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      Individual Frailty Components and Mortality in Kidney Transplant Recipients :

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          Abstract

          <div class="section"> <a class="named-anchor" id="S1"> <!-- named anchor --> </a> <h5 class="section-title" id="d2470530e338">Background</h5> <p id="P16">Frailty increases early hospital readmission and mortality risk among kidney transplant (KT) recipients. While frailty represents a high-risk state for this population, the correlates of frailty, the patterns of the 5 frailty components, and the risk associated with these patterns are unclear. </p> </div><div class="section"> <a class="named-anchor" id="S2"> <!-- named anchor --> </a> <h5 class="section-title" id="d2470530e343">Methods</h5> <p id="P17">663 KT recipients were enrolled in a cohort study of frailty in transplantation (12/2008-8/2015). Frailty, ADL/IADL disability, CESD depression, education, and HRQOL were measured. We used multinomial regression to identify frailty correlates. We identified which patterns of the 5 components were associated with mortality using adjusted Cox proportional hazards models. </p> </div><div class="section"> <a class="named-anchor" id="S3"> <!-- named anchor --> </a> <h5 class="section-title" id="d2470530e348">Results</h5> <p id="P18">Frailty prevalence was 19.5%. Older recipients (adjusted prevalence ratio [PR]=2.22, 95%CI:1.21-4.07) were more likely to be frail. The only other factors that were independently associated with frailty were IADL disability (3.22, 95%CI:1.72-6.06), depressive symptoms (11.31, 95%CI:3.02-31.82), less than a high school education (3.10, 95% CI:1.30-7.36) and low HRQOL (Fair/Poor:3.71, 95%CI:1.48-9.31). The most common pattern was poor grip strength, low physical activity and slowed walk speed (19.4%). Only 2 patterns of the 5 components emerged as having an association with post-KT mortality. KT recipients with exhaustion and slowed walking speed (HR=2.43, 95%CI:1.17-5.03) and poor grip strength, exhaustion, and slowed walking speed (HR=2.61, 95%CI:1.14-5.97) were at increased mortality risk. </p> </div><div class="section"> <a class="named-anchor" id="S4"> <!-- named anchor --> </a> <h5 class="section-title" id="d2470530e353">Conclusion</h5> <p id="P19">Age was the only conventional factor associated with frailty among KT recipients; however, factors rarely measured as part of clinical practice, namely HRQOL, IADL disability and depressive symptoms, were significant correlates of frailty. Redefining the frailty phenotype may be needed to improve risk stratification for KT recipients. </p> </div>

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          Most cited references21

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          Significance of frailty among dialysis patients.

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            Adapting the Charlson Comorbidity Index for use in patients with ESRD.

            Accurate prediction of survival for patients with end-stage renal disease (ESRD) and multiple comorbid conditions is difficult. In nondialysis patients, the Charlson Comorbidity Index has been used to adjust for comorbidity. The purpose of this study is to assess the validity of the Charlson index in incident dialysis patients and modify the index for use specifically in this patient population. Subjects included all incident hemodialysis and peritoneal dialysis patients starting dialysis therapy between July 1, 1999, and November 30, 2000. These 237 patients formed a cohort from which new integer weights for Charlson comorbidities were derived using Cox proportional hazards modeling. Performance of the original Charlson index and the new ESRD comorbidity index were compared using Kaplan-Meier survival curves, change in likelihood ratio, and the c statistic. After multivariate analysis and conversion of hazard ratios to index weights, only 6 of the original 18 Charlson variables were assigned the same weight and 6 variables were assigned a weight higher than in the original Charlson index. Using Kaplan-Meier survival curves, we found that both the original Charlson index and the new ESRD comorbidity index were associated with and able to describe a wide range of survival. However, the new study-specific index had better validated performance, indicated by a greater change in the likelihood ratio test and higher c statistic. This study indicates that the original Charlson index is a valid tool to assess comorbidity and predict survival in patients with ESRD. However, our modified ESRD comorbidity index had slightly better performance characteristics in this population.
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              Frailty as a novel predictor of mortality and hospitalization in individuals of all ages undergoing hemodialysis.

              To quantify the prevalence of frailty in adults of all ages undergoing chronic hemodialysis, its relationship to comorbidity and disability, and its association with adverse outcomes of mortality and hospitalization. Prospective cohort study. Single hemodialysis center in Baltimore, Maryland. One hundred forty-six individuals undergoing hemodialysis enrolled between January 2009 and March 2010 and followed through August 2012. Frailty, comorbidity, and disability on enrollment in the study and subsequent mortality and hospitalizations. At enrollment, 50.0% of older (≥ 65) and 35.4% of younger (<65) individuals undergoing hemodialysis were frail; 35.9% and 29.3%, respectively, were intermediately frail. Three-year mortality was 16.2% for nonfrail, 34.4% for intermediately frail, and 40.2% for frail participants. Intermediate frailty and frailty were associated with a 2.7 times (95% confidence interval (CI) = 1.02-7.07, P = .046) and 2.6 times (95% CI = 1.04-6.49, P = .04) greater risk of death independent of age, sex, comorbidity, and disability. In the year after enrollment, median number of hospitalizations was 1 (interquartile range 0-3). The proportion with two or more hospitalizations was 28.2% for nonfrail, 25.5% for intermediately frail, and 42.6% for frail participants. Although intermediate frailty was not associated with number of hospitalizations (relative risk = 0.76, 95% CI = 0.49-1.16, P = .21), frailty was associated with 1.4 times (95% CI = 1.00-2.03, P = .049) more hospitalizations independent of age, sex, comorbidity, and disability. The association between frailty and mortality (interaction P = .64) and hospitalizations (P = .14) did not differ between older and younger participants. Adults of all ages undergoing hemodialysis have a high prevalence of frailty, more than five times as high as community-dwelling older adults. In this population, regardless of age, frailty is a strong, independent predictor of mortality and number of hospitalizations. © 2013, Copyright the Authors Journal compilation © 2013, The American Geriatrics Society.
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                Author and article information

                Journal
                Transplantation
                Transplantation
                Ovid Technologies (Wolters Kluwer Health)
                0041-1337
                2017
                September 2017
                : 101
                : 9
                : 2126-2132
                Article
                10.1097/TP.0000000000001546
                5405005
                27779573
                a9336906-2025-45e2-bbd1-e73342f102d1
                © 2017
                History

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