Redesigning peritoneal dialysis care: The introduction of frailty-informed pathways

In this issue of PDI, Gaube et al. show a high incidence of frailty in patients starting peritoneal dialysis (PD). They confirm a relationship with subsequent modality failure and mortality. ¹ The authors present data from an impressively large, incident, cohort of 182 individuals assessed at the time of starting dialysis and followed for a median of 1.6 years. They demonstrate more than 1/3 of their population were designated as frail at the time of starting maintenance peritoneal dialysis (defined by clinical frailty score (CFS) ≥ 4). Notably, their data suggest that there is an incremental relationship with mortality and/or transfer to hemodialysis with each point increase in the clinical frailty score. Key to these findings is how we, as a community of healthcare professionals, integrate this knowledge beyond the research domain into clinical care.

Is it possible / feasible to integrate frailty assessment into clinical practice?

Is there value in integration of frailty assessment into clinical practice?

Work from numerous other areas of medicine suggests it is possible to integrate frailty into routine clinical care. The majority of studies in the nephrology literature define frailty using the Fried Frailty Index. This is a validated tool that relies exclusively on measures of the physical performance phenotype of frailty, distinguishing fit patients from prefrail (or vulnerable) and frail patients. ² The Fried Frailty Index is however limited by the need for specific assessments (such as hand grip measurement), and even small variations in testing methodology can lead to variability in results. ³ The Comprehensive Geriatric Assessment (CGA) remains the gold standard method for assessing older patients, as it assesses multiple important domains beyond the medical illness itself. The CGA however remains time consuming, and results from the ongoing GOAL trial will help inform us about the benefits of CGA in kidney care. ⁴ In the Australian multicentred GOAL trial, the CGA will be administered to patients with chronic kidney disease stages 3 to 5 (including dialysis) as part of a cluster-randomized controlled study. Centres randomized to the active arm will follow protocols administering both the CGA and targeted multidisciplinary interventions, while the centres in the control arm will continue their standard care. The primary study outcome will compare if patient-identified goals are met at 1 year. Additional data on frailty outcomes, hospitalization and morbidity will also be collected.

Comparisons of frailty screening tools, across studies in the nephrology literature confirm variable sensitivity with different tools. No one tool can be deemed ‘the best’.^3,5,6 The Clinical Frailty Scale (CFS) screening tool, used by Gaube et al., is derived from the comprehensive geriatric assessment and is widely used throughout the field of geriatrics. It has a strong association with clinical outcomes. ⁷ It is easily scored and as noted by the authors has a high inter-rater reliability. ⁸ Additional CFS strengths are that it captures multiple dimensions of health, often implicitly, including the burden of disease, how the patient is navigating day-to-day life despite disease, as well as other parameters of social and cognitive functioning.

Cognitive frailty, defined as the presence of mild or moderate cognitive deficits in those with physical frailty (but without clear manifestations of dementia) ⁹ is particularly important for PD care for several reasons. In patients receiving PD, cognitive changes may impact both how patients report important treatment-associated signs and symptoms (such as decreased urine output, abdominal pain or cloudy bags) as well as health activities that extend beyond the treatment. Such activities may include attending appointments, medication use, personal hygiene or food choices. Social Frailty is also emerging as a significant health determinant. ¹⁰ It refers to individuals with reduced social wellbeing, connectedness or social resources. Although there are limited data in PD, it is plausible that an individual receiving home dialysis may become socially isolated over time. Small adjustments to the daily routine, arising from doing simple dialysis tasks or waiting for a nurse, may impact personal activities and social connections thus contributing to social frailty. Caregiver health or capacity may alter, and patients may find themselves increasingly isolated. In the hemodialysis population, low social wellbeing (and hence social frailty) is associated with increased mortality. ¹¹ The nature of the hemodialysis treatment can however improve social connectedness. Patients and family members value the regular contact with staff and other patients, describing the experience “coming into this room we become a family, we care about each other, we look after each other”. ¹² The use of assisted PD can also positively impact social connections, although the need for, or receipt of, assistance may not directly correlate with observed frailty. ¹³ It is also likely that there is substantial variability, across jurisdictions, as to whether visits are limited to treatment-associated tasks or if patients also receive other types of care (toileting, help with meals etc.). One is left questioning whether more ‘intensive’ treatment protocols, such as use of more frequent erythropoiesis-stimulating agents (ESA) dosing or increased frequency of PD exchanges, could increase wellbeing purely as a result of the increased number of visits.

Being described as frail, even within the general population, is understood to imply both a higher risk of health decline and shorter lifespan. Multidisciplinary interventions can be effective in reversing frailty, and results of the ongoing GOAL study will allow a better understanding of when and how to best intervene. ⁴ Beyond these interventions, however, we propose adapting the approach of our colleagues in oncology. ¹⁴ In oncology, the aggressiveness of treatment interventions is determined by the frailty status at the onset of each treatment cycle. Those presenting with higher levels of frailty undergo modified routines, designed to limit treatment-associated risks. ¹⁵ Improved recognition of health trajectories leads to earlier palliative care consultation, often with good effect. A parallel model applied to dialysis care may move the focus on healthTREATMENTS to one of healthCARE. By overlapping frailty assessments with our understanding of kidney trajectories of health and disability, we propose novel care pathways that promote flexibility of treatment preferences, while ensuring care remains holistic and realistic (Figure 1, Figure 2). Individuals on the bridge to a kidney transplant pathway could be empowered (and expected) to adapt their lifestyles, with the goal of maintaining or improving their health. They may be charged with higher responsibility to ensure lifestyle change (exercise, treatment adherence) as well as preparatory work for transplantation such as how to navigate drug costs, insurance plans etc. In contrast, those undergoing frailty-informed care may have modified goals. Hospital clinic visits may alternate with in-home clinic visits; dialysis care targets may be softened to allow mitigation of symptom burden; and dialysis care packages may be extended to include other services such as scheduled home physiotherapy or occupational therapy visits. Dialysis prescriptions may be modified so, for example, paid caregivers help with both manual dialysis exchanges and with personal care. Home visits from physicians and nurses could involve other trusted clinicians, including spiritual care, palliative care and/or social workers. Care would extend, over time, to include discussions about the future, including the option of dialysis discontinuation or the potential need for placement in care homes and hospice. ¹⁶ In a paradigm shift, care-pathways could be uniquely customized, to mirror transitions in health and wellbeing, and patient care plans adjust as patients switch from one category to another, or back, placing the focus back on comprehensive caring.

“The last thing you ever want to do is extend the period of frailty and disability and make people unhealthy for a longer time period. So lifespan extension in and of itself should not be the goal of medicine, nor should it be the goal of public health, nor should it be the goal of aging science.” Dr S. Jay Olshansky

Figure 1.

Figure showing suggested care pathways for those starting maintenance dialysis. Based on frailty assessments, patients would be placed on one of three care pathways, each with focused health targets.

Figure 2.

Figure illustrating the CKD health trajectory. ​ The blue line represents the most common health trajectory seen in dialysis patients. As kidney failure advances patients present with increased symptoms often leading to dialysis initiation. Most will stabilize and have a slow age-related decline in function, punctuated variably by intercurrent illnesses. A few individuals will have significant health improvement over time (green line) and clinical frailty scores will improve, while others may have a rapid deterioration in overall wellbeing and higher clinical frailty scores (red line). As illustrated by the blue line, patients may transition between care pathways while, for example, recovering from an acute illness. As transitions may occur bidirectionally, shorter assessment intervals may be appropriate in those recently discharged after acute care hospitalization.