An overview of frailty in kidney transplantation: measurement, management and future considerations

Abstract

The construct of frailty was first developed in gerontology to help identify older adults with increased vulnerability when confronted with a health stressor. This article is a review of studies in which frailty has been applied to pre- and post-kidney transplantation (KT) populations. Although KT is the optimal treatment for end-stage kidney disease (ESKD), KT candidates often must overcome numerous health challenges associated with ESKD before receiving KT. After KT, the impacts of surgery and immunosuppression represent additional health stressors that disproportionately impact individuals with frailty. Frailty metrics could improve the ability to identify KT candidates and recipients at risk for adverse health outcomes and those who could potentially benefit from interventions to improve their frail status. The Physical Frailty Phenotype (PFP) is the most commonly used frailty metric in ESKD research, and KT recipients who are frail at KT (~20% of recipients) are twice as likely to die as nonfrail recipients. In addition to the PFP, many other metrics are currently used to assess pre- and post-KT vulnerability in research and clinical practice, underscoring the need for a disease-specific frailty metric that can be used to monitor KT candidates and recipients. Although frailty is an independent risk factor for post-transplant adverse outcomes, it is not factored into the current transplant program risk-adjustment equations. Future studies are needed to explore pre- and post-KT interventions to improve or prevent frailty.

Prevalence of Frailty in Patients Referred to the Kidney Transplant Waitlist

“…This study has several strengths. It is the first study to assess frailty in patients referred to the kidney transplant waitlist using a Frailty Index and the Clinical Frailty Scale (9), and the first to compare these tools to the FP. It is also one of the few studies to assess frailty in Canadian kidney transplant candidates, and the inclusion of subjects from multiple sites increased diversity within the population.…”

“…It is uncertain which instruments yield the most clinically relevant measurement of frailty or how frail transplant candidates differ between measures. Gaining a better understanding of the differences in measured frailty using alternate tools in those being evaluated for kidney transplant has recently been identified as an important area of research (9).…”

Aorto-Iliac Artery Calcification Prior to Kidney Transplantation

“…Kidney transplantation improves survival of patients with end-stage renal disease (ESRD) and reduces cardiovascular disease burden [1,2]. Despite the improved prognosis after transplantation, patients remain vulnerable, with cardiovascular disease as the leading cause of death [2,3]. A high overall prevalence of cardiovascular disease in the first year after kidney transplantation is reported, with myocardial infarction (MI) in 5.1%, cerebrovascular accident (CVA)/transient ischemic attack (TIA) in 7.3%, and peripheral artery disease (PAD) in 15.8% of patients [2,4].…”

Frailty and the Potential Kidney Transplant Recipient: Time for a More Holistic Assessment?

“…After initial screening, we suggest patients identified at risk of frailty using the CFS should undergo further extensive assessment. Physical frailty, identified by the frailty phenotype (FP), is predictive of outcomes posttransplantation (42,43). It includes assessments of unintentional weight loss, handgrip strength, self-perceived exhaustion, walking speed, and physical activity (42).…”