Dynamic Frailty Before Kidney Transplantation: Time of Measurement Matters

Abstract

Background. Frail kidney transplant (KT) recipients have higher risk of adverse post-KT outcomes. Yet, there is interest in measuring frailty at KT evaluation and then using this information for post-KT risk stratification. Given long wait times for KT, frailty may improve or worsen between evaluation and KT. Patterns, predictors, and post-KT adverse outcomes associated with these changes are unclear. Methods. Five hundred sixty-nine adult KT candidates were enrolled in a cohort study of frailty (November 2009-September 2017) at evaluation and followed up at KT. Patterns of frailty transitions were categorized as follows: (1) binary state change (frail/nonfrail), (2) 3-category state change (frail/intermediate/nonfrail), and (3) raw score change (−5 to 5). Adjusted Cox proportional hazard and logistic regression models were used to test whether patterns of frailty transitions were associated with adverse post-KT outcomes. Results. Between evaluation and KT, 22.0% became more frail, while 24.4% became less frail. Black race (relative risk ratio, 1.98; 95% confidence interval [CI], 1.07-3.67) was associated with frail-to-nonfrail transition, and diabetes (relative risk ratio, 2.56; 95% CI, 1.22-5.39) was associated with remaining stably frail. Candidates who became more frail between 3-category states (hazard ratio, 2.27; 95% CI, 1.11-4.65) and frailty scores (hazard ratio, 2.36; 95% CI, 1.12-4.99) had increased risk of post-KT mortality and had higher odds of length of stay ≥2 weeks (3-category states: odds ratio, 2.02; 95% CI, 1.20-3.40; frailty scores: odds ratio, 1.92; 95% CI, 1.13-3.25). Conclusions. Almost half of KT candidates experienced change in frailty between evaluation and KT, and those transitions were associated with mortality and longer length of stay. Monitoring changes in frailty from evaluation to admission may improve post-KT risk stratification.

Implications of Frailty for Peritransplant Outcomes in Kidney Transplant Recipients

“…Such timing is practical and useful for research studies but requires modification for useful clinical practice. Measuring frailty at the time of transplant evaluation can help inform transplant candidacy and type of transplant offered but may miss deceased donor transplant candidates who become frail while awaiting transplant 36 . Measuring frailty immediately prior to transplant can help guide post-transplant management but will have little bearing on decisions and counseling regarding transplant candidacy.…”

Frailty Prevalence in Younger End-Stage Kidney Disease Patients Undergoing Dialysis and Transplantation

“…Differences in prevalence across the ESKD care continuum may be attributable to the greater risk of mortality and reduced chance of KT among frail patients as suggested by prior studies [19]. Additionally, prior studies have demonstrated the dynamic nature of frailty among ESKD patients undergoing HD, on the waitlist, or recipients post-KT, such that improvements in frailty scores can be observed over time [39-41]. This suggests that frailty in many cases is not an irreversible state of low physiological reserve [41, 42], which provides an optimistic avenue for intervention.…”

Prevalence of frailty among kidney transplant candidates and recipients in the United States: Estimates from a National Registry and Multicenter Cohort Study

“…We studied the Fried physical frailty phenotype as defined 1 in older adults as well as in end-stage renal disease and KT populations. [2][3][4][5][6][7][8]10,11,14,[18][19][20][21][22][23] The Fried physical frailty phenotype was based on five components: shrinking (self-report of unintentional weight loss of more than 10 pounds in the past year based on dry weight); weakness (grip-strength below an established cutoff based on gender and BMI); exhaustion (self-report); low activity (kcals/week below an established cutoff); and slowed walking speed (walking time of 15 feet below an established cutoff by gender and height). 1 Each of the five components was scored as 0 or 1, representing the absence or presence of that component.…”