Frailty and access to kidney transplantation

Abstract

Background and objectives Frailty, a syndrome distinct from comorbidity and disability, is clinically manifested as a decreased resistance to stressors and is present in up to 35% of patient with ESKD. It is associated with falls, hospitalizations,poor cognitive function, andmortality.Also, frailty is associatedwithpooroutcomes afterkidney transplant, including delirium and mortality. Frailty is likely also associated with decreased access to kidney transplantation, given its association with poor outcomes on dialysis and post-transplant. Yet, clinicians have difficulty identifyingwhich patients are frail; therefore,we sought to quantify if frail kidney transplant candidates had similar access to kidney transplantation as nonfrail candidates. Design, setting, participants, & measurements We studied 7078 kidney transplant candidates (2009-2018) in a three-center prospective cohort study of frailty. Fried frailty (unintentional weight loss, grip strength, walking speed, exhaustion, andactivity level)wasmeasuredatoutpatient kidney transplant evaluation.We estimatedtime to listing andtransplant rate by frailty statususingCoxproportional hazards andPoisson regression, adjusting for demographic and health factors. Results The mean age was 54 years (SD 13; range, 18-89), 40% were women, 34% were black, and 21% were frail. Frail participants were almost half as likely to be listed for kidney transplantation (hazard ratio, 0.62; 95% confidence interval, 0.56 to 0.69; P<0.001) compared with nonfrail participants, independent of age and other demographic factors. Furthermore, frail candidates were transplanted 32% less frequently than nonfrail candidates (incidence rate ratio, 0.68; 95% confidence interval, 0.58 to 0.81; P<0.001). Conclusions Frailty is associated with lower chance of listing and lower rate of transplant, and is a potentially modifiable risk factor.