Evaluation of the effect of sarcopenia and frailty on quality of life in older hemodialysis patients

Abstract

Background:

This study aimed to evaluate the impact of sarcopenia and frailty on the quality of life of older hemodialysis patients.

Methods:

Seventy hemodialysis patients aged ⩾60 years were assessed. Daily living activities (Katz Index), depression (Yesavage Scale), frailty (Fried’s Criteria), and sarcopenia (EWGSOP2) were evaluated. Quality of life was measured using the KDQOL-36 questionnaire.

Results:

The median age was 67 years, and 50% were female. Nineteen patients (27.1%) were partially dependent, 71.4% were pre-frail, and 15.7% were frail. Probable sarcopenia was detected in 77.1%, and sarcopenia in 8.6% of patients. Sarcopenia was associated with older age, higher dependency, depression, lower income, and frailty (p < 0.05). It was also related to the KDQOL-36 physical component (p = 0.031), while frailty correlated with the symptom component (p = 0.047).

Conclusion:

Frailty and sarcopenia are common in older hemodialysis patients and adversely affect their quality of life.

Keywords

Hemodialysis sarcopenia frailty quality of life older adults

Introduction

The prevalence of chronic kidney disease (CKD) in the general population is approximately 14%, while the prevalence of albuminuria is around 7%.¹ Globally, CKD accounted for 1% of disability-adjusted life years and 1%–3% of life lost in 2012.²

Sarcopenia is associated with functional impairments, reduced quality of life, falls, osteoporosis, dyslipidemia, increased cardiovascular risk, metabolic syndrome, and immunosuppression. The decline in muscle mass and muscle function are linked to a 3.7-fold increase in mortality and a twofold increase in the risk of falls.^3–5 Sarcopenia is also associated with a 50% higher risk of hospital admission, a 20-day increase in hospital length of stay, and approximately a 34% increase in hospital care costs.^6,7 Frail older adults are less able to tolerate or adapt to stressors such as acute illness, surgery, medical interventions, or trauma compared to younger or non-frail older adults.⁸ After adjusting for comorbidities, frailty predicts hip fractures, disability, and hospitalizations.⁹ Furthermore, frailty is associated with adverse outcomes related to kidney transplantation and surgical interventions.^10,11

The quality of life in hemodialysis patients can be adversely affected due to their dependence on the dialysis machine and the strict conditions they must adhere to. Psychiatric problems such as depression and anxiety are also frequently observed in this patient group, further impacting their quality of life. There is a lack of sufficient clinical studies focusing on frailty and sarcopenia in older hemodialysis patients. To the best of our knowledge, there is no study examining both syndromes and their effects on the quality of life in hemodialysis patients in our country.

The aim of this study is to investigate if sarcopenia and frailty affect the quality of life in older patients undergoing hemodialysis.

Materials and methods

This study included 70 hemodialysis patients from two centers. Ethical approval was obtained from the local ethics committee (approval no: 2019/005). Patients aged ⩾60 years who volunteered and were able to complete questionnaires were included. Those with active malignancy, recent hospitalization or surgery, acute infection, advanced dementia, psychiatric or degenerative neurological disorders were excluded. Demographic and clinical data were recorded. The Katz Index of Independence in Activities of Daily Living¹² assessed daily living activities, and the Yesavage Geriatric Depression Scale¹³ evaluated emotional status. Comorbidity burden was determined using the Charlson Comorbidity Index.¹⁴

Frailty was determined by Fried’s criteria.^15,16 Patients meeting ⩾3 criteria were classified as frail, 1–2 as pre-frail, and none as robust. Sarcopenia was diagnosed using EWGSOP2 criteria.¹⁷ Walking speed (4-m test), handgrip strength (CAMBRY EH101 dynamometer), and muscle mass (TANITA BC-418 MA bioimpedance) were measured. Cutoffs were ⩽0.8 m/s for slow walking, <22 kg (women) and <32 kg (men) for low grip strength,¹⁸ and FFMI <17.51 kg/m² (men) or <14.52 kg/m² (women) for low muscle mass.¹⁹ Low strength alone indicated probable sarcopenia; combined low strength and mass indicated sarcopenia; additional slow walking indicated severe sarcopenia. The Katz Index (0–6 points) measured independence.¹² The short-form Yesavage scale classified scores 0–4 as normal, 5–10 as mild depression, and >10 as moderate-to-severe.²⁰ Quality of life was evaluated using the KDQOL™-36, which includes general and kidney disease-specific sections with five subscales scored 0–100, where higher scores indicate better quality of life.^21,22

Analyses were performed using SPSS 24.0 (IBM, Armonk, NY, USA). Categorical variables were compared using Chi-square or Fisher’s exact tests. Normality was assessed with the Kolmogorov–Smirnov test. Parametric data were analyzed with Student’s t-test or ANOVA; nonparametric data with Mann–Whitney U or Kruskal–Wallis tests. Correlations were evaluated with Spearman’s test, and p < 0.05 was considered statistically significant.

Results

A total of 70 patients participated in the study, with 35 (50%) female. The median age of the participants was 67 years (range 60–80). The median duration of hemodialysis was 24 months (range 1–240). According to the Katz scale, 51 participants (72.9%) were fully independent, while 18 (25.7%) had mild depression based on the Yesavage scale. In terms of depression severity, 16 participants (22.9%) were classified as having moderate to severe depression. Regarding frailty status, 50 participants (71.4%) were pre-frail, and 11 (15.7%) were frail. According to the EWGSOP2 criteria, 54 participants (77.1%) had probable sarcopenia, and 6 (8.6%) had sarcopenia.

When comparing the clinical characteristics of patients based on sarcopenia status, it was found that sarcopenic patients were older, weaker, more frail, had higher Yesavage scores, and lower activity of daily living scores (all had p-value <0.05). A statistically significant relationship was found between sarcopenia and KDQOL36’s physical component (p = 0.031; Table 1).

Table 1.

Comparison of patients based on sarcopenia status.

Parameters	All participants	No sarcopenia	Probable sarcopenia	Sarcopenic	p-value
Parameters	N = 70 (100.0%)	n = 16 (22.9%)	n = 48 (68.6%)	n = 6 (8.6%)	p-value
Gender, female, n (%)	35 (50)	8 (50)	24 (50)	3 (50)	1.000
Age, years	67 (60-80)	64.5 (60-80)	67 (60-79)	73 (67-80)	0.049
Marital status, married, n (%)	54 (77.1)	15 (93.8)	36 (75)	3 (50)	0.077
BMI, kg/m²	27.75 ± 4.92	27.73 ± 5.02	28.56 ± 4.48	21.36 ± 3.72	0.002
Dialysis duration, months	24 (1–240)	35 (5–240)	24 (1–216)	9 (3–84)	0.283
Comorbidities, n (%)
CAD	19 (27.1)	7 (43.8)	9 (18.8)	3 (50)	0.063
CHF	6 (8.6)	1 (6.3)	4 (8.3)	1 (16.7)	0.735
CVD	3 (4.3)	0 (0)	2 (4.2)	1 (16.7)	0.228
Asthma/COPD	18 (25.7)	5 (31.3)	10 (20.8)	3 (50)	0.258
DM	25 (35.7)	9 (56.3)	14 (29.2)	2 (33.3)	0.146
HT	53 (75.7)	12 (75)	36 (75)	5 (83.3)	0.902
Hypothyroidism	3 (4.3)	0 (0)	3 (6.3)	0 (0)	0.488
Modified Charlson Comorbidity Index	7 (4–11)	8 (5–11)	6.5 (4–10)	9 (7–11)	0.056
Number of daily medications	7 (3–14)	7.5 (5–14)	7 (3–11)	8 (3–9)	0.223
Katz’s independence status, Fully independent, n (%)	51 (72.9)	15 (93.8)	34 (70.8)	2 (33.3)	0.015
Yesavage depression, n (%)					0.028
Normal	36 (51.4)	11 (68.8)	23 (47.9)	2 (33.3)
Mild depression	18 (25.7)	4 (25)	13 (27.1)	1 (16.7)
Moderate/severe depression	16 (22.9)	1 (6.3)	12 (25)	3 (50)
Frailty status, n (%)					<0.001
Robust	9 (12.9)	8 (50)	1 (2.1)	0 (0)
Pre-frail	50 (7.4)	8 (50)	37 (77.1)	5 (83.3)
Frail	11 (15.7)	0 (0)	10 (20.8)	1 (16.7)
Quality of Life Scale
KDQOL36, symptom	93.75 (41.67–100)	95.83 (75–97.92)	92.71 (62.5–100)	91.67 (41.67–100)	0.859
KDQOL36, disease impact	84.38 (21.88–100)	85.94 (37.5–100)	84.38 (21.88–100)	87.5 (56.25–100)	0.927
KDQOL36, disease burden	31.25 (0–100)	40.63 (6.25–87.5)	34.38 (0–100)	12.5 (0–75)	0.224
KDQOL36, physical component	39.75 (23.05–60.93)	48.39 (24.72–56.17)	38.98 (23.05–60.93)	32.54 (23.86–41.54)	0.031
KDQOL36, mental component	43.04 (11.57–60)	43.45 (28.11–59.56)	43.04 (11.57–60)	45.3 (22.46–56.1)	0.799

BMI: body mass index; CAD: coronary artery disease; CHF: congestive heart failure; CVD: cerebrovascular disease; COPD: chronic obstructive pulmonary disease; DM: diabetes mellitus; HT: hypertension; KDQOL36: Kidney Disease Quality of Life Instrument.

When comparing patients based on frailty status, statistically significant relationships were found between frailty and the Katz dependency score, asthma/COPD diagnosis, Yesavage depression status, dialysis duration (p = 0.012, p = 0.037, p = 0.01, and p = 0.003, respectively), and sarcopenia (p < 0.001). When assessing the quality of life using the KDQOL36 scale according to frailty status (robust, prefrail, and frail), no statistical significance was observed between the symptom, disease impact, disease burden, and physical and mental component groups. However, upon a detailed examination of each subgroup, it was visually observed that the scores worsened as the frailty status progressed from the robust to the frail group. On the other hand, when the patients were divided into two groups as having or not having frailty, it was observed there was a significant relation between frailty and the KDQOL36 symptom component (p = 0.047; Table 2).

Table 2.

Comparison of patients based on frailty status.

Parameters	Robust	Prefrail	Frail	p-value
Parameters	n = 9	n = 50	n = 11	p-value
Gender, female, n (%)	5 (55.6)	24 (48)	6 (54.5)	0.868
Age, years	65 (60–80)	66.5 (59–80)	70 (60–79)	0.172
Marital status, married, n (%)	9 (100)	38 (76)	7 (63.6)	0.146
BMI, kg/m²	25.17 ± 3.87	28.08 ± 4.63	28.37 ± 6.53	0.241
Dialysis duration, months	60 (24–240)	24 (1–216)	12 (6–72)	0.003
Comorbidities, n (%)
CAD	5 (55.6)	11 (22)	3 (27.3)	0.114
CHF	0 (0)	6 (12)	0 (0)	0.269
CVD	0 (0)	1 (2)	2 (18.2)	0.045
Asthma/COPD	3 (33.3)	9 (18)	6 (54.5)	0.037
DM	3 (33.3)	16 (32)	6 (54.5)	0.364
HT	6 (66.7)	39 (78)	8 (72.7)	0.742
Hypothyroidism	0 (0)	2 (4)	1 (9.1)	0.597
Modified Charlson Comorbidity Index	6 (5–11)	7 (4–11)	8 (5–10)	0.202
Number of daily medications	8 (5–14)	7 (3–11)	7 (3–10)	0.270
Katz’s independence status, fully independent, n (%)	7 (77.8)	40 (80)	4 (36.4)	0.012
Yesavage depression, n (%)				0.010
Normal	8 (88.9)	27 (54)	1 (9.1)
Mild depression	1 (11.1)	12 (24)	5 (45.5)
Moderate/severe depression	0 (0)	11 (22)	5 (45.5)
Walking speed decrease, n (%)	1 (11.1)	42 (84)	11 (100)	<0.001
Sarcopenia status, n (%)				<0.001
No sarcopenia	8 (88.9)	8 (16)	0 (0)
Probable sarcopenia	1 (11.1)	37 (74)	10 (90.9)
Sarcopenic	0 (0)	5 (10)	1 (9.1)
FFMI, kg/m²	18.27 (15.42–23.7)	19.83 (12.19–23.66)	19.53 (12.58–24.87)	0.827
Quality of Life Scale
KDQOL36, symptom	95.83 (81.25–97.92)	93.75 (41.67–100)	89.58 (66.67–93.75)	0.138
KDQOL36, disease impact	90.63 (65.63–100)	85.94 (21.88–100)	75 (59.38–100)	0.454
KDQOL36, disease burden	31.25 (6.25–75)	37.5 (0–100)	18.75 (0–68.75)	0.175
KDQOL36, physical component	46.8 (24.72–56.17)	40.31 (23.05–60.93)	33.29 (24.39–57.05)	0.147
KDQOL36, mental component	47.95 (29.95–59.56)	43.21 (19.99–60)	39.59 (11.57–54.95)	0.415

A statistically significant relationship was found between decreased muscle strength, muscle mass loss, and sarcopenia with the KDQOL36 SF-12 physical component and between frailty and the KDQOL36-Symptom component. A statistically significant relationship was found between muscle strength and mass decreases, frailty, sarcopenia, and the Katz dependency score. A statistically significant relationship was also found between decreased muscle strength, frailty, and the Yesavage depression score. Detailed comparisons are provided in Table 3.

Table 3.

Comparison of patients based on muscle strength, muscle mass, sarcopenia, and frailty status in terms of quality of life, activity, and mood.

Parameters	KDQOL36 symptom	KDQOL36 disease impact	KDQOL36 disease burden	KDQOL36 physical component	KDQOL36 mental component	Katz	Yesavage
Muscle strength
Decreased (n = 54)	91.7 (41.7–100)	84.4 (21.9–100)	31.3 (0–100)	37.9 (23.1–60.9)	43 (11.6–60)	6 (1–6)	5 (0–15)
Normal (n = 16)	95.8 (75–97.9)	85.9 (37.5–100)	40.6 (6.3–87.5)	48.4 (24.7–56.2)	43.5 (28.1–59.6)	6 (4–6)	2 (0–10)
p-value	0.683	0.955	0.337	0.045	0.515	0.039	0.009
Muscle mass
Decreased (n = 6)	91.7 (41.7–100)	87.5 (56.3–100)	12.5 (0–75)	32.5 (23.9–41.5)	45.3 (22.5–56.1)	3 (1–6)	10 (2–14)
Normal (n = 64)	93.8 (62.5–100)	84.4 (21.9–100)	34.4 (0–100)	40.6 (23.1–60.9)	43 (11.6–60)	6 (2–6)	4 (0–15)
p-value	0.665	0.697	0.115	0.043	0.958	0.004	0.170
Sarcopenia
Present (n = 6)	91.7 (41.7–100)	87.5 (56.3–100)	12.5 (0–75)	32.5 (23.9–41.5)	45.3 (22.5–56.1)	3 (1–6)	10 (2–14)
Absent (n = 64)	93.8 (62.5–100)	84.4 (21.9–100)	34.4 (0–100)	40.6 (23.1–60.9)	43 (11.6–60)	6 (2–6)	4 (0–15)
p-value	0.665	0.697	0.115	0.043	0.958	0.004	0.170
Frailty
Present (n = 11)	89.6 (66.7–93.8)	75 (59.4–100)	18.8 (0–68.8)	33.3 (24.4–57.1)	39.6 (11.6–55)	5 (2–6)	9 (3–15)
Absent (n = 59)	93.8 (41.7–100)	87.5 (21.9–100)	37.5 (0–100)	40.7 (23.1–60.9)	43.7 (20–60)	6 (1–6)	3 (0–15)
p-value	0.047	0.221	0.063	0.119	0.415	0.009	0.003
Frailty status
Robust (n = 9)	95.8 (81.3–97.9)	90.6 (65.6–100)	31.3 (6.3–75)	46.8 (24.7–56.2)	48 (30–59.6)	6 (4–6)	1 (0–6)
Prefrail (n = 50)	93.8 (41.7–100)	85.9 (21.9–100)	37.5 (0–100)	40.3 (23.1–60.9)	43.2 (20–60)	6 (1–6)	4 (0–15)
Frail (n = 11)	89.6 (66.7–93.8)	75 (59.4–100)	18.8 (0–68.8)	33.3 (24.4–57.1)	39.6 (11.6–55)	5 (2–6)	9 (3–15)
p-value	0.138	0.454	0.175	0.147	0.415	0.033	0.001

Discussion

In our study, the prevalence of frailty and sarcopenia among hemodialysis-dependent CKD patients was 15.7% and 8.6%, respectively. Frail and sarcopenic patients showed marked impairments in quality-of-life domains, particularly in the physical and symptom components, as well as in daily activities and emotional well-being.

Previous studies have reported high dependency rates among older dialysis patients. Cook et al.²³ found that 85 of 162 patients over 65 years were dependent, while Johansen et al.²⁴ showed that physical performance declined with age, low serum albumin, and dialysis dose. Similarly, we found a dependency rate of 25.7%, underlining the need for early identification and management of contributing factors.

Depression is also common in this population. Reported rates range from 17% to 51%,^25–27 while in our study, 25.9% had mild and 22.7% had moderate-to-severe depression. The higher rate may be attributed to the older age of our cohort.

Meta-analyses and cohort studies have shown frailty rates between 21% and 56% in dialysis patients.^28–30 Our study found 71.4% pre-frailty and 15.7% frailty, likely reflecting the older age of participants. Patient education, prevention strategies, and targeted management are essential.

Sarcopenia prevalence in dialysis patients varies between 8% and 33% depending on criteria^31–33; our finding of 8.6% aligns with these reports. Sarcopenia screening and intervention should be part of routine care. Consistent with previous studies, 66.7% of sarcopenic patients in our cohort were partially dependent,^34–36 emphasizing the importance of effective sarcopenia management.

Depression was also frequent in sarcopenic patients, with rates of 51%–67% reported in the literature^37,38 and 66.7% in our study, highlighting the need for psychological assessment in this group.

Studies have shown reduced quality of life in sarcopenic individuals, particularly in mobility and physical domains.^39,40 We also observed lower physical component scores, though not statistically significant, likely due to limited sample size. Identifying and addressing modifiable factors remains crucial.

Frailty has also been linked to lower quality of life.^41,42 Although our study did not demonstrate statistically significant differences, quality-of-life scores declined progressively from robust to frail patients. Correlations between FFMI, handgrip strength, walking speed, and quality-of-life subdomains support that both sarcopenia and frailty are major determinants of well-being in dialysis patients.

Conclusion

Our findings indicate that frailty and sarcopenia are common in older dialysis patients and negatively impact their quality of life. Addressing these conditions may enhance patient well-being. The main limitations of this study are its small sample size and cross-sectional, single-center design. Despite the lack of statistical significance, the trend toward lower quality-of-life scores in sarcopenic patients provides valuable insights for future research.

Footnotes

CRediT authorship contribution statement

FBÇK: Conceptualization, Methodology, Investigation, Formal analysis, Writing – original draft. FE: Conceptualization, Investigation, Visualization, Writing – review & editing ÇK: Conceptualization, Investigation, Visualization. Writing – review & editing FS: Conceptualization, Investigation, Visualization, Writing – review & editing IG: Software, Formal analysis, Writing – original draft, Visualization Conceptualization, Methodology, Writing – review & editing, Supervision. MCK: Conceptualization, Methodology, Formal analysis, Writing – review & editing, Supervision

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Ethics approval statement

Approval was obtained from the Ethics Committee for Non-Drug and Non-Medical Device Research of Necmettin Erbakan University on May 17, 2024, with the decision number 2024/4986.

Consent to participate

The study was conducted in accordance with the Declaration of Helsinki and was approved by the Ethics Committee of Non-Drug and Non-Medical Device Research of Necmettin Erbakan University (no. 2024/4986) on May 17, 2024, with the need for written informed consent waived.

Consent for publication

Not applicable.

ORCID iD

Fatih Ergül

References

Coresh

Astor

Greene

, et al. Prevalence of chronic kidney disease and decreased kidney function in the adult US population: Third National Health and Nutrition Examination Survey. Am J Kidney Dis 2003; 41: 1–12.

Webster

Nagler

Morton

, et al. Chronic kidney disease. Lancet 2017; 389: 1238–1252.

Bischoff-Ferrari

Orav

Kanis

, et al. Comparative performance of current definitions of sarcopenia against the prospective incidence of falls among community-dwelling seniors age 65 and older. Osteoporos Int 2015; 26: 2793–2802.

Cheung

Lam

Cheung

BM.

Evaluation of cutpoints for low lean mass and slow gait speed in predicting death in the national health and nutrition examination survey 1999–2004. J Gerontol A Biol Sci Med Sci 2016; 71: 90–95.

Baumgartner

Wayne

Waters

, et al. Sarcopenic obesity predicts instrumental activities of daily living disability in the elderly. Obes Res 2004; 12: 1995–2004.

Beaudart

Zaaria

Pasleau

, et al. Health outcomes of sarcopenia: a systematic review and meta-analysis. PLoS One 2017; 12: e0169548.

Sousa

Guerra

Fonseca

, et al. Financial impact of sarcopenia on hospitalization costs. Eur J Clin Nutr 2016; 70: 1046–1051.

Clegg

Young

Iliffe

, et al. Frailty in elderly people. Lancet 2013; 381: 752–762.

Woods

LaCroix

Gray

, et al. Frailty: emergence and consequences in women aged 65 and older in the Women’s Health Initiative Observational Study. J Am Geriatr Soc 2005; 53: 1321–1330.

10.

Makary

Segev

Pronovost

, et al. Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg 2010; 210: 901–918.

11.

Garonzik-Wang

Govindan

Grinnan

, et al. Frailty and delayed graft function in kidney transplant recipients. Arch Surg 2012; 147: 190–193.

12.

Arik

Varan

Yavuz

, et al. Validation of Katz index of independence in activities of daily living in Turkish older adults. Arch Gerontol Geriatr 2015; 61: 344–350.

13.

Yesavage

Brink

Rose

, et al. Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res 1982; 17: 37–49.

14.

Charlson

Pompei

Ales

, et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987; 40: 373–383.

15.

Fried

Conference on the physiologic basis of frailty. April 28, 1992, Baltimore, Maryland, USA introduction. Aging 1992; 4: 251–252.

16.

Varan

Deniz

Çöteli

, et al. Validity and reliability of Fried frailty phenotype in Turkish population. Turk J Med Sci 2022; 52: 323–328.

17.

Cruz-Jentoft

Bahat

Bauer

, et al. Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing 2019; 48: 16–31.

18.

Bahat

Tufan

, et al. Cut-off points to identify sarcopenia according to European Working Group on Sarcopenia in Older People (EWGSOP) definition. Clin Nutr 2016; 35: 1557–1563.

19.

Kuyumcu

Halil

Kara

, et al. Ultrasonographic evaluation of the calf muscle mass and architecture in elderly patients with and without sarcopenia. Arch Gerontol Geriatr 2016; 65: 218–224.

20.

Durmaz

Soysal

Ellidokuz

, et al. Validity and reliability of geriatric depression scale-15 (short form) in Turkish older adults. North Clin Istanb 2018; 5: 216–220.

21.

Hays

Kallich

Mapes

, et al. Development of the kidney disease quality of life (KDQOL TM) instrument. Qual Life Res. 1994; 3: 329–338.

22.

Yıldırım

Ogutmen

Bektas

, et al. Translation, cultural adaptation, initial reliability, and validation of the Kidney Disease and Quality of Life–Short Form (KDQOL-SF 1.3) in Turkey. Transplant Proc 2007; 39: 51–54.

23.

Cook

Jassal

Functional dependencies among the elderly on hemodialysis. Kidney Int 2008; 73: 1289–1295.

24.

Johansen

Chertow

Da Silva

, et al. Determinants of physical performance in ambulatory patients on hemodialysis. Kidney Int 2001; 60: 1586–1591.

25.

Čengič

Resic

Depression in hemodialysis patients. Bosn J Basic Med Sci 2010; 10: S73.

26.

Cukor

Peterson

Cohen

, et al. Depression in end-stage renal disease hemodialysis patients. Nat Clin Pract Nephrol 2006; 2: 678–687.

27.

Hinrichsen

Lieberman

Pollack

, et al. Depression in hemodialysis patients. Psychosomatics 1989; 30: 284–289.

28.

Lee

H-J

Son

Y-J.

Prevalence and associated factors of frailty and mortality in patients with end-stage renal disease undergoing hemodialysis: a systematic review and meta-analysis. Int J Environ Res Public Health 2021; 18: 3471.

29.

Salter

Gupta

Massie

, et al. Perceived frailty and measured frailty among adults undergoing hemodialysis: a cross-sectional analysis. BMC Geriatr 2015; 15: 1–7.

30.

Takeuchi

Uchida

Kakio

, et al. The prevalence of frailty and its associated factors in Japanese hemodialysis patients. Aging Dis 2018; 9: 192.

31.

Shu

Lin

Wang

, et al. Diagnosis, prevalence, and mortality of sarcopenia in dialysis patients: a systematic review and meta-analysis. J Cachexia Sarcopenia Muscle 2022; 13: 145–158.

32.

Kittiskulnam

Carrero

Chertow

, et al. Sarcopenia among patients receiving hemodialysis: weighing the evidence. J Cachexia Sarcopenia Muscle 2017; 8: 57–68.

33.

Kim

J-K

Kim

J-E

, et al. Impact of sarcopenia on long-term mortality and cardiovascular events in patients undergoing hemodialysis. Korean J Intern Med 2017; 34: 599.

34.

Cesari

Rolland

Abellan Van Kan

, et al. Sarcopenia-related parameters and incident disability in older persons: results from the “invecchiare in Chianti” study. J Gerontol A Biol Sci Med Sci 2015; 70: 457–463.

35.

Tanimoto

Watanabe

Sun

, et al. Association of sarcopenia with functional decline in community-dwelling elderly subjects in Japan. Geriatr Gerontol Int 2013; 13: 958–963.

36.

Cheng

Zhang

Wang

, et al. Association between sarcopenia and its components and dependency in activities of daily living in patients on hemodialysis. J Ren Nutr 2021; 31: 397–402.

37.

Hayashi

Umegaki

Makino

, et al. Association between sarcopenia and depressive mood in urban-dwelling older adults: a cross-sectional study. Geriatr Gerontol Int 2019; 19: 508–512.

38.

Pasco

Sui

West

, et al. Operational definitions of sarcopenia should consider depressive symptoms. JCSM Clin Rep 2021; 6: 62–68.

39.

Cha

Lee

, et al. Association between sarcopenia, bone density, and health-related quality of life in Korean men. Korean J Fam Med 2013;34:281.

40.

Giglio

Kamimura

Lamarca

, et al. Association of sarcopenia with nutritional parameters, quality of life, hospitalization, and mortality rates of elderly patients on hemodialysis. J Ren Nutr 2018; 28: 197–207.

41.

Jafari

Kour

Giebel

, et al. The burden of frailty on mood, cognition, quality of life, and level of independence in patients on hemodialysis: Regina Hemodialysis Frailty Study. Can J Kidney Health Dis 2020; 7:1–11.

42.

Yao

Yin

Liu

P1512 The relationship among anxiety, depression and frailty in maintenance hemodialysis patient. Nephrol Dial Transplant 2020; 35: gfaa142.