Johansen Kirsten L, Dalrymple Lorien S, Delgado Cynthia, Chertow Glenn M, Segal Mark R, Chiang Janet, Grimes Barbara, Kaysen George A
Divisions of Nephrology and.
Department of Epidemiology and Biostatistics, University of California, San Francisco, California.
Clin J Am Soc Nephrol. 2017 Jul 7;12(7):1100-1108. doi: 10.2215/CJN.12131116. Epub 2017 Jun 2.
Frailty is common among patients on hemodialysis and associated with adverse outcomes. However, little is known about changes in frailty over time and the factors associated with those changes.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: To address these questions, we examined 762 participants in the A Cohort to Investigate the Value of Exercise/Analyses Designed to Investigate the Paradox of Obesity and Survival in ESRD cohort study, among whom frailty was assessed at baseline and 12 and 24 months. We used ordinal generalized estimating equations analyses and modeled frailty (on a scale from zero to five possible components) and death during follow-up.
The mean frailty score at baseline was 1.9, and the distribution of frailty scores was similar at each evaluation. However, most participants' scores changed, with patients improving almost as often as worsening (overall change, 0.2 points per year; 95% confidence interval, 0.1 to 0.3). Hispanic ethnicity (0.6 points per year; 95% confidence interval, 0.0 to 1.1) and diabetes (0.7 points per year; 95% confidence interval, 0.3 to 1.0) were associated with higher frailty scores and higher serum albumin concentration with lower frailty scores (-1.1 points per g/dl; 95% confidence interval, -1.5 to -0.7). In addition, patients whose serum albumin increased over time were less likely to become frail, with each 1-g/dl increase in albumin associated with a 0.4-point reduction in frailty score (95% confidence interval, -0.80 to -0.05). To examine the underpinnings of the association between serum albumin and frailty, we included serum IL-6, normalized protein catabolic rate, and patient self-report of hospitalization within the last year in a second model. Higher IL-6 and hospitalization were statistically significantly associated with worse frailty at any point and worsening frailty over time, whereas normalized protein catabolic rate was not independently associated with frailty.
There was substantial year to year variability in frailty scores, with approximately equal numbers of patients improving and worsening. Markers of inflammation and hospitalization were independently associated with worsening frailty. Studies should examine whether interventions to address inflammation or posthospitalization rehabilitation can improve the trajectory of frailty.
衰弱在血液透析患者中很常见，且与不良结局相关。然而，对于衰弱随时间的变化以及与这些变化相关的因素知之甚少。
设计、地点、参与者及测量方法：为解决这些问题，我们在“运动价值队列研究/旨在调查终末期肾病肥胖与生存悖论的分析”队列研究中对762名参与者进行了研究，其中在基线、12个月和24个月时评估了衰弱情况。我们使用有序广义估计方程分析，并对随访期间的衰弱（从0到5个可能的组成部分进行评分）和死亡进行建模。
基线时衰弱评分的平均值为1.9，每次评估时衰弱评分的分布相似。然而，大多数参与者的评分发生了变化，病情改善的患者与病情恶化的患者数量几乎相同（总体变化为每年0.2分；95%置信区间为0.1至0.3）。西班牙裔（每年0.6分；95%置信区间为0.0至1.1）和糖尿病（每年0.7分；95%置信区间为0.3至1.0）与较高的衰弱评分相关，而血清白蛋白浓度较高与较低的衰弱评分相关（每克/分升-1.1分；95%置信区间为-1.5至-0.7）。此外，血清白蛋白随时间增加的患者衰弱的可能性较小，白蛋白每增加1克/分升，衰弱评分降低0.4分（95%置信区间为-0.80至-0.05）。为研究血清白蛋白与衰弱之间关联的基础，我们在第二个模型中纳入了血清白细胞介素-6、标准化蛋白分解代谢率以及患者过去一年的住院自我报告。较高的白细胞介素-6和住院在任何时间点均与更差的衰弱以及随时间推移衰弱加剧在统计学上显著相关，而标准化蛋白分解代谢率与衰弱无独立关联。
衰弱评分每年存在很大差异，病情改善和恶化的患者数量大致相等。炎症标志物和住院与衰弱加剧独立相关。研究应探讨针对炎症或出院后康复的干预措施是否能改善衰弱的发展轨迹。
