Abstract
Background and Aims
Patients with chronic kidney disease (CKD) report high symptom-burden that adversely affects health-related quality of life (HRQOL). Frailty is an independent predictor of poor HRQOL in those with CKD.
Although there is a clear relationship between frailty and HRQOL in patients with CKD, the associated relationship with symptom experience is not well understood. Understanding how living with both frailty and CKD influences symptom-burden could inform management strategies that improve HRQOL of this vulnerable patient group. This study’s aim was to evaluate the symptom experience of patients living with frailty and CKD.
Methods
A total of 353 participants were recruited between February 2018 and October 2018 to this cross-sectional observational study. Participants completed physical activity (GP Physical Activity Questionnaire [GPPAQ]), cardiopulmonary fitness (Duke Activity Status Index, providing estimated VO2 peak), symptom-burden (Kidney Symptom Questionnaire [KSQ]) and HRQOL (Short Form 12 [SF-12]) questionnaires. Frailty was assessed using a modified Frailty Phenotype comprising 3 self-report components:
1) weakness/slowness defined as a SF-12 Physical Functioning score <75; 2) low physical activity defined as ‘inactive’ by the GPPAQ; and 3) exhaustion defined as a SF-12 Vitality score <55. Participants were categorised as frail if ≥2 components were present. Multiple imputation was performed for data considered to be either missing completely at random or missing at random. Regression analyses were used to assess the association between frailty, symptom-burden and HRQOL. Principal Component Analysis (PCA) was performed to explore symptom clusters experienced by non-frail and frail participants.
Results
Two hundred and twenty-five (64%) participants were categorised as frail. Frail participants were significantly older (77.7 vs. 71.5 years, p<0.001) and had a significantly lower eGFR (45.8 vs. 50.9 mL/min/1.73m2, p<0.001), albumin concentration (39.2 vs. 41.4 g/L, p<0.001) and estimated VO2 peak (21.7 vs. 33.9 mL/kg/min, p<0.001) than non-frail participants. Frailty, when adjusted for age, sex, eGFR and haemoglobin, was independently associated with higher KSQ total symptom score (p<0.001) and lower SF-12 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores (p<0.001 and p=0.001, respectively). Lower eGFR was associated with higher KSQ total symptom score (p=0.004) and lower SF-12 PCS score (p=0.01). Frailty, when adjusted for age, sex, eGFR and haemoglobin, was independently associated with a two- to over five-fold increase in odds of experiencing all reported symptoms frequently, except loss of appetite and urinary frequency. Lower eGFR was only associated with increased odds of reporting frequent loss of muscle strength (p=0.04). PCA revealed two symptom clusters for non-frail participants and three symptom clusters for frail participants. Both non-frail and frail participants had symptom clusters associated with sleep disturbance and musculoskeletal symptoms. There was an additional unique symptom cluster (comprising loss of appetite, tiredness, feeling cold and poor concentration) experienced by frail participants.
Conclusion
Frailty is an independent predictor of high symptom-burden and poor HRQOL. Furthermore, symptom experience for people living with frailty and CKD is distinct from non-frail individuals, reporting a unique symptom cluster that may be a consequence of the frailty syndrome itself. This group of patients should be offered a holistic assessment so that problematic symptoms can be identified and addressed early before they impact more significantly on HRQOL. Future efforts should be focused on evaluating holistic models of care, such as the comprehensive geriatric assessment, for patients living with frailty and CKD.
Symptom Experience in Patients with Gynecological Cancers: The Development of Symptom Clusters through Patient Narratives
