Prognostic Signature of Chronic Kidney Disease in Advanced Age: Secondary Analysis from the InGAH Study with One-Year Follow-Up

Abstract

The negative impact of chronic kidney disease (CKD) on health status and quality of life in older patients has been well documented. However, data on frailty trajectories and long-term outcomes of older CKD patients undergoing structured Comprehensive Geriatric Assessment (CGA) with multidimensional frailty evaluation are sparse. Here, we analysed records from 375 CKD patients admitted to our university hospital (mean age 77.5 (SD 6.1) years, 36% female) who had undergone a CGA-based calculation of the frailty score with the multidimensional prognostic index (MPI) as well as follow-up evaluations at 3, 6 and 12 months after discharge. Based on the MPI score at admission, 21% of the patients were frail and 56% were prefrail. MPI values were significantly associated with KDIGO CKD stages (p = 0.003) and rehospitalisation after 6 months (p = 0.027) and mortality at 3, 6 and 12 months (p = 0.001), independent of chronological age. Kidney transplant recipients (KTR) showed a significantly lower frailty compared to patients with renal replacement therapy (RRT, p = 0.028). The association between frailty and mortality after 12 months appeared particularly strong for KTR (mean MPI 0.43 KTR vs. 0.52 RRT, p < 0.001) and for patients with hypoalbuminemia (p < 0.001). Interestingly, RRT was per se not significantly associated with mortality during follow up. However, compared to patients on RRT those with KTR had a significantly lower grade of care (p = 0.031) and lower rehospitalisation rates at 12 months (p = 0.010). The present analysis shows that the large majority of older CKD inpatients are prefrail or frail and that the risk for CKD-related adverse outcomes on the long term can be accurately stratified by CGA-based instruments. Further studies are needed to explore the prognostic and frailty-related signature of laboratory biomarkers in CKD.

Keywords: chronic kidney disease; frailty; kidney transplantation; laboratory signature; prognosis; renal replacement therapy (RRT).

Figure 1

Structural and functional changes in the aging kidney. Cell senescence leading to microscopic and macroscopic changes imply changes in kidney function. These are accompanied by clinical changes. (Modified from [1,4,18,19,20]), EZM: extra cellular matrix; GFR: glomerular filtration rate; CKD: chronic kidney disease; AKI: acute kidney injury; RAS: renin-angiotensin-system; NO: nitrogen).

Figure 2

Flowchart.

Figure 3

Albumin at admission according to MPI group. ° marks statistical outliers.

Figure 4

AUC area for one-year all-cause mortality. (a) All CKD patients with 0.71 (95% CI, 0.64–0.76); (b) KTR patients with 0.88 (95% CI, 0.78–0.98); (c) RRT patients with 0.67 (95% CI, 0.57–0.78).

Figure 5

Cumulative Kaplan–Meier survival after 12 months in CKD patients according to MPI, compared to patients without hypoalbuminemia ((a), on the left) and with hypoalbuminaemia ((b), on the right).

Figure 6

Cumulative Kaplan–Meier survival after 12 months in KTR patients according to MPI.

Figure 7

Cumulative Kaplan–Meier survival after 12 months in patients with KDIGO stage G4–5 without receiving renal replacement therapy (RRT) according to their MPI group at admission (a, on the left), according to whether they receive RRT or not (b, in the middle) and patients with KDIGO stage G4-5 without RRT according to hypoalbuminaemia ((c), on the right). (a) Patients with G4/5 and no dialysis according to MPI. (b) Patients with G4/5 according to chronic dialysis. (c) Patients with G4/5 and no dialysis according to hypoalbuminaemia.