Prevalence of pre-frailty and frailty in hemodialysis patients
The incidence of pre-frailty and frailty among patients undergoing hemodialysis is a significant concern, especially given the physical and psychological implications it brings. Our study has revealed that the prevalence of frailty among hemodialysis patients stands at 38.5%, with a substantial proportion of these patients being aged 60 and above (59.9%). This finding aligns with previous studies conducted in Japan35,36 and Taiwan37, where the prevalence ranged from 23–39.7%.The literature, as compiled in a Systematic Review and Meta-Analysis8,indicates a wide range of frailty prevalence among patients with End-Stage Renal Disease (ESRD) undergoing hemodialysis, spanning from 29.6–81.5%.Of note, the Fried phenotype has emerged as a prevalent screening tool for frailty, with studies reporting a prevalence ranging from 31.0–81.5%15,38–42.In our study, we delved deeper into the risk factors for pre-frailty among hemodialysis patients. We observed a considerable prevalence of pre-frailty in this cohort, accounting for 26.2% of the patients. This finding is comparable to the 35.4% range reported in studies conducted in the East China region21.Furthermore, a recent 2022 study revealed that pre-frailty and frailty are prevalent even in younger hemodialysis patients, with a prevalence of 23.0% among those under 50 years old, which increases significantly with age11.
While the majority of frailty research has focused on elderly hemodialysis patients, our findings highlight the significant burden of pre-frailty and frailty among non-elderly patients. Our study revealed that the prevalence of pre-frailty and frailty among non-elderly participants was over 40% and more than half, respectively. This aligns with a two-center prospective analysis43, which reported a frailty prevalence of 71.4% among older patients and 47.3% among younger patients, indicating a substantial burden among the younger age group.However, it is noteworthy that the prevalence of frailty increases as people age, with older age being associated with a 2.90-fold increase in frailty43.
To mitigate the substantial incidence of frailty among elderly dialysis patients, preemptive measures are crucial, especially when implemented at an earlier age. Multiple variables, each with its unique influence, contribute significantly to the progression of frailty. Patients undergoing hemodialysis undergo inevitable amino acid and protein losses due to the dialysis process itself44.Additionally, the triad of insulin resistance, chronic inflammation, and vascular calcification acts synergistically to promote the depletion of musculoskeletal mass45–47, thereby heightening the risk of frailty among this patient cohort.
Beyond these physiological factors, the constellation of symptoms such as inactivity, diminished muscle mass, comorbidities, and reduced physical and cognitive functions have been identified as pivotal contributors to frailty34.These factors, in combination, likely contribute to a higher prevalence of pre-frailty and frailty among hemodialysis patients compared to the general elderly population. Among the various indicators of frailty, fatigue and resistance were observed to have the highest prevalence (48.8% and 43.1% respectively), pointing to potential avenues for future intervention studies.
Factors influencing pre-frailty and frailty in hemodialysis patients
When delving into the factors that influence pre-frailty and frailty in hemodialysis patients, we uncovered a diverse array of determinants.We found that factors influencing frailty in hemodialysis patients were advanced age, having child, low monthly household income,smokers,non-exercise,falls,vascular acces,diabetes,heart disease,cerebral disease,resignation and psychological resilience.Multivariate logistic regression analysis showed that age, having child, education level, monthly household income,smoking status,drinking status,exercise,falls,vascular acces,diabetes,heart disease,cerebral disease,resignation and psychological resilience are associated with frailty.Multivariate logistic regression analysis showed that weight, smoking status,falls,heart disease and Psychological resilience are associated with pre-frailty.
We have observed a clear association between advancing age and the emergence of frailty.This correlation aligns well with previous research48. aging as a significant risk factor for frailty, particularly in the context of chronic diseases, depressive symptoms, and a general decline in cognitive and functional abilities. As individuals age, the likelihood of developing frailty increases, reflecting the cumulative impact of physiological changes and environmental factors.Moreover, our study has uncovered an intriguing trend regarding familial structures and frailty. Specifically, we have noted a higher incidence of frailty among hemodialysis patients who are part of families with children. This finding may be attributed to the increased demands placed on caregivers, who often devote significant time and energy to their children's education, potentially compromising their own health and well-being.When considering socioeconomic factors, we have observed that frailty is less prevalent among patients with higher per capita monthly household incomes. This could be explained by the fact that a greater financial cushion enables patients to access superior hemodialysis treatments and a broader range of healthcare services, thereby mitigating the risk of frailty.
In addition to socioeconomic considerations, lifestyle habits also play a pivotal role in the development of frailty. This aligns with previous research that has linked unhealthy lifestyle choices to an increased risk of frailty.For instance, Sho Kojima and his team have demonstrated a connection between frailty and a decline in exercise capacity among hemodialysis patients36.Similarly, Cynthia Delgado and her colleagues have found that newly initiated dialysis patients who report frailty have a significantly higher incidence of medically urgent falls or fractures compared to those without frailty20.This finding resonates with our own observations, further highlighting the importance of preventing falls in dialysis patients as they can significantly elevate the risk of pre-frailty.Furthermore,a study has also observed a link between frailty and specific medical conditions in hemodialysis patients. Serum parathyroid hormone concentrations, as well as CKD-mineral and bone disorder (CKD-MBD) medication, have been associated with an increased risk of fracture in patients with ESRD patients20.Similarly, a prospective Taiwanese cohort study has revealed a correlation between frailty and a higher incidence of vascular access thrombosis37.Notably, in this study, central venous catheters and artificial blood vessels were identified as posing a greater risk of frailty compared to arteriovenous fistulas.
The phenomenon of frailty in hemodialysis (HD) patients is intricately linked to a range of comorbidities, prior among them being their primary illness, congestive heart failure, and other cardiac afflictions.Our current research has revealed a significant association between the presence of comorbidities such as diabetes, heart disease, and cerebral disease, and a heightened incidence of frailty in HD patients, compared to those without such comorbidities.A noteworthy study has underscored diabetes mellitus as a pivotal risk factor for the progression and manifestation of frailty8.Kakio and colleagues have further corroborated this by highlighting the elevated predisposition of diabetic renal disease patients to frailty compared to their non-diabetic chronic kidney disease (CKD) counterparts49. The heightened risk in diabetic patients can be attributed to the confluence of neuropathy and physiological dysfunction, cognitive impairment stemming from cerebrovascular disease or brain degeneration, inflammatory mechanisms, and the loss of self-care abilities50,51. Additionally, insulin resistance, hyperglycemia, and diabetic neuropathy in diabetic patients may contribute to skeletal muscle loss, thereby enhancing frailty.Moreover, HD patients suffering from congestive heart failure or other cardiac conditions exhibit a fivefold higher risk of developing pre-frailty and frailty compared to patients with other diseases34.This correlation can be explained by the shared etiological factors between frailty and cardiovascular disease, including inflammatory response, endothelial dysfunction, and testosterone insufficiency. Chronic inflammation, specifically, plays a pivotal role in frailty by precipitating other illnesses. Cerebrovascular disorders, in particular, are linked to atherosclerosis, which alters systemic metabolism and pathophysiology, thus escalating the risk of frailty.Consequently, the imperative lies in the management and control of comorbidities to bolster the physical constitution and reduce the incidence of frailty among HD patients. This approach not only addresses the comorbidities themselves but also aims to mitigate their detrimental impact on the overall frailty status of HD patients.
Frailty status,medical coping modes, psychological resilience in hemodialysis patients
The state of frailty, medical coping mechanisms, and the psychological resilience exhibited by hemodialysis patients rarely faces scrutiny in the medical literature. The frequency of hemodialysis sessions, often exceeding two per week52,, poses unique challenges for patients. The recurring punctures, limitations on fluid intake and dietary restrictions, as well as potential complications that may arise during these regular treatments, can significantly contribute to psychological distress among HD patients.This distress often manifests in the form of anxiety53, depression54, and a heightened sense of symptom burden55.Moreover, the economic burden of regular dialysis sessions, prolonged medication regimens, and frequent laboratory tests can impose a substantial financial strain on patients' families. This financial pressure can lead to feelings of guilt and further exacerbate the psychological stress experienced by these patients56.When it comes to psychological resilience, this refers to a person's capacity to adapt to and overcome physiological stress, particularly the kind that significantly disrupts normal physiological equilibrium. It is noteworthy that as individuals age, their psychological resilience tends to diminish, while frailty concurrently increases. Notably, research has indicated that HD patients exhibit consistently weaker psychological resilience compared to the general population57.Early research suggested that the loss of early physiological resilience is a factor of frailty58.This study found a negative association between psychological resilience, pre-frailty, and frailty among HD patients,which is similar to early study7.As a result, psychological resilience could be regarded as a protective factor against pre-frailty and frailty. Patients with higher psychological resilience function better in the face of physical challenges.In the quest to understand and manage these complex psychological and medical challenges, it is crucial to delve deeper into the various coping strategies and resilience factors that may help HD patients navigate their treatment journey with greater ease. As a result, psychological treatment should be addressed in order to promote psychological resilience and reduce the incidence of pre-frailty and frailty in HD.
The concept of coping style denotes the diverse strategies individuals adopt when confronted with diverse traumatic life experiences. These varying coping techniques exhibit differing impacts on the progression of various illnesses. Three fundamental styles of coping are commonly recognized: confrontation, avoidance, and resignation. Notably, the confrontational approach is deemed positive, whereas the other two methodologies are regarded as negative59.Our in-depth analysis has unearthed a positive correlation between frailty and the resignation-based coping mode, whereas psychological resilience is positively linked to confrontation-based and avoidance-based coping, while inversely related to resignation-based coping.
The confrontation-oriented coping style signifies that patients maintain a high level of attention to their illness and actively seek constructive help and support. This approach mitigates feelings of anxiety and despair, fostering both physical and mental well-being, while also alleviating caregiver stress.60,61Conversely, patients' negative coping mechanisms intensify caregiving demands, augmenting the responsibilities associated with daily living and social interactions, ultimately elevating the risk of mental health issues such as depression and anxiety62.This, in turn, undermines the quality of care provided63.Our findings align with previous research conducted by Alshammari et al., which revealed that patients' attitudes towards their illness, the duration of care, and the nature of their therapy all contribute to the caregiver's burden64,65. To mitigate caregiver burden and improve quality of nursing, medical professionals can evaluate and address patients' coping styles through cognitive-behavioral therapy. Additionally, they should remain vigilant to patients' psychological fluctuations and offer tailored psychological support to foster a positive approach towards disease management.
Strengths and limitations
This study has several strengths. Firstly, it was conducted at multiple centers in central China. Additionally, it further elucidates the relationship between psychological resilience and pre-frailty and frailty. However, there are also limitations to consider. The use of convenience sampling may introduce selection bias and limit the generalizability of the results. Furthermore, the cross-sectional design impedes the establishment of a temporal relationship between the variables studied and pre-frailty and frailty. Future research should utilize longitudinal designs, ideally with samples collected from various medical centers and geographic locations. Additionally, due to financial constraints, laboratory indicators were not included in this study. Given the importance of laboratory indicators in hemodialysis patients, future studies should investigate the association between these indicators and pre-frailty and frailty.