An Overview of Frailty in Kidney Transplantation

Measurement, Management and Future Considerations

Meera N. Harhay; Maya K. Rao; Kenneth J. Woodside; Kirsten L. Johansen; Krista L. Lentine; Stefan G. Tullius; Ronald F. Parsons; Tarek Alhamad; Joseph Berger; XingXing S. Cheng; Jaqueline Lappin; Raymond Lynch; Sandesh Parajuli; Jane C. Tan; Dorry L. Segev; Bruce Kaplan; Jon Kobashigawa; Darshana M. Dadhania; Mara A. McAdams-DeMarco


Nephrol Dial Transplant. 2020;35(7):1099-1112. 

In This Article

Abstract and Introduction


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.


Frailty is a syndrome characterized by diminished strength, endurance and reduced physiologic function, increasing an individual's vulnerability for developing increased dependency and/or dying when confronted with a stressor.[1] The construct of frailty was first established by geriatricians and gerontologists who identified the need to distinguish the physiological age from the chronological age of older adults.[2] Metrics of frailty were developed to improve the ability to accurately identify the most vulnerable individuals in older populations by going beyond traditional risk factors such as age and comorbidity. In recent years there has also been a proliferation of research on frailty in nonelderly populations and in numerous medical subpopulations, including those with kidney disease and solid organ transplants.[3,4]

In kidney transplantation (KT), clinical care paradigms are adapting to an aging transplant candidate pool[5–7] and increasing waiting times.[8,9] These trends underscore the need to accurately identify KT candidates and recipients who are at higher risk of adverse outcomes when facing health stressors, including the surgical and immunologic stressors of KT. Some experts suggest that a patient's frailty status could inform decisions about the referral, evaluation and management of KT candidates as well as optimal rehabilitation plans after transplant surgery.[10,11]

In this review we summarize available tools to measure frailty. We then discuss the impact of frailty on access to KT and on morbidity and mortality before and after KT. Next, we consider topics relating to the immunosuppressive management of frail KT recipients and examine the most recent data on interventions to improve frailty. Finally, we emphasize key areas in which research is needed to improve the identification and clinical management of frailty in the KT patient population.