Talk delivered to Somerset dietitians on 30th Sept 2015

1. Aging, frailty, nutrition
and renal disease

2. overview
• Again: Interactive session
• Prevalence:
– Long term conditions
– Disability in CKD
– Frailty in CKD
• Sarcopenia in Dialysis
• Cases 1-5
• Prevalence of hearing, eyesight, memory
problems

4. Renal disease and disability
Cook & Jassal, 2008, Kidney International

5. Prevalence of frailty in CKD
Roshanravan 2012, AJKD

6. The elderly patient
Roshanravan 2012, AJKD
60% Frail

7. Fahal 2014, Nephrology Dialysis & Transplantation

8. Muscle mass and strength in Dialysis
Isoyama, 2014, Clinical Journal of the American Society of Nephrology

9. Who has frailty? Cases 1&2
Patient 1, 82 years, male
Data baseline-one year
Patient 2, 85 years, male
Data baseline-one year
Weight (kgs) 68 -63.3 59
BMI (kg/m2) 23-22 22.5
eGFR mls/min 21-12 21-19
Urea mmol/L 23.3-34.7 18-20
Comorbidities CKD, IHD, PVD, LV
dysfunction, arthritis
CKD, IHD
What do you notice that is the
same AND different between
these two cases
Any features of frailty or
sarcopenia?

10. The older person
When treating the
older, frail person,
what issues should be
considered?
• Nutritional status
• Clinical signs
– Symptoms
• Physical abilities
– Walking aids
– Shopping
– Senses: eyesight, hearing, taste
– Skill set and abilities: cooking
• Social support
– Social functionality/ family
– Caregiver network
• Emotional health
– Life changes
– Mood
– Cognition
• Cognitive function
– Memory
– Decision making

11. Patient 1, 82 years, male
Data baseline-one year
Patient 2, 85 years, male
Data baseline-one year
Poor Appetite None - moderate None
Nausea None- slight None
Lack of energy Moderate- Severe Mild- none
SGA At risk of malnutrition At risk – to no risk
Walking aids Walking stick None
Handgrip (kgs) 17-18 29-33
4m walk test (seconds) 5.1-6.5 4.3-4.9
Lean tissue index (kg/m2) 11.3-9.1 12.1-12.4
Fat tissue index (kg/m2) 9.9-11.9 9.7-9.1
Sight problems No Yes
Hearing problems Yes No
Cognitive problems
(15max)
6, 13, 8 14, 14, 11
Anxiety/Depression Moderate None

12. Learning points case 1&2
• Same BMI, same age, same CKD diagnosis,
same muscle mass
• BUT
• Different symptoms, different strength,
different function, different QOL

13. Case 3-Beth
Beth, baseline Beth, 6months Beth, 12 months
Weight (kgs) 64 66 64
BMI (kg/m2) 26 27 26
eGFR mls/min 10 9 dialysis
Urea mmol/L 24 23 14
Creatinine umol/L 379 419 490
Comorbidities CKD, cancer
What might be happening to Beth now?

14. Beth, baseline Beth, 6mos Beth, 12 mos
Poor Appetite None Moderate None
Nausea Moderate Moderate None
Lack of energy None Severe Moderate
SGA Good Risk Malnutr Good
Walking aids Walking stick Walking stick None
Handgrip (kgs) 20 unable Unable
4m walk test (seconds) 4.2 5.8 4.1
Lean tissue index (kg/m2) 8.6 9.8 9.0
Fat tissue index (kg/m2) 17.4 16.1 16.7
Sight problems None None None
Hearing problems None None None
Cognitive problems (15max) 8 14 14
Anxiety/Depression Moderate Moderate None

15. Learning points case 3
• Aspects of frailty can be reversed by
treatments

16. Case 4-Henry
Henry, baseline Henry, 6 mo Henry, 12 mo
Weight (kgs) 73 70 63
BMI (kg/m2) 24 23.5 21
eGFR mls/min 22 13 dialysis
Urea mmol/L 17.5 32.9 29.8
Creatinine umol/L 255 406 531
Comorbidities CKD, IHD
What is happening to Henry now?

17. Henry, baseline Henry, 6 mo Henry, 12 mo
Poor Appetite None Moderate None
Nausea None Mild None
Lack of energy Severe Moderate Moderate
SGA Good Risk malnutr Risk malnutr
Walking aids None Walking stick Walking stick
Handgrip (kgs) 32 26 23
4m walk test (seconds) 5.4 5.9 8.6
Lean tissue index (kg/m2) 14.3 12.6 12.4
Fat tissue index (kg/m2) 8.6 8.4 7.8
Sight problems No No Yes
Hearing problems Yes Yes Yes
Cognitive problems (15max) 9 6 7
Anxiety/Depression Moderate Moderate Moderate

18. Case 5-Joe
Joe, baseline Joe, 6 mo Joe, 12 mo
Weight (kgs) 106.5 101.4 99.5
BMI (kg/m2) 38.6 36.7 36.0
eGFR mls/min 14 11 12
Urea mmol/L 18 22 19
Creatinine umol/L 365 455 428
Comorbidities CKD, IHD, PVD, CVA
What can we notice about Joe?

19. Joe, baseline Joe, 6 mo Joe, 12 mo
Poor Appetite Slight Slight Slight
Nausea None Moderate None
Lack of energy Slight Slight Moderate
SGA Risk malnutr Risk malnutr Good
Walking aids Walking stick Walking stick Walking stick
Handgrip (kgs) 32 24 24
4m walk test (seconds) 11 9.3 9.3
Lean tissue index (kg/m2) 10.6 9.9 10.5
Fat tissue index (kg/m2) 27.2 26.6 26.0
Sight problems Yes Yes Yes
Hearing problems No No Yes
Cognitive problems (15max) 9 7 6
Anxiety/Depression None None None

20. Eyesight, Hearing, Memory
(self-reported problems over approx 6 months-1 year)
0
5
10
15
20
25
30
35
40
45
50
Good Problem Worse Fluctuates Improved
Eyesight
Hearing
Memory

21. Key points
• Frailty is a syndrome : regardless of primary
diagnosis
• Treat as a whole person
• Aspects of frailty can improve

22. 22