Chapter 2: Hemodialysis (Complications, Nursing Care, Home Care)

Nakamoto H, et al. (eds): Recent Advances in Dialysis Therapy in Japan.

Contrib Nephrol. Basel, Karger, 2018, vol 196, pp 101–109 (DOI: 10.1159/000485707)

Management of Physical Frailty in Patients

Requiring Hemodialysis Therapy
Ryota Matsuzawa a · Baback Roshanravan b
a Department of Rehabilitation, Kitasato University Hospital, Sagamihara, Japan; b Kidney Research Institute,
University of Washington, Seattle, WA, USA

Abstract individualized prescription of exercise. While expert clini-

Background: The mean age of people undergoing dialysis cal guidelines focus on management of patients in the
therapy has been on the rise because of improved sur- outpatient dialysis care setting, it is not included in routine
vival in this patient population, as well as the reduced clinical care of dialysis facilities. Little is known about the
availability of transplants for elderly patients. Aging in Jap- management of frailty in the hemodialysis population and
anese dialysis patients is more rapid than those in the Unit- its effects on health outcomes. Further research is needed
ed States and Europe. Frailty is generally considered as an to define optimal strategies for screening and treatment
age-related fragile state, and a condition in which the in- of frailty in this vulnerable population. Key Messages:
dividual is in a vulnerable state at increased risk of adverse Management of physical frailty, which is composed of
health outcomes and/or dying when exposed to a stress- identification of poor physical performance and physical
or. This review focuses on the underscoring the impor- inactivity and exercise intervention, as usual care in pa-
tance of identifying physical frailty in hemodialysis pa- tients undergoing hemodialysis may improve their quality
tients and proposes an algorithm integrating frailty of life and prognosis. © 2018 S. Karger AG, Basel
assessment into the routine care of patients treated with
dialysis. Summary: Physical frailty is highly prevalent in
patients undergoing hemodialysis, and can potentially be
prevented or treated with management of physical frailty. An aging population and the increasing prevalence
The management of physical frailty consists of identifying of lifestyle-related diseases have led to a worldwide
physical inactivity and poor physical performance and the increase in the rate of chronic kidney disease
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(CKD) requiring renal replacement therapy [1]. Alternative questionnaire-based definitions
The mean age of people undergoing dialysis thera- of physical frailty have been applied to patients
py has been on the rise because of the aging demo- with chronic illness. A recent study assessed the
graphic, improved survival in this patient popula- discriminating abilities of 6 screening tools for
tion, and the reduced availability of transplants for detecting frailty in elderly people with end-stage
elderly patients. Significant increases in the age of renal disease and concluded that these screening
dialysis people were observed in almost all 12 na- tools could be used as a first step to detect frailty
tions included in the Dialysis Outcomes and Prac- [8]. In particular, the Clinical Frailty Scale has
tice Patterns Study (DOPPS), an international co- been used to measure the level of frailty in clinical
hort study [2]. The DOPPS data also revealed that settings. This scale is based on clinical judgement
aging in Japanese dialysis patients is more rapid using available clinical information [9], and it is
than aging in the United States and Europe [3]. The graded from 1 to 7 (1, very fit; 2, well without ac-
Japanese Society for Dialysis Therapy (JSDT) has tive disease; 3, well with treated comorbid dis-
performed a nationwide renal data registry. Ac- ease; 4, apparently vulnerable; 5, mildly frail; 6,
cording to the data, in particular, the mean age in moderately frail; 7, severely frail) which is strong-
the Japanese dialysis population was 67.5 years in ly associated with mortality in cardiac [10] and
2014, showing a 12.2-year increase since the end of CKD [11] patients.
1991. Furthermore, the proportion of people aged According to a previously conducted meta-
60 years and older was 78.5% of patients who start- analysis, the prevalence of frailty based on the
ed dialysis therapy in 2014 and 76.7% of the entire Fried criteria was 7.4% in Japanese elderly people
dialysis population [4]. [12]. On the other hand, patients treated with
Frailty is generally considered as an age-relat- chronic renal replacement therapy have a higher
ed fragile state, characterized by physiologic vul- prevalence of frailty, estimated at 30–40% [7, 13].
nerability to stress associated with increased risk Furthermore, among elderly patients treated
of adverse health outcomes [5, 6]. Frailty is high- with chronic hemodialysis, over 70% of them are
ly prevalent in patients with CKD who require classified as frail [14, 15]. Previous studies, how-
hemodialysis therapy, and the prevalence rate of ever, have noted a wide variation in the preva-
frailty in this population was 36.8% based on a lence of frailty in the dialysis population depend-
previously performed meta-analysis [7]. Frailty is ing on the application of different criteria of frail-
also a treatable condition, and therefore it is im- ty and participant characteristics. Johansen et al.
portant for kidney health providers to consider [16] have investigated the clinical factors associ-
management of physical frailty in the routine ated with worsening in frailty in hemodialysis pa-
clinical care of vulnerable patients treated with tients, and revealed that hospitalization events
hemodialysis. were a powerful predictor of worsening frailty in
this population. This study showed the impor-
tance of constant observation of patients’ physi-
Evaluation of Frailty in the Hemodialysis cal conditions, especially after hospital discharge.
Population These findings underscore the importance of ex-
ercise-based “renal rehabilitation” in hemodialy-
The phenotype of frailty was first defined by sis patients after hospital discharge.
Fried et al. [5], based on the following 5 criteria:
shrinking, weakness, poor endurance and energy,
slowness, and a low physical activity level. Frailty Physical Activity and Physical Performance
is identified by the presence of 3 or more of the
above components, and an intermediate frailty Patients with CKD who have a high prevalence of
phenotype is commonly defined as having one or frailty are associated with higher risks of adverse
two of these conditions. health outcomes [17]. The most prevalent and po-
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Fig. 1. Minimum recommendation
level of physical activity on non-dial-
ysis day for hemodialysis patients
(modified from Matsuzawa et al.
[25]). An optimum cutoff value for
the number of steps discriminating
dialyzed patients at high risk of mor-
tality based on the Youden index
was approximately 4,000 steps per
non-dialysis day.

tentially modifiable components of frailty in the tivity over time, which was defined as a de-
CKD population are physical inactivity and poor crease in activity of >30% compared to activity
physical performance. Recent findings from a at 1 year before, was seen in almost one quarter
multicenter randomized controlled trial of exer- of the patients undergoing hemodialysis and
cise in dialysis patients indicate individualized ex- was associated with elevated mortality risk in-
ercise prescriptions may improve physical perfor- dependent of not only patient characteristics
mance and reduce the risk of hospitalizations [18]. but also baseline activity level [27]. Expert clin-
ical guidelines reported by Kidney Disease Im-
Physical Activity proving Global Outcomes Chronic Kidney Dis-
Patients on hemodialysis remain substantially ease Work Group (KDIGO) [28], National Kid-
less active than the general healthy sedentary ney Foundation (NKF) [29], and European
population. Low physical activity at baseline, Renal Best Practice (ERBP) guideline develop-
assessed by questionnaire- [19–23] or acceler- ment group [30] state that kidney health pro-
ometer-based [24, 25] methods, is strongly as- viders regularly need to encourage patients with
sociated with poor prognosis among end-stage CKD to undertake regular physical activity and
renal disease patients treated with chronic he- to prevent a deterioration of physical activity
modialysis. Goal setting is well known as a key over time. Hence, we recommend that physi-
motivational factor for increasing physical ac- cians encourage the patients to engage in at
tivity level and is absolutely essential for suc- least 4,000 steps per non-dialysis day in order to
cessful intervention. We propose 4,000 steps prevent a decline in physical activity over time
per non-dialysis day as an initial minimum rec- as a routine dialysis care.
ommendation of physical activity for mobility
disability-free hemodialysis patients who need- Physical Performance
ed no assistance in walking from another per- Muscle weakness and slow gait speed are often
son (Fig. 1) [25]. This is a realistic and specific used as markers of poor physical performance in
goal consistent with the recommendations of patients with CKD [31, 32] and end-stage kidney
the American College of Sports Medicine which disease requiring dialysis [33–35]. These physical
recommends 4,000 steps per day for older performance measures are strongly associated
adults [26]. In addition, a decline in physical ac- with risk of mortality [32, 34, 35] across multiple
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Table 1. Physical performance tests and cutoff points in patients with chronic kidney disease

Tests Cutoffs Ref.

Usual gait speed <0.6 m/s; <0.8 m/s; <1.0 m/s [32, 35]
Maximum gait speed Male: <1.48 m/s, female: <1.42 m/s [33]
Short physical performance battery <9 points; <10 points [40, 41]
Timed up and go test ≥12 s [32]
Isokinetic knee extensor muscle strength <40% dry weighta [34]
Five sit-to-stand >14.5 s [42, 43]
Handgrip strength Male: <26 kg, female: <18 kg [44]
One-leg standing time <5 s; <10 s; <20 s [45–47]
Six-minute walk distance <300 m; <350 m; <400 m; <450 m; [32, 48–50]
every 20 m increases
Peak VO2 <17.5 mL/min/kg [51]

a
Isokinetic knee extensor muscle strength was divided by dry weight and expressed as a percentage to adjust for the
difference in physical constitution among subjects.

populations including patients with kidney dis- cle weakness group. On the other hand, low mus-
ease. cle mass by itself was not a better predictor of
We previously performed a prospective co- mortality than muscle strength alone in patients
hort study among mobility disability-free 190 on hemodialysis [36, 37]. Cheema et al. [38] in-
Japanese outpatients undergoing hemodialysis vestigated the effect of resistance training on skel-
and examined the association of muscle weak- etal muscle quantity and strength in hemodialysis
ness in lower extremity with all-cause mortality patients, and found that it improved muscle
[34]. Lower-extremity muscle strength directly strength but not muscle mass. Muscle strength is
impacts walking ability, standing balance func- a meaningful target of exercise interventions with
tion, difficulty in activities of daily living, and implications for ambulatory function and mor-
quality of life. Lower extremity strength can also tality risk.
be trained by resistance training. Unlike hand Slowness detected by usual gait speed (0.6
strength, lower extremity performance is less im- m/s [35] or 0.8 m/s [32]) or maximum gait
pacted by dialysis-related amyloidosis leading to speed (men: 1.32 m/s; women: 1.2 m/s) [33]
carpal tunnel syndrome, cubital tunnel syn- tests is also a strong predictor of poor survival
drome, or destructive cervical spondylosis. Fur- in CKD patients. Gait speed is a useful quantita-
thermore, lower extremity muscle strength links tive tool that provides a generally accepted clin-
the metabolic derangements associated with kid- ical index of physical frailty. Gait speed assess-
ney disease with mobility important for function- ment is convenient, rapid, and reproducible
al independence. In a recent study of patients [39] requiring neither a large amount of space
with end-stage renal disease treated with hemo- (distance of at least 4 m) nor substantial special
dialysis who were able to ambulate without assis- examiner training.
tance, we showed that only half of them had The importance of physical assessments is un-
achieved minimum recommended level of mus- derscored by clinical practice guidelines from
cle strength, which discriminates whether people KDIGO, NKF, and ERBP [28–30], but not JSDT.
need any assistance with walking or not. Further- Principal physical performance tests and cutoffs
more, mortality risk in the weak muscle strength discriminating poor performance are summa-
group was 2.7-fold higher than that in non-mus- rized in Table 1 [32–35, 40–51].
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Exercise Training in CKD Patients motivation to exercise. Supervised exercise train-
ing such as intradialytic or multiple low-intensity
Frailty is a dynamic condition that can improve exercise [58, 59] and chair stand exercise [57] are
or worsen over time. Physical frailty, which is potentially safer and more effective methods to
characterized by diminished strength, endur- improve physical functioning in elderly frail pa-
ance, and reduced physiologic reserve, is a man- tients undergoing hemodialysis. Additionally, a
ageable condition. Physical frailty can be poten- combined program of exercise training and neu-
tially prevented or treated with exercise interven- romuscular electrical stimulation use, which can
tion [9]. safely induce muscle contraction without the vo-
A multicenter, randomized controlled trial in litional effort of the patients, would be more ef-
Italian patients on dialysis revealed that home- fective to improve their physical performance
based walking program managed by the dialysis [60, 61].
staff improved the functional status such as mus-
cle strength and walking ability and a part of
quality of life compared with usual care [18]. This Management of Physical Frailty in
intervention was a simple, personalized, and low- Hemodialysis Patients
intensity program, and was well accepted by
study participants on dialysis. However, it is best Early identification of physical frailty and inter-
to be fully aware that this study population was vention are essential to establish a comprehen-
younger and had no clinical limitation to mobil- sive management plan for hemodialysis patients.
ity. We have conducted the systematic review and One potential clinical algorithm for management
meta-analysis to update the evidence base for rec- of physical frailty among Japanese dialysis pa-
ommendation of supervised exercise interven- tients is illustrated in Figure 2. This is a modified
tion for hemodialysis patients [52]. Our findings version of Roshanravan’s algorithm [31] tailored
suggest that supervised exercise training has sig- to the Japanese dialysis population. The algo-
nificant beneficial effects on exercise tolerance, rithm consisted of understanding of a patient’s
walking ability, muscle strength, and quality of physical performance and physical activity level
life in these populations, and this result was gen- and exercise interventions. In patients with a de-
erally in agreement with those of previous meta- cline in physical performance and/or sedentary
analyses [53–55]. In our subgroup analysis, su- lifestyle who were screened by routine evaluation
pervised exercise also improved depressive symp- based on the algorism, we encourage them to par-
toms, although it was a small sample size [56]. ticipate in a supervised and/or home-based exer-
Regarding elderly frail patients with end-stage cise program.
renal disease treated with hemodialysis, there has
been 1 study evaluating the impact of exercise on
frailty [57]. The results demonstrated that the im- Conclusions
provement in activities of daily living was greater
in the subjects who received intervention with Physical frailty is highly prevalent in patients un-
chair stand exercise than the control group. dergoing hemodialysis, and is strongly associated
There is still insufficient evidence regarding the with higher mortality. Screening for physical frail-
effect of exercise training in this population. For ty is the first step in identifying patients at high
elderly frail patients on hemodialysis, the choice risk of functional decline and prescription of an
of a suitable exercise modality depends on the effective exercise intervention. Although the clin-
barriers to exercise participation such as self-effi- ical importance of physical activity for patients on
cacy, discomfort, disability, fear of injury, habits, hemodialysis has already been emphasized in clin-
environmental factors, cognitive decline, fatigue, ical practice guidelines published by the academic
functional status, comorbid severity, pain, and societies of the US and Europe, there is less recog-
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 Fig. 2. Clinical algorithm of management of physical frailty in hemodialysis patients (modified from
Roshanravan et al. [31]).

nition and emphasis in the care of Japanese pa- Disclosure Statement

tients. However, current knowledge about appli-
cation of management of frailty in clinical dialysis The authors declare that they have no conflicts of
care includes the lack of evidence for the effects of interest.
management of physical frailty on health out-
comes in elderly frail patients on hemodialysis.
Further studies are needed to investigate the im- Funding Sources
pact of targeted lifestyle interventions on this vul-
nerable population in order to inform guidelines This work was supported by grants from the NID-
directed at improving physical function among DK (1K23DK099442 to B.R.).
the elderly frail hemodialysis population.

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Ryota Matsuzawa, PT, PhD

Department of Rehabilitation
Kitasato University Hospital
1-15-1 Kitasato, Sagamihara, Kanagawa 252-0375 (Japan)
128.32.10.230 - 7/26/2018 6:00:04 PM

E-Mail [email protected]
Univ.of California Berkeley

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Contrib Nephrol. Basel, Karger, 2018, vol 196, pp 101–109 (DOI: 10.1159/000485707)