Conservative Care for Advanced CKD Falls Short

Early Dialysis Initiation Associated With Lower Risks for Death, MACE

Recent finding from an observational study contrasts with previous research

EARLY INITIATION of dialysis may modestly reduce the risks for death and major adverse cardiovascular events (MACE), an observational study finds. But the tradeoff may be in quality of life. Among 10,290 patients with advanced chronic kidney disease (median age 73 years; 36% women) in the National Swedish Renal Registry, 3822 started

Lowest death risk observed when dialysis started at an eGFR of 15-16.

dialysis, 4160 died, and 2446 had a MACE (a composite of cardiovascular death, nonfatal myocardial infarction, or non-fatal stroke). Investigators examined dialysis initiation in this cohort at estimated glomerular filtration rates (eGFR; in mL/min/1.73 m2) from 4 to 19 in increments of 1.

Mortality displayed a U-shaped curve with eGFR, with the lowest death risk at eGFR 15-16. Compared with dialysis initiation at eGFR 6-7, initiation at eGFR 15-16 was significantly associated with a 5.1% lower absolute risk for death within 5 years, Edouard L. Fu, MD, PhD, of Leiden University Medical Center, Leiden, The Netherlands, and colleagues reported in BMJ.

“This 5.1% absolute risk difference corresponded to a mean postponement of death of 1.6 months over five years of follow-up,” Dr Fu’s team wrote. “However, dialysis would need to be started four years earlier.” For most patients, this purported survival benefit would not outweigh the burden of more years spent on dialysis, according to the investigators.

The lowest absolute risk for MACE was 3.3% when dialysis was initiated at an eGFR of 13-14, using an eGFR of 6-7 as a reference.

The investigators adjusted analyses for multiple relevant factors, such as laboratory values and comorbidities. However, the study lacked information on nutritional status or muscle mass, uremic symptoms, volume status, and quality of life or physical activity. The team also noted that optimal eGFR to start dialysis may differ between hemodialysis and peritoneal dialysis; up to 39% of patients in Sweden start with peritoneal dialysis.

“Our results further suggest that in the absence of symptoms or strong indications, initiation of dialysis may be postponed until lower eGFR values are reached (intent to defer), without a large increase in mortality or cardiovascular events,” according to Dr Fu’s team.

The new findings differ from those of some previous reports, including one in Hemodialysis International in 2021. That report, which provides details of a study involving 676,196 adult patients initiating hemodialysis between 2006 and 2014, found that patients who started hemodialysis early (eGFR 13 or higher) had a significant 93% increased risk for all-cause mortality compared with those who started late (eGFR less than 8.7). ■

Poor Nutrition at Dialysis Start Ups Mortality Odds

PATIENTS WITH POOR or declining nutritional status during dialysis initiation are at higher risk for death for up to 5 years afterward, according to investigators.

“This calls for special attention to be paid to diet and adequate treatment of comorbidities as patients approach dialysis, in order to optimize survival after dialysis start,” Sara Blumberg Benyamini, PhD, of Wolfson Medical Center in Holon, Israel, and colleagues reported in the Journal of Renal Nutrition.

They also observed, “Our study also suggests the importance of improving the nutritional status during the first months in dialysis. Dietary intervention at this time, during the first 3 months on dialysis, might improve survival during the 3 years following RRT commencement.”

The investigators calculated an Integrative Clinical Nutrition Dialysis Score (ICNDS) for 297 patients at dialysis initiation and 1, 2, and 3 months later. For each patient, they ranked 7 parameters — serum albumin, creatinine, and urea, cholesterol, dialysis adequacy, C-reactive protein (CRP), and post-dialysis weight change — on a scale from 1 (abnormal) to 5 (meets guideline recommendations) and tallied the score. Weight change and albumin levels each accounted for 25% of the ICNDS, and the remaining 5 parameters each made up 10%. A low

Findings suggest special attention be paid to diet as patients approach dialysis.

ICNDS was less than 75 and a high ICNDS 75 or more.

Patients with a low vs high ICNDS at baseline had 2.5- and 1.5-fold increased odds of all-cause death at 1 and 5 years, respectively. Deterioration of nutritional status within the first 3 months of dialysis (indicated by a negative vs positive ICNDS slope) was significantly associated with 1.7-fold increased odds of mortality within 3 years — even among those with favorable nutritional status at baseline.

Patients with a low ICNDS at dialysis initiation were significantly older and had a higher prevalence of diabetes, cardiovascular disease, and malignancy. They also had higher CRP levels. According to the investigators, protein-energy wasting and inflammation, together known as malnutritioninflammation complex syndrome, likely explains the differences between the low and high ICNDS groups.

“We suggest a multidisciplinary approach that includes attention to diet and provision of adequate treatment for comorbidities in the period before initiation of dialysis, with the aim of increasing the ICNDS during the transition to [RRT],” Dr Benyamini’s team wrote. “This then might improve survival odds after dialysis initiation.”

The authors acknowledged a number of study limitations. For example, it had a relatively small sample size and was conducted at a single dialysis center, “thereby limiting the possibility of generalizing these findings.” ■

Allopurinol May Improve KT Outcomes

URATE-LOWERING treatment with allopurinol may help maintain graft function in kidney transplant (KT) recipients with elevated serum uric acid levels, a new study suggests.

In the ADOPTR (Allopurinol Drug use on GFR and Proteinuria in Renal Transplantation Recipients) study, researchers randomly assigned 124 KT recipients to receive allopurinol (300 mg once daily) or matched placebo. Mean serum uric acid levels significantly decreased from 6.98 mg/dL at baseline to 6.00 mg/dL at 24 weeks in the allopurinol group, but did not change significantly in the placebo group, Özlem Usalan, MD, and colleagues from Gaziantep University School of Medicine, Gaziantep, Turkey, reported in Transplant Immunology. In the allopurinol group, mean estimated glomerular filtration rate (eGFR; according to the Modification of Diet in Renal Disease study equation) significantly increased from 68.05 to 71.97 mL/ min/1.73 m2 and mean urinary albumin to creatinine ratio (UACR) significantly decreased from 325.14 to 319.29 mg/g. No meaningful kidney function changes occurred in the placebo group. C-reactive protein levels increased significantly over 24 weeks in the placebo group but not the allopurinol group.

“Our results seem to support the view that lowering circulating urate levels plays a role in improving kidney function in kidney transplant recipients,” Dr Usalan’s team concluded.

They acknowledged that elevated uric acid levels may reflect metabolic acidosis or other conditions, and not just hyperuricemia. Routine prophylaxis of asymptomatic hyperuricemia is not recommended in current guidelines.

Previous studies have yielded conflicting results on the use of allopurinol in patients at various stages of chronic kidney disease.

Limitations of the study include its small sample size and short duration of follow-up, the investigators noted. ■

In-Hospital AKD Tied to Adverse Outcomes

Data reveal higher risks for heart failure hospitalizations, death, and major adverse kidney events

BY NATASHA PERSAUD ACUTE KIDNEY disease (AKD) is increasingly recognized as a state that requires medical attention to avoid adverse outcomes. AKD reflects nonrecovery from acute kidney injury (AKI) persisting for 7-90 days or enduring subclinical alterations in kidney function without an AKI diagnosis, according to the Acute Disease Quality Initiative (ADQI). Recent studies on patients hospitalized with heart failure, cirrhosis, and critical illness find that AKD often leads to major adverse kidney events (MAKEs) and death.

Heart Failure In Kidney International Reports, investigators reported outcomes from 7519 patients admitted for acute decompensated heart failure (ADHF), of whom AKI and AKD occurred in 9% and 21.2%, respectively. Within the AKI group, 39.4% of patients progressed to AKD as defined by ADQI criteria. In the group without prior AKI, AKD developed in 19.4% of patients.

AKD was significantly associated with 32%, 30%, and 20% increased risks for all-cause death, MAKEs, and heart failure hospitalization, respectively, during 5 years of follow-up, corresponding author Chih-Hsiang Chang, MD, of Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taipei, Taiwan, and colleagues reported. MAKEs included end-stage kidney disease requiring long-term renal replacement therapy (RRT), new-onset chronic kidney disease (CKD), and death.

Dr Chang’s team developed prediction models that identified patients at high risk of any-stage AKD and stage 3 AKD or mortality. According to the investigators, it is an easy-to-use tool that can effectively predict the risk of AKD after ADHF and aid in early AKD diagnosis and intervention. The scoring system requires additional validation.

“Our scoring system is an easy-to-use tool that can effectively predict the risk of AKD after ADHF and thus aid in early AKD diagnosis and intervention,” the authors wrote.

Identified risk factors for any AKD included female sex, AKI, AKI severity, diabetes, CKD, laboratory values including creatinine, hemoglobin, albumin, and B-type natriuretic peptide, and cumulative dosage of inotropes and intravenous loop diuretics. Age, blood urea nitrogen, and outpatient loop diuretic prescription were additional predictors for stage 3 AKD (defined as a serum creatinine level 3.0 times baseline, an absolute serum creatinine increase of 4.0 mg/ dL or more, or RRT after 7 days and within 90 days).

“Until evidence-based quality metrics are established, we should stick with a repertoire of common sense strategies for high-risk patients after ADHF: careful volume status and laboratory

assessments, vigilant medication reconciliation, dietary counseling, careful titration of heart failure medications, and removal of aggravating (true) nephrotoxic factors,” Dr Chang and colleagues wrote. “Nephrologists should also assume an expert role in managing potential metabolic derangements from heart failure therapies (e.g., hyper/hypokalemia and dysnatremias), along with offering reassurance to patients and team members when small changes in [serum creatinine] are detected after therapy titrations.”

Cirrhosis In the Journal of Hepatology, another team of investigators reported that AKD (also defined by ADQI criteria) developed in 32% of 6250 patients hospitalized with cirrhosis who had community- or hospital-acquired AKI. The risk for mortality at both 90 and 180 days was a significant 1.4-fold higher for patients with vs without AKD.

Compared with patients who did not have AKD, patients with AKD and AKD non-recovery were at significantly higher risk for short- and longer-term mortality, Kavish R. Patidar, DO, of Indiana University School of Medicine, Indianapolis, Indiana, and colleagues wrote.

De novo CKD occurred in a significantly higher proportion of the AKD vs no AKD group: 64.0% vs 30.7%. The investigators found that AKD was independently associated with a 2.5-fold increased risk for de novo CKD.

Dr Patidar’s team identified several independent risk factors for AKD. AKI stage 2 or 3 and communityacquired AKI were significantly

AKI stage 2 and 3, ascites, and obesity are among the risk factors for AKD.

Study: HRQOL in Advanced CKD May Vary By Sex

BY JOHN SCHIESZER HEALTH-RELATED quality of life (HRQOL) in patients with chronic kidney disease (CKD) may differ between men and women, according to a recent study.

At the start of the study, which enrolled 1421 patients aged 65 years or older with advanced CKD but not on dialysis, women had lower average physical and mental HRQOL scores compared with men. These scores, however, declined approximately twice as fast in men as in women during a 4-year study period, Nicholas C. Chesnaye, PhD, and colleagues reported in the Clinical Journal of the American Society of Nephrology.

Better understanding of sex-specific HRQOL over the course of pre-dialysis CKD and the potential mechanisms underlying any differences may provide insights into a patient’s health and other needs, according to the investigators. “It could also aid sex-specific clinical monitoring, and the [kidney replacement therapy] decision making process,” said Dr Chesnaye, who is in the department of medical informatics at the University of Amsterdam and the Amsterdam Public Health Research Institute in The Netherlands.

Multinational Study Population The investigators analyzed questionnaire responses from the European Quality Study on Treatment in Advanced Chronic Kidney Diseases (EQUAL). The study included patients receiving routine medical care in Germany, Italy, the Netherlands, Poland, Sweden, and the United Kingdom.

The researchers analyzed answers to the 36-Item Short Form Survey at 3 to 6 month intervals between April 2012 and September 2020. Dr Chesnaye’s team evaluated 5345 HRQOL measurements from 485 women and 936 men.

At baseline, patients had a mean age of 76 years and eGFR of 17 mL/min per 1.73 m2. Compared with men, women were older, more likely to be widowed, and had lower levels of education. They had higher body mass index and higher values of serum calcium, cholesterol, and potassium as well as lower levels of hemoglobin, lower albumin-creatinine ratio and higher baseline eGFR. Women had a mean physical component score of 42 and mental component score of 60. Men had mean scores of 55 and 69, respectively. During the study period, physical and mental component scores declined significantly faster in men (by 2.5 and 2.7 points per year, respectively) compared with women (by 1.1 and 1.6 points per year, respectively).

The finding that women perceive an overall poorer HRQOL compared with men is consistent with what has been found in patients on dialysis and in several studies in patients with nondialysis dependent CKD. “The few longitudinal studies exploring the role of sex on HRQOL trajectories over time in advanced stage CKD found, in contrast to our own results, no difference in the rate of HRQOL decline between men and women,” Dr Chesnaye said.

Sex-Specific Determinants The current study showed that decreasing kidney function occurred at a faster rate in men than women, according to the study. Higher phosphate and lower hemoglobin levels and the presence of preexisting diabetes were associated

New findings may offer insights into a patient’s health and other needs.

RCC Outcomes Not Worse With Minimally Invasive PN

PARTIAL NEPHRECTOMY for renal cell carcinoma (RCC) with a minimally invasive approach is not associated with worse oncologic outcomes compared with an open procedure, a recent study suggests.

In fact, minimally invasive modalities resulted in a lower risk for recurrence and death from any cause, investigators reported in Urologic Oncology.

The finding supports previous reports suggesting that minimally invasive surgery is not associated with increased risk for port-site incisional or peritoneal seeding, they noted.

“There have been a few anecdotal arguments that minimal invasive renal surgery is not safe and puts patients at a higher risk of tumor recurrence,” said lead investigator Reza Mehrazin, MD, associate professor of urologic oncology at the Icahn School of Medicine at Mount Sinai in New York, New York. “This multicenter study shows that this is not true.”

Dr Mehrazin and colleagues studied a cohort of 2440 patients who underwent partial nephrectomy at 2 urban quaternary referral centers and identified 190 patients who underwent an open partial nephrectomy (OPN) and 190 propensity score-matched patients who underwent a minimally invasive partial nephrectomy (MIPN), either laparoscopic or robotic-assisted. The median follow-up duration was significantly longer in the OPN than the MIPN group (59 vs 23 months).

Cancer recurrence was significantly more common in the OPN group than the MIPN group (10% vs 3.2%),

Dr Mehrazin’s team reported. The surgical approach did not predict location of recurrence. Time to recurrence did not differ significantly between the OPN and MIPN groups (23.8 and 26.3 months, respectively), according to the investigators. On multivariable analysis, however, OPN was significantly associated with a 3.9-fold increased risk for recurrence compared with MIPN. In addition, the all-cause mortality rate was significantly higher in the OPN group (10.5% vs 2.6%).

“There likely remains some patient selection bias that is unaccounted for in the statistical analysis,” the authors wrote. “Nevertheless, the design of this study is concrete, and the outcomes should warrant reconsideration of the current opinion that OPN and MIPN result in equivalent long-term oncological outcomes.” ■

Recurrence risk found to be higher with open partial nephrectomy.

In-hospital AKD

continued from page 19

associated with 9.4- and 1.6-fold increased odds for AKD, respectively. Pre-existing CKD and elevated serum albumin at the time of AKI were significantly associated with 3.1- and 1.4fold increased odds of AKD, respectively. For every 1 mm Hg decrease in mean arterial pressure at the time of AKI, the odds of AKD significantly increased 1%. Ascites and obesity were significantly associated with 1.6- and 1.5-fold increased odds of AKD. Etiology of cirrhosis, presence of diabetes or hypertension, and vasopressor use within 7 days of AKI onset were not associated with AKD.

For cirrhosis patients with AKI, the investigators urged early nephrology consultation with follow-up and frequent lab monitoring and medication adjustments based on kidney function during and after hospitalization to help prevent AKD.

Critical Illness In eClinicalMedicine, a product of The Lancet Discovery Science, researchers examined MAKEs and mortality outcomes among 5334 patients in intensive care (ICU), of whom 1620 (30.4%) had de novo AKI. AKD — defined as AKI persisting for longer than 7 days — occurred in 403 patients (24.9%).

Mark Andonovic, MD, of the University of Glasgow, Glasgow, UK, and colleagues observed significantly higher mortality rates in the ICU (16.1% vs 6.2%) and in the hospital (26.1% vs 11.6%) among patients with AKD compared with AKI that recovered. Longterm survival did not differ significantly between groups.

MAKEs occurred in a significantly higher proportion of the AKD group (54.2%) than the AKI group (41.9%). By component, a decline in estimated glomerular filtration rate (eGFR) of more than 30% from baseline (50.4% vs 41.9%), a doubling in serum creatinine (26.4% vs 18.8%), and initiation of long-term RRT (2.8% vs 0.6%) occurred in significantly more of the AKD group. AKD was significantly associated with 1.3-fold increased odds for MAKEs, the investigators found.

With respect to AKD risk factors, baseline eGFR of 30-60 or less than 30 mL/min/1.73 m2 was significantly associated with 1.4- and 2.0-fold increased odds for progression to AKD, respectively, the investigators reported. Male sex and admission due to sepsis were significantly associated with 1.3- and 1.4-fold increased odds for AKD, respectively. ■

HRQOL in advanced CKD

continued from page 19

with lower physical and mental scores in men, but to a lesser extent in women. Higher serum phosphate, lower hemoglobin, and the presence of preexisting diabetes were associated with lower physical scores.

Dr Chesnaye noted that CKD is highly prevalent in adults over age 65, and with life expectancies rising, efforts to improve HRQOL in this patient population are badly needed. “Participants in our international cohort were prospectively included when their eGFR dropped below the pre-defined level of 20 mL/min/1.73 m2, thus minimizing the risk of survivor bias,” he said. “Our study is also subject to several limitations. We were unable to capture the complex interplay between demographic, psychosocial, and biological factors not collected by our study.”

Nephrologist Jennifer S. Scherer, MD, assistant professor of medicine at NYU Langone Health in New York, New York, said she was surprised by the stark differences in HRQOL between women and men. “With chronic diseases, we have to look at how the patients feel every day,” Dr Scherer

Over a 4-year period, physical and mental HRQOL deteriorated more rapidly in men.

said. “The study’s outcome is a patientreported outcome, so we are getting important data about how people feel as a result of their disease.”

While the study has limitations, Dr Scherer said most studies focus on disease-centered outcomes. “We have to refocus our research on how the patient is experiencing their disease and how to improve any suffering,” she said.

May Be ‘Missing the Mark’ “The patient lives with the disease. If we aren’t helping them live better with their disease, then we are missing the mark. We need to see more studies that are done like this and take a longitudinal perspective. Data like these really help us when we want to set up our care models.”

Stephen Seliger, MD MS, an associate professor in the Division of Nephrology at the University of Maryland School of Medicine in Baltimore, said the design of the new study makes it impossible to measure many confounding variables. “The authors point out that there were important differences in medical comorbidities between men and women, and I think it explains a lot,” Dr Seliger said. “Women were more likely to be taking antidepressants. They were also heavier and had higher potassium and cholesterol levels. So, if the 2 groups had been more similar, the outcome might have been different.”

Critical Insights Yelena Drexler, MD, assistant professor of clinical medicine in the Katz Family Division of Nephrology and Hypertension at the University of Miami in Florida, said patients who have a high burden of comorbidities and CKD-related complications may have significantly better outcomes with a deeper understanding of sex differences regarding patient-reported outcomes. “This study provides critical insights into the intersection between sex differences and the changes in patients’ perception of their quality of life over time,” Dr Drexler said. “Future research should explore the impact of interventions targeting the potentially modifiable factors identified in this study, and whether such interventions might attenuate the sex disparities in outcomes among patients with CKD.”■

Pre-Kidney Transplant Costs Rising Rapidly

Efforts to expand kidney waiting list access may accelerate increases in spending

MEDICARE spending through the Organ Acquisition Cost Center (OACC) for kidney transplantation evaluation and waiting list management have risen by a median of 4.4% annually per transplant from 2012 to 2017, according to a recent study.

During that time frame, Medicare’s share of OACC costs increased from $0.95 billion to $1.32 billion, which was 3.7% of total Medicare spending through its end-stage kidney disease (ESKD) program, Xingxing S. Cheng, MD, MS, of Stanford University in Stanford, California, and colleagues reported in JAMA Network Open. Median OACC costs per kidney transplantation increased from $81,000 in 2012 to $100,000 in 2017.

Policy reforms aimed at expanding the kidney waiting list could result in substantial increases in OACC expenditures, according to the researchers.

The investigators observed that the existence of a transplant waiting list is evidence that a shortage of kidneys and not a shortage of patients eligible for transplantation limits the volume of kidney transplantation in the United States.

“Measures solely to increase waiting list access, unaccompanied by measures to improve organ availability, are unlikely to succeed in increasing the number of kidney transplants,” they wrote. “Our findings suggest that such measures may also have the unintended consequence of diminishing efficiency and substantially increasing the OACC and overall costs of the Medicare ESKD program.”

Dr Cheng and colleagues noted that the median 4.4% annual increase in OACC costs per transplant is higher than that of Medicare’s expenditures per patient with ESKD, which rose by 2.6% annually during the same study period.

The investigators calculated that for a median-sized transplantation program, costs per transplantation significantly increased $4400 annually, $1900 per 10-point increase in local price index, and $3100 per 100 patients listed “active” on the waiting list.

Patient factors appear to be the main drivers of rising costs. From 2012 to 2017, transplantation hospitals experienced increases in kidney waiting list volume, kidney waiting list active volume, and comorbidity burden, according to the investigators. The study also revealed that greater kidney transplantation volume offset costs. For a median-sized program, mean OACC costs per transplantation significantly decreased $3500 for every 10 transplants performed. ■

OACC Spending Increasing

Medicare reimburses transplant programs for costs attributable to kidney transplantation evaluation and waiting list management through the Organ Acquisition Cost Center (OACC). A recent study has documented a rapid increase in OACC expenditures from 2012 to 2017.

$0.95 billion $1.32 billion

$81,000 $100,000

2012

2017

Medicare share of OACC costs

2012

2017

Median OACC costs per kidney transplant

Source: Cheng XS, et al. Trends in cost attributable to kidney transplantation evaluation and waiting list management in the United States, 2012-2017. JAMA Netw Open. Published online March 10, 2022.

Allopurinol, Febuxostat Found Similarly Effective for Gout Flares

ALLOPURINOL AND FEBUXOSTAT are similarly effective in controlling flares in patients with gout, including those with stage 3 chronic kidney disease (CKD), according to trial results published in the New England Journal of Medicine.

In the double-blind CSP594 Comparative Effectiveness in Gout: Allopurinol versus Febuxostat trial, investigators randomly assigned 940 patients with hyperuricemia to receive allopurinol or febuxostat at titrated doses to achieve a serum urate target of 6mg/dL or lower (or 5mg/dL or lower if tophi were present). Approximately a third of patients in both groups had stage 3 CKD (30-59mL/min/1.73m2 using the Modification of Diet in Renal Disease study formula for estimated glomerular filtration rate). The allopurinol and febuxostat groups received daily doses of 100 and 40mg, respectively, to start, then therapies were titrated until attainment of target uric acid levels or maximal dose. Patients also received guideline-directed anti-inflammatory prophylaxis with colchicine, nonsteroidal anti-inflammatory drugs, or glucocorticoids. After the maintenance phase, no study drug dose adjustments were allowed, and all antiinflammatory treatments were discontinued except in the event of gout flare.

Results showed that 36.5% of the allopurinol group and 43.5% of the febuxostat group experienced the primary outcome of 1 or more gout flares during the observation phase — a 7% difference that met a criterion for noninferiority, James R. O’Dell, MD, of Veterans Affairs (VA) Nebraska-Western Iowa Health Care System in Omaha, Nebraska, and colleagues reported. Among patients with stage 3 CKD, allopurinol also proved noninferior to febuxostat with 31.9% vs 45.3% experiencing a gout flare, respectively, the investigators reported.

In both the allopurinol and febuxostat groups, 80% of patients — including those with stage 3 CKD — achieved and maintained target serum urate levels at 1 year. ■

Frailty Ups Risks After Sling Surgery

FRAILTY INCREASES the risk for complications, repeat procedures, and death after sling surgery in women, a new study finds.

Using 2014-2016 Medicare data, investigators stratified 54,112 women aged 66 years and older who underwent sling surgery (with or without concomitant prolapse repair) by frailty status. The Claims-based Frailty Index (CFI) described 4 categories: not frail (CFI less than 0.15), pre-frail (0.150.25), mildly frail (0.25-0.35), and moderately-severely frail (0.35 or more). Of the cohort, 4.8% patients were mildly frail and 0.4% were moderately to severely frail.

On multivariate analysis, the relative risk for 30-day complications was significantly increased 1.8- and 2.5fold among mildly and moderately to severely frail patients, respectively, compared with patients who were not frail, Michelle E. Van Kuiken, MD, and colleagues from the University of California, San Francisco reported in The Journal of Urology. Moderately to severely frail women experienced high rates of urinary tract infections (UTI; 15.7%), cardiovascular complications (19.9%), and pulmonary complications (9.4%). The relative risk for UTIs was significantly increased 1.7- and 2.4-fold in the mild and moderate-severe frailty groups, respectively.

Frailty also significantly increased the risk for repeat sling surgery, urethral bulking, sling revision, or urethrolysis procedures for persistent incontinence or obstructed voiding within 1 year by 1.4-fold, the investigators reported.

In addition, the relative risk for 1-year mortality was significantly increased 3.4- and 6.7-fold among the mildly and moderately-severe frail groups, respectively, compared with the no-frailty group.

“Our findings underscore the importance of considering and measuring frailty in the preoperative setting, as an emerging body of evidence demonstrates the negative association that frailty has on the risk of postoperative complications,” Dr Van Kuiken’s team wrote.

Frailty was independently associated with these increased risks even after adjusting for age, Charlson comorbidity index, and concomitant pelvic organ prolapse repair, “demonstrating the value of assessing frailty independently,” according to the researchers.■