Frail patients on hemodialysis have greater likelihood of dying, being hospitalized, and being placed in long-term care, a new study confirms. However, patients whose frailty status improves over time have better clinical outcomes than those who remain frail.

In a prospective cohort study of 985 adults on hemodialysis in Canada, 760 (77%) reported frailty at some point. Frailty was defined as a score of 3 or higher on a 5-point scale that included 1 point each for physical inactivity, poor endurance or exhaustion, and malnutrition, and 2 points for slowness and/or weakness. The components were defined by the CKDCS survey, Kidney Disease Quality of Life instrument, or ICD codes.

In fully adjusted analyses, higher frailty scores were significantly associated with a 1.6-fold increased risk for all-cause mortality and a 1.2-fold increased risk for all-cause hospitalization per unit increase in score from 3 to 5, Marcello Tonelli, MD, SM, MSc, of the University of Calgary in Alberta, Canada, and colleagues reported in Kidney Medicine. In analyses adjusted for age, sex, and number of comorbidities, frail patients also had a significant 1.6-fold increased risk for long-term care placement.

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Among patients without baseline frailty, 46% became frail over a median 33 months of follow-up. Among patients with baseline frailty, 78% remained frail and 23% improved to nonfrail status. Patients who improved during follow-up had a significant 43% lower risk for all-cause mortality and a 30% lower risk for hospitalization compared with patients who remained frail, the investigators reported.

Patients with frailty tended to be older, female, White, and have multiple comorbidities at baseline. They also had significantly higher rates of pre-existing atrial fibrillation, acute myocardial infarction, congestive heart failure, diabetes, as well as psychiatric illness. Comorbidity burden did not fully explain results. Over time, malnutrition increased, physical inactivity slightly decreased, and the other frailty components remained the same in this cohort.

“These findings emphasize the importance of identifying and implementing effective treatments for frailty in patients receiving maintenance hemodialysis,” according to Dr Tonelli’s team.


Tonelli M, Wiebe N, Gill JS, et al. Frailty and clinical outcomes in patients treated with hemodialysis: A prospective cohort study. Kidney Med. 2023 Aug; 5(8). Published online June 1, 2023. doi:10.1016/j.xkme.2023.100684