Saudi Journal of Kidney Diseases and Transplantation

ORIGINAL ARTICLE
Year
: 2017  |  Volume : 28  |  Issue : 1  |  Page : 15--22

A study of clinical assessment of frailty in patients on maintenance hemodialysis supported by cashless government scheme


Manjusha Yadla1, Jyothi Priyadarshini John1, Mahesh Mummadi2,  
1 Department of Nephrology, Gandhi Medical College, Hyderabad, Telangana, India
2 Department of Epidemiology and Statistics, Community Medicine, Gandhi Medical College, Hyderabad, Telangana, India

Correspondence Address:
Manjusha Yadla
Department of Nephrology, Gandhi Medical College, Hyderabad - 500 071, Telangana
India

Abstract

This is a prospective cohort study to assess the prevalence of frailty in patients undergoing maintenance hemodialysis (HD) under the government-funded scheme at our center and to assess the relationship between frailty and falls, hospitalizations, and mortality. This was done at our center which is completely supported by the government, which provides HD to all the patients under poverty line. Epidemiological data, anthropometric measurements, comorbidities assessment, frailty assessment using Fried criteria, subsequent hospitalizations, falls, and mortality were recorded in our prevalent dialysis population at our center between October 2014 and October 2015. Two hundred and twenty-six patients were enrolled during this period. Twenty-one patients were excluded as they did not satisfy the inclusion criteria. Two hundred and five prospective patients were studied for the predictors of frailty. Frailty was present in 82% of the study population. Mean age of our study population was 44.95 ± 13.27 years. On univariate analysis, diabetes mellitus, hypertension (HTN), cerebrovascular accident (CVA), left ventricular dysfunction (LVD), peripheral vascular disease (PVD), smoking, hepatitis C, inadequate dialysis, intradialytic hypotension (IDH), interdialytic weight gain, low serum creatinine <4 mg/dL, and anemia (Hb <10 g/dL) were found to be statistically significantly different between frail and nonfrail groups On multivariate regression analysis, only HTN, PVD, CVA, anemia, smoking, and IDH were found to be significant. Frailty is highly prevalent among dialysis population. Factors predicting frailty include HTN, smoking, LVD, PVD, CVA, smoking, anemia, and IDH. Frailty is a significant risk factor for falls and hospitalizations.



How to cite this article:
Yadla M, John JP, Mummadi M. A study of clinical assessment of frailty in patients on maintenance hemodialysis supported by cashless government scheme.Saudi J Kidney Dis Transpl 2017;28:15-22


How to cite this URL:
Yadla M, John JP, Mummadi M. A study of clinical assessment of frailty in patients on maintenance hemodialysis supported by cashless government scheme. Saudi J Kidney Dis Transpl [serial online] 2017 [cited 2017 Sep 19 ];28:15-22
Available from: http://www.sjkdt.org/text.asp?2017/28/1/15/198102


Full Text

 Introduction



Frailty is defined by loss of reserves in energy, physical ability, health, and cognition. There are different scales of assessment of frailty. Most widely used index is Fried frailty index according to which frailty is determined to be present if three of the following five criteria are met: unintentional weight loss over one year, weak grip strength, self-report exhaustion, slow gait speed, and low physical activity.[1] Frailty reflects decrease in physical strength and ultimately causes increased incidence of hospitalizations, hip fractures, physical disability, and reduced capacity to do daily activities of living and deaths.[2] ,[3] ,[4]

Irrespective of the age group studied, frailty was reported to be associated with adverse health outcomes in those with chronic diseases including mild-to-moderate chronic kidney disease (CKD) and also in those on dialysis.[5] Frailty is common among elderly population. A high prevalence of frailty was reported in elderly patients with mild-to-moderate CKD. A variable prevalence of frailty was reported in patients on hemodialysis (HD). Clinical features of frailty have a close resemblance to those of uremia. However, the improvement of uremia with the initiation of dialysis differentiates the presence of frailty in patients who are already on HD.

We undertook a study to assess the presence of frailty in patients on maintenance HD. Our HD populations are placed under a scheme funded by the government (Aarogyasri). This is a flagship scheme providing free health care for the poor. All the patients in this group are below poverty line. Under this scheme, patients are given 10-12 dialysis sessions per month. Dialysis is done using F6 polysulfone membrane using Fresenius 4008 machines. Each session of dialysis would last 4 h. Online Kt/v is assessed periodically. Dialyzer is reused with the assessment of total cell volume using reprocessor. Average reuse of dialyzer in our unit is eight. In addition, weekly dose of erythropoietin is given free of cost. Monthly assessment of hemoglobin, serum creatinine, and viral markers is done under this scheme.

 Patients and Methods



All the patients on maintenance HD in our center for a minimum period of six months between October 2014 and October 2015 and who have given the consent to participate were enrolled in the study

The primary outcome of the study was the assessment of prevalence of frailty among this population, and the secondary outcome is to assess if frailty as a marker of falls, hospitalizations, and deaths.

The following data were recorded: age, gender, economic status, native kidney disease, duration of dialysis, comorbidities, history of falls, hospitalizations, death anthropology parameters, access, and biochemical parameters.

The presence of comorbidities such as diabetes mellitus (DM), hypertension (HTN), smoking, and peripheral vascular disease (PVD) was assessed. Left ventricular dysfunction (LVD) was noted based on echocardiogram reports. Assessment of cerebrovascular accident (CVA) was done based on the history and the presence of residual paralysis. History of pulmonary tuberculosis was noted in all the patients.

Patients were followed up for a duration of one year to assess secondary outcomes.

Assessment of frailty

Fried frailty criteria were used to assess frailty. Apart from the assessment of weight loss, physical exertion, and physical inactivity based on a questionnaire, walking speed and hand grip strength using Rudham meter were assessed. Those who satisfied >3 criteria were included in the frail group and with <3 were included in the nonfrail group.

Outcomes assessment recorded included falls, hospitalizations, and deaths.

Definition of fall: Sudden fall onto the ground/floor due to give a way of lower limbs happening in his/her cognizance.

 Statistical Analysis



Analysis is done using Statistical Package for the Social Science (SPSS) software version 17 (SPSS Inc., Chicago, IL, USA). P <0.05 was considered statistically significant. Multivariate regression analysis is used to find the significance of various predictors. Hazard ratio for secondary outcomes and survival curves were analyzed.

 Results



Of the total number of 226 patients in our center, 21 patients were excluded as they did not satisfy the inclusion criteria. Frailty index was assessed in 205 patients and was found to be present (≥3 criteria) in 82% (167/205) patients. Frailty was not seen in 18% (38/205) patients. Mean age of our study population was 44.95 ± 13.27 years. Mean age in men was 45.02 ± 12.89 years and in women was 44.87 ± 14.82 years. There were 142 men and 63 women in our group. Mean duration of dialysis in our group was 2.5 ± 1.3 years. Duration of dialysis was <2 years in 52.6% (108/205) and was >2 years in 47.31% (97/205). Eighty-five percent (176/205) had AVF as a vascular access and 14% (29/205) were on temporary internal jugular catheter.

Components of frailty are assessed in each patient. Distribution of each component is tabulated in [Figure 1]. Weight loss, physical inactivity, physical exhaustion, and weak hand grip were seen in 53-62% of the patients, and prolonged gait speed was seen in 77% of the group.{Figure 1}

In the frail group, 42% (69/167) were under 40 years of age, 67% (112/167) were men, and 32% (55/167) were women. In the nonfrail group, 28.94% (11/38) were under 40 years of age, 78% were men (were 30/38), and 22% were women (8/38). The baseline characteristics of frail and nonfrail patients are mentioned in [Table 1].{Table 1}

On univariate analysis, DM, HTN, CVA, LVD, PVD, smoking, hepatitis C, inadequate dialysis, intradialytic hypotension (IDH), interdialytic weight gain, low serum creatinine <4 mg/dL, and anemia (Hb <10 g/dL) were found to be statistically significant between frail and nonfrail groups, However, on multivariate regression analysis, only HTN, PVD, CVA, anemia, smoking, and IDH were found to be significant ([Table 2]). HTN, CVA, LVD, PVD, smoking, IDH, Kt/V, serum creatinine, and hemoglobin were found to be associated with relative risk (RR) of 1.1-1.5 ([Table 3]).{Table 2}{Table 3}

Secondary outcomes (falls, hospitalizations, and deaths) were compared between the frail and nonfrail groups during one-year follow-up period ([Table 4]).{Table 4}

Although our study population was small, we tried to assess hazard ratio and survival analysis curves ([Table 5]). Survival analysis curves for deaths, falls, and hospitalizations ([Figure 2], [Figure 3] and [Figure 4]) are done using Kaplan-Meier analysis.{Figure 2}{Figure 3}{Figure 4}{Table 5}

 Discussion



Frailty is a state where there is depletion of physiological reserves of energy, thus increasing the predisposition to decreased activity in daily living, falls, hospitalizations, and death. Of the various scales available to measure frailty, the most widely used is Fried frailty index.

Prevalence of frailty in patients with kidney diseases was reported to vary between 21% and 77% in various studies.[6] ,[7] ,[8] ,[9] ,[10] Prevalence of frailty was reported to be high in elderly with even mild-moderate CKD compared to age-matched community dwellers.[11]

In our study, prevalence of frailty was quite high at 81%. The mean age of our study population is 44.95 ± 13.27 years. Mean age in men is 45.02 ± 12.89 years and in women is 44.87 ± 14.82 years.

Approximately, 40% of our study populations are under 40 years of age. This is in concordance with Johansen study where 44% of population were under 40 years of age.[10] This suggests that the presence of CKD itself is an important risk factor for the development of frailty irrespective of the age.

In various studies, women are reported to be more frail than men in the dialysis population.[10] However, McAdams-DeMarco et al noted no association of frailty with gender.[8] In our study among 167 patients with frailty, 67% were males and 32% were females. We did not find an increase in frailty in women (P = 0.65).

Mean duration of dialysis in our study was 2.5 ± 1.3 years (range 1-10 years). Among the frail group, 52% (108/167) of them were of vintage of <2 years and 47% (97) were >2 years duration. Thus did not find that the vintage of dialysis as a predictor for the development of frailty in our study.

In a few studies, it was shown that those with permanent access have a lesser incidence of frailty than those with temporary access.[10] However, in our study, this finding was not observed, but this may be related to the small number of patients using temporary access.

Regarding the distribution of components of frailty criteria ([Figure 1]), weight loss was seen in 64%, severe physical inactivity in 55%, severe physical exertion in 58%, hand grip strength as measured by Rudham meter was weak in 55%, and walking speed was >15 s in 58%.

By multivariate regression analysis, only HTN, smoking, PVD, anemia, and IDH were found to be significantly associated with facility.

Frailty was found in 108/117 patients with DM and in 136/150 patients with HTN. Patients with these two factors may have a higher incidence of frailty (P <;0.0001). Frailty was also higher in those with CVA (72/74, P = 0.003).

Frailty in those with serological infections due to hepatitis B and hepatitis C was found in 14/15 patients and 36/37 patients, respectively (P = 0.31 and P = 0.004).

In our study, the presence of PVD, CVA, and LVD was found to be significant predictors of frailty. This is in concordance with a study done by Kutner et al[9] Similar findings were noted by others.[8] ,[12]

In a systematic search of 1020 studies, Kojima et al reported that smoking is associated with increasing frailty in community-dwelling population.[13] However, the influence of smoking was not studied in the dialysis population. In our group, smoking was found to be associated with frailty (RR of 1.18).

It is well known that frailty, a physiologic precursor of disability, thus leads to increased incidence of falls.[1] The incidence of falls and hospitalizations was reported to be five times more common among the patients on HD with frailty compared to community dwellers with frailty.[8]

In our study, severity of frailty correlated with falls and hospitalizations but not deaths. This is in agreement with previous reports.[7] ,[14]

Studies have shown that frailty in dialysis patients is associated with decreased survival.[15] - [18] We did not find this in our study.

Evaluation for frailty is essential as frailty predicts adverse outcomes in population with CKD of any age. Intervention measures in alleviating the frailty score may yield better outcomes with falls, hospitalizations, and deaths.[19] ,[20]

 Observations



Prevalence of frailty is high in patients on HD, supported by cashless government-funded scheme.

Risk factors such as HTN, PVD, CVA, and LVD are associated with higher incidence of frailty.

Falls and hospitalizations are more frequent in patients with frailty.

 Limitation



The size of the population study is smallDuration of study was limited to one yearOther biochemical parameters influencing frailty could not be done under cashless scheme.

Conflict of interest: None declared.

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