Falls in Moroccan chronic hemodialysis patients: toward a prevention-focused strategy

¹University Mohammed VI of Health Sciences, Mohamed VI International University Hospital- Bouskoura, Physical Medicine and Rehabilitation, Bouskoura, Morocco, ²University Mohammed VI of Health Sciences, Neurology Department Cheikh Khalifa Ibn Zayed Hospital, Casablanca, Morocco, ³University Mohammed VI of Health Sciences, Nephrology Hemodialysis and Transplantation, Cheikh Khalifa Ibn Zayed Hospital, Casablanca, Morocco

^&Corresponding author
Mouna Asly, University Mohammed VI of Health Sciences, Mohamed VI International University Hospital- Bouskoura, Physical Medicine and Rehabilitation, Bouskoura, Morocco

Introduction    

Chronic renal disease, comorbidities and hemodialysis are associated with hormonal, bone and hematologic abnormalities. These patients are prone to falls and their complications [1,2]. They are at a higher risk of falls, ranging from 13% to 25%, compared to the general population [3-5]. The rate of falls after hemodialysis is significantly higher compared to pre-hemodialysis, revealing a negative effect of hemodialysis on postural stability [3]. Falls are defined by the World Health Organization as inadvertently falling to the ground or at another lower level [6]. They can be classified as: accidental, when caused by environmental or by loss of the patient´s balance [4-6]. Falls in chronic renal patients are responsible for functional and emotional limitations with an important negative impact on the quality of life of people affected by this pathology, especially in elderly [7,8]. However, there have been few large studies on the etiology of falls occurring among HD patients [1,9-15]. Despite the growing burden of chronic kidney disease in low- and middle-income countries, data regarding falls among hemodialysis patients in North Africa remain limited. Identifying fall prevalence and associated risk factors is essential for implementing effective preventive strategies. This study aimed to assess the prevalence of falls during the previous year among chronic hemodialysis patients in Casablanca, Morocco, and to examine the association between falls and sociodemographic, clinical, and functional factors.

Methods     

Study design: a descriptive, cross-sectional, and multicentric study was conducted in a four nephrology centers in the city of Casablanca to determine the risk factors of falls in chronic hemodialysis patients.

Study setting and population: Morocco is a North African country bordered by the Atlantic Ocean and the Mediterranean Sea to the west and north, Algeria to the east, and Mauritania to the south. Administratively, the country is divided into 12 regions, which are further subdivided into provinces and prefectures. The Casablanca-Settat region is the most populous region in Morocco and includes the city of Casablanca, the country´s main economic hub and largest urban center. Chronic kidney disease is a major public health challenge in Morocco. The national Magredial registry, established in 2005, reported a crude prevalence of 267.1 cases per million inhabitants [16]. This study was a descriptive, multicenter, cross-sectional study conducted between April 2 and June 30, 2025, in four nephrology and hemodialysis centers in Casablanca, Morocco.

Participants: eligible participants were adults aged ≥ 18 years, undergoing maintenance hemodialysis for at least six months, and who provided informed consent. Patients with cognitive impairment, limb amputation, or who declined participation were excluded. The sample size corresponded to all eligible patients attending the participating centers during the study period.

Ethical considerations: the study protocol was approved by the Research Ethics Committee of Mohammed VI University of Health Sciences (CE/UM6SS/16/25). All participants were informed of the study objectives and confidentiality procedures.

Data collection and variables: data were collected using a structured, interviewer-administered questionnaire in the local language. Variables included sociodemographic characteristics (age, sex), clinical features (comorbidities, dialysis duration and modality), fall history (number of falls in the past 12 months), and potential risk factors such as polypharmacy, vitamin D deficiency, orthostatic hypotension, sedentary lifestyle, visual impairment, and diabetic neuropathy. Sedentary lifestyle was defined according to the World Health Organization as any waking activity with low energy expenditure (≤ 1.5 METs) while sitting, reclining, or lying, indicating lack of regular physical activity. Polypharmacy was defined as the use of five or more medications, and vitamin D deficiency was defined based on standard laboratory thresholds.

Functional assessment: fall risk was assessed using the Timed Up and Go (TUG) test [17]. A TUG time ≥ 13.5 seconds was considered indicative of high fall risk.

Statistical analysis: data were analyzed using Jamovi software (2021). Quantitative variables were expressed as mean ± standard deviation or median (interquartile range), as appropriate. Qualitative variables were expressed as percentages. Univariate logistic regression was performed to identify factors associated with falls. Variables with p < 0.15 in univariate analysis were entered into a multivariate logistic regression model. Statistical significance was set at p < 0.05.

Results     

Socio-demographic analysis: a total of 127 patients were included, 43.3% were men and 56.7% women, with sex ratio of 1: 1.3. The mean age of the participants was 64.6 ±13.8 years. The primary cause of nephropathy was diabetes in 41.7% of the population, nephroangiosclerosis in 25.2% and amyloidosis in 19.7%. Participants´ median time since dialysis start was 5 years [2- 9.5years]. The mode of dialysis was conventional hemodialysis in 73.2% of the population and Online Hemodiafiltration (OL-HDF) in 26.8%. The main characteristics of the study population are presented in Table 1.

Descriptive analysis: the prevalence of at least one fall in the previous year was 28.3%. Among fallers, 68.4% experienced more than one fall (Table 2). Eighty patients (63%) had a TUG score ≥ 13.5 seconds, indicating high fall risk. Reduced mobility requiring assistance was observed in 45.7% of participants. Fall risk factors presented the following characters: association of multiple factors at the same patient, prevalence of high blood pressure (73.2%), Vitamin D deficiency (75.6%), balance disorders (63%), sedentary lifestyle (64.6%), orthostatic hypotension (62.2%), vision problems (65.4%) and polypharmacy (55.1%) (Table 3).

Univariate analysis: univariate analysis identified several fall risk factors significantly associated with recent falls, including age [odds ratio (OR): 1.07, 95% confidence interval (CI): 1.03-1.12, P < 0.01], dialysis duration (OR: 0.91, 95% CI: 0.83-0.99, P = 0.028), diabetic neuropathy (OR: 1.42, 95% CI: 1.53-2.7, P = 0.03), polypharmacy (OR: 2.77, 95% CI: 1.2-3.4, P = 0.017), vitamin D deficiency (OR: 2.58, 95% CI: 1.38-4.28, P = 0.014), balance disorders (OR: 2.29, 95% CI: 1.94-5.9, P < 0.01), sedentary lifestyle (OR: 2.42, 95% CI: 1.69-4.3, P < 0.01), orthostatic hypotension (OR: 1.48, 95% CI: 1.24-2.9, P < 0.01), reduced mobility (OR: 2.11, 95% CI: 1.28-3.48, P < 0.01), and visual impairment (OR: 1.2, 95% CI: 1.12-2.16, P = 0.027) (Table 4).

Multivariate analysis: after adjusting for potential confounders in multivariate analysis, diabetic neuropathy (OR: 1.82, 95% CI: 1.23-2.2, P = 0.042), vitamin D deficiency (OR: 2.18, 95% CI: 1.11-4.11, P < 0.001), balance disorders (OR: 2.12, 95% CI: 1.67-4.6, P = 0.011), sedentary lifestyle (OR: 2.04, 95% CI: 1.2-3.5, P = 0.045), and dialytic hypotension (OR: 1.2, 95% CI: 1.21-2.5, P = 0.008) remained statistically significant and clinically relevant predictors of falls.

Discussion     

Patients undergoing hemodialysis are at a higher risk of falls compared to the general population [1,3,14]. In our study, the annual prevalence of falls was 28.3%, consistent with previous reports. Cook et al. in Canada [1], Roberts et al. in the United Kingdom [9], and Abdel-Rahman et al. in the United States [13] reported fall incidences of 27%, 30%, and 26.3%, respectively, highlighting that falls are a common problem in dialysis populations globally. Consistent with prior research [1,9-15], we observed a strong correlation between fall incidence and advancing age. Age-related changes in muscle strength, balance, and gait likely contribute to the increased vulnerability of older hemodialysis patients.

Balance disorders and impaired mobility are well-established predictors of falls [18,19]. In our cohort, more than half of the patients demonstrated high fall risk based on the Timed Up and Go (TUG) test, and a subset required walking assistance, reflecting a high degree of motor fragility and functional dependence in this population. Vitamin D plays a key role in lower limb muscle function, postural stability, and gait [13]. Low serum 25(OH)D levels have been strongly associated with increased fall risk and fall frequency [20,21]. In our study, vitamin D deficiency was highly prevalent, and most patients were inadequately supplemented, underscoring a modifiable risk factor that warrants intervention. Diabetic peripheral neuropathy is another important contributor to falls, causing muscle weakness, reduced ankle reflexes, and impaired balance and gait coordination [22-24]. We found a significant association between diabetic neuropathy and fall risk, consistent with previous studies. Additional factors, including polypharmacy, orthostatic hypotension, vision impairment, and sedentary lifestyle, were significantly associated with falls in our cohort, in line with previous research [9,10,25,26]. These findings emphasize that multiple, potentially modifiable factors contribute to fall risk in hemodialysis patients. Preventing falls in high-risk dialysis patients requires a multidisciplinary and individualized approach. Strategies should include:

Medical interventions: regular review of medications to minimize polypharmacy, vitamin D supplementation, and management of orthostatic hypotension.

Physical interventions: exercise and rehabilitation programs, low-impact exercises during dialysis sessions, and use of assistive devices to improve strength and balance.

Environmental adaptations: home safety evaluations and modifications to reduce hazards.

Education: patient and caregiver training on fall prevention, safe mobility, and recognition of early warning signs.

Sensory aids: Regular vision and hearing assessments with corrective interventions as needed.

Psychological support: counseling and cognitive-behavioral strategies to reduce fear of falling and increase confidence.

Multidisciplinary planning and monitoring: individualized fall prevention plans with ongoing follow-up to ensure adherence and evaluate effectiveness [27].

Our results underscore the importance of early identification of high-risk patients and the implementation of comprehensive preventive measures to reduce falls and improve functional outcomes in the hemodialysis population. This study has some limitations. Its cross-sectional design precludes establishing causal relationships between risk factors and falls. The sample size was relatively small, and the study was conducted over a short duration, which may limit the generalizability of the findings. Additionally, falls were self-reported, introducing potential recall bias.

Conclusion     

Falls are common among Moroccan chronic hemodialysis patients, affecting more than one-quarter of the population in this study. Several modifiable factors-including vitamin D deficiency, balance disorders, diabetic neuropathy, sedentary lifestyle, and orthostatic hypotension-were independently associated with increased fall risk. These findings highlight the need for a multidisciplinary, prevention-focused approach in the management of dialysis patients. Interventions should combine medical optimization, physical rehabilitation, environmental modifications, patient and caregiver education, and ongoing monitoring to reduce fall risk and improve functional outcomes.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Mouna Asly: conceptualization, methodology, formal analysis, writing - original draft. Asmaa Hazim, Jehanne Aasfara, Hiba Eloury: data curation, writing - review and editing. Abdelatif Elfatimi: supervision. All the authors read and approved the final version of this manuscript.

Acknowledgments     

Our thanks to Professor Driss Zaid, Dr Abdelaziz Jabrane for their valuable contribution in Data collection.

Tables     

Table 1: sociodemographic characteristics (age, gender, primary renal disease, dialysis mode and duration) of adult patients undergoing hemodialysis in four nephrology centers in Casablanca, Morocco, April - June 2025 (N = 127)

Table 2: characteristics and frequency of falls in the previous 12 months among adult patients undergoing hemodialysis in four nephrology centers in Casablanca, Morocco, April - June 2025 (N = 127; 36 patients with falls)

Table 3: clinical and functional risk factors for falls among adult patients undergoing hemodialysis in four nephrology centers in Casablanca, Morocco, April - June 2025 (N = 127)

Table 4: univariate and multivariate logistic regression of sociodemographic, clinical, and functional risk factors associated with recent fall in the previous 12 months among adult patients undergoing hemodialysis in four nephrology centers in Casablanca, Morocco, April - June 2025 (N = 127)

References