Abstract
BackgroundFrailty is associated with multiple adverse outcomes in stage-5 chronic kidney disease (CKD-5) and upwards of one third of people receiving haemodialysis (HD) are frail. While many frailty screening methods are available in both uremic and non-uremic populations, their implementation in clinical settings is often challenged by time and resource constraints. In this study, we explored the diagnostic accuracy of time-efficient screening tools in people receiving HD.MethodsA convenience sample of 76 people receiving HD [mean age = 61.1 years (SD = 14), 53.9% male] from three Renal Units were recruited for this cross-sectional study. Frailty was diagnosed by means of the Fried phenotype. Physical performance-based screening tools encompassed handgrip strength, 15-ft gait speed, timed up and go (TUG), and five-repetition sit to stand (STS-5) tests. In addition, participants completed the SF-36 Health Survey, the short-form international physical activity questionnaire and the Tinetti falls efficacy scale (FES) as further frailty-related measures. Outcome measures included the area under the curve (AUC), sensitivity, specificity, positive (PPV) and negative predictive values (NPV). The diagnostic performance of screening tools in assessing fall-risk was also investigated.ResultsOverall, 36.8% of participants were classified as frail. All the examined instruments could significantly discriminate frailty status in the study population. Gait speed [AUC = 0.89 (95%CI: 0.81–0.98), sensitivity = 75%, specificity = 93%] and TUG [AUC = 0.90 (95%CI: 0.80–0.99), sensitivity = 89%, specificity = 85%] exhibited the highest diagnostic accuracy. There was a significant difference in gait speed AUC (20%, p = 0.013) between participants aged 65 years or older (n = 36) and those under 65 years of age (n = 40), with better discriminating performance in the younger sub-group. The Tinetti FES was the only instrument showing good diagnostic accuracy (AUCs≥0.80) for both frailty (sensitivity = 82%, specificity = 79%) and fall-risk (sensitivity = 82%, specificity = 71%) screening.ConclusionsThis cross-sectional study revealed that time- and cost-efficient walking performance measures can accurately be used for frailty-screening purposes in people receiving HD. While self-selected gait speed had an excellent performance in people under 65 years of age, TUG may be a more suitable screening method for elderly patients (≥65 years). The Tinetti FES may be a clinically useful test when physical testing is not achievable.
Highlights
Frailty is associated with multiple adverse outcomes in stage-5 chronic kidney disease (CKD-5) and upwards of one third of people receiving haemodialysis (HD) are frail
In this study, we explored the diagnostic accuracy of selected screening tools to expedite assessment of frailty in people receiving HD, using the Fried phenotype as the reference standard
In agreement with this study, we found that gait speed had an excellent diagnostic accuracy, with comparable area under the curve (AUC) (0.89 vs 0.97), Positive predictive value (PPV) (0.86 vs 0.84) and negative predictive values (NPV) (0.87 vs 0.96) values
Summary
Frailty is associated with multiple adverse outcomes in stage-5 chronic kidney disease (CKD-5) and upwards of one third of people receiving haemodialysis (HD) are frail. Many clinicians still find this procedure timeconsuming and potentially unpractical in the context of renal outpatient services [12] To overcome this implementability issue, several researchers have designed alternative operationalisations of the Fried phenotype by replacing the performance-based measures with subjective (questionnaire-based) assessments in both CKD [16] and non-CKD populations [17, 18]. These selfreported definitions of frailty perform well in predicting adverse outcomes [5], they are often less accurate than objective assessments of physical performance in diagnosing frailty in people living with CKD-5 [12, 16]. Several “field” performance-based tests such as gait speed, timed up and go, and repeated chair stands are commonly employed to assess physical function in CKD [19] and may represent a viable solution
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