KDOQI GUIDELINE 12 ASSOCIATION OF LEVEL OF GFR WITH INDICES OF FUNCTIONING AND WELLBEING.docx
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KDOQI GUIDELINE 12 ASSOCIATION OF LEVEL OF GFR WITH INDICES OF FUNCTIONING AND WELLBEING.docx
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KDOQIGUIDELINE12ASSOCIATIONOFLEVELOFGFRWITHINDICESOFFUNCTIONINGANDWELLBEING
KDOQIClinicalPracticeGuidelinesforChronicKidneyDisease:
Evaluation,Classification,andStratification
PART6.ASSOCIATIONOFLEVELOFGFRWITHCOMPLICATIONSINADULTS
GUIDELINE12.ASSOCIATIONOFLEVELOFGFRWITHINDICESOFFUNCTIONINGANDWELL-BEING
Impairmentsindomainsoffunctioningandwell-beingdevelopduringthecourseofchronickidneydiseaseandareassociatedwithadverseoutcomes.Impairedfunctioningandwell-beingmayberelatedtosociodemographicfactors,conditionscausingchronickidneydisease,complicationsofkidneydisease,orpossiblydirectlyduetoreducedGFR.
PatientswithGFR<60mL/min/1.73m2shouldundergoregularassessmentforimpairmentoffunctioningandwell-being:
oToestablishabaselineandmonitorchangesinfunctioningandwell-beingovertime
oToassesstheeffectofinterventionsonfunctioningandwell-being.
BACKGROUND
Whenthereisnocureforachronicillness,anessentialhealthcaregoalmustbetomaximizequalityoflife.Thepurposeofthisguidelineistoidentifystagesandcomplicationsofkidneydiseasethatplaceadultpatientsatgreaterriskforreducedqualityoflife.Thisguidelineisnotintendedtocoverallthequalityoflifeconcernsthatapplytochildrenandadolescents,norisitintendedtorecommendinterventionstoimprovequalityoflifeinanyagegroup.Forthepurposeofthisguideline,conceptsthatembodypertinentcomponentsofqualityoflifewillbereferredtoas"functioningandwell-being."Recentstudiesshowthatthefunctioningandwell-beingofindividualswithchronickidneydiseaseisrelatedtosuchfactorsas:
latereferralandinadequatepre-dialysiscare80;symptoms;effectsofillnessonphysical,psychological,andsocialfunctioning;andsatisfactionwithhealthandcare.452Complicationsofchronickidneydisease,suchasanemia,malnutrition,bonedisease,neuropathy,andcomorbidconditions,suchasdiabetesandcardiovasculardisease,cannegativelyaffectfunctioningandwell-being.Toimprovefunctioningandwell-being,patientsmustbereferredsoonerandcomplicationsandcomorbidconditionsmustbemanagedappropriately.
Thisguidelinedescribestheassociationbetweenthelevelofkidneyfunctionanddomainsoffunctioningandwell-beinginpatientswithchronickidneydisease.Onemustanalyzethefullcontinuumofstagesofchronickidneydiseasetounderstandtherisksforcompromisedfunctioningandwell-being.Armedwiththisknowledge,clinicianscanmorequicklyidentifystagesofchronickidneydiseaseatwhichdeficitsarelikelytooccuranddevelopstrategiestotreathigherriskpatientsandameliorateoreliminatedeficitsbeforetheybecomesevereorirreversible.
RATIONALE
Definitions
Healthstatusoutcomesexpertsrecommenddefining"qualityoflife"toincludevariablesthathealthprofessionalscanidentify,quantify,andmodify:
(1)healthstatus(signsandsymptoms,labvalues,death);
(2)functionalstatus(physical,mental,social,androlefunctioning),and(3)well-being(energy/fatigue,pain,healthperceptions,andsatisfaction).453,454Self-reportispreferabletostaffreportsinceoutcomesaredependentonthelivedexperienceandexpectationsoftheindividualpatient.
Difficultiesinmeasuringthispoorlyunderstoodconcepthaveledresearchersinthearticlesreviewedtostudyseveralvariablesusingdifferentmethodsandinstruments(Table102).Useofdifferentinstrumentshasimpededcomparingfindings,interpretingresults,anddrawingconclusions.
StrengthofEvidence
Indicesoffunctioningandwell-beingareimpairedinchronickidneydisease(R).Dialysispatientsreportsignificantlymorebodilypain,lowervitality,poorergeneralhealth,greaterphysical,mental,andsocialdysfunction,andgreaterlimitationsintheirabilitytoworkandparticipateinactivitiesduetotheirhealthandemotionsthantheUSreferencenorm.Atleast25%aredepressed.455Dialysispatients'exercisecapacityissignificantlyworsethanthatofhealthycontrols.456Kidneyfailurenegativelyaffectssenseofcontrolandhealthoutlookinthoseondialysis.457About39%ofthosewhoworkedfullorpart-time6monthsbeforedialysisdonotcontinueworkingwhentheystartdialysis.4Elderlypeopleondialysisengageinfewpreviouslyenjoyedactivitiesoutsidetheirhomesandmanyleavehomeonlyfordialysisbecauseofweakness.458
Impairmentinindicesoffunctioningandwell-beingareassociatedwithworseoutcomesinchronickidneydisease(R).Impairedfunctioningandwell-beingindialysispatientsislinkedtoincreasedriskofdeathandhospitalizationwhileimprovementinscoreshasbeenassociatedwithbetteroutcomes.PatientswithSF-36PhysicalComponentSummary(PCS)scores<34.6hada2.03relativeriskofdyinganda1.67relativeriskofbeinghospitalized.Each5-pointimprovementinPCSscoreswasassociatedwith10%longersurvivaland6%fewerhospitaldays.OntheSF-36,aMentalHealthscalescore
52andaMentalComponentSummary(MCS)score
42indicatedepression.Each5-pointimprovementintheMCSscoreisassociatedwith2%fewerhospitaldays.455
Impairmentinfunctioningandwell-beingareassociatedwithsociodemographiccharacteristics(R).Lowincomeandloweducationwereassociatedwithgreaterimpairmentsinfunctioningandwell-beinginpatientswithchronickidneydisease.459
Impairmentinfunctioningandwell-beingmaybeduetoconditionsthatcausechronickidneydisease(suchasdiabetesorhypertension)orcomplicationsofdecreasedGFR(suchasanemia,malnutrition,bonedisease,orneuropathy)(R).Hypertension,diabeteswithangina,priorcardiacinfarction,460osteoporosis,bonefractures,461andmalnutrition462havebeenshowntoimpairfunctioningandwell-beinginthosewithnoknownkidneydisease.Amongveteranswithdiabetes,neuropathyandkidneydiseasehavebeenassociatedwiththegreatestdecreaseinfunctioningandwell-being.463
Anemiahasbeenlinkedtopoorfunctioningandwell-beinginpatientswithseverelydecreasedGFRanddialysispatients,andimprovinganemiawitherythropoietinhasbeenlinkedtoimprovementinfunctioningandwell-being.284,464-468
Indicesoffunctioningandwell-beingarerelatedtothelevelofGFR;belowaGFRofapproximately60mL/min/1.73m2,thereisahigherprevalenceofimpairmentsinindicesoffunctioningandwell-being(S,C).Datafromcross-sectionalstudiesandbaselinedatafromlongitudinalstudieswerereviewedtoassesstherelationshipbetweenlevelofkidneyfunctionandleveloffunctioningandwell-being.Populationsstudiedincludethosewithdecreasedkidneyfunction,includingthosewithfunctioningtransplants,anddialysispatientswhencomparedwithhealthysubjectsorkidneytransplantrecipients.Whilemuchofthedataonfunctioningandwell-beingrelatedtooutcomeshavebeenobtainedindialysispatients,thereisconvincingevidencethatabnormalitiesinfunctioningandwell-beingbeginearlierinchronickidneydiseaseandmaywellberelatedtodecliningGFR.
Symptoms(Table103andFig44).
Figure44
Kidneyfunction(GFR)andoddsofhavingsymptomsaffectingqualityoflifeandwell-beingintheMDRDStudy,controlledforage,gender,race,kidneydiagnosis,education,income,andsmokingstatus.Reprintedwithpermission.469
(Clickonimagetoenlarge)
Reducedkidneyfunctionisassociatedwithincreasingsymptomssuchastiringeasily,weakness,lowenergy,cramps,bruising,badtastingmouth,hiccoughs,andpoorodorperception.Thisistrueinpatientswithnativekidneydiseaseandthosewithkidneytransplants.Diabeticdialysisandtransplantpatientsaremorelikelytoreportpoorhealththandialysisortransplantpatientswhodonothavediabetes.
PhysicalFunctioning(Table104andFigs45and46).
Figure45
AdjustedprevalenceofphysicalinabilitytowalkbyGFRcategory(NHANESIII).Predictedprevalenceofphysicalinabilitytowalkone-quartermileamongadultparticipantsage20yearsandolderinNHANESIII,1988to1994.Valuesareadjustedtoage60yearsusingapolynomialregression.95%confidenceintervalsareshownatselectedlevelsofestimatedGFR.
(Clickonimagetoenlarge)
Figure46
AdjustedprevalenceofphysicalinabilitytoliftbyGFRcategory(NHANESIII).Predictedprevalenceofphysicalinabilitytolift10poundsamongadultparticipantsage20yearsandolderinNHANESIII,1988to1994.Valuesareadjustedtoage60yearsusingapolynomialregression.95%confidenceintervalsareshownatselectedlevelsofestimatedGFR.
(Clickonimagetoenlarge)
DecreasedGFRinNHANESIIIsubjectsisassociatedwithimpairedwalkingandliftingability.Intransplantrecipients,reducedkidneyfunctionisalsoassociatedwithpoorerphysicalfunctionscores.InonestudyofpatientswithdecreasedGFR,impairmentinphysicalfunctionwasnotsignificantlyrelatedtothelevelofkidneyfunction,butphysicalimpairmentwas8timesworsethaninthegeneralpopulation.Dialysispatientsreportgreaterphysicaldysfunctionthantransplantrecipientsanddiabeticdialysisandtransplantpatientsaremorelikelytoreportphysicaldysfunctionthanthosepatientswhodonothavediabetes.
Depression(Table105).
Reducedkidneyfunctionisassociatedwithpoorerpsychosocialfunctioning,higheranxiety,higherdistress,decreasedsenseofwell-being,higherdepression,andnegativehealthperception.Depressedpatientsaremorelikelytoreportpoorlifesatisfaction,irrespectiveofkidneyfunction.Dialysispatientsreportsignificantlylower"happinesswithpersonallife"andlowerpsychosocialfunctioningthantransplantrecipients.InelderlyMexicanAmericans,k
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