Use of frailty assessment instruments in nephrology populations: a scoping review

Abstract

Background Frailty is a clinical syndrome of accelerated aging associated with adverse outcomes. Frailty is prevalent among patients with chronic kidney disease but is infrequently assessed in clinical settings, due to lack of consensus regarding frailty definitions and diagnostic tools. This study aimed to review the practice of frailty assessment in nephrology populations and evaluate the context and timing of frailty assessment. Methods The search included published reports of frailty assessment in patients with chronic kidney disease, undergoing dialysis or in receipt of a kidney transplant, published between January 2000 and November 2021. Medline, CINAHL, Embase, PsychINFO, PubMed and Cochrane Library databases were examined. A total of 164 articles were included for review. Results We found that studies were most frequently set within developed nations. Overall, 161 studies were frailty assessments conducted as part of an observational study design, and 3 within an interventional study. Studies favoured assessment of participants with chronic kidney disease (CKD) and transplant candidates. A total of 40 different frailty metrics were used. The most frequently utilised tool was the Fried frailty phenotype. Frailty prevalence varied across populations and research settings from 2.8% among participants with CKD to 82% among patients undergoing haemodialysis. Studies of frailty in conservatively managed populations were infrequent (N = 4). We verified that frailty predicts higher rates of adverse patient outcomes. There is sufficient literature to justify future meta-analyses. Conclusions There is increasing recognition of frailty in nephrology populations and the value of assessment in informing prognostication and decision-making during transitions in care. The Fried frailty phenotype is the most frequently utilised assessment, reflecting the feasibility of incorporating objective measures of frailty and vulnerability into nephrology clinical assessment. Further research examining frailty in low and middle income countries as well as first nations people is required. Future work should focus on interventional strategies exploring frailty rehabilitation.

Narrative Review: Clinical Implications and Assessment of Frailty in Patients With Advanced CKD

“… 19 , 20 , 21 , 22 Among patients with advanced CKD, frailty ranges from 42.6% to 74.1% in patients with stage 4 CKD and 53.8 to 4.7% in predialysis populations. 18 , 23 , 24 Frailty appears to develop alongside kidney disease progression with incidence rate of 44.5% described in one heterogenous CKD cohort. 25 Rates as high as 82% have been described in hemodialysis (HD) populations 26 and up to 75% in patients incident to peritoneal dialysis.…”

“…We refer to our recently published scoping review which provides an overview of frailty prevalence by nephrology population and choice of frailty assessment tool. 18 A number of studies report variation in frailty prevalence using different screening tools within the same study population, allowing a comparison of frailty metrics. 19 , 20 , 21 , 22 Among patients with advanced CKD, frailty ranges from 42.6% to 74.1% in patients with stage 4 CKD and 53.8 to 4.7% in predialysis populations.…”

“… 7 , 85 , 91 , 93 , 111 , 112 , 113 , 114 , 115 , 116 Frailty in PD populations remains a neglected area of research activity. 18 , 29 Studies of dialysis populations consistently report 1.4- to 3-fold increased risk of hospitalization and emergency department presentations and 2- to 5-fold hazard ratio for mortality, when adjusted for age and comorbidity. 7 , 8 , 33 , 44 , 74 Hospitalization contributes to frailty progression and deterioration in frailty scores.…”

“…Risk stratification using frailty assessment demonstrates increasing uptake and much research interest. 18 , 124 , 125 Transplant centers that assess frailty as part of clinical practice demonstrate better patient-level outcomes, including waitlist mortality and death-censored graft loss. 126 Such improvements in patient outcomes appear to come at the cost of reduced access to transplantation among frail candidates, although a number of centers did describe provision of additional social and home support, along with prehabilitation.…”

“… 146 In nephrology settings, it has been most frequently operationalized in nondialysis CKD populations where competing comorbidities were of equal or equivalent relevance. 18 , 29 …”