Nursing Facility (NF) Residents with Anemia Associated with Chronic Kidney Disease (CKD) Require Greater Assistance in Performing Activities of Daily Living (ADL) Compared to Residents with CKD without Anemia.
Authors: Schnelle John , Osterweil Dan , Globe Denise , Sciarra Angela , Barlev Arie 
Published: October 2019

Abstract
Anemia is a well known complication of CKD and is associated with symptoms of fatigue, decreased muscle strength, and reduced oxygen capacity. However, the effect of anemia associated with CKD on ADLs in NF residents has not been well described. The purpose of this analysis was to evaluate the effect of the anemia associated with CKD on ADLs in NF residents. ALTER (Anemia and associated outcomes in Long-TErm care Residents) was a retrospective study conducted in a representative sample of 24 NFs. Chart data was integrated with electronic Minimum Data Set (MDS) records and prescription claims for the 1-year period before the date of data abstraction. Eligible residents were ≥ 65 years, not receiving dialysis, and not comatose. CKD was conservatively defined as eGFR < 60mL/min/1.73 m2 (MDRD equation). Anemia was defined by the WHO criteria (< 13g/dL for men and < 12g/dL for women). Residents were stratified into two groups: those with CKD and anemia and those with CKD but had no anemia. The first available record to estimate GFR was used to establish the presence of CKD. Diagnosis of anemia was established by an indication of anemia in the chart records as well as a laboratory diagnosis of anemia within 15 days of the chart record. Residents who did not have anemia had no records of an anemia diagnosis either in their chart or as a laboratory diagnosis. Section G of the MDS was used to describe ADLs. ADL scores of 0 or 1 were described as residents who needed slight help in performing an activity, and scores of 2, 3, or 4 were described as residents who needed moderate/significant help. Residents who did not perform an activity during a 7 day period were excluded (ADL score of 8). Bootstrapping, a statistical method which allows for the estimation of population parameters in order to draw inferences about the population(s) from which the data came, was applied to analyze the association of ADLs with CKD and anemia. From a database of 2204 residents, 1501 had a GFR record for CKD diagnosis. Of the 1501, 4.6% (69/1501) had CKD and a confirmed indication of anemia, and 6.9% (104/1501) had CKD but no anemia. The association between ADLs and disease are shown below. The results indicate that a greater percent of residents with CKD and anemia than residents with CKD but no anemia require moderate to significant assistance for their daily physical functioning and suggests that treating anemia may improve ADLs.
Percent of residents requiring moderate to significant help (bootstrap 95% CI) ADL CKD, anemic (n=69) CKD, no anemia (n=104) Bed Mobility 78% (72%, 83%) 57% (52%, 62%) Transfer 83% (79%, 88%) 62% (58%, 67%) Walk in Room 71% (61%, 79%) 44% (38%, 51%) Walk in Corridor 70% (61%, 79%) 44% (37%, 51% Locomotion on Unit 72% (67%, 78%) 57% (51%, 62%) Locomotion off Unit 73% (67%, 79%) 64% (60%, 69%) Dressing 89% (86%, 93%) 79% (75%, 83%) Eating 25% (20%, 32%) 23% (20%, 27%) Toilet Use 84% (80%, 88%) 71% (67%, 74%) Personal Hygiene 84% (81%, 91%) 75% (72%, 79%)