Frailty may explain early dialysis initiation and mortality link

By Liam Davenport, MedWire Reporter

A high prevalence of frailty among patients starting dialysis may help to explain why early dialysis initiation in chronic kidney disease is associated with a reported increase in mortality, say US researchers.

While the proportion of patients starting dialysis earlier in the course of chronic kidney disease has increased markedly in recent decades, there has been no evidence of a survival benefit, with a higher eGFR at dialysis initiation linked to increased mortality.

Believing that frailty may be linked to increased eGFR and may confound the mortality association, Yeran Bao, from the University of California in San Francisco, and colleagues studied 1576 participants in the Comprehensive Dialysis Study, assessing patients for vital status and time to first hospitalization.

The team reports in the Archives of Internal Medicine that 73% of the overall patient group was frail, including 63% of patients aged less than 40 years. Frail patients had a significantly higher average eGFR at dialysis initiation than other patients, at 10.4 versus 8.8 mL/min per 1.73 m². Furthermore, multivariate analysis revealed that, independent of other factors, higher eGFR at dialysis initiation was associated with an increased likelihood for frailty, at an odds ratio of 1.44 per 5 mL/min per 1.73 m² increase.

During a median follow-up period of 2.9 years, 529 patients died. Multivariate analysis indicated that frailty was significantly associated with mortality risk, at a hazard ratio of 1.57, but eGFR was not when frailty was included in the model.

The team also found that, with 1148 patients hospitalized at least once during a median follow up of 1.2 years, frailty was significantly associated with shorter time to first hospitalization, at a hazard ratio of 1.26, as was eGFR, at a hazard ratio of 1.08 per 5 mL/min per 1.73 m² increase.

"In light of the recent trend toward earlier initiation of dialysis despite the absence of supportive evidence, it will be important to determine whether overall health and functional capacity improve with dialysis," the researchers write. "Comprehensive efforts other than dialysis aimed to improve functional capacity in this population should also be considered."

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