Frailty in advanced CKD varies based on tool, provider; impacts dialysis prescription
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For patients with advanced chronic kidney disease, the prevalence of frailty varied widely based on the tool used for assessment, according to a study conducted in Canada.
Furthermore, health care providers came to differing diagnoses of frailty and these subjective impressions affected whether in-center hemodialysis or home dialysis was prescribed.
“In the general population, most measures of frailty are associated with poor clinical outcomes,” Ranveer S. Brar, BSc, of the University of Manitoba, and colleagues wrote. “Although there have been several studies in patients with early stages of CKD and those on dialysis, very few studies have examined the effect of frailty on the clinical trajectory of patients with advanced CKD (stages 4 and 5; eGFR, < 30ml/min/per 1.73 m2). In particular, no study has yet examined the effect that frailty may have on decisions surrounding choices for dialysis modalities, which are currently on the basis of subjective patient, caregiver and care provider factors.”
For the study, researchers objectively measured frailty in 603 patients utilizing Fried criteria, which was then compared with physical function score based on the short physical performance battery (SPPB). In addition, to explore subjective measures of frailty and how these impact treatment course, researchers utilized a Likert scale, asking nurses and nephrologists to rank patients as fit or frail.
Results indicated that the prevalence of frailty varied based on which tool was used, as well as between health care providers. More specifically, the Fried criteria identified 34% of patients as frail, physicians identified 44% as frail, nurses identified 36% as frail and the SPPB determined the prevalence of poor physical function to be 55%.
During a mean follow-up of 1,455 days, 227 patients developed kidney failure and began dialysis; 226 died.
After researchers adjusted findings for age, sex, and comorbid conditions, they found the Fried criteria and SPPB were both associated with a two-fold higher risk of all-cause mortality.
Regarding dialysis choice, results showed patients who were considered frail by physicians and nurses were three to four times more likely to initiate treatment with in-center hemodialysis (ORs = 3.41 and 3.87, respectively), with researchers adding that neither the Fried criteria nor the SPPB appeared to affect dialysis choice.
“Although we did not ask patients to classify themselves as frail [vs.] nonfrail, our findings suggest that physicians and nurses may be more likely to recommend in-center HD to patients they perceive are frail [vs.] those diagnosed as frail or having poor physical function using the Fried or SPPB based criteria, respectively,” Brar and colleagues wrote of the findings. “This discordance is concerning, as provider perception had poor agreement with objective measures of frailty or physical function and was not as strongly associated with a definitive clinical outcome (mortality), whereas the Fried and SPPB criteria were. This important discordance between clinician perception and objectively measured frailty and physical function suggests that clinical gestalt alone may be an inappropriate guide for dialysis modality choice and that subjective and objective definitions of frailty should not be considered interchangeable.”
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