Physical Frailty and Functional Status in Patients With Advanced Chronic Kidney Disease: A Systematic Review.

Background: With an aging population and growing number of patients with chronic kidney disease (CKD), integrating the latest risk factors when deciding on a treatment plan can result in better patient care. Frailty remains a prevalent syndrome in CKD resulting in adverse health outcomes. However, measures of frailty and functional status remain excluded from clinical decision making. Objective: To examine the degree to which different measures of frailty and functional status are associated with mortality, hospitalization, and other clinical outcomes in patients with advanced CKD. Design: Systematic review. Setting: Observation studies including cohort study, case-control study, or cross-sectional study examining frailty and functional status on clinical outcomes. There were no restrictions on type of setting or country of origin. Patients: Adults with advanced CKD, including both types of dialysis patients. Measurements: Data including demographic information (e.g., sample size, follow-up time, age, country), assessments of frailty or functional status and their domains, and outcomes including mortality, hospitalization, cardiovascular events, kidney function, and composite outcomes were extracted. Methods: A search was conducted using databases Medline, Embase, and Cochrane Central Register for Controlled Trials. Studies were included from inception to March 17, 2021. The eligibility of studies was screened by 2 independent reviewers. Data were presented by instrument and clinical outcome. Point estimates and 95% confidence intervals from the fully adjusted statistical model were reported or calculated from the raw data. Results: A total of 117 unique instruments were found among 140 studies. The median sample size of studies was 319 (interquartile range, 161-893). Most studies focused on incident and chronic dialysis patient populations, with only 15% of studies examining non-dialysis CKD patients. Frailty and lower functional status were associated with an increased risk for adverse clinical outcomes such as mortality and hospitalization. The 5 individual domains of frailty were also found to be associated with poor health outcomes. Limitations: Meta-analysis could not be performed due to significant heterogeneity between studies and methods used to measure frailty and functional status. Many studies had issues with methodological rigor. Selection bias and the validity of data collection could not be ascertained for some studies. Conclusion: Frailty and functional status measures should be integrated to help guide clinical care decision making for a comprehensive assessment of risk for adverse outcomes among patients with advanced CKD. Registration PROSPERO: CRD42016045251.

Contexte: Compte tenu du vieillissement de la population et du nombre croissant de patients atteints d'insuffisance rénale chronique (IRC), l'intégration des plus récents facteurs de risque dans le processus de prise de décision d'un plan de traitement pourrait améliorer les soins aux patients. La fragilité demeure un syndrome prévalant en contexte d'IRC, qui entraîne des effets néfastes sur la santé. Pourtant, les mesures de la fragilité et de l'état fonctionnel demeurent exclues de la prise de décisions cliniques. Objectif: Déterminer à quel point les différentes mesures de la fragilité et de l'état fonctionnel sont associées à la mortalité, à l'hospitalisation et à d'autres résultats cliniques chez les patients atteints d'IRC avancée. Type d'étude: Examen systématique. Sources: Des études d'observation, y compris des études de cohorte, des études cas-témoins ou des études transversales examinant le rôle de la fragilité et de l'état fonctionnel sur les résultats cliniques. Il n'y avait pas de restrictions quant au cadre ou au pays d'origine de l'étude. Sujets: Des adultes atteints d'IRC avancée, y compris les deux types de patients sous dialyse. Mesures: Les données suivantes ont été extraites : les données démographiques (taille de l'échantillon, temps de suivi, âge des patients, pays), les évaluations de la fragilité ou de l'état fonctionnel et de leurs domaines, et les résultats cliniques (mortalité, hospitalisation, événements cardiovasculaires, fonction rénale et résultats composites). Méthodologie: Une recherche a été effectuée dans les bases de données Medline, embase et Cochrane Central Register for Controlled Trials pour répertorier les études de la création jusqu'au 17 mars 2021. L'admissibilité des études a été déterminée par deux examinateurs indépendants. Les données ont été présentées par instrument et par résultat clinique. Des estimations ponctuelles et des intervalles de confiance à 95 % du modèle statistique ajusté ont été rapportés ou calculés à partir des données brutes. Résultats: Parmi les 140 études répertoriées, 117 instruments uniques ont été trouvés. La taille médiane des échantillons était de 319 patients (ÉIQ : 161 à 893). La plupart des études portaient sur des populations de patients incidents et sous dialyse chronique, seulement 15 % des études portaient sur des patients atteints d'IRC non dialysés. La fragilité et un faible état fonctionnel ont été associés à un risque accru de résultats cliniques défavorables comme une hospitalisation ou le décès. Les cinq domaines individuels de la fragilité ont également été associés à de mauvais résultats de santé. Limites: L'hétérogénéité significative entre les études et les méthodes utilisées pour mesurer la fragilité et l'état fonctionnel ne permettait pas de procéder à une méta-analyse. De nombreuses études n'étaient pas rigoureuses sur le plan méthodologique. Les biais de sélection et la validité de la collecte des données n'ont pas pu être vérifiés pour certaines études. Conclusion: Les mesures de la fragilité et de l'état fonctionnel devraient être intégrées au processus de prise de décision afin d'orienter les soins cliniques et de permettre une évaluation complète du risque d'effets indésirables chez les patients atteints d'IRC avancée. Enregistrement PROSPERO: CRD42016045251.

Quality Metrics in Solid Organ Transplantation: A Systematic Review.

BACKGROUND: The best approach for determining whether a transplant program is delivering high-quality care is unknown. This review aims to identify and characterize quality metrics in solid organ transplantation. METHODS: Medline, Embase, and Cochrane Central Register of Controlled Trials were searched from inception until February 1, 2017. Relevant full text reports and conference abstracts that examined quality metrics in organ transplantation were included. Two reviewers independently extracted study characteristics and quality metrics from 52 full text reports and 24 abstracts. PROSPERO registration: CRD42016035353. RESULTS: Three hundred seventeen quality metrics were identified and condensed into 114 unique indicators with sufficient detail to be measured in practice; however, many lacked details on development and selection, were poorly defined, or had inconsistent definitions. The process for selecting quality indicators was described in only 5 publications and patient involvement was noted in only 1. Twenty-four reports used the indicators in clinical care, including 12 quality improvement studies. Only 14 quality metrics were assessed against patient and graft survivals. CONCLUSIONS: More than 300 quality metrics have been reported in transplantation but many lacked details on development and selection, were poorly defined, or had inconsistent definitions. Measures have focused on safety and effectiveness with very few addressing other quality domains, such as equity and patient-centeredness. Future research will need to focus on transparent and objective metric development with proper testing, evaluation, and implementation in practice. Patients will need to be involved to ensure that transplantation quality metrics measure what is important to them.

Physical frailty and functional status in patients with advanced kidney disease: a protocol for a systematic review.

BACKGROUND: Predicting outcomes in those with chronic kidney disease or following transplantation is challenging, and current models lack detailed patient-level information. Frailty and poor functional status are risk factors for adverse patient outcomes that may be useful additions to prognostic tools in patients with chronic kidney disease. The purpose of this systematic review is to examine whether frailty or functional status are associated with increased risk of mortality or adverse clinical outcomes in patients with advanced kidney disease. METHODS/DESIGN: We will conduct a systematic review to identify and evaluate studies linking frailty and functional status with patient outcomes in populations with advanced kidney disease. We will search MEDLINE, Embase, and the Cochrane Central Register for Controlled Trials. Two reviewers will conduct all screening and data extraction independently. A modified version of the Quality In Prognosis Studies tool will be used to evaluate the quality of the studies. If meta-analysis of outcome data is possible, a random effects model will be used. DISCUSSION: The results of this review will inform the development, selection, and validation of appropriate metrics needed to improve prognostication in patients with chronic kidney disease. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016045251.