Impact of Dialysis Duration and Frailty on Frailty Progression: A Japanese Nationwide Cohort Study

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Importance Frailty is common among dialysis patients and significantly affects the quality of life for both patients and their caregivers. However, limited evidence exists on the long- term changes in physical function in this population. Objective To examine 8-year trajectories of physical function and assess associations with baseline dialysis duration and physical function status among Japanese dialysis patients. Design Nationwide, cohort study. Setting Japan; data obtained from a registry. Participants 223,501 Japanese adults receiving hemodialysis enrolled in the 2010 Japanese Society for Dialysis Therapy Renal Data Registry. Exposures Baseline dialysis duration (<5, 5–<10, 10–<20, 20–<30, ≥30 years) and physical function were assessed using the Eastern Cooperative Oncology Group Performance Status, categorized as non-frail, frail, or bedridden. Main Outcomes and Measures Physical function at 8 years was similarly classified as non- frail, frail, bedridden, or deceased. Multinomial logistic regression was used to estimate adjusted odds ratios, average marginal effects, and predicted probabilities based on baseline exposures. Results Among patients with complete baseline and 8-year follow-up data, 59.9% died, 8.8% became frail, 2.4% were bedridden, and 28.9% remained non-frail. Longer dialysis duration and baseline frailty or bedridden status were associated with increased odds of subsequent frailty, bedridden status, and mortality. Compared with patients with <5 years of dialysis, those with ≥30 years had a 1.6% (95% confidence interval, 0.6%–2.6%) higher probability of frailty and a 13.0% (95% confidence interval, 11.8%–14.3%) higher probability of death. Compared with non-frail status at baseline, frailty was associated with a 0.0% (95% confidence interval, −0.4% to 0.4%) change in frailty and a 15.8% (95% confidence interval, 14.5%–17.0%) increase in death; bedridden status was associated with a 1.7% (95% confidence interval, 1.1%–2.3%) increase in being bedridden and a 27.6% (95% confidence interval, 26.5%–28.8%) increase in death. Conclusions and Relevance In this nationwide 8-year study, majority of the hemodialysis patients experienced either death or functional decline. Longer dialysis duration and baseline frailty were associated with adverse outcomes, although absolute increases in frailty were modest. These findings highlight the need for early, values-based shared decision-making in the management of dialysis patients.