail. Frail participants had a higher 12-month mortality risk compared to the non frail ones, hazard ratio 2.6 (95 % CI 0.9–7.9). Frail 12-month survivors presented an improvement in median GDS scores (10 to 9; p = .009). There was no change in frail survivors from SPPB ≤ 6 to SPPB > 6 and a shift in 29.3 % of non-frail survivors from SPPB > 6 to SPPB ≤ 6 (p = .007) after 12-month follow-up. Median CRP and haemoglobin levels improved in frail 12-month survivors from 13.9 to 8.3 mg/dL (p = .019) and 9.9–11.1 g/dL (p < .001) respectively.

Conclusions

Frail older adults that initiate hemodialysis present higher mortality than the non-frail ones at 12-month follow-up. Frail patients that survive improve physical function, depression and inflammatory profile compared to the non frail ones.

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.

References (37)

  • L.S. Dalrymple et al.

    Kidney function and prevalent and incident frailty

    CJASN

    (2013)
  • K. Farrington et al.

    ERBP guideline development group. Clinical Practice Guideline on management of older patients with chronic kidney disease stage 3b or higher (eGFR <45 mL/min/1.73 m2)

    Nephrology, Dialysis, Transplantation : Official Publication of the European Dialysis and Transplant Association - European Renal Association

    (2016)
  • M. Fernández-San Martín et al.

    Validation of the Spanish version of the geriatric depression scale (GDS) in primary care

    International Journal of Geriatric Psychiatry

    (2002)
  • L.P. Fried et al.

    Frailty in older adults: Evidence for a phenotype. Cardiovascular health study collaborative research group

    The Journals of Gerontology Series A, Biological Sciences and Medical Sciences

    (2001)
  • J.M. Guralnik et al.

    A short physical performance battery assessing lower extremity function: Association with self-reported disability and prediction of mortality and nursing home admission

    Journal of Gerontology

    (1994)
  • S.V. Jassal et al.

    Loss of independence in patients starting dialysis at 80 years of age or older

    The New England Journal of Medicine

    (2009)
  • K.L. Johansen et al.

    Significance of frailty among dialysis patients

    Journal of the American Society of Nephrology : JASN

    (2007)
  • K.L. Johansen et al.

    Association between body composition and frailty among prevalent hemodialysis patients: A USRDS special study

    Journal of the American Society of Nephrology : JASN

    (2014)
  • Cited by (16)

    • Frailty as a Predictor of Negative Health Outcomes in Chronic Kidney Disease: A Systematic Review and Meta-Analysis

      2021, Journal of the American Medical Directors Association
      Citation Excerpt :

      After screening titles and abstracts, 51 articles were considered potentially eligible. After full-text review, 18 cohort articles22–39 fulfilled the entry criteria and were subjected to final analysis. Characteristics of 18 studies (n = 22,788 patients) with longitudinal data are described in Table 1.

    View all citing articles on Scopus
    View full text