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

Abstract

Frailty is an age-related clinical syndrome characterized by a decline in physiologic reserve and an associated decreased ability to respond to stressor events (1). Importantly, frailty is associated with an increased risk of adverse outcomes, including falls, hospitalization, poorer health-related quality of life (HRQOL), and ultimately earlier than expected death (1). Frailty is a significant health burden for patients with advanced CKD (2). The decline from fitness to frailty is influenced by an array of factors, such as sarcopenia, infection and inflammation, cognitive impairment, reduced physical exercise threshold, vitamin D deficiency, metabolic acidosis, and cellular senescence (2⇓⇓⇓⇓–7). Pathophysiologic processes inherent to CKD exacerbate this decline (2). Although the concept of frailty has received more attention in recent years within nephrology, there remain uncertainties as to how it should be best used to inform shared decision making around RRT, including transplantation. Research has been performed on frailty in solid organ (other than kidney) and stem cell transplantation. A recent consensus conference sponsored by the American Society of Transplantation concluded that the optimal methods by which frailty should be measured in each organ group are yet to be determined, and that interventions to reverse frailty vary among organ groups and appear promising if unproven (8). Frailty is generally well accepted as a predictor of short-term mortality with surgery (9) and after admission to critical care environments (10). One may wonder about the relevance of frailty in lung transplantation in what is perhaps the most vulnerable group of patients pre- and post-transplant. An earlier study suggested increased risk of death and delisting in lung transplant candidates living with frailty (11). We also know that frailty is common at discharge after lung transplantation (12). Somewhat surprisingly, frailty does not seem to correlate with length of hospital stay nor …