Functional impairment and risk of mortality in patients on chronic hemodialysis: results of the Lazio Dialysis Registry
- 139 Downloads
Functional impairment is associated with adverse outcomes in older people, as well as in patients on chronic hemodialysis. The aim of this study was to evaluate if functional impairment represents a risk factor for reduced survival in patients on chronic hemodialysis.
All incident chronic hemodialysis patients of Lazio, a large region of central Italy, registered in the Dialysis and Transplant Lazio Region Registry (DTLRR) in the period 2008–2013 were considered eligible. Inclusion criteria were: age > 18 years, resident in Lazio, still doing dialysis after 90 days from incidence date, doing hemodialysis or hemodiafiltration treatment for > 9 h/week. Patients were stratified into three classes of functional activity: total autonomy, autonomy in some activities, and not self-sufficient. Functional activity was assessed for each patient by the referring physician for the DTLRR from the ~ 90 hemodialysis units of the Lazio region. Each patient was followed from date of first dialysis treatment to the end of the study (31/12/2015) or death or renal transplant, whichever occurred first. Cox proportional hazard models were performed to obtain mortality hazard ratios (HR), 95% confidence intervals (CI), for each class of functional activity adjusting for sex, age, country of birth, city of residence, body mass index (BMI), type of nephropathy, vascular access, previous nephrology counselling, weekly hours of hemodialysis, serum albumin, hemoglobin, and presence of comorbidities (e.g. vascular diseases, coronary disease, and diabetes).
A total of 3356 patients were studied. In the whole follow-up period, 1622 deaths occurred (48%). Functional impairment was associated with the risk of mortality: compared to ‘total autonomy’, the HR for ‘autonomy in some activities’ was 1.30 [95% CI: 1.14–1.49] and for ‘not self-sufficient’ 1.71 [1.47–1.99] (p for trend < 0.05). The number of evitable deaths attributable to reduced functional activity was 237.
Functional impairment represents a risk factor for reduced survival in chronic hemodialysis patients. There is a need for early identification of patients who might benefit from interventions aimed at preventing, reversing or delaying the functional impairment.
KeywordsHemodialysis Mortality Survival Disability Functional impairment
Members of the Lazio Dialysis Registry (on December 2017): Alfarone C, Aloisio GM, Amoroso F, Andrietti M, Baldinelli M, Barone P, Basili A, Bianchi M, Canulla F, Capobianco L, Chiappini MG, Costantini S, Cuzziol C, D’Apollo A, De Bella E, De Cicco C, De Paolis P, Della Rovere FR, Di Daniele N, Di Legge R, Di Pietro G, Di Toro Mammarella R, Felicioni R, Feriozzi S, Ferrazzano MT, Filippini A, Fini R, Firmi G, Flammini A, Forte F, Gambaro G, Gamberini M, Iamundo V, Lavini R, Lonzi M, Maggisano V, Malaguti M, Marinelli R, Mauro LM, Mazzaferro S, Morabito S, Morosetti M, Nazzaro L, Nicolais R, Nusca C, Pace G, Palumbo R, Pantano L, Paone A, Picca S, Polito P, Puliti M, Punzo G, Rifici N, Riveruzzi P, Rossi V, Rossini B, Santoboni A, Sfregola P, Shamsan H, Simonelli R, Spaziani M, Splendiani G, Stranges V, Sturnolo A, Torre MC, Treglia A, Tullio T, Valentini W, Vastano S, Vega A, Ventola F.
Members Scientific Commettee: Nera Agabiti, Carmine De Cicco, Salvatore Di Giulio, Anteo Di Napoli, Sandro Feriozzi, Giovanni Gambaro, Moreno Malaguti, Paolo Menè, Nicola Petrosillo, Stefano Picca, Luigi Tazza, Giuseppe Tisone, Maurizio Valeri.
Compliance with ethical standards
Conflict of interest
None of the authors has conflict of interest.
The study was conducted by the Department of Epidemiology of Lazio Regional Health Service, namely the regional referral center for epidemiological research which has full access to anonymized data. As a consequence, ethics approval was not required for this study.
For this type of study patients’ consent is not required.
- 4.Kramer A, Pippias M, Stel VS et al. (2016) Renal replacement therapy in Europe: a summary of the 2013 ERA-DTA Registry Annual Report with a focus on diabetes mellitus. Clin Kidney J 9:457–69Google Scholar
- 7.Gitto LSV, Santoro D, Bellinghieri G et al (2008) Survival in octogenarian dialysis patients: Analysis in two Southern Italian regions. J Nephrol 21:118–123Google Scholar
- 10.Fujiwara Y, Shinkai S, Kumagai S et al. (2003) Longitudinal changes in higher-level functional capacity of an older population living in a Japanese urban community. Arch Gerontol Geriatr. 36: 141–53Google Scholar
- 12.Landi F, Russo A, Cesari M et al. (2005) The ilSIRENTE study: a prospective cohort study on persons aged 80 years and older living in a mountain community of Central Italy. Aging Clin Exp Res. 17:486–93Google Scholar
- 17.Kutner NG, Zhang R, Allman RM, Bowling CB. (2014) Correlates of ADL difficulty in a large hemodialysis cohort. Hemodial Int 8: 70–7Google Scholar
- 18.Di Napoli A, Lapucci E, Baglio G, Di Giulio S; Registro Regionale Dialisi e Trapianto del Lazio [Lazio dialysis registry: natives vs. foreigners]. G Ital Nefrol. 2015;32(3)Google Scholar
- 21.Di Napoli A, Pezzotti P, Di Lallo D et al. (2006) Epidemiology of hepatitis C virus among long-term dialysis patients: a 9-year study in an Italian region. Am J Kidney Dis 48:629–37Google Scholar
- 22.Kovar MG, Lawton PM (1994) Functional Disability: Activities and Instrumental Activities of Daily Living. In: Lawton PM, Teresi JA (eds) Focus on Assessment Techniques, vol 14. Springer Publishing Company, New York, pp 57–75Google Scholar
- 24.Lawton MP, Brody EM. (1969) Assessment of older people: self-maintaining and Instrumental Activities of Daily Living Gerontology. 9:179–186Google Scholar
- 26.Schag CC, Heinrich RL, Ganz PA. (1984) Karnofsky performance status revisited: reliability, validity, and guidelines. J Clin Oncol. 2:187–93Google Scholar
- 27.Ifudu O, Paul HR, Homel P, Friedman EA. (1998) Predictive value of functional status for mortality in patients on maintenance hemodialysis. Am J Nephrol 18:109–16Google Scholar
- 28.Crooks V, Waller S, Smith T, Hahn TJ (1991) The use of the Karnofsky Performance Scale in determining outcomes and risk in geriatric outpatients. J Gerontol 46: M139-44 Google Scholar
- 29.McClellan WM, Anson C, Birkeli K, Tuttle E (1991) Functional status and quality of life: predictors of early mortality among patients entering treatment for end stage renal disease. J Clin Epidemiol 44:83–9Google Scholar
- 34.Jassal SV, Karaboyas A, Comment LA et al. (2016) Functional Dependence and Mortality in the International Dialysis Outcomes and Practice Patterns Study (DOPPS). Am J Kidney Dis 67:283–92Google Scholar
- 42.Farragher J, Jassal SV. (2012) Rehabilitation of the geriatric dialysis patient. Semin Dial. 25:649–56Google Scholar