Ripple Effects: CKD and Physical Function

Physical function enables independence and underlies quality of life. Pediatricians celebrate a child’s first steps; geriatricians worry when an older adult walks more slowly. Chronic kidney disease (CKD) drives muscle loss,1Troutman A.D. Arroyo E. Lim K. Moorthi R.N. Avin K.G. Skeletal Muscle Complications in Chronic Kidney Disease.Curr Osteoporos Rep. 2022; 20: 410-421https://doi.org/10.1007/s11914-022-00751-wCrossref PubMed Scopus (2) Google Scholar and prior work has shown that limited physical function predicts mortality in CKD.2Roshanravan B. Robinson-Cohen C. Patel K.V. et al.Association between physical performance and all-cause mortality in CKD.J Am Soc Nephrol. 2013; 24 (10.1681/ASN.2012070702): 822-830https://doi.org/10.1681/ASN.2012070702Crossref PubMed Scopus (296) Google Scholar Despite nearly one-fifth of people with CKD using an assistive device for ambulation,2Roshanravan B. Robinson-Cohen C. Patel K.V. et al.Association between physical performance and all-cause mortality in CKD.J Am Soc Nephrol. 2013; 24 (10.1681/ASN.2012070702): 822-830https://doi.org/10.1681/ASN.2012070702Crossref PubMed Scopus (296) Google Scholar the trajectory of how physical function changes with CKD progression, including the transition to dialysis, is not well understood. In this issue of Kidney Medicine, Hart and colleagues addresses this gap in our understanding about physical function over the course of kidney disease, including the transition to dialysis, in community-dwelling adults with CKD.3Hart A. Horak K. Roetker Nicholas S. Farnum A. Murray A.M. Johansen K.L. Kidney Function and Physical Performance Decline: The BRINK Cohort Study.Kidney Med. 2023; Abstract Full Text Full Text PDF Google Scholar The investigators evaluated the trajectory of physical function over time using data from the Brain in Kidney Disease longitudinal cohort. Over 5.25 years, 562 persons with CKD were assessed annually in-person with the Short Physical Performance Battery (SPPB) and gait speed. The SPPB evaluates balance, gait speed, and ability to get out of a chair; gait speed assesses walking pace. Both assessments are highly predictive of future mortality and disability.4Guralnik J.M. Ferrucci L. Simonsick E.M. Salive M.E. Wallace R.B. Lower-extremity function in persons over the age of 70 years as a predictor of subsequent disability.N Engl J Med. 1995; 332: 556-561https://doi.org/10.1056/NEJM199503023320902Crossref PubMed Scopus (3125) Google Scholar, 5Minneci C. Mello A.M. Mossello E. et al.Comparative study of four physical performance measures as predictors of death, incident disability, and falls in unselected older persons: The Insufficienza Cardiaca negli Anziani residenti a Dicomano study.J Am Geriatr Soc. 2015; 63 (doi:10.1111/jgs.13195): 136-141Crossref PubMed Scopus (11) Google Scholar, 6Studenski S. Perera S. Patel K. et al.Gait speed and survival in older adults.JAMA. 2011; 305 (10.1001/jama.2010.1923): 50-58https://doi.org/10.1001/jama.2010.1923Crossref PubMed Scopus (2987) Google Scholar If a person started dialysis, an additional in-person visit within 1-3 months post-initiation was conducted, and the frequency of in-person visits was increased to twice each year. Using both measures, the investigators found that physical function declined over time, with the greatest losses seen among those with the most advanced stages of CKD. For persons who had a baseline eGFR < 15 mL/min/1.73m2Roshanravan B. Robinson-Cohen C. Patel K.V. et al.Association between physical performance and all-cause mortality in CKD.J Am Soc Nephrol. 2013; 24 (10.1681/ASN.2012070702): 822-830https://doi.org/10.1681/ASN.2012070702Crossref PubMed Scopus (296) Google Scholar, they lost 0.47 points per year on the SPPB, and 0.035 meters/second per year for gait speed. As the minimally clinical important difference for the SPPB is 0.5 points and 0.05 meters/second for gait speed,7Perera S. Mody S.H. Woodman R.C. Studenski S.A. Meaningful change and responsiveness in common physical performance measures in older adults.J Am Geriatr Soc. 2006; 54: 743-749https://doi.org/10.1111/j.1532-5415.2006.00701.xCrossref PubMed Scopus (1674) Google Scholar these results mean that every two years, these individuals experienced a clinically notable decline in their physical function. Among those who started dialysis, gait speed continued to decline after dialysis initation. These findings suggest that there is an overall downward decline in physical function in CKD, and hints that dialysis initiation likely does not improve physical function. This article has several key strengths. First, the study is longitudinal, and followed over 500 persons with CKD for over five years. Participants were assessed in-person, either annually or biannually, and thus the study reflects an enormous commitment of time and resources. Second, the study used the Short Physical Performance Battery and gait speed. These are validated assessments that use minimal equipment, facilitating reproducibility. Third, when a participant started dialysis, more frequent assessments were added, enabling a better understanding about this pivotal period. We do note that the study had limited diversity, with most participants identifying as white and having some college education. In addition, no data are presented on the physical function of participants who pursued supportive care for kidney failure as opposed to dialysis initiation. Such data would provide a more complete picture of the trajectory of physical function as the disease worsens. This article by Hart and colleagues is important for two reasons. First, physical function is important to persons with CKD and their families. Through the Standardized Outcomes in Nephrology Initiative, persons with CKD and their families identified “life participation”, or the ability to pursue desired activities and interactions with others, as a key outcome for CKD research.8Tong A. Crowe S. Chando S. et al.Research Priorities in CKD: Report of a National Workshop Conducted in Australia.Am J Kidney Dis. 2015; 66: 212-222https://doi.org/10.1053/j.ajkd.2015.02.341Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar As physical function underlies the feasibility of different activities, this research is clearly addressing a priority of persons with CKD. Second, this study provides evidence that for community-dwelling individuals in the U.S., physical function does not improve with dialysis initiation. These findings complement the work of the Indiana University Longitudinal Study of Incident Dialysis study, who found that over half of their 183 participants experienced losses in gait speed after dialysis initiation.9Moorthi R.N. Fadel W.F. Cranor A. et al.Mobility Impairment in Patients New to Dialysis.Am J Nephrol. 2020; 51: 705-714https://doi.org/10.1159/000509225Crossref Scopus (6) Google Scholar Similarly, the Canadian Frailty Observation and Interventions Trial (CanFIT) demonstrated that transition to dialysis was associated with losses in the ability to get out of a chair.10Rampersad C. Darcel J. Harasemiw O. et al.Change in Physical Activity and Function in Patients with Baseline Advanced Nondialysis CKD.Clin J Am Soc Nephrol. 2021; 16: 1805-1812https://doi.org/10.2215/cjn.07050521Crossref PubMed Scopus (0) Google Scholar In the Netherlands, Goto and colleagues found physical function, as measured by independent activities of daily living, decreased within the first six months of initiating dialysis.11Goto N.A. Loon I.N.V. Boereboom F.T.J. et al.Association of initiation of maintenance dialysis with functional status and caregiver burden.Clin J Am Soc Nephrol. 2019; 14: 1039-1047https://doi.org/10.2215/CJN.13131118Crossref PubMed Scopus (40) Google Scholar Clinically, the findings of Hart and colleagues have several implications. Given that life participation is a priority for persons with CKD, these findings suggest that, when dialysis initiation is being discussed, the impact on physical function should be an integral part of the conversation. This includes a discussion that improvements in physical function are highly unlikely, even with the routine removal of excess fluid and toxins, and that some may even experience a decline in physical function. Moreover, these changes should also be discussed with the families of persons with CKD. As a person’s physical function declines, their reliance on others for support for essential and routine tasks increases. For a person with CKD, these changes mean likely reduced quality of life, and, for their families, increased responsibilities. Informing persons with CKD and their families of these anticipated changes, especially for those who live alone, is essential. Ideally, family members are aware and prepared for these changes. Clinicians should also consider if other options for support are appropriate, such as in-home support services (often funded by Medicaid), relocation to a more supportive living environment such as assisted living, or hiring a private aide or caregiver if financially feasible. Clinicians should also utilize Medicare-supported benefits for durable medical equipment, such as cane/walkers, raised toilet seats, and tub grab bars. As a person with CKD loses physical function and becomes less independent, their resulting needs inevitably increase the responsibilities of family members providing assistance. Yet work by O’Hare and colleagues have documented that family members are infrequently approached and often feel overlooked and invisible to clinicians.12O’Hare A.M. Szarka J. McFarland L.V. et al.“Maybe they don’t even know that I exist”: Challenges faced by family members and friends of patients with advanced kidney disease.Clin J Am Soc Nephrol. 2017; 12: 930-938https://doi.org/10.2215/CJN.12721216Crossref PubMed Scopus (9) Google Scholar Given that loved ones often help persons with CKD navigate the healthcare system, manage competing priorities, and assist in making medical decisions, including them is crucial for shared decision-making and person-centered care. The increased responsibilities of family members increase caregiver burden, defined as the adverse effects on an individual’s mental, physical, and financial health due to caregiving responsibilities.13Adelman R.D. Tmanova L.L. Delgado D. Dion S. Lachs M.S. Caregiver burden: A clinical review.JAMA - J Am Med Assoc. 2014; 311: 1052-1059https://doi.org/10.1001/jama.2014.304Crossref PubMed Scopus (1219) Google Scholar Ramifications include greater rates of depression, heart disease, and future mortality.14Gallagher D. Rose J. Rivera P. Lovett S. Thompson L.W. Prevalence of depression in family caregivers.Gerontologist. 1989; 29: 449-456https://doi.org/10.1093/geront/29.4.449Crossref PubMed Scopus (265) Google Scholar, 15Lee S. Colditz G.A. Berkman L.F. Kawachi I. Caregiving and risk of coronary heart disease in U.S. women: A prospective study.Am J Prev Med. 2003; 24: 113-119https://doi.org/10.1016/S0749-3797(02)00582-2Abstract Full Text Full Text PDF PubMed Scopus (428) Google Scholar, 16Schulz R. Beach S.R. Caregiving as a risk factor for mortality: The caregiver health effects study.J Am Med Assoc. 1999; 282: 2215-2219https://doi.org/10.1001/jama.282.23.2215Crossref PubMed Scopus (2570) Google Scholar To truly execute comprehensive care for a person with CKD, clinicians should solicit input of family members and assess for caregiver burden. Although in general there are few resources to address caregiver burden in the U.S.,17Caregivers Worry About a Lack of Resources for Long-term Care - The New York Times. Accessed November 18, 2023. https://www.nytimes.com/2023/11/14/health/long-term-care-resources-caregivers.html?searchResultPosition=2Google Scholar acknowledgement by clinicians about the vital contributions of families is the first step to addressing this essential but often ignored component of medical care for person with CKD. Finally, clinicians should also pay attention to the mental health of persons with CKD as the disease progresses. Anxiety, or feelings of uncertainty, dread, and fearfulness in anticipation of the future, is common in persons with CKD.18Loosman WL, Rottier MA, Honig A, Siegert CEH. Association of depressive and anxiety symptoms with adverse events in Dutch chronic kidney disease patients: a prospective cohort study. Published online 2015. doi:10.1186/s12882-015-0149-7Google Scholar Better information of what to expect, including what will likely occur with physical function, may ameliorate feelings of uncertainty for persons with CKD, especially if they transition to dialysis. While prediction of when kidney failure will occur is still somewhat imprecise, equipping persons with CKD and their families with knowledge and potential tools to address upcoming challenges in physical function may reduce anxiety and promote adaptation to these changes.19Liu C.K. Seo J. Lee D. et al.Mobility in Older Adults Receiving Maintenance Hemodialysis: A Qualitative Study.Am J Kidney Dis. 2021; (0(0))https://doi.org/10.1053/J.AJKD.2021.07.010Abstract Full Text Full Text PDF Google Scholar Despite the name, CKD is a disease that impacts multiple aspects of a person’s health and well-being. This study by Hart and colleagues demonstrates how CKD changes physical function as kidney health declines. To fully prepare persons with CKD and their families for next steps, clinicians should share the trajectory of projected changes in physical function. Such information will help persons with CKD and their families anticipate future needs, whether it be more hands-on physical assistance, reaching out to a support group, or investigating local services in the community for those with limited physical function. While a person’s trajectory with CKD is unlikely to ever be simple or easy, sharing the potential details of this path may ease the journey for persons with CKD and their families.

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