PERVASIVE FAILED REHABILITATION IN CENTER-BASED MAINTENANCE HEMODIALYSIS-PATIENTS

At its inception in 1972, the end-stage renal disease (ESRD) program was conceived with a set of assumptions about cost, rate of growth, and treatment outcomes in its client population. Despite the potential to correct anemia with recombinant erythropoietin (EPO) introduced in 1987 and improved survival, the level of physical activity among some segments of the hemodialysis population remains suboptimal. This study was undertaken, among other reasons, to identify correlates of poor functional status as measured by a modified Karnofsky scale. Using a modified Karnofsky scale, we measured the functional status of 430 patients who had been treated by hemodialysis for at least 1 year and some of whom were also receiving concomitant treatment with EPO. Patients studied were randomly selected from eight dialysis units in urban New York and suburban New Jersey. A Kamofsky score of less than 70 indicated frank disability-the subject was unable to perform routine living chores without assistance. In addition, current vocational activity was ascertained, and comorbid conditions were quantified. The necessity for wheelchair dependence was noted for each patient. The mean age (±SD) of the study population was 56 ± 14 years (range, 21 to 92 years). Subjects had been on maintenance hemodialysis for 4.09 ± 3.8 years (range, 1 to 23 years). The study group included 215 men and 215 women, of whom 65% were black, 27% white, 6% Hispanic, and 2% Asian; 36.5% had diabetes mellitus. Although 376 members (87%) of the study group were under treatment with EPO, the mean hematocrit of the study population was only 29% ± 4.5%. As rated by the Karnofsky scale, 154 (36%) of 430 patients were unable to perform routine living chores without assistance. Dependence on a wheelchair was reported by 73 members (17%) of the study group, and severe debility resulted in 36 (8.4%) patients requiring a home attendant. The comorbidity index of patients who scored less than 70 on the Karnofsky scale was 3 ± 1.6, which indicated a substantive prevalence of comorbid conditions as compared with 0.9 ± 0.7 for those who scored at least 70 on the Kamofsky scale (P < 0.001). Only 43 (10%) patients were employed outside the home, although 147 members (33%) of the entire group were younger than age 50. Analysis of covariance showed that race (P < 0.001), gender (P < 0.002), age (P < 0.0001), and diabetes (P < 0.001) all independently affected functional status. Tukey's multiple comparison test (adjusted least-squares mean ± SE) showed that blacks had a higher score on the Karnofsky scale (74.4 ± 0.96) than did Hispanics (63.8 ± 2.8, P < 0.001), and whites also scored higher (71.5 ± 1.5) than Hispanics (P < 0.04). Men (72.3 ± 1.3) scored higher than women (67.6 ± 1.34, P < 0.002) on the Karnofsky scale, and nondiabetic patients (72.7 ± 1.3) scored higher than diabetic patients (67.2 ± 1.5, P < 0.001). Karnofsky scores decreased with advancing age (P < 0.0001). Of the laboratory variables measured, only serum creatinine concentration correlated significantly with Karnofsky scores (r = 0.39, P < 0.001). Indeed, 155 (56%) of the 276 patients who scored at least 70 on the modified Karnofsky scale had a serum creatinine concentration exceeding 12.5 mg/dL, as contrasted with 38 (25%) of 154 patients who scored less than 70 on the modified Karnofsky scale (P < 0.00001). Although the age-adjusted mean ± SE serum creatinine level was higher in blacks (13 ± 0.2 mg/dL) than in whites (10.5 ± 0.3 mg/dL), Kamofsky scale scores were equivalent for both races (P < 0.232). We conclude that a significant proportion of hemodialysis patients are functionally debilitated. Diabetics, women, Hispanics, the elderly, and patients with low serum creatinine concentrations were at greater risk for poor functional status than their respective counterparts. Also, the rate of employment of hemodialysis patients remains very low. Treatment with EPO did not necessarily result in rehabilitation. © 1994, National Kidney Foundation. All rights reserved. All rights reserved.