Application of the Clinical Frailty Score and body composition and upper arm strength in haemodialysis patients

Abstract

Background To improve outcomes, simple screening tests are required to detect patients at increased risk of mortality. As patients with muscle weakness and wasting are at increased risk of death, we wished to review the use of the Clinical Frailty Score (CFS). Patients and methods Dialysis staff graded haemodialysis (HD) patients attending for routine outpatient sessions using the CFS, a functional scoring scale, for patients who require help with their instrumental activities of daily living, classified as clinically frail with scores >4, which were compared with contemporaneous Stoke–Davies comorbidity scores, post-HD body composition measured by bioimpedance, hand grip strength (HGS) and standard laboratory investigations. Results The results from 2089 patients (60.2% male) were reviewed, with 890 (42.6%) classified as frail. Frail patients were older [mean ± standard deviation (SD) 71.5 ± 15.6 versus 59.1 ± 15.6 years) and female (50.7% versus 37.3%) and had greater comorbidity {median 2 [interquartile range (IQR) 1–3] versus 1 [0–2]}, body mass index (BMI) (26.0 ± 6.7 versus 25.5 ± 5.4 kg/m2), C-reactive protein (CRP) [8 (IQR 3–20) versus 5 (2–11) mg/L], lower serum albumin (37.6 ± 4.7 versus 40.1 ± 4.7 g/L), lean BMI (8.9 ± 1.7 versus 9.7 ± 1.6 kg/m2) and HGS [13.4 (IQR 9.6–18.8) versus 20.9 (14.5–29) kg] (all P < 0.001). Frailty was independently associated in a multivariable logistic model with age {odds ratio [OR] 2.33 [95% confidence limit (CL) 2.01–2.7]}, body fat mass [OR 1.02 (CL 1.01–1.03)], log CRP [OR 1.63 (CL 1.28–2.07)] (all P < 0.001) and comorbidity [OR 1.45 (CL 1.17–1.8); P = 0.001] and negatively associated with albumin [OR 0.95 (CL 0.92–0.98) and HGS [OR 0.91 (CL 0.9–0.93)] (both P < 0.001). Conclusion Frail patients are at increased risk of mortality and, as such, simple reliable screening tools are required to rapidly detect patients at risk. The CFS is a useful screening tool that can be readily performed by dialysis staff to identify frail patients. Frailty in HD patients was associated with increasing age, comorbidity, fat weight and inflammation and reduced muscle strength and muscle mass. There is an overlap between frailty and both sarcopenia and protein energy wasting, which requires additional assessments, potentially including body composition, strength, dietary assessments and laboratory investigations. In addition, as the CFS offers a scale, patient trajectories can potentially be serially monitored over time, thus allowing patient-specific interventions or holistic care plans.

Peri‐dialytic hypoglycemia with hemodialysis and online post‐dilutional hemodiafiltration

“…Similarly, there were no differences in dialysis session urea clearance or length of dialysis sessions, or pre-dialysis urea or creatinine. Previous reports have suggested that peri-dialytic hypoglycemia is likely to occur with OL-HDF compared to hemodialysis [13]. However, we found no difference between dialysis modes, and although glucose containing dialysate was directly re-infused with OL-HDF, all cases of peri-dialytic hypoglycemia occurred with OL-HDF treatments.…”

“…Over time not only have the number of patients treated by dialysis increased in Western Europe and North America, but also the demographics of the dialysis population have changed, particularly in terms of increasing numbers of elderly and frail patients [13,14] and those with diabetes. In view of these reports of peridialytic hypoglycemia, we wished to determine whether this was a clinical risk for contemporary dialysis patients treated by both hemodialysis and OL-HDF.…”

Frailty, appendicular lean mass, osteoporosis and osteosarcopenia in peritoneal dialysis patients

“…Changes in the demographics of the dialysis population, with increasing numbers of older patients, lead to a more complex pattern of chronic kidney disease mineral bone disorder (CKD-MBD) due to varying amounts of osteoporosis and renal osteodystrophy [3,4]. Muscle mass declines with age, but dialysis patients are at greater risk of muscle loss, more so than that which would be expected with age alone, often termed sarcopenia [5], and the combination with frailty [6] and reduced physical activity [7], leads to higher risks for both falls and bone fractures [8].…”

Clinical performance, intermediate and long‐term outcomes of high‐volume hemodiafiltration in patients with kidney failure

“…35 The demographics of the dialysis population in economically developed countries has changed over time, with increasing numbers of older, diabetic, and more frail patients. 36 As such, nutrition and preservation of nutritional status including body composition are now key elements of dialysis adequacy. On one hand, HDF, by increasing the spectrum of cleared waste products of metabolism, may be beneficial but could also lead to the removal of small protein and other nutrient losses.…”

“…The patients with ESKD treated by dialysis are at increased risk of sarcopenia and protein energy wasting 35 . The demographics of the dialysis population in economically developed countries has changed over time, with increasing numbers of older, diabetic, and more frail patients 36 . As such, nutrition and preservation of nutritional status including body composition are now key elements of dialysis adequacy.…”