Association between frailty and adverse outcomes in patients undergoing maintenance hemodialysis: a systematic review and meta-analysis

Figures & data

Figure 1. Flow diagram of study selection.

Table 1. Characteristics and quality assessment of the included studies.

Author/Year	County	Age/years	Design	Prevalence of frailty%	N (female%)	Frailty Criteria	Follow-up	Effect measure	Outcomes	Quality
Yoshikoshi 2024 [22]	Japan	67.5 ± 12.2	Cross-sectional study	22.50%	360 (38.3%)	FP	4y	OR	Sleep disturbances	7/11
Tonelli 2023 [11]	Canada	63	Cohort study	27.70%	985 (38.7%)	FP	2.75y	HR, RR	Mortality, hospitalization	7/9
Stavert 2023 [48]	Australia	64.4	Cohort study	24.10%	2302 (38.6%)	HFRS	2y	HR	Mortality, hospitalization, vascular access events	8/9
Imamura 2023 [23]	Japan	72.4 ± 7.8	Cohort study	56.70%	344 (39.2%)	FP	3y	HR, RR	Mortality, hospitalization	7/9
Yang 2023 [24]	China	63–74	Cohort study	37.6%	157 (49%)	FP	3m	HR	Mortality, hospitalization	7/9
Hamiduzzaman 2023 [36]	USA	57.1 ± 14.2	Cohort study	31.4%	764 (40.6%)	FP	2y	HR	Mortality	7/9
Barbosa 2023 [47]	Brazil	61	Longitudinal study	36.50%	137 (40%)	FRAIL	9m	HR	Hospitalization	5/9
Anderson 2023 [50]	UK	63	Cohort study	41.90%	485 (41.4%)	FP	1.8y	HR, RR	Mortality, hospitalization	7/9
Anderson 2023 [51]	UK	≥18	Cohort study	NR	448 (57.3%)	FP	1.8y	OR, HR, RR	Cognitive Impairment, mortality, hospitalization	6/9
Zhu 2023 [25]	China	>65	Cross-sectional study	33.60%	140 (53.6%)	FP	1y	HR, RR	Mortality, emergency visits	6/11
Luo 2022 [26]	China	65 ± 13	Cohort study	31%	761 (46%)	FP	2y	HR	Vascular access events	8/9
Santos 2022 [37]	Brazil	59.63 ± 15.14	Cross-sectional study	73.80%	80 (55%)	FP	8m	OR	Depression	5/11
Soldati 2022 [13]	Italy	79.1 ± 7.6	Longitudinal study	55%	105 (35%)	FI	1.75 y	HR	Mortality, hospitalization	6/9
Guo 2022 [27]	China	71.65 ± 5.89	Cohort study	72.06%	204 (39.71%)	FP	1y	HR	Mortality	7/9
Woo 2022 [38]	USA	>18	Cohort study	22%	41471 (46.3%)	FP	5y	HR	Mortality	8/9
Chen 2022 [28]	China	66.13 ± 12.47	Cohort study	40.30%	313 (42.5%)	FP	2y	HR	Vascular access events	8/9
Chi 2022 [29]	China	61.1 ± 12.0	Cross-sectional study	12.60%	151 (33.1%)	FRAIL	2y	OR	Depression	8/11
Jafari 2021 [24]	Canada	63.3 ± 14.2	Cross-sectional study	59.30%	109 (38.5%)	FP	1y	OR	Fracture	8/11
Wu 2021 [22]	China	68.61 ± 7.59	Cross-sectional study	35.98%	264 (40.15%)	FP	6m	OR	Mortality, falls, hospitalization, depression, quality of life	9/11
Bloomfield 2021 [49]	New Zealand	61.5 ± 13.5	Cohort study	37%	138 (50.7%)	FP	3y	OR	Mortality, hospitalization	6/9
Li 2021 [31]	China	69	Cohort study	34.7%	150 (51.3%)	FP	1y	HR, RR	Mortality, hospitalization, emergency visits, falls,	8/9
Fu 2021 [32]	China	60.5 ± 12.7	Cohort study	25.40%	208 (45.7%)	FP	2y	OR	Mortality	6/9
López-Montes 2020 [52]	Spain	78.1 ± 4.1	Cohort study	53.80%	117 (36.8%)	FP	1y	HR	Mortality	6/9
Zanotto 2020 [53]	UK	61.7 ± 13.3	Cohort study	37.70%	69 (44.9%)	FP	1y	RR	Falls	6/9
Sy 2019 [40]	USA	57.2 ± 14.2	Cohort study	31.90%	746 (40.6%)	FP	2y	OR, HR	Depression, mortality	7/9
Johansen 2019 [41]	USA	57.2 ± 14.3	Cohort study	41.40%	727 (40.8%)	FP	4y	HR	Mortality	8/9
Fitzpatrick 2019 [42]	Canada	54.9 ± 13.1	Cohort study	52%	370 (42%)	FP	3.7y	HR	Mortality	8/9
Garcia-Canton 2019 [54]	Spain	65	Longitudinal study	29.60%	277 (34.3%)	EFS	1y	HR, RR	Mortality, hospitalization, emergency visits	8/9
Du 2018 [33]	China	63.76 ± 6.54	Cohort study	44.20%	380 (44.2%)	FP	5y	HR	Mortality	8/9
Zhu 2017 [34]	China	54.3 ± 13.6	Cohort study	37.60%	186 (43%)	FRAIL	1y	OR	Falls	6/9
Yadla 2017 [35]	India	44.95 ± 13.27	Cohort study	82%	205 (30.7%)	FP	1y	HR	Mortality, falls, hospitalization	5/9
Lee 2017 [12]	Korea	55.9 ± 12.9	Cohort study	34.80%	1658 (44.3%)	FP	1.4y	HR	Mortality, hospitalization	7/9
Johansen 2016 [43]	USA	57.1 ± 14.2	Cohort study	31%	762 (40.7%)	FP	1.7y	HR	Mortality	8/9
Delgado 2015 [44]	USA	63	Cohort study	76.70%	1053 (45%)	FP	2.5y	HR	Fall or fracture	7/9
McAdams 2013 [45]	USA	60.5 ± 12.6	Cohort study	46.30%	95 (46.3%)	FP	6.7m	RR	Falls	5/9
McAdams 2013 [46]	USA	60.6 ± 13.6	Cohort study	41.80%	146 (46.6%)	FP	3y	HR, RR	Mortality, hospitalization	8/9

FP: frailty phenotype; FI: frailty index; CFS: Clinical Frailty Scale; EFS: Edmonton Frailty Scale; HFRS: Hospital Frailty Risk Score; NR: not reported.

Table 3. Subgroup analysis of the association between frailty and hospitalization in patients undergoing maintenance hemodialysis.

Variables	No. of studies	I^2 (%)	RR (95%CI)	p
Frailty assessment tools
FP	6	97.9	1.43 (0.99-2.08)	.057
EFS	1	–	1.78 (1.15-2.76)	–
Region
America	2	0.0	1.40 (1.22-1.61)	<.001
Europe	3	63.8	1.09 (0.96-1.24)	.202
Asia	2	27.5	2.33 (1.79-3.02)	<.001
Follow-up
<2y	4	61.7	1.12 (0.97-1.29)	.114
≥2y	3	95.6	1.72 (1.10-2.69)	.017

–: Not applicable.

Figure 2. Forest plot comparing risk of mortality in patients undergoing maintenance hemodialysis between frail and non-frail patients (or).

Figure 3. Forest plot comparing risk of mortality in patients undergoing maintenance hemodialysis between frail and non-frail patients (HR).

Figure 4. Forest plot of the association between frailty and hospitalization measure by HR.

Figure 5. Forest plot of the association between frailty and hospitalization measure by RR.

Figure 6. Forest plot of the association between frailty and vascular access events measure.

Table 2. Subgroup analysis of the association between frailty and mortality in patients undergoing maintenance hemodialysis.

Variables	No. of studies	I^2 (%)	HR (95%CI)	p
Frailty assessment tools
FP	19	91.7	1.91 (1.54-2.36)	<.001
HFRS	1	–	2.65 (1.72-4.08)	–
FI	1	–	2.60 (1.04-6.49)	–
EFS	1	–	2.34 (1.39-3.94)	–
Region
America	8	81.6	1.92 (1.54-2.40)	<.001
Asia	8	86.8	2.35 (1.37-4.02)	.002
Europe	5	57.1	1.50 (1.16-1.93)	.002
Oceania	1	–	2.65 (1.72-4.08)	–
Female ratio
<50%	20	91.2	1.92 (1.57-2.34)	<.001
≥50%	2	0.0	4.11 (1.68-10.03)	.002
Study design
Cohort study	19	91.7	1.91 (1.55-2.35)	<.001
Longitudinal study	2	0	2.39 (1.54-3.72)	<.001
Cross-sectional study	1	–	4.12 (1.23-13.78)	–
Sample size
<500	14	80.8	1.94 (1.49-2.52)	<.001
≥500	8	80.6	2.00 (1.62-2.47)	<.001
Follow-up
<2y	12	60.9	1.87 (1.44-2.43)	<.001
≥2y	10	93.0	1.99 (1.56-2.55)	<.001

–: not applicable.

Figure 7. Trim-and-fill figure of the effect of frailty on mortality.

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