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, and mortality. Also, frailty is associated with poor outcomes after kidney 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 identifying which 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, and activity level) was measured at outpatient kidney transplant evaluation. We estimated time to listing and transplant rate by frailty status using Cox proportional hazards and Poisson 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.

Keywords: Accidental Falls; Cognition; Comorbidity; Counseling; Frailty; Hand Strength; Incidence; Kidney Failure, Chronic; Outpatients; Prospective Studies; Transplants; Walking Speed; Weight Loss; hospitalization; kidney transplantation; outcomes; renal dialysis; risk factors.

Graphical abstract

Figure 1.

Frailty is associated with decrease cumulative incidence of listing for kidney transplantation (log rank P<0.001). Cumulative incidence of listing for kidney transplantation in evaluation participants (n=5423) by frailty status.

Figure 2.

Prevalence of frailty is higher in older, black, and non-Hispanic candidates. AA, black participants.

Figure 3.

Frail kidney transplant candidates had a higher cumulative incidence of waitlist mortality (log rank P<0.001). Cumulative incidence of waitlist mortality in 4558 waitlisted participants by frailty status. Kidney transplant was considered a competing risk for waitlist mortality.

Figure 4.

Frail kidney transplant candidates had a lower cumulative incidence of transplant (log rank P<0.001). Cumulative incidence of kidney transplantation in 4552 waitlisted participants by frailty status. Kidney transplant candidates only contributed time to the risk set while active on the waitlist. Waitlist mortality was considered a competing risk for kidney transplant.