KDOQI GUIDELINE 12 ASSOCIATION OF LEVEL OF GFR WITH INDICES OF FUNCTIONING AND WELLBEING.docx

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