Frailty in hemodialysis patients: results of a screening program and multidisciplinary interventions

Abstract

Background: The number of frail patients of advanced age with end-stage kidney disease (ESKD) undergoing hemodialysis is increasing globally. Here we evaluated a frailty screening program of ESKD patients starting hemodialysis, and subsequent multidisciplinary interventions.

Methods: This was a prospective observational study of ESKD patients in a hemodialysis program. Patients were evaluated for frailty (Fried frail phenotype) before and after a 12-month period. Patients followed standard clinical practice at our hospital, which included assessment and multidisciplinary interventions for nutritional (malnutrition-inflammation score, protein-energy wasting), physical [short physical performance battery (SPPB)] and psychological status.

Results: A total of 167 patients (mean ± standard deviation age 67.8 ± 15.4 years) were screened for frailty, and 108 completed the program. At screening, 27.9% of the patients were frail, 40.0% pre-frail and 32.1% non-frail. Nutritional interventions (enrichment, oral nutritional supplements, intradialytic parenteral nutrition) resulted in stable nutritional status for most frail and pre-frail patients after 12 months. Patients following recommendations for intradialytic, home-based or combined physical exercise presented improved or stable in SPPB scores after 12 months, compared with those that did not follow recommendations, especially in the frail and pre-frail population (P = .025). A rate of 0.05 falls/patient/year was observed. More than 60% of frail patients presented high scores of sadness and anxiety.

Conclusions: Frailty screening, together with coordinated interventions by nutritionists, physiotherapists, psychologists and nurses, preserved the health status of ESKD patients starting hemodialysis. Frailty assessment helped in advising patients on individual nutritional, physical or psychological needs.

Keywords: end-stage kidney disease; frailty; hemodialysis; nutritional assessment; physical assessment.

Graphical Abstract

Figure 1:

Patient disposition.

Figure 2:

Fried phenotypes at the baseline and final visits.

Figure 3:

Changes in SPPB scores (decrease, no change, increase) according to the acceptance by the patients of the recommendations by the physiotherapist (A) and, in those who accepted, the type of exercise program followed (B).

Figure 4:

Psychological assessment according to Fried phenotype. Percentage of patients with EED score ≥4 (range 0–10) in the psychological evaluation. A total of 120 patients were assessed (non-frail = 38, pre-frail = 53, frail = 28). As indicated in Materials and methods, no 12-month evaluation was possible due to the limitations imposed by the COVID-19 pandemic.