Matching nephrology care to the needs of vulnerable patients: assessing frailty in patients with chronic kidney disease

Abstract

Background: Chronic kidney disease (CKD) is experienced by 11% of the Australian population. This patient population is recognised to demand greater management complexity and healthcare resources. The clinical syndrome of frailty is likely contributary to this phenomenon but is rarely assessed within nephrology clinical practice. Frailty is a multidimensional syndrome leading to lack of physiological reserve and increased vulnerability to clinically minor insults. Frailty assessment and management among nephrology populations has been hampered to date by a lack of consensus diagnostic approach to frailty, under-recognition of the clinical significance of frailty and absence of evidence-based intervention. Aims: We aimed to explore frailty assessment tools and their relevance to CKD populations. We wished to understand clinicians’ perceptions and practices with regards to frailty. We to operationalised frailty assessment among a population of patients with advanced CKD or end stage kidney disease (ESKD) undergoing haemodialysis (HD) and explored the associations with hospitalisation and mortality outcomes. This study uniquely examined frailty dynamics. We sought to understand the lived experience of frailty and priorities for frailty rehabilitation. Methodological approach: This body of work employed a mixed-methods approach including systematic scoping review, cross-sectional analysis, prospective observational cohort study and embedded qualitative enquiry. Results Our literature reviews describe the pathogenesis of frailty in the CKD context, identifying key pathophysiologic processes. These review papers highlight the various strengths and weaknesses of different frailty assessment tools, validating Fried frailty phenotype. Our examination of practice patterns revealed that respondents considered frailty to be a useful concept when evaluating patients with kidney disease, influencing candidacy for renal replacement therapy and supporting shared decision-making and prompting advanced care planning. Frailty assessments were inconsistently used in clinical practice, favouring subjective clinical impressions. We demonstrated weak to moderate correlation between experienced clinician impression and objective Fried phenotype. In our clinical research, frailty was present in 36.3% of 256 participants while a further 46.5% demonstrated prefrailty. Frailty and prefrailty were equally distributed among patients with advanced CKD and those undergoing HD. We found that mortality risk among people with frailty or prefrailty is independent of age, sex, comorbidity, disability or markers of inflammation. Frailty phenotype was highly dynamic over longitudinal follow-up and transitions in frailty state corresponded to altered prognosis. Frailty and prefrailty independently influenced emergency department presentations, hospitalisation and days of hospital stay in a dose-dependent manner. Our qualitative enquiry found that frailty was a psycho-emotional-social experience which threatened health and well-being. There was strong endorsement of consumer design for frailty intervention and attention to and management of unaddressed symptoms which limited participation in existing rehabilitation models. This work provides novel insights into key attributes for successful frailty rehabilitation in the kidney disease context. Conclusions: Across these lines of research, we identify an opportunity to enrich nephrology practice and support quality care. We substantiate the utility of Fried frailty assessment in the outpatient setting and identify opportunity for frailty intervention. We offer novel risk stratification approaches to identify hospitalisation and mortality events, which out-perform traditional tools. Frailty assessment supports shared decision-making and advanced communication practices. In the only existing studies describing the CKD experience of frailty, we identify attributes for a fit-for-purpose consumer-informed frailty intervention, along with a clear sense of urgency and engagement from the kidney disease community.