Table 2.
Association of functional and cognitive impairment and frailty with adverse health outcomes
| Authors | No. of Patients | Treatment Modality | Geriatric Assessment | Outcome | Associationa |
|---|---|---|---|---|---|
| Alfaadhel et al. (47) | 390 | HD, PD | CFS | Mortality | Frailty at dialysis initiation was associated with higher mortality risk with each 1-point increase in CFS (aHR, 1.32; 95% CI, 1.15 to 1.52) |
| Arai et al. (35) | 202 | HD, PD | Mobility (ability or lack of ability to walk without assistance) | 6-mo Mortality | Impaired mobility at dialysis initiation was associated with higher 6-mo mortality risk (aHR, 4.94; 95% CI, 1.42 to 17.1) |
| Bao et al. (46) | 1576 | HD, PD | Modified version of Fried criteria for frailty | Mortality, time to first hospitalization | Frailty at dialysis initiation was associated with higher mortality risk (aHR, 1.57; 95% CI, 1.25 to 1.97) and time to first hospitalization (aHR, 1.26; 95% CI, 1.09 to 1.45) |
| Bowling et al. (31) | 27,913 | HD, PD | Functional impairment (inability to walk or transfer or requiring assistance with daily activities) | Mortality | Functional impairment at dialysis initiation was associated with a higher mortality risk (aHR, 1.25; 95% CI, 1.20 to 1.31) |
| Carlson et al. (23) | 979 | HD, PD | KPS | Mortality | KPS scores at dialysis initiation in patients still alive after 2 yr of follow-up were higher compared with those in patients who died (KPS=65.6 versus 53.6, respectively; P<0.001) |
| Chandna et al. (19) | 292 | HD, PD | KPS | Mortality | Lower KPS at dialysis initiation was associated with higher mortality risk (aHR, 0.98; 95% CI, 0.97 to 0.99 per KPS point) |
| Couchoud et al. (36) | 2500 | HD, PD | Mobility (walk without help, assistance with or total dependency for transfers); severe behavioral disorders (including dementia) | 6-mo Mortality | Total dependency for transfers at dialysis initiation was associated with higher 6-mo mortality risk (aOR, 1.7; 95% CI, 1.4 to 2.0) compared with assistance or no help needed; presence of severe behavioral disorders was associated with higher 6-mo mortality (aOR, 1.5; 95% CI, 1.2 to 1.8) |
| Couchoud et al. (37) | 12,500 | HD, PD | Mobility (walk without help, assistance with or total dependency for transfers); severe behavioral disorders (including dementia) | 3-mo Mortality | Impaired mobility at dialysis initiation was associated with higher 3-mo mortality risk: requiring assistance for transfers aOR, 2.47; 95% CI, 2.10 to 2.91 and total dependency for transfers aOR, 6.53; 95% CI, 5.38 to 7.92 compared with no help needed; presence of severe behavioral disorders was associated with higher 3-mo mortality (aOR, 1.44; 95% CI, 1.12 to 1.85) |
| Decourt et al. (38) | 1459 | HD, PD | Mobility (inability to walk without help) | Mortality | Impaired mobility at dialysis initiation was associated with higher mortality risk (aHR, 1.93; 95% CI, 1.58 to 2.36) |
| Doi et al. (29) | 688 | HD | WHO performance score | 1-yr Mortality | Higher WHO performance score at dialysis initiation was associated with higher 1-yr mortality risk: WHO scores 1 and 2 aOR, 2.03; 95% CI, 0.45 to 9.13 and WHO scores 3 and 4 aOR, 6.75; 95% CI, 1.51 to 30.1 |
| Dusseux et al. (34) | 8955 | HD, PD | Mobility (walk without help, assistance with or total dependency for transfers); severe behavioral disorders (including dementia) | 3-yr Mortality | Impaired mobility at dialysis initiation was associated with higher 3-yr mortality risk: requiring assistance for transfers aOR, 1.67; 95% CI, 1.47 to 1.90 and total dependency for transfers aOR, 2.99; 95% CI, 2.34 to 3.83 compared with no help needed; presence of severe behavioral disorders was associated with higher 3-yr mortality (aOR, 2.14; 95% CI, 1.62 to 2.84) |
| Glaudet et al. (33) | 557 | HD, PD | Mobility (walk without help, assistance with or total dependency for transfers) | 4-yr Mortality | Impaired mobility at dialysis initiation was associated with higher 4-yr mortality risk in patients >75 yr old: requiring assistance for transfers aHR, 1.43; 95% CI, 1.16 to 1.74 and total dependency for transfers aHR, 1.42; 95% CI, 0.97 to 1.96 compared with no help needed |
| Hussain et al. (28) | 441 | HD, PD, CKM | WHO performance score | Mortality | Higher WHO performance score was associated with lower survival after both dialysis initiation and CKM (univariate analysis without reported estimate; P<0.001) |
| Isoyama et al. (41) | 330 | HD, PD | HGS | Mortality | Lower HGS (<20 kg in women, <30 kg in men) at dialysis initiation was associated with higher mortality risk (aHR, 1.79; 95% CI, 1.09 to 2.94) |
| Johansen et al. (45) | 2275 | HD, PD | Modified version of Fried criteria for frailty | Mortality, hospitalization | Frailty at dialysis initiation was associated with higher mortality risk (aHR, 2.24; 95% CI, 1.60 to 3.15) and combined outcome of death or hospitalization (aHR, 1.56; 95% CI, 1.36 to 1.79 |
| Joly et al. (21) | 144 | HD, CKM | KPS; documented clinical diagnosis of dementia | Overall and 1-yr mortality | Functional dependency at dialysis initiation was associated with higher 1-yr mortality (aHR, 2.34; 95% CI, 1.00 to 5.50) but not with >12-mo mortality (aHR, 1.00; 95% CI, 0.42 to 2.36); presence of dementia was not significantly associated with mortality (no estimate reported) |
| Krishnan et al. (39) | 45,357 | HD, PD | Mobility (inability to ambulate from at least one claim for a wheelchair or wheelchair accessories) | 1-yr Mortality | Impaired mobility before dialysis initiation was associated with higher 1-yr mortality risk: impaired mobility from Medical Evidence Report aHR, 1.92; 95% CI, 1.84 to 2.00 and claims aHR, 1.25; 95% CI, 1.19 to 1.31 |
| Kurella et al. (32) | 83,996 | HD, PD | Nonambulatory status (inability to walk or transfer) | Mortality | Nonambulatory status at dialysis initiation was associated with higher mortality risk in octo- and nonagenarians (aRR, 1.54; 95% CI, 1.49 to 1.58) |
| Kurella Tamura et al. (43) | 3702 | HD, PD | Documented clinical diagnosis of dementia | Functional status trajectory | Presence of dementia at dialysis initiation was associated with lower odds of maintained functional status 12 mo after start of dialysis (aOR, 0.6; 95% CI, 0.4 to 0.9) |
| Lopez Revuelta et al. (24) | 318 | HD, PD | Modified version of the KPS | Mortality, hospitalization days | Lower KPS score at dialysis initiation was associated with higher mortality risk (aHR, 1.69; 95% CI, 1.44 to 1.97 per 10 points lower on KPS score) and no. of hospitalization days (aHR, 1.25; 95% CI, 1.05 to 1.48 per 10 points lower on KPS score) |
| Mauri et al. (20) | 3445 | HD | Modified version of the KPS | 1-yr Mortality | Functional dependency at dialysis initiation was associated with higher 1-yr mortality risk: requiring special care for daily living aOR, 3.83; 95% CI, 2.84 to 5.16 and having limited functional autonomy aOR, 1.88; 95% CI, 1.45 to 2.43 compared with patients with normal functional independence |
| McClellan et al. (25) | 294 | HD, PD | KPS; clinical diagnosis of depression | Mortality | Lower KPS score at dialysis initiation was associated with higher mortality: cumulative 1-yr survival was 94.5% in the highest quartile and 55.7% in the lowest quartile of functional status (P<0.001); depression diagnosed before dialysis initiation was associated with higher mortality: cumulative 1-yr survival was 58.3% versus 81.9% in patients without a history of depression (P=0.01) |
| Meulendijks et al. (48) | 65 | HD, PD, CKM | Groningen Frailty Indicator | 1-yr Mortality, hospitalization | 1-yr Mortality risk was higher in frail patients compared with nonfrail patients (30% versus 9%; P=0.04); hospitalization risk within 1 yr was higher in frail patients compared with nonfrail patients (90% versus 53%; P<0.01) |
| Murtagh et al. (22) | 74 | CKM | KPS | Mortality | Functional status at study entry was lower in patients on CKM who died during follow-up versus those still alive at study end (KPS score 60% versus 70%; P=0.01) |
| Park et al. (44) | 24,738 | HD | Documented diagnosis of dementia (on the basis of coding in Health Insurance database) | Mortality | Dementia diagnosed before dialysis initiation was associated with higher mortality (aHR, 1.40; 95% CI, 1.34 to 1.46) |
| Rakowski et al. (40) | 272,024 | HD, PD | Documented diagnosis of dementia (on the basis of coding in Medicare system); nonambulatory status (inability to walk or transfer) | Mortality | Dementia diagnosed before dialysis initiation was associated with higher mortality (aHR, 1.91; 95% CI, 1.77 to 1.98); nonambulatory status at dialysis initiation was associated with higher mortality risk: inability to walk aHR, 1.36; 95% CI, 1.30 to 1.43 and inability to transfer aHR, 1.47; 95% CI, 1.43 to 1.52 |
| Shum et al. (27) | 199 | PD, CKM | Basic Activities of Daily Living | Mortality, hospitalization, hospital days | Impairment in basic activities of daily living at PD initiation was associated with higher mortality risk (aHR, 2.11; 95% CI, 1.28 to 3.46) as well as emergency hospitalization (β=0.20; P<0.01) and hospital days (β=0.22; P<0.01) after log transformation |
| Soucie et al. (26) | 15,245 | HD, PD | Modified version of the KPS; clinical diagnosis of depression | Mortality | Impaired functional status at dialysis initiation was associated with a higher risk of early mortality within 90 d (aOR, 1.5; 95% CI, 0.9 to 2.3 for moderate impairment and aOR, 2.3; 95% CI, 1.4 to 3.6 for severely impaired functional status); depression diagnosed before dialysis initiation was associated with a higher risk of early mortality within 90 d after dialysis initiation (aOR, 1.3; 95% CI, 1.0 to 1.6) |
| Stenvinkel et al. (42) | 206 | HD, PD, KT | HGS | Mortality | Higher HGS at RRT initiation was significantly associated with lower mortality compared with those with HGS below the median (log rank =7.2; P<0.01) |
| Thamer et al. (30) | 52,796 | HD, PD | Assistance with daily living (requiring assistance with daily living, inability to ambulate, or has an amputation); documented diagnosis of dementia | 3-mo Mortality | Requiring assistance with daily living or walking at dialysis initiation was associated with higher 3-mo mortality risk (aOR, 1.43; 95% CI, 1.34 to 1.53) compared with no help needed; patients who died within 3 mo were more likely to have dementia compared with patients who did not die (8% versus 5.6%; P<0.001) |
HD, hemodialysis; PD, peritoneal dialysis; CFS, Clinical Frailty Scale; aHR, adjusted hazard ratio; 95% CI, 95% confidence interval; KPS, Karnofsky Performance Scale; aOR, adjusted odds ratio; WHO, World Health Organization; CKM, conservative kidney management; HGS, handgrip strength; aRR, adjusted relative risk; KT, kidney transplantation.
a
All reported hazard ratios, odds ratios, and relative risks are adjusted for at least age and sex.