The prevalence of frailty according to kidney function and its association with cognitive impairment, nutritional status, and clinical outcome

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The prevalence of frailty in patients with chronic kidney disease (CKD) is more common than in the general population. Frailty is associated with a poor clinical prognosis, malnutrition, and cognitive impairment; however, studies on these factors in patients with CKD are lacking. Therefore, we aimed to evaluate the relationship between CKD and frailty, nutritional status, and cognitive impairment and their influence on clinical outcomes. Methods We prospectively enrolled participants from June 2019 to December 2020 and divided them into three CKD groups according to kidney function (non-CKD, CKD stage 3–4, and CKD stage 5D). Clinical outcomes were defined as the composite outcomes of all-cause death, hospitalization, and cardiovascular outcomes, including nonfatal myocardial infarction, revascularization, or stroke. To calculate the relative risk of frailty, cognitive impairment, nutritional status, and clinical outcome, odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using logistic regression analysis. Result A total of 88 patients were included, of whom 30.7% had frailty and 17.0% had cognitive impairment. In the CKD stage 5D group, the prevalence of frailty (56.7%, n = 17) was significantly higher, and the nutritional quotient score was lower in the other groups. The Korean-Montreal Cognitive Assessment score was significantly lower in the CKD stage 5D group; however, cognitive impairment did not differ among the three groups. Frailty was significantly associated with cognitive impairment and CKD stage 5D group. Cognitive impairment was significantly associated with older age and higher BMI. Well-nourished status was significantly associated with BMI and CKD stage 5D group. Patients in the CKD 5D group were significantly more likely to have adverse clinical outcomes. Conclusions The prevalence of frailty increased significantly as the CKD stage progressed. Particularly, CKD stage 5D group correlated with frailty and nutritional status, leading to poor clinical outcomes. CKD frailty nutritional status cognitive impairment clinical outcomes Figures Figure 1 Introduction Frailty is a state of vulnerability to poor homeostatic resolution after a stressful event [ 1 ]. The prevalence of frailty varies with age, sex, income, and comorbidities [ 2 – 5 ], and has been reported to be 15% in elderly patients with chronic kidney disease (CKD), which is higher than the 6% in the elderly with normal kidney function [ 6 ]. In particular, in patients with end-stage kidney disease, the prevalence of frailty is high as 44.4%, even in those the age of 40 years, and increases sharply with age [ 7 ]. Frailty in CKD patients is a multifactorial condition. Uremic toxins and decreased cytokine clearance lead to increased levels of proinflammatory cytokines such as interleukin-6, and tumor necrosis factor alpha [ 8 – 10 ]. This contributes to the occurrence of sarcopenia and anorexia, and a reduced energy intake due to anorexia and dietary restrictions is associated with protein energy wasting (PEW) and frailty [ 11 – 13 ]. In addition, decreased production of and acquired resistance to anabolic hormones, and metabolic acidosis may lead to malnutrition and sarcopenia, which are ultimately associated with frailty [ 14 ]. Frailty in patients with CKD is associated with all-cause mortality and poor clinical outcomes such as hospitalization, impaired quality of life, and cognitive impairment [ 15 – 17 ]. However, there is a lack of research on the relationship between cognitive impairment and frailty in patients with CKD and on the mechanisms behind these associations. We aimed to evaluate the relationship between CKD and frailty, nutritional status, and cognitive impairment, and their influence on clinical outcomes. Therefore, using a prospective observational cohort study, we hypothesized that frailty, nutritional status, and cognitive impairment would differ depending on kidney function at baseline, and that these would be closely related to each other and ultimately be associated with a poor prognosis. Materials and Methods Study population This study prospectively enrolled adult (aged ≥ 18 years) outpatients visiting Gyeongsang National University Changwon Hospital from June 2019 to December 2020. Informed consent was obtained from each study participant. Patients who were unable or unwilling to provide written consent, had malignant tumors, dementia, no available serum creatinine levels, no frailty data, or no Nutritional Quotient (NQ) scores were excluded (Additional File 1). This study was approved by the Institutional Review Board of Gyeongsang National University Hospital (IRB No. 2019-03-014-001). Clinical parameters Well-trained nurses investigated data on demographic and clinical characteristics, laboratory findings, and comorbidities through in-person interviews or by reviewing medical records at the time of enrollment. Body mass index (BMI) was calculated as weight (kg) ÷ height ( m). Systolic and diastolic blood pressure were measured using a mercury sphygmomanometer. The estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet in Renal Disease (MDRD) study formula [1.86 × (plasma creatinine) – 1.154 × (age) – 0.203) × (0.74 if female) × (1.210 if black)]. We divided patients into tertiles to categorized their kidney function as follows: non-CKD (MDRD-GFR ≥ 60mL/min/1.73 m 2 ), CKD stage 3–4 (MDRD-GFR < 60mL/min/1.73 m 2 ), and CKD stage 5 on dialysis (5D). Frailty Frailty was measured by well-trained nurses using the Fried Frailty Index [ 18 ]. Each of the five items (shrinking, weakness, poor endurance, slowness, low activity) was scored as zero or one. A total score of 3–5 for the five items was defined as frailty, and a score less than 3 was defined as not frailty [ 18 , 19 ]. Cognitive impairment The Montreal Cognitive Assessment (MoCA) was developed to determine mild cognitive impairment more accurately than the Mini-Mental State Examination (MMSE). The MoCA is a one-page 30-point test administered for 10 min. It consists of short-term memory(5 points; two learning trials of five nouns and delayed recall after approximately 5 minutes), visuospatial abilities (3 points: clock-drawing task; 1 point; three-dimensional cube copy), executive functions (1 point: trail making B task; 1 point: phonemic fluency task; 2 points: two-item verbal abstraction task), attention (1 point: sustained attention task; 3 points: serial subtraction task, 1 point each; digits forward and backward), language (3 points: three-item confrontation naming task; 2 points: repetition of two syntactically complex sentences), and orientation to time and place (6 points). Kang et al. developed the Korean-Montreal Cognitive Assessment (K-MoCA) and verified its reliability and validity in consideration of the cultural and linguistic characteristics of Koreans [ 20 , 21 ]. In addition, they presented a cutoff value according to the level of education and age. In this study, the K-MoCA was used to determine cognitive impairment. Nutritional status Nutritional status was assessed using the Nutrition Quotient (NQ) for patients under the age of 65 years and NQ-elderly (NQ-E) for patients age of 65 years or older. The NQ and NQ-E are tools that comprehensively evaluates the nutritional status and meal quality of individuals or groups of adults according to their age (NQ for adults aged 19–64 years, NQ-E for adults over 65 years of age). The NQ and NQ-E were developed and validated by the Korean Society of Nutrition in 2018 based on data from the National Health and Nutrition Examination Survey [ 22 , 23 ]. The NQ and NQ-E consisted of four categories (balance, diversity, moderation, and dietary behavior). The NQ consists of 21 items and nutritional status is evaluated as high, medium, and low, whereas the NQ-E consists of 19 items and nutritional status is evaluated as high, medium high, medium low, and low. We defined the patient's nutritional status as high, medium, or low by changing from medium high and medium low to medium in the NQ-E. Clinical outcomes The clinical outcomes were defined as the composite outcomes of all-cause death, hospitalization, and cardiovascular outcomes, including nonfatal myocardial infarction, revascularization, or stroke. Statistical analysis Participants were divided into three groups based on their kidney function. The chi-square test and t-test were used to compare categorical and continuous clinical and laboratory parameters, respectively, among the three groups. Univariate and multivariate linear regression analyses were performed to investigate the association between clinical factors and frailty. The variables were selected using a forward conditional method. Statistical analyses were performed using the SPSS for Windows (ver. 25.0; IBM corp., Armonk, NY.). Statistical significance was defined as P < 0.05. Results Baseline characteristics according to kidney function We prospectively enrolled 106 patients, and excluded 18 with underlying dementia, or no available serum creatinine levels (Additional file 1). The mean age of the 88 patients included in this study was 62.4 years, and 58% were male. Regarding the patients’ kidney function, 30 were assigned to the non-CKD group, 28 to the CKD stage 3-4 group, and 30 to the CKD stage 5D group. The CKD stage 5D group had significantly lower serum hemoglobin, cholesterol, and albumin levels than the other groups, this group also had the highest percentage of patients with diabetes mellitus and hypertension. The proportion of patients with coronary artery disease and cerebrovascular disease was higher in the CKD stage 5D group than in the non-CKD group but was highest in the CKD stage 3-4 group (Table 1). In the CKD stage 5D group, the median dialysis vintage was 19.6 months (0.0 – 172.4 months). Frailty and kidney function Frailty was observed in 27 patients (30.7%):, 4 patients (13.3%) in the non-CKD group, 6 patients (21.4%) in the CKD stage 3-4 group, and 17 patients (56.7%) in the CKD stage 5D group ( P =0.001) (Table 1, Figure 1). CKD was significantly associated with frailty even after adjustment for covariates (Table 2). Among CKD groups, the CKD stage 5D group showed a significantly higher odds ratio (OR) of frailty compared to the non-CKD group (OR, 7.99; 95% confidence interval [CI], 2.10 – 30.32; P =0.002). In addition, frailty was significantly related to cognitive impairment (OR 7.85; 95% CI 2.18 – 28.26; P=0.002), but other clinical factors, including nutritional status, were not significantly related (Table 2). Cognitive impairment and kidney function Cognitive impairment was observed in 15 patients (17.0%): 4 patients (13.3%) in the non-CKD group, 4 patients (14.3%) in the CKD stage 3-4 group, and 7 patients (23.3%) in the CKD stage 5D group ( P =0.527) (Table 1, Figure 1). The proportion of patients with cognitive impairment increased with decreased kidney function’ however, the difference was not statistically significant. Nevertheless, the K-MoCA scores were significantly lower in the dialysis group than in the other groups (Tabel 1). Logistic regression analysis was used to evaluate factors associated with cognitive impairment. CKD was not significantly associated with cognitive impairment. Only age (OR 1.34, 95% CI 1.13 – 1.58, P =0.001), and BMI (OR 1.19, 95% CI 1.03 – 1.37, P =0.018) were related to cognitive impairment (Table 3). Nutritional status and kidney function The NQ score was lowest in the dialysis group, and the proportion of high nutritional status (well-nourished status) was also lower than in the other groups. (Table 1, Figure 1, Supplementary table 1). Table 4 shows that CKD groups had a significant association with well-nourished status in the crude and fully adjusted models. The CKD 5D group had a significantly lower OR of a well-nourished status compared to the non-CKD group (OR 0.21, 95% CI 0.06 – 0.75, P =0.030). In univariate analysis, well-nourished status was significantly associated with BMI, frailty, cognitive impairment, serum protein level, and CKD. However, only CKD groups and BMI (OR 0.87, 95% CI 0.76 – 0.99, P =0.034) were significantly associated with well-nourished status after adjusting for covariates. Clinical outcomes During the follow up period of 141.6 ± 67.7 months, the composite clinical outcome was observed in 54.5% (N = 48) of patients, of which all-cause death occurred in 5.7% (N = 5), cardiovascular outcome occurred in 8.0% (N = 7), and hospitalization occurred in 53.4% (N = 47). Patients in the CKD 5D group were significantly more likely to achieve the composite clinical outcomes compared with the non-CKD group (OR 6.94, 95% CI 2.18 – 22.12, P =0.001). In the univariate analysis, frailty, cognitive impairment, and nutritional status were not significantly associated with the clinical outcomes (Table 5). When evaluating the relationship between each component of clinical outcome and the CKD group, statistical significance was only observed for hospitalization, and not for all-cause death or cardiovascular outcomes (Additional file 2). Discussion In this prospective outpatient cohort study, we explored the associations between kidney function and frailty, nutritional status, cognitive impairment, and clinical outcomes. We found that the prevalence of frailty increased in patients with CKD, especially in those receiving dialysis (CKD stage 5D group), and that impaired kidney function was significantly related to frailty, nutritional status, and clinical outcomes, but not with cognitive impairment. Previous studies have shown that the prevalence of frailty, malnutrition, and cognitive impairment as well as clinical outcomes such as death, cardiovascular events, and hospitalization are higher in patients with CKD than in those without CKD [ 17 , 24 , 25 ]. Wilhelm-Leen et al. analyzed the association between frailty and CKD using data from the Third National Health and Nutrition Examination Survey. In present study, frailty was significantly associated with CKD, and both frailty and CKD were independently associated with mortality [ 19 ]. Kopple et al. examined protein-energy nutritional status according to kidney function in the Modification of Diet in Renal Disease Study, and showed that nutritional status declines as the kidney function decreases [ 26 ]. In another study, Tseng et al. assessed the relationship between frailty and nutritional status in patients with stage 3–5 CKD. They found that the PEW was significantly associated with frailty in CKD [ 27 ]. Coppolino et al. revealed that cognitive capacity decrease across CKD stages, and frailty is common in elderly patients with CKD [ 28 ]. In the general population, frailty and cognitive impairment have shown a close relationship in previous studies [ 29 , 30 ]. However, research on the relationship between frailty and cognitive impairment in patients with CKD is lacking. In addition, there is still very little research on the relationship between frailty, nutritional status, and cognitive impairment according to kidney function, and its impact on clinical outcomes, including death. Our study showed that at baseline, especially in the CKD stage 5D group, the proportion of frailty was higher and the NQ and K-MoCA scores were significantly lower than those in the other groups, which is consistent with previous studies [ 12 , 15 , 17 ]. In contrast to previous studies, however, the present study evaluated frailty, nutritional status, cognitive impairment, and kidney function These factors did not all exhibit a close relationship with each other; significant associations were seen between CKD and frailty, CKD and nutritional status, and cognitive impairment and frailty. Furthermore, frailty, nutritional status, and cognitive impairment at the time of enrollment had no significant association with clinical outcomes; the only significant relationship with clinical outcomes was observed in the CKD stage 5D group compared with the non-CKD group. In summary of previous results, frailty, PEW, and cognitive impairment were significantly associated with CKD. However, studies comprehensively examining these factors are lacking. In this respect, our study has the advantage of comprehensively investigating the relationship between kidney function and other important factors in patients with CKD. We suggest several explanations for the association between CKD and frailty, nutritional status, and clinical outcomes, but not cognitive impairment. First, CKD is not only a risk factor for frailty and malnutrition, but also shares pathophysiological mechanisms, such as oxidative stress, renin-angiotensin-aldosterone system activation, inflammation, and metabolic acidosis; therefore, they are closely related and influence each other, ultimately leading to poor clinical outcomes. Second, patients with CKD stage 5D showed the most significant correlation with clinical outcomes, which may be because the progression to kidney failure itself has an influence on clinical factors and because the number of enrolled patients was relatively small. Third, because the duration of dialysis was short and relatively young patients were included, a correlation between kidney function and cognitive impairment may not have been present. The association with dementia in patients undergoing dialysis is usually explained by the hemodynamic instability during dialysis, decreased brain perfusion, and uremic toxicity. However, in our study, the median vintage of dialysis patients was 19.6 months, which means that maintenance dialysis duration was relatively short; this means that residual kidney function could be preserved, decreasing the risk of uremia and intradialytic hypotension. Our study suggests that clinicians should pay attention to the frailty and nutritional status of patients with CKD, especially those requiring dialysis, regardless of age, as even relatively healthy patients receiving outpatient treatment warrant this attention. Additionally, since patients with CKD stage 5D have poor clinical outcomes compared to patients without CKD, clinicians should make efforts to delay CKD progression. Our study had several limitations. First, due to the single-center design and to small number of observational cohort characteristics, the causality between kidney function and worsened frailty, nutritional status, and clinical outcomes cannot be determined and should be interpreted as a relationship. Second, our study enrolled relatively healthy patients who were eligible for outpatient treatment and did not include patients with severe frailty, malnourishment, or cognitive impairment. Third, our study investigated the relationship between cognitive impairment and kidney function at baseline and did not assess cognitive function at follow-up. Therefore, caution is needed when interpreting the relationship between kidney function and cognitive impairment, and additional research is needed in the future. Despite these limitations, the strength of our study was that we examined the relationship between kidney function and frailty, nutritional status, cognitive impairment, and clinical outcomes. Conclusions This study showed that CKD, especially CKD stage 5D, is significantly associated with frailty, nutritional status, and poor clinical outcomes. This suggests that we need to focus more on frailty, nutrition, and prevention of progression to kidney failure in patients with CKD. Abbreviations BMI, body mass index; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; K-MoCA, Korean-Montreal Cognitive Assessment; MDRD, Modification of Diet in Renal Disease; MMSE, Mini-Mental State Examination; MoCA, Montreal Cognitive Assessment; NQ, Nutritional Quotient; NQ-E, Nutritional Quotient-elderly; OR, odds ratio; PEW, protein energy wasting Declarations Data availability The data that support the findings of this study are available from the corresponding author upon reasonable request. Ethics approval and consent to participate This study was approved by the Institutional Review Board of Gyeongsang National University Hospital (IRB No. 2019-03-014-001). We obtained informed consent from each participant. Consent for publication Not applicable. Competing interests The authors declare no conflicts of interest. Funding This study was supported by the Lee Jung Ja research grant of Gyeongsang National University Hospital (LJJ-GNUH-2019-0006), and National Research Foundation of Korea (NRF) grant funded by the Korean government (MSIT) [grant number: 2020R1C1C1011380]. Authors' contributions Conceptualization: TWY, and EB; methodology: YMK, DHK, and OYK; validation: YMK and YSK; formal analysis: YMK, DHK, and TWL; writing: TWY, DJP and EB.; supervision: OYK, DJP and EB; Funding Acquisition TWY, and EB. Acknowledgements None References Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K: Frailty in elderly people . Lancet 2013, 381 (9868):752-762. Gale CR, Cooper C, Aihie Sayer A: Prevalence of frailty and disability: findings from the English Longitudinal Study of Ageing . Age and Ageing 2014, 44 (1):162-165. 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Baseline characteristics of the study population stratified by CKD group Variables Total (N =88) Non-CKD (N =30) CKD stage 3-4 (N =28) CKD stage 5D (N =30) P Age (years) 62.4 ± 11.7 59.6 ± 11.9 64.9 ± 10.4 62.9 ± 12.3 0.227 Men, % 58.0 40.0 64.3 70.0 0.045 Education level, % 0.043 Less than elementary school 3.4 0.0 10.7 0.0 Middle school 26.1 23.3 32.1 23.3 High school 39.8 30.0 35.7 53.3 College 30.7 46.7 21.4 23.3 BMI (kg/m 2 ) 23.8 ± 4.0 24.0 ± 3.3 23.8 ± 4.2 23.7 ± 4.6 0.743 SBP (mmHg) 137.0 ± 20.5 131.7± 17.8 140.5 ± 21.3 139.0 ± 21.8 0.217 DBP (mmHg) 74.0 ± 13.4 75.4 ± 12.0 72.6 ± 13.1 73.8 ± 15.1 0.532 Frailty, % 30.7 13.3 21.4 56.7 0.001 Nutritional Quotient score 61.4 ± 8.8 62.3 ± 8.1 64.3 ± 9.6 57.8 ± 7.8 0.014 Nutritional status 0.055 High, % 39.8 53.3 46.4 20.0 Medium, % 55.7 46.7 46.4 73.3 Low, % 4.5 0.0 7.1 6.7 Cognitive impairment, % 17.0 13.3 14.3 23.3 0.527 K-MoCA 23.7 ± 5.9 25.4 ± 4.5 23.1 ± 6.5 22.6 ± 6.4 0.044 Hemoglobin (g/dL) 12.0 ± 1.9 13.9 ± 1.5 11.6 ± 1.5 10.5 ± 1.0 <0.001 Glucose (mg/dL) 133.8 ± 50.3 123.6 ± 57.1 129.9 ± 47.2 147.8 ± 44.1 0.004 Cholesterol (mg/dL) 160.7 ± 49.7 190.9 ± 46.2 156.8 ± 38.8 134.1 ± 46.5 <0.001 Protein (g/dL) 6.9 ± 0.6 7.2 ± 0.5 6.8 ± 0.6 6.8 ± 0.6 0.004 Albumin (g/dL) 4.0 ± 0.4 4.3 ± 0.4 3.9 ± 0.4 3.8 ± 0.4 <0.001 CRP (mg/L) 5.2 ± 14.5 1.4 ± 2.1 8.1 ± 16.3 6.4 ± 18.9 0.073 Hypertension, % 68.2 20.0 85.7 100.0 <0.001 Diabetes, % 47.7 13.3 50.0 80.0 <0.001 Coronary artery disease, % 17.0 0.0 28.6 23.3 0.008 Cerebrovascular disease, % 6.8 0.0 14.3 6.7 0.098 Malignancy, % 11.4 10.0 14.3 10.0 0.840 BMI, body mass index; CKD, chronic kidney disease; CRP, C-reactive protein; DBP, diastolic blood pressure; K-MoCA, Korean-Montreal Cognitive Assessment; ND, non-dialysis; SBP, systolic blood pressure; 5D, on dialysis Table 2. Odds ratios for frailty risk factors Univariate Multivariate OR (95% CI) P OR (95% CI) P Age (years) 1.04 (0.99 – 1.08) 0.099 Sex, female (ref. male) 0.93 (0.37 – 2.32) 0.869 Well-nourished status (ref. low to medium) 0.32 (0.11 – 0.89) 0.029 Cognitive impairment (ref. no) 4.58 (1.43 – 14.65) 0.010 4.46 (1.23 – 16.12) 0.023 Hemoglobin (g/dL) 0.65 (0.49 – 0.87) 0.004 Protein (g/dL) 0.37 (0.16 – 0.87) 0.022 CKD group (ref. non-CKD) 0.001 0.003 CKD stage 3-4 1.77 (0.44 – 7.09) 0.418 1.69 (0.40 – 7.14) 0.473 CKD stage 5D 8.50 (2.37 – 30.47) 0.001 7.99 (2.10 – 30.32) 0.002 CI: confidence interval; CKD, chronic kidney disease; OR, odds ratio; 5D, on dialysis Adjusted for age, sex, nutritional status, cognitive impairment, serum hemoglobin, protein, CKD group. Table 3. Odds ratios for cognitive impairment Univariate Multivariate OR (95% CI) P OR (95% CI) P Age (years) 1.21 (1.05 – 1.39) 0.010 1.34 (1.13 – 1.58) 0.001 Sex, female (ref. male) 1.25 (0.41 – 3.83) 0.691 BMI (kg/m 2 ) 1.21 (1.05 – 1.39) 0.010 1.40 (1.09 – 1.80) 0.009 Frailty (ref. no) 4.58 (1.43 – 14.65) 0.010 Well-nourished status (ref. low to medium) 0.19 (0.04 – 0.89) 0.035 CKD group (ref. non-CKD) 0.534 CKD stage 3-4 1.08 (0.24 – 4.82) 0.913 CKD stage 5D 1.98 (0.51 – 7.64) 0.322 Cerebrovascular disease (ref. No) 5.83 (1.05 – 32.36) 0.044 CI: confidence interval; CKD, chronic kidney disease; OR, odds ratio; 5D, on dialysis Adjusted for age, sex, BMI, frailty, nutritional status, CKD group, cerebrovascular disease. Table 4. Odds ratios for well-nourished status Univariate Multivariate OR (95% CI) P OR (95% CI) P Age (years) 0.98 (0.94 – 1.02) 0.256 Sex, female (ref. male) 1.90 (0.80 – 4.52) 0.149 BMI (kg/m 2 ) 0.89 (0.79 – 0.99) 0.049 0.85 (0.73 – 0.98) 0.022 Frailty (ref. no) 0.32 (0.11 – 0.89) 0.029 Cognitive impairment (ref. no) 0.19 (0.04 – 0.89) 0.035 Hemoglobin (g/dL) 1.15 (0.91 – 1.45) 0.241 Albumin (g/dL) 3.39 (1.09 – 10.54) 0.035 CKD group (ref. non-CKD) 0.027 0.010 CKD stage 3-4 0.76 (0.27 – 2.13) 0.600 0.61 (0.20 – 1.82) 0.370 CKD stage 5D 0.22 (0.07 – 0.69) 0.009 0.15 (0.04 – 0.52) 0.003 CI: confidence interval; CKD, chronic kidney disease; OR, odds ratio; 5D, on dialysis Adjusted for age, sex, BMI, frailty, cognitive impairment, serum hemoglobin, albumin, CKD group. Table 5 . Odds ratios for clinical outcomes Univariate Multivariate OR (95% CI) P OR (95% CI) P Age (years) 1.01 (0.97 – 1.04) 0.769 Sex, female (ref. male) 1.17 (0.50 – 2.73) 0.723 BMI (kg/m 2 ) 1.01 (0.91 – 1.12) 0.840 Frailty (ref. no) 2.62 (0.99 – 6.89) 0.051 Cognitive impairment (ref. no) 1.31 (0.42 – 4.05) 0.642 Well-nourished status (ref. low to middle) 0.983 (0.42 – 2.32) 0.968 Hemoglobin (g/dL) 0.70 (0.55 – 0.90) 0.006 Albumin (g/dL) 0.35 (0.12 – 1.03) 0.056 CKD group (ref. non-CKD) 0.002 0.005 CKD stage 3-4 3.11 (1.06 – 9.18) 0.040 2.82 (0.95 – 8.38) 0.063 CKD stage 5D 7.67 (2.42 – 24.25) 0.001 6.94 (2.18 – 22.12) 0.001 Hypertension (ref. no) 3.92 (1.51 – 10.18) 0.005 Diabetes mellitus (ref. no) 2.60 (1.09 – 6.19) 0.031 CI: confidence interval; CKD, chronic kidney disease; OR, odds ratio; 5D, on dialysis Adjusted for age, sex, BMI, frailty, serum hemoglobin, albumin, CKD group, hypertension, diabetes mellitus. Additional Declarations No competing interests reported. Supplementary Files Supplementarymaterial.docx supplementaryfigure1.tif Cite Share Download PDF Status: Published Journal Publication published 10 Feb, 2025 Read the published version in BMC Nephrology → Version 1 posted Editorial decision: Revision requested 27 Dec, 2024 Reviews received at journal 25 Dec, 2024 Reviewers agreed at journal 17 Dec, 2024 Reviews received at journal 04 Dec, 2024 Reviewers agreed at journal 03 Dec, 2024 Reviewers invited by journal 03 Dec, 2024 Editor assigned by journal 03 Dec, 2024 Editor invited by journal 17 May, 2024 Submission checks completed at journal 17 May, 2024 First submitted to journal 14 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4417340","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":307347738,"identity":"ca17645e-0d32-4f8e-bbd2-2d8e6353b1e3","order_by":0,"name":"Tae-Won Yang","email":"","orcid":"","institution":"Gyeongsang National University College of Medicine, Gyeongsang National University Changwon Hospital","correspondingAuthor":false,"prefix":"","firstName":"Tae-Won","middleName":"","lastName":"Yang","suffix":""},{"id":307347739,"identity":"fc59606a-b600-472c-9ea8-401bf4ce74b3","order_by":1,"name":"YooMee Kang","email":"","orcid":"","institution":"Gyeongsang National University College of Medicine, Gyeongsang National University Changwon Hospital","correspondingAuthor":false,"prefix":"","firstName":"YooMee","middleName":"","lastName":"Kang","suffix":""},{"id":307347740,"identity":"ba466456-cb02-4d23-83fd-b9b3ff54bd32","order_by":2,"name":"Do-Hyung Kim","email":"","orcid":"","institution":"Samsung Changwon Hospital, Sungkyunkwan University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Do-Hyung","middleName":"","lastName":"Kim","suffix":""},{"id":307347741,"identity":"81274ecf-39d0-477b-84ae-4a0d20bc6f31","order_by":3,"name":"Young-Soo Kim","email":"","orcid":"","institution":"Gyeongsang National University College of Medicine, Gyeongsang National University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Young-Soo","middleName":"","lastName":"Kim","suffix":""},{"id":307347742,"identity":"8cd00603-d4f0-4536-bd45-876fe4fbd25d","order_by":4,"name":"Oh-Young Kwon","email":"","orcid":"","institution":"Gyeongsang National University College of Medicine, Gyeongsang National University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Oh-Young","middleName":"","lastName":"Kwon","suffix":""},{"id":307347743,"identity":"64ecc9d0-304d-403a-b521-94ffaabb7782","order_by":5,"name":"Tae Won Lee","email":"","orcid":"","institution":"Gyeongsang National University College of Medicine, Gyeongsang National University Changwon Hospital","correspondingAuthor":false,"prefix":"","firstName":"Tae","middleName":"Won","lastName":"Lee","suffix":""},{"id":307347744,"identity":"f0d8343e-4832-4496-9993-98fe9afeb0c5","order_by":6,"name":"Dong Jun Park","email":"","orcid":"","institution":"Gyeongsang National University College of Medicine, Gyeongsang National University Changwon Hospital","correspondingAuthor":false,"prefix":"","firstName":"Dong","middleName":"Jun","lastName":"Park","suffix":""},{"id":307347745,"identity":"4ab60237-b145-4c21-9125-0cf76e8f8eb6","order_by":7,"name":"Eunjin Bae","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIiWNgGAWjYDCCA8wNBxgbGOr7mfk/PiBSCyNIiwHjzPYGYwOitTCAtGzoOWAmQZQOvuONjQe/7vjDbCCRkFZdUHNYzryB+eGjG3i0SJ452HBY9owBm7lEwrHbM44dNpY5wGZsnINHi8GNxIbDkm0GPJYzEttu87ClJc5g4GGTxqvl/kOwFgmDG8lsxTz/0uoJa7nB2HDwY5uBgcGZY2zMvG02CRKEtEieATqMsc04QbK9h1mat8/GcAYzAb/wHT98+OPPNrkEfmYexs883yTkJdibHz7GpwUEmHlQuQSUgwDjDyIUjYJRMApGwQgGABkeUJ9caF1tAAAAAElFTkSuQmCC","orcid":"","institution":"Gyeongsang National University College of Medicine, Gyeongsang National University Changwon Hospital","correspondingAuthor":true,"prefix":"","firstName":"Eunjin","middleName":"","lastName":"Bae","suffix":""}],"badges":[],"createdAt":"2024-05-14 07:44:41","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4417340/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4417340/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12882-025-04006-5","type":"published","date":"2025-02-10T15:57:49+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":57629955,"identity":"688b168b-8f9a-4ec6-837c-d15520e8d47c","added_by":"auto","created_at":"2024-06-03 14:38:51","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":23232,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe proportion of frailty and cognitive impairment and NQ score according to kidney function\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong CKD groups, the CKD 5D group had the highest proportion of frailty and cognitive impairment and the lowest Nutritional Quotient (NQ) score.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4417340/v1/d17ac8def954eb9c85b91395.png"},{"id":76487594,"identity":"befd481d-9d34-4725-b86a-82afd0a07f00","added_by":"auto","created_at":"2025-02-17 16:09:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2254688,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4417340/v1/80c44960-ca2d-47e9-962f-ac995b99ab01.pdf"},{"id":57629956,"identity":"cf3dc7ea-fdbf-4668-a6c5-31105ebeb803","added_by":"auto","created_at":"2024-06-03 14:38:52","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":25521,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-4417340/v1/6fc91e5b01c79b78804fbf30.docx"},{"id":57629957,"identity":"e064a8c1-bde2-4414-8f33-693b2504b2c4","added_by":"auto","created_at":"2024-06-03 14:38:52","extension":"tif","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":77966,"visible":true,"origin":"","legend":"","description":"","filename":"supplementaryfigure1.tif","url":"https://assets-eu.researchsquare.com/files/rs-4417340/v1/1055d8e81dff3810e19da567.tif"}],"financialInterests":"No competing interests reported.","formattedTitle":"The prevalence of frailty according to kidney function and its association with cognitive impairment, nutritional status, and clinical outcome","fulltext":[{"header":"Introduction","content":"\u003cp\u003eFrailty is a state of vulnerability to poor homeostatic resolution after a stressful event [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The prevalence of frailty varies with age, sex, income, and comorbidities [\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], and has been reported to be 15% in elderly patients with chronic kidney disease (CKD), which is higher than the 6% in the elderly with normal kidney function [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In particular, in patients with end-stage kidney disease, the prevalence of frailty is high as 44.4%, even in those the age of 40 years, and increases sharply with age [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFrailty in CKD patients is a multifactorial condition. Uremic toxins and decreased cytokine clearance lead to increased levels of proinflammatory cytokines such as interleukin-6, and tumor necrosis factor alpha [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. This contributes to the occurrence of sarcopenia and anorexia, and a reduced energy intake due to anorexia and dietary restrictions is associated with protein energy wasting (PEW) and frailty [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In addition, decreased production of and acquired resistance to anabolic hormones, and metabolic acidosis may lead to malnutrition and sarcopenia, which are ultimately associated with frailty [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFrailty in patients with CKD is associated with all-cause mortality and poor clinical outcomes such as hospitalization, impaired quality of life, and cognitive impairment [\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. However, there is a lack of research on the relationship between cognitive impairment and frailty in patients with CKD and on the mechanisms behind these associations. We aimed to evaluate the relationship between CKD and frailty, nutritional status, and cognitive impairment, and their influence on clinical outcomes. Therefore, using a prospective observational cohort study, we hypothesized that frailty, nutritional status, and cognitive impairment would differ depending on kidney function at baseline, and that these would be closely related to each other and ultimately be associated with a poor prognosis.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy population\u003c/h2\u003e \u003cp\u003eThis study prospectively enrolled adult (aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years) outpatients visiting Gyeongsang National University Changwon Hospital from June 2019 to December 2020. Informed consent was obtained from each study participant. Patients who were unable or unwilling to provide written consent, had malignant tumors, dementia, no available serum creatinine levels, no frailty data, or no Nutritional Quotient (NQ) scores were excluded (Additional File 1). This study was approved by the Institutional Review Board of Gyeongsang National University Hospital (IRB No. 2019-03-014-001).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eClinical parameters\u003c/h2\u003e \u003cp\u003eWell-trained nurses investigated data on demographic and clinical characteristics, laboratory findings, and comorbidities through in-person interviews or by reviewing medical records at the time of enrollment. Body mass index (BMI) was calculated as weight (kg)\u0026thinsp;\u0026divide;\u0026thinsp;height ( m). Systolic and diastolic blood pressure were measured using a mercury sphygmomanometer. The estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet in Renal Disease (MDRD) study formula [1.86 \u0026times; (plasma creatinine) \u0026ndash; 1.154 \u0026times; (age) \u0026ndash; 0.203) \u0026times; (0.74 if female) \u0026times; (1.210 if black)]. We divided patients into tertiles to categorized their kidney function as follows: non-CKD (MDRD-GFR\u0026thinsp;\u0026ge;\u0026thinsp;60mL/min/1.73 m\u003csup\u003e2\u003c/sup\u003e), CKD stage 3\u0026ndash;4 (MDRD-GFR\u0026thinsp;\u0026lt;\u0026thinsp;60mL/min/1.73 m\u003csup\u003e2\u003c/sup\u003e), and CKD stage 5 on dialysis (5D).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eFrailty\u003c/h2\u003e \u003cp\u003eFrailty was measured by well-trained nurses using the Fried Frailty Index [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Each of the five items (shrinking, weakness, poor endurance, slowness, low activity) was scored as zero or one. A total score of 3\u0026ndash;5 for the five items was defined as frailty, and a score less than 3 was defined as not frailty [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eCognitive impairment\u003c/h2\u003e \u003cp\u003eThe Montreal Cognitive Assessment (MoCA) was developed to determine mild cognitive impairment more accurately than the Mini-Mental State Examination (MMSE). The MoCA is a one-page 30-point test administered for 10 min. It consists of short-term memory(5 points; two learning trials of five nouns and delayed recall after approximately 5 minutes), visuospatial abilities (3 points: clock-drawing task; 1 point; three-dimensional cube copy), executive functions (1 point: trail making B task; 1 point: phonemic fluency task; 2 points: two-item verbal abstraction task), attention (1 point: sustained attention task; 3 points: serial subtraction task, 1 point each; digits forward and backward), language (3 points: three-item confrontation naming task; 2 points: repetition of two syntactically complex sentences), and orientation to time and place (6 points). Kang et al. developed the Korean-Montreal Cognitive Assessment (K-MoCA) and verified its reliability and validity in consideration of the cultural and linguistic characteristics of Koreans [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In addition, they presented a cutoff value according to the level of education and age. In this study, the K-MoCA was used to determine cognitive impairment.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eNutritional status\u003c/h2\u003e \u003cp\u003eNutritional status was assessed using the Nutrition Quotient (NQ) for patients under the age of 65 years and NQ-elderly (NQ-E) for patients age of 65 years or older. The NQ and NQ-E are tools that comprehensively evaluates the nutritional status and meal quality of individuals or groups of adults according to their age (NQ for adults aged 19\u0026ndash;64 years, NQ-E for adults over 65 years of age). The NQ and NQ-E were developed and validated by the Korean Society of Nutrition in 2018 based on data from the National Health and Nutrition Examination Survey [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The NQ and NQ-E consisted of four categories (balance, diversity, moderation, and dietary behavior). The NQ consists of 21 items and nutritional status is evaluated as high, medium, and low, whereas the NQ-E consists of 19 items and nutritional status is evaluated as high, medium high, medium low, and low. We defined the patient's nutritional status as high, medium, or low by changing from medium high and medium low to medium in the NQ-E.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eClinical outcomes\u003c/h2\u003e \u003cp\u003eThe clinical outcomes were defined as the composite outcomes of all-cause death, hospitalization, and cardiovascular outcomes, including nonfatal myocardial infarction, revascularization, or stroke.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eParticipants were divided into three groups based on their kidney function. The chi-square test and t-test were used to compare categorical and continuous clinical and laboratory parameters, respectively, among the three groups. Univariate and multivariate linear regression analyses were performed to investigate the association between clinical factors and frailty. The variables were selected using a forward conditional method. Statistical analyses were performed using the SPSS for Windows (ver. 25.0; IBM corp., Armonk, NY.). Statistical significance was defined as \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eBaseline characteristics according to kidney function\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe prospectively enrolled 106 patients, and excluded 18 with underlying dementia, or no available serum creatinine levels (Additional file 1). The mean age of the 88 patients included in this study was 62.4 years, and 58% were male. Regarding the patients\u0026rsquo; kidney function, 30 were assigned to the non-CKD group, 28 to the CKD stage 3-4 group, and 30 to the CKD stage 5D group. The CKD stage 5D group had significantly lower serum hemoglobin, cholesterol, and albumin levels than the other groups, this group also had the highest percentage of patients with diabetes mellitus and hypertension. The proportion of patients with coronary artery disease and cerebrovascular disease was higher in the CKD stage 5D group than in the non-CKD group but was highest in the CKD stage 3-4 group (Table 1). In the CKD stage 5D group, the median dialysis vintage was 19.6 months (0.0 \u0026ndash; 172.4 months). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFrailty and kidney function\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eFrailty was observed in 27 patients (30.7%):, 4 patients (13.3%) in the non-CKD group, 6 patients (21.4%) in the\u0026nbsp;CKD stage 3-4 group, and 17\u0026nbsp;patients (56.7%) in the CKD stage 5D group (\u003cem\u003eP\u003c/em\u003e=0.001) (Table 1, Figure 1). CKD was significantly associated with frailty even after adjustment for covariates (Table 2). Among CKD groups, the CKD stage 5D group showed a significantly higher odds ratio (OR) of frailty compared to the non-CKD group (OR, 7.99; 95% confidence interval [CI], 2.10 \u0026ndash; 30.32; \u003cem\u003eP\u003c/em\u003e=0.002). In addition, frailty was significantly related to cognitive impairment (OR 7.85; 95% CI 2.18 \u0026ndash; 28.26; P=0.002), but other clinical factors, including nutritional status, were not significantly related (Table 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCognitive impairment and kidney function\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCognitive impairment was observed in 15 patients (17.0%): 4 patients (13.3%) in the non-CKD group, 4 patients (14.3%) in the\u0026nbsp;CKD stage 3-4 group, and 7\u0026nbsp;patients (23.3%) in the CKD stage 5D group (\u003cem\u003eP\u003c/em\u003e=0.527) (Table 1, Figure 1). The proportion of patients with cognitive impairment increased with decreased kidney function\u0026rsquo; however, the difference was not statistically significant. Nevertheless, the K-MoCA scores were significantly lower in the dialysis group than in the other groups (Tabel 1). Logistic regression analysis was used to evaluate factors associated with cognitive impairment. CKD was not significantly associated with cognitive impairment. Only age (OR 1.34, 95% CI 1.13 \u0026ndash; 1.58, \u003cem\u003eP\u003c/em\u003e=0.001), and BMI (OR 1.19, 95% CI 1.03 \u0026ndash; 1.37, \u003cem\u003eP\u003c/em\u003e=0.018) were related to cognitive impairment (Table 3). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNutritional status and kidney function\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe NQ score was lowest in the dialysis group, and the proportion of high nutritional status (well-nourished status) was also lower than in the other groups. (Table 1, Figure 1, Supplementary table 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 4 shows that CKD groups had a significant association with well-nourished status in the crude and fully adjusted models. The CKD 5D group had a significantly lower OR of a well-nourished status compared to the non-CKD group (OR 0.21, 95% CI 0.06 \u0026ndash; 0.75, \u003cem\u003eP\u003c/em\u003e=0.030). In univariate analysis, well-nourished status was significantly associated with BMI, frailty, cognitive impairment, serum protein level, and CKD. However, only CKD groups and BMI (OR 0.87, 95% CI 0.76 \u0026ndash; 0.99, \u003cem\u003eP\u003c/em\u003e=0.034) were significantly associated with well-nourished status after adjusting for covariates. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring the follow up period of 141.6 \u0026plusmn; 67.7 months, the composite clinical outcome was observed in 54.5% (N = 48) of patients, of which all-cause death occurred in 5.7% (N = 5), cardiovascular outcome occurred in 8.0% (N = 7), and hospitalization occurred in 53.4% (N = 47). Patients in the CKD 5D group were significantly more likely to achieve the composite clinical outcomes compared with the non-CKD group (OR 6.94, 95% CI 2.18 \u0026ndash; 22.12, \u003cem\u003eP\u003c/em\u003e=0.001). In the univariate analysis, frailty, cognitive impairment, and nutritional status were not significantly associated with the clinical outcomes (Table 5). When evaluating the relationship between each component of clinical outcome and the CKD group, statistical significance was only observed for hospitalization, and not for all-cause death or cardiovascular outcomes (Additional file 2).\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this prospective outpatient cohort study, we explored the associations between kidney function and frailty, nutritional status, cognitive impairment, and clinical outcomes. We found that the prevalence of frailty increased in patients with CKD, especially in those receiving dialysis (CKD stage 5D group), and that impaired kidney function was significantly related to frailty, nutritional status, and clinical outcomes, but not with cognitive impairment.\u003c/p\u003e \u003cp\u003ePrevious studies have shown that the prevalence of frailty, malnutrition, and cognitive impairment as well as clinical outcomes such as death, cardiovascular events, and hospitalization are higher in patients with CKD than in those without CKD [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Wilhelm-Leen et al. analyzed the association between frailty and CKD using data from the Third National Health and Nutrition Examination Survey. In present study, frailty was significantly associated with CKD, and both frailty and CKD were independently associated with mortality [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eKopple et al. examined protein-energy nutritional status according to kidney function in the Modification of Diet in Renal Disease Study, and showed that nutritional status declines as the kidney function decreases [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. In another study, Tseng et al. assessed the relationship between frailty and nutritional status in patients with stage 3\u0026ndash;5 CKD. They found that the PEW was significantly associated with frailty in CKD [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCoppolino et al. revealed that cognitive capacity decrease across CKD stages, and frailty is common in elderly patients with CKD [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. In the general population, frailty and cognitive impairment have shown a close relationship in previous studies [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. However, research on the relationship between frailty and cognitive impairment in patients with CKD is lacking. In addition, there is still very little research on the relationship between frailty, nutritional status, and cognitive impairment according to kidney function, and its impact on clinical outcomes, including death.\u003c/p\u003e \u003cp\u003eOur study showed that at baseline, especially in the CKD stage 5D group, the proportion of frailty was higher and the NQ and K-MoCA scores were significantly lower than those in the other groups, which is consistent with previous studies [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In contrast to previous studies, however, the present study evaluated frailty, nutritional status, cognitive impairment, and kidney function These factors did not all exhibit a close relationship with each other; significant associations were seen between CKD and frailty, CKD and nutritional status, and cognitive impairment and frailty. Furthermore, frailty, nutritional status, and cognitive impairment at the time of enrollment had no significant association with clinical outcomes; the only significant relationship with clinical outcomes was observed in the CKD stage 5D group compared with the non-CKD group.\u003c/p\u003e \u003cp\u003eIn summary of previous results, frailty, PEW, and cognitive impairment were significantly associated with CKD. However, studies comprehensively examining these factors are lacking. In this respect, our study has the advantage of comprehensively investigating the relationship between kidney function and other important factors in patients with CKD.\u003c/p\u003e \u003cp\u003eWe suggest several explanations for the association between CKD and frailty, nutritional status, and clinical outcomes, but not cognitive impairment. First, CKD is not only a risk factor for frailty and malnutrition, but also shares pathophysiological mechanisms, such as oxidative stress, renin-angiotensin-aldosterone system activation, inflammation, and metabolic acidosis; therefore, they are closely related and influence each other, ultimately leading to poor clinical outcomes. Second, patients with CKD stage 5D showed the most significant correlation with clinical outcomes, which may be because the progression to kidney failure itself has an influence on clinical factors and because the number of enrolled patients was relatively small. Third, because the duration of dialysis was short and relatively young patients were included, a correlation between kidney function and cognitive impairment may not have been present. The association with dementia in patients undergoing dialysis is usually explained by the hemodynamic instability during dialysis, decreased brain perfusion, and uremic toxicity. However, in our study, the median vintage of dialysis patients was 19.6 months, which means that maintenance dialysis duration was relatively short; this means that residual kidney function could be preserved, decreasing the risk of uremia and intradialytic hypotension. Our study suggests that clinicians should pay attention to the frailty and nutritional status of patients with CKD, especially those requiring dialysis, regardless of age, as even relatively healthy patients receiving outpatient treatment warrant this attention. Additionally, since patients with CKD stage 5D have poor clinical outcomes compared to patients without CKD, clinicians should make efforts to delay CKD progression.\u003c/p\u003e \u003cp\u003eOur study had several limitations. First, due to the single-center design and to small number of observational cohort characteristics, the causality between kidney function and worsened frailty, nutritional status, and clinical outcomes cannot be determined and should be interpreted as a relationship. Second, our study enrolled relatively healthy patients who were eligible for outpatient treatment and did not include patients with severe frailty, malnourishment, or cognitive impairment. Third, our study investigated the relationship between cognitive impairment and kidney function at baseline and did not assess cognitive function at follow-up. Therefore, caution is needed when interpreting the relationship between kidney function and cognitive impairment, and additional research is needed in the future. Despite these limitations, the strength of our study was that we examined the relationship between kidney function and frailty, nutritional status, cognitive impairment, and clinical outcomes.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study showed that CKD, especially CKD stage 5D, is significantly associated with frailty, nutritional status, and poor clinical outcomes. This suggests that we need to focus more on frailty, nutrition, and prevention of progression to kidney failure in patients with CKD.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBMI, body mass index; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; K-MoCA, Korean-Montreal Cognitive Assessment; MDRD, Modification of Diet in Renal Disease; MMSE, Mini-Mental State Examination; MoCA, Montreal Cognitive Assessment; NQ, Nutritional Quotient; NQ-E, Nutritional Quotient-elderly; OR, odds ratio; PEW, protein energy wasting\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Board of Gyeongsang National University Hospital (IRB No. 2019-03-014-001). We obtained informed consent from each participant.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the Lee Jung Ja research grant of Gyeongsang National University Hospital (LJJ-GNUH-2019-0006), and National Research Foundation of Korea (NRF) grant funded by the Korean government (MSIT) [grant number: 2020R1C1C1011380].\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization: TWY, and EB; methodology: YMK, DHK, and OYK; validation: YMK and YSK; formal analysis: YMK, DHK, and TWL; writing: TWY, DJP and EB.; supervision: OYK, DJP and EB; Funding Acquisition TWY, and EB. \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eClegg A, Young J, Iliffe S, Rikkert MO, Rockwood K: \u003cstrong\u003eFrailty in elderly people\u003c/strong\u003e. \u003cem\u003eLancet \u003c/em\u003e2013, \u003cstrong\u003e381\u003c/strong\u003e(9868):752-762.\u003c/li\u003e\n\u003cli\u003eGale CR, Cooper C, Aihie Sayer A: \u003cstrong\u003ePrevalence of frailty and disability: findings from the English Longitudinal Study of Ageing\u003c/strong\u003e. \u003cem\u003eAge and Ageing \u003c/em\u003e2014, \u003cstrong\u003e44\u003c/strong\u003e(1):162-165.\u003c/li\u003e\n\u003cli\u003eCorbi G, Cacciatore F, 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Screening Battery (SNSB)\u003c/strong\u003e. \u003cem\u003eDement Neurocogn Disord \u003c/em\u003e2021, \u003cstrong\u003e20\u003c/strong\u003e(3):28-37.\u003c/li\u003e\n\u003cli\u003e이 정, 김 혜, 황 지, 권 세, 정 해, 곽 동, 강 명, 최 영, Lee J-S, Kim H-Y\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003e한국 성인을 위한 영양지수 개발과 타당도 검증\u003c/strong\u003e. \u003cem\u003eJ Nutr Health \u003c/em\u003e2018, \u003cstrong\u003e51\u003c/strong\u003e(4):340-356.\u003c/li\u003e\n\u003cli\u003eKim DE, Lim HS, Ahn H, Kim YS, Park YK: \u003cstrong\u003eSex Differences in the Association between Living Environmental Factors and Nutritional Status in Community-Dwelling Elderly Koreans\u003c/strong\u003e. \u003cem\u003eInt J Environ Res Public Health \u003c/em\u003e2020, \u003cstrong\u003e17\u003c/strong\u003e(17).\u003c/li\u003e\n\u003cli\u003eChan GC-K, Kalantar-Zadeh K, Ng JK-C, Tian N, Burns A, Chow K-M, Szeto C-C, Li PK-T: \u003cstrong\u003eFrailty in Patients on Dialysis\u003c/strong\u003e. \u003cem\u003eKidney international\u003c/em\u003e.\u003c/li\u003e\n\u003cli\u003eAlfaadhel TA, Soroka SD, Kiberd BA, Landry D, Moorhouse P, Tennankore KK: \u003cstrong\u003eFrailty and mortality in dialysis: evaluation of a clinical frailty scale\u003c/strong\u003e. \u003cem\u003eClinical journal of the American Society of Nephrology : CJASN \u003c/em\u003e2015, \u003cstrong\u003e10\u003c/strong\u003e(5):832-840.\u003c/li\u003e\n\u003cli\u003eKopple JD, Greene T, Chumlea WC, Hollinger D, Maroni BJ, Merrill D, Scherch LK, Schulman G, Wang SR, Zimmer GS: \u003cstrong\u003eRelationship between nutritional status and the glomerular filtration rate: results from the MDRD study\u003c/strong\u003e. \u003cem\u003eKidney international \u003c/em\u003e2000, \u003cstrong\u003e57\u003c/strong\u003e(4):1688-1703.\u003c/li\u003e\n\u003cli\u003eTseng PW, Lin TY, Hung SC: \u003cstrong\u003eAssociation of Frailty With Nutritional Status in Patients With Chronic Kidney Disease\u003c/strong\u003e. \u003cem\u003eJournal of renal nutrition : the official journal of the Council on Renal Nutrition of the National Kidney Foundation \u003c/em\u003e2024, \u003cstrong\u003e34\u003c/strong\u003e(2):133-140.\u003c/li\u003e\n\u003cli\u003eCoppolino G, Bolignano D, Gareri P, Ruberto C, Andreucci M, Ruotolo G, Rocca M, Castagna A: \u003cstrong\u003eKidney function and cognitive decline in frail elderly: two faces of the same coin?\u003c/strong\u003e \u003cem\u003eInternational urology and nephrology \u003c/em\u003e2018, \u003cstrong\u003e50\u003c/strong\u003e(8):1505-1510.\u003c/li\u003e\n\u003cli\u003eKulmala J, Nyk\u0026auml;nen I, M\u0026auml;nty M, Hartikainen S: \u003cstrong\u003eAssociation between frailty and dementia: a population-based study\u003c/strong\u003e. \u003cem\u003eGerontology \u003c/em\u003e2014, \u003cstrong\u003e60\u003c/strong\u003e(1):16-21.\u003c/li\u003e\n\u003cli\u003eSugimoto T, Arai H, Sakurai T: \u003cstrong\u003eAn update on cognitive frailty: Its definition, impact, associated factors and underlying mechanisms, and interventions\u003c/strong\u003e. \u003cem\u003eGeriatrics \u0026amp; gerontology international \u003c/em\u003e2022, \u003cstrong\u003e22\u003c/strong\u003e(2):99-109.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e\u003cstrong\u003e. Baseline characteristics of the study population stratified by CKD group\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.166666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(N =88)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon-CKD\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(N =30)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.708333333333332%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCKD\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003estage\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e3-4\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;(N =28)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCKD\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003estage\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e5D\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(N =30)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.458333333333334%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.166666666666668%\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e62.4 \u0026plusmn; 11.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e59.6 \u0026plusmn; 11.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.708333333333332%\"\u003e\n \u003cp\u003e64.9 \u0026plusmn; 10.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e62.9 \u0026plusmn; 12.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.458333333333334%\" colspan=\"2\"\u003e\n \u003cp\u003e0.227\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.166666666666668%\"\u003e\n \u003cp\u003eMen, %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e58.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e40.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.708333333333332%\"\u003e\n \u003cp\u003e64.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e70.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.458333333333334%\" colspan=\"2\"\u003e\n \u003cp\u003e0.045\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.166666666666668%\"\u003e\n \u003cp\u003eEducation level, %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.708333333333332%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.458333333333334%\" colspan=\"2\"\u003e\n \u003cp\u003e0.043\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.166666666666668%\"\u003e\n \u003cp\u003eLess than elementary school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e3.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.708333333333332%\"\u003e\n \u003cp\u003e10.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.458333333333334%\" colspan=\"2\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.166666666666668%\"\u003e\n \u003cp\u003eMiddle school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e26.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e23.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.708333333333332%\"\u003e\n \u003cp\u003e32.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e23.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.458333333333334%\" colspan=\"2\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.166666666666668%\"\u003e\n \u003cp\u003eHigh school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e39.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e30.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.708333333333332%\"\u003e\n \u003cp\u003e35.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e53.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.458333333333334%\" colspan=\"2\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.166666666666668%\"\u003e\n \u003cp\u003eCollege\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e30.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e46.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.708333333333332%\"\u003e\n \u003cp\u003e21.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e23.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.458333333333334%\" colspan=\"2\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.166666666666668%\"\u003e\n \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e23.8 \u0026plusmn; 4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e24.0 \u0026plusmn; 3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.708333333333332%\"\u003e\n \u003cp\u003e23.8 \u0026plusmn; 4.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e23.7 \u0026plusmn; 4.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.458333333333334%\" colspan=\"2\"\u003e\n \u003cp\u003e0.743\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.166666666666668%\"\u003e\n \u003cp\u003eSBP (mmHg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e137.0 \u0026plusmn; 20.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e131.7\u0026plusmn; 17.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.708333333333332%\"\u003e\n \u003cp\u003e140.5 \u0026plusmn; 21.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e139.0 \u0026plusmn; 21.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.458333333333334%\" colspan=\"2\"\u003e\n \u003cp\u003e0.217\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.166666666666668%\"\u003e\n \u003cp\u003eDBP (mmHg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e74.0 \u0026plusmn; 13.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e75.4\u0026nbsp;\u0026plusmn; 12.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.708333333333332%\"\u003e\n \u003cp\u003e72.6 \u0026plusmn; 13.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e73.8 \u0026plusmn; 15.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.458333333333334%\" colspan=\"2\"\u003e\n \u003cp\u003e0.532\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.166666666666668%\"\u003e\n \u003cp\u003eFrailty, %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e30.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e13.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.708333333333332%\"\u003e\n \u003cp\u003e21.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e56.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.458333333333334%\" colspan=\"2\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.166666666666668%\"\u003e\n \u003cp\u003eNutritional Quotient score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e61.4 \u0026plusmn; 8.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e62.3\u0026nbsp;\u0026plusmn; 8.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.708333333333332%\"\u003e\n \u003cp\u003e64.3 \u0026plusmn; 9.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e57.8 \u0026plusmn; 7.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.458333333333334%\" colspan=\"2\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.166666666666668%\"\u003e\n \u003cp\u003eNutritional status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.708333333333332%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.458333333333334%\" colspan=\"2\"\u003e\n \u003cp\u003e0.055\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.166666666666668%\"\u003e\n \u003cp\u003e\u0026nbsp; High, %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e39.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e53.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.708333333333332%\"\u003e\n \u003cp\u003e46.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e20.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.458333333333334%\" colspan=\"2\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.166666666666668%\"\u003e\n \u003cp\u003e\u0026nbsp; Medium, %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e55.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e46.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.708333333333332%\"\u003e\n \u003cp\u003e46.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e73.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.458333333333334%\" colspan=\"2\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.166666666666668%\"\u003e\n \u003cp\u003e\u0026nbsp; Low, %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.708333333333332%\"\u003e\n \u003cp\u003e7.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e6.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.458333333333334%\" colspan=\"2\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.166666666666668%\"\u003e\n \u003cp\u003eCognitive impairment, %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e17.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e13.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.708333333333332%\"\u003e\n \u003cp\u003e14.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e23.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.458333333333334%\" colspan=\"2\"\u003e\n \u003cp\u003e0.527\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.166666666666668%\"\u003e\n \u003cp\u003eK-MoCA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e23.7 \u0026plusmn; 5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e25.4 \u0026plusmn; 4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.708333333333332%\"\u003e\n \u003cp\u003e23.1 \u0026plusmn; 6.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e22.6 \u0026plusmn; 6.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.458333333333334%\" colspan=\"2\"\u003e\n \u003cp\u003e0.044\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.166666666666668%\"\u003e\n \u003cp\u003eHemoglobin (g/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e12.0 \u0026plusmn; 1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e13.9\u0026nbsp;\u0026plusmn; 1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.708333333333332%\"\u003e\n \u003cp\u003e11.6\u0026nbsp;\u0026plusmn; 1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e10.5\u0026nbsp;\u0026plusmn; 1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.125%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.166666666666668%\"\u003e\n \u003cp\u003eGlucose (mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e133.8 \u0026plusmn; 50.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e123.6 \u0026plusmn; 57.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.708333333333332%\"\u003e\n \u003cp\u003e129.9 \u0026plusmn; 47.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e147.8 \u0026plusmn; 44.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.125%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.166666666666668%\"\u003e\n \u003cp\u003eCholesterol (mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e160.7 \u0026plusmn; 49.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e190.9 \u0026plusmn; 46.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.708333333333332%\"\u003e\n \u003cp\u003e156.8 \u0026plusmn; 38.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e134.1 \u0026plusmn; 46.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.125%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.166666666666668%\"\u003e\n \u003cp\u003eProtein (g/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e6.9 \u0026plusmn; 0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e7.2\u0026nbsp;\u0026plusmn; 0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.708333333333332%\"\u003e\n \u003cp\u003e6.8\u0026nbsp;\u0026plusmn; 0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e6.8\u0026nbsp;\u0026plusmn; 0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.125%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.166666666666668%\"\u003e\n \u003cp\u003eAlbumin (g/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e4.0\u0026nbsp;\u0026plusmn; 0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e4.3\u0026nbsp;\u0026plusmn; 0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.708333333333332%\"\u003e\n \u003cp\u003e3.9\u0026nbsp;\u0026plusmn; 0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e3.8\u0026nbsp;\u0026plusmn; 0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.125%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.166666666666668%\"\u003e\n \u003cp\u003eCRP (mg/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e5.2 \u0026plusmn; 14.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e1.4 \u0026plusmn; 2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.708333333333332%\"\u003e\n \u003cp\u003e8.1 \u0026plusmn; 16.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e6.4 \u0026plusmn; 18.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\"\u003e\n \u003cp\u003e0.073\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.125%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.166666666666668%\"\u003e\n \u003cp\u003eHypertension, %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e68.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e20.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.708333333333332%\"\u003e\n \u003cp\u003e85.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e100.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.125%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.166666666666668%\"\u003e\n \u003cp\u003eDiabetes, %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e47.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e13.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.708333333333332%\"\u003e\n \u003cp\u003e50.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e80.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.125%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.166666666666668%\"\u003e\n \u003cp\u003eCoronary artery disease, %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e17.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.708333333333332%\"\u003e\n \u003cp\u003e28.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e23.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\"\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.125%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.166666666666668%\"\u003e\n \u003cp\u003eCerebrovascular disease, %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e6.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.708333333333332%\"\u003e\n \u003cp\u003e14.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e6.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\"\u003e\n \u003cp\u003e0.098\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.125%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.166666666666668%\"\u003e\n \u003cp\u003eMalignancy, %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e11.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\"\u003e\n \u003cp\u003e10.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.708333333333332%\"\u003e\n \u003cp\u003e14.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e10.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\"\u003e\n \u003cp\u003e0.840\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.125%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eBMI, body mass index; CKD, chronic kidney disease; CRP, C-reactive protein; DBP, diastolic blood pressure; K-MoCA, Korean-Montreal Cognitive Assessment; ND, non-dialysis; SBP, systolic blood pressure; 5D, on dialysis \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Odds ratios for frailty risk factors\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.35353535353536%\" valign=\"top\"\u003e\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.323232323232325%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnivariate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.323232323232325%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMultivariate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\"\u003e\n \u003cp\u003e1.04 (0.99 \u0026ndash; 1.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e0.099\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\"\u003e\n \u003cp\u003eSex, female (ref. male)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\"\u003e\n \u003cp\u003e0.93 (0.37 \u0026ndash; 2.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e0.869\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\"\u003e\n \u003cp\u003eWell-nourished status (ref. low to medium)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\"\u003e\n \u003cp\u003e0.32 (0.11 \u0026ndash; 0.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e0.029\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\"\u003e\n \u003cp\u003eCognitive impairment (ref. no)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\"\u003e\n \u003cp\u003e4.58 (1.43 \u0026ndash; 14.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e0.010\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e4.46 (1.23 \u0026ndash; 16.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e0.023\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\"\u003e\n \u003cp\u003eHemoglobin (g/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\"\u003e\n \u003cp\u003e0.65 (0.49 \u0026ndash; 0.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\"\u003e\n \u003cp\u003eProtein (g/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\"\u003e\n \u003cp\u003e0.37 (0.16 \u0026ndash; 0.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e0.022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\"\u003e\n \u003cp\u003eCKD group (ref. non-CKD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\"\u003e\n \u003cp\u003e\u0026nbsp; CKD stage 3-4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\"\u003e\n \u003cp\u003e1.77 (0.44 \u0026ndash; 7.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e0.418\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e1.69 (0.40 \u0026ndash; 7.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e0.473\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\"\u003e\n \u003cp\u003eCKD stage 5D\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\"\u003e\n \u003cp\u003e\u0026nbsp;8.50 (2.37 \u0026ndash; 30.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;7.99 (2.10 \u0026ndash; 30.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eCI: confidence interval; CKD, chronic kidney disease; OR, odds ratio; 5D, on dialysis\u003c/p\u003e\n\u003cp\u003eAdjusted for age, sex, nutritional status, cognitive impairment, serum hemoglobin, protein, CKD group.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Odds ratios for cognitive impairment\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.35353535353536%\" valign=\"top\"\u003e\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.323232323232325%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnivariate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.323232323232325%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMultivariate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\" valign=\"top\"\u003e\n \u003cp\u003e1.21 (1.05 \u0026ndash; 1.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e0.010\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e1.34 (1.13 \u0026ndash; 1.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\"\u003e\n \u003cp\u003eSex, female (ref. male)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\" valign=\"top\"\u003e\n \u003cp\u003e1.25 (0.41 \u0026ndash; 3.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e0.691\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\"\u003e\n \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\" valign=\"top\"\u003e\n \u003cp\u003e1.21 (1.05 \u0026ndash; 1.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e0.010\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e1.40 (1.09 \u0026ndash; 1.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e0.009\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\"\u003e\n \u003cp\u003eFrailty (ref. no)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\"\u003e\n \u003cp\u003e4.58 (1.43 \u0026ndash; 14.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e0.010\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\"\u003e\n \u003cp\u003eWell-nourished status (ref. low to medium)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\"\u003e\n \u003cp\u003e0.19 (0.04 \u0026ndash; 0.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e0.035\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\"\u003e\n \u003cp\u003eCKD group (ref. non-CKD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e0.534\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\"\u003e\n \u003cp\u003e\u0026nbsp; CKD stage 3-4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\"\u003e\n \u003cp\u003e1.08 (0.24 \u0026ndash; 4.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e0.913\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\"\u003e\n \u003cp\u003eCKD stage 5D\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\"\u003e\n \u003cp\u003e1.98 (0.51 \u0026ndash; 7.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e0.322\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\"\u003e\n \u003cp\u003eCerebrovascular disease (ref. No)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\"\u003e\n \u003cp\u003e5.83 (1.05 \u0026ndash; 32.36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e0.044\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eCI: confidence interval; CKD, chronic kidney disease; OR, odds ratio; 5D, on dialysis\u003c/p\u003e\n\u003cp\u003eAdjusted for age, sex, BMI, frailty, nutritional status, CKD group, cerebrovascular disease.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4. Odds ratios for well-nourished status\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.35353535353536%\" valign=\"top\"\u003e\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.323232323232325%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnivariate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.323232323232325%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMultivariate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\" valign=\"top\"\u003e\n \u003cp\u003e0.98 (0.94 \u0026ndash; 1.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e0.256\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\"\u003e\n \u003cp\u003eSex, female (ref. male)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\" valign=\"top\"\u003e\n \u003cp\u003e1.90 (0.80 \u0026ndash; 4.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e0.149\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\"\u003e\n \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\" valign=\"top\"\u003e\n \u003cp\u003e0.89 (0.79 \u0026ndash; 0.99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e0.049\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e0.85 (0.73 \u0026ndash; 0.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e0.022\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\"\u003e\n \u003cp\u003eFrailty (ref. no)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\"\u003e\n \u003cp\u003e0.32 (0.11 \u0026ndash; 0.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e0.029\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\"\u003e\n \u003cp\u003eCognitive impairment (ref. no)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\"\u003e\n \u003cp\u003e0.19 (0.04 \u0026ndash; 0.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e0.035\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\"\u003e\n \u003cp\u003eHemoglobin (g/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\"\u003e\n \u003cp\u003e1.15 (0.91 \u0026ndash; 1.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e0.241\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\"\u003e\n \u003cp\u003eAlbumin\u0026nbsp;(g/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\"\u003e\n \u003cp\u003e3.39 (1.09 \u0026ndash; 10.54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e0.035\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\"\u003e\n \u003cp\u003eCKD group (ref. non-CKD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e0.027\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e0.010\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\"\u003e\n \u003cp\u003e\u0026nbsp; CKD stage 3-4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\"\u003e\n \u003cp\u003e0.76 (0.27 \u0026ndash; 2.13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e0.600\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e0.61 (0.20 \u0026ndash; 1.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e0.370\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\"\u003e\n \u003cp\u003eCKD stage 5D\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\"\u003e\n \u003cp\u003e0.22 (0.07 \u0026ndash; 0.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e0.009\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e0.15 (0.04 \u0026ndash; 0.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eCI: confidence interval; CKD, chronic kidney disease; OR, odds ratio; 5D, on dialysis\u003c/p\u003e\n\u003cp\u003eAdjusted for age, sex, BMI, frailty, cognitive impairment, serum hemoglobin, albumin, CKD group.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e5\u003c/strong\u003e\u003cstrong\u003e. Odds ratios for\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eclinical outcomes\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.35353535353536%\" valign=\"top\"\u003e\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.323232323232325%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnivariate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.323232323232325%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMultivariate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\" valign=\"top\"\u003e\n \u003cp\u003e1.01 (0.97 \u0026ndash; 1.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e0.769\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\"\u003e\n \u003cp\u003eSex, female (ref. male)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\" valign=\"top\"\u003e\n \u003cp\u003e1.17 (0.50 \u0026ndash; 2.73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e0.723\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\"\u003e\n \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\" valign=\"top\"\u003e\n \u003cp\u003e1.01 (0.91 \u0026ndash; 1.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e0.840\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\"\u003e\n \u003cp\u003eFrailty (ref. no)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\"\u003e\n \u003cp\u003e2.62 (0.99 \u0026ndash; 6.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e0.051\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\"\u003e\n \u003cp\u003eCognitive impairment (ref. no)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\"\u003e\n \u003cp\u003e1.31 (0.42 \u0026ndash; 4.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e0.642\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\"\u003e\n \u003cp\u003eWell-nourished status (ref. low to middle)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\"\u003e\n \u003cp\u003e0.983 (0.42 \u0026ndash; 2.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e0.968\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\"\u003e\n \u003cp\u003eHemoglobin (g/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\"\u003e\n \u003cp\u003e0.70 (0.55 \u0026ndash; 0.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\"\u003e\n \u003cp\u003eAlbumin (g/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\"\u003e\n \u003cp\u003e0.35 (0.12 \u0026ndash; 1.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e0.056\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\"\u003e\n \u003cp\u003eCKD group (ref. non-CKD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\"\u003e\n \u003cp\u003e\u0026nbsp; CKD stage 3-4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\"\u003e\n \u003cp\u003e3.11 (1.06 \u0026ndash; 9.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e0.040\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e2.82 (0.95 \u0026ndash; 8.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e0.063\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\"\u003e\n \u003cp\u003eCKD stage 5D\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\"\u003e\n \u003cp\u003e7.67 (2.42 \u0026ndash; 24.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e6.94 (2.18 \u0026ndash; 22.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\"\u003e\n \u003cp\u003eHypertension (ref. no)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\"\u003e\n \u003cp\u003e3.92 (1.51 \u0026ndash; 10.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\"\u003e\n \u003cp\u003eDiabetes mellitus (ref. no)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\"\u003e\n \u003cp\u003e2.60 (1.09 \u0026ndash; 6.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" valign=\"top\"\u003e\n \u003cp\u003e0.031\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.3265306122449%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eCI: confidence interval; CKD, chronic kidney disease; OR, odds ratio; 5D, on dialysis\u003c/p\u003e\n\u003cp\u003eAdjusted for age, sex, BMI, frailty, serum hemoglobin, albumin, CKD group, hypertension, diabetes mellitus.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nephrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bnep","sideBox":"Learn more about [BMC Nephrology](http://bmcnephrol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bnep/default.aspx","title":"BMC Nephrology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"CKD, frailty, nutritional status, cognitive impairment, clinical outcomes","lastPublishedDoi":"10.21203/rs.3.rs-4417340/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4417340/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eFrailty is a state of vulnerability to poor homeostatic resolution of after a stressful event. The prevalence of frailty in patients with chronic kidney disease (CKD) is more common than in the general population. Frailty is associated with a poor clinical prognosis, malnutrition, and cognitive impairment; however, studies on these factors in patients with CKD are lacking. Therefore, we aimed to evaluate the relationship between CKD and frailty, nutritional status, and cognitive impairment and their influence on clinical outcomes.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe prospectively enrolled participants from June 2019 to December 2020 and divided them into three CKD groups according to kidney function (non-CKD, CKD stage 3\u0026ndash;4, and CKD stage 5D). Clinical outcomes were defined as the composite outcomes of all-cause death, hospitalization, and cardiovascular outcomes, including nonfatal myocardial infarction, revascularization, or stroke. To calculate the relative risk of frailty, cognitive impairment, nutritional status, and clinical outcome, odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using logistic regression analysis.\u003c/p\u003e\u003ch2\u003eResult\u003c/h2\u003e \u003cp\u003eA total of 88 patients were included, of whom 30.7% had frailty and 17.0% had cognitive impairment. In the CKD stage 5D group, the prevalence of frailty (56.7%, n\u0026thinsp;=\u0026thinsp;17) was significantly higher, and the nutritional quotient score was lower in the other groups. The Korean-Montreal Cognitive Assessment score was significantly lower in the CKD stage 5D group; however, cognitive impairment did not differ among the three groups. Frailty was significantly associated with cognitive impairment and CKD stage 5D group. Cognitive impairment was significantly associated with older age and higher BMI. Well-nourished status was significantly associated with BMI and CKD stage 5D group. Patients in the CKD 5D group were significantly more likely to have adverse clinical outcomes.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe prevalence of frailty increased significantly as the CKD stage progressed. Particularly, CKD stage 5D group correlated with frailty and nutritional status, leading to poor clinical outcomes.\u003c/p\u003e","manuscriptTitle":"The prevalence of frailty according to kidney function and its association with cognitive impairment, nutritional status, and clinical outcome","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-03 14:38:47","doi":"10.21203/rs.3.rs-4417340/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-12-27T12:37:21+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-12-25T08:28:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"15435594181929528184257218639030709478","date":"2024-12-17T14:45:25+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-12-05T00:51:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"59021161210725901714066293681040269928","date":"2024-12-04T03:58:39+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-12-04T02:18:51+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-12-04T01:56:08+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-05-17T09:16:56+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-17T09:16:03+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nephrology","date":"2024-05-14T07:43:32+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nephrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bnep","sideBox":"Learn more about [BMC Nephrology](http://bmcnephrol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bnep/default.aspx","title":"BMC Nephrology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a1a8fb1a-a0a4-4769-a4e3-05257f8e1f8d","owner":[],"postedDate":"June 3rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-02-17T16:03:40+00:00","versionOfRecord":{"articleIdentity":"rs-4417340","link":"https://doi.org/10.1186/s12882-025-04006-5","journal":{"identity":"bmc-nephrology","isVorOnly":false,"title":"BMC Nephrology"},"publishedOn":"2025-02-10 15:57:49","publishedOnDateReadable":"February 10th, 2025"},"versionCreatedAt":"2024-06-03 14:38:47","video":"","vorDoi":"10.1186/s12882-025-04006-5","vorDoiUrl":"https://doi.org/10.1186/s12882-025-04006-5","workflowStages":[]},"version":"v1","identity":"rs-4417340","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4417340","identity":"rs-4417340","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}