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Kidney Transplantation and the Impact on Health-Related Quality of Life in Frail Patients

Hoffman, Arika L. MD1; Matemavi, Praise DO1

doi: 10.1097/TP.0000000000001979

The commentators describe what frailty is, how to diagnose it, and the implications for transplantation in the context of McAdams-DeMarco et al findings that there is a greater improvement in Health-Related Quality of Life (HRQOL) among frail kidney transplant recipients than nonfrail recipients.

1 Department of Surgery University of Nebraska Medical Center, Omaha, NE.

Received 11 September 2017.

Accepted 23 September 2017.

The authors declare no funding or conflicts of interest.

A.L.H. participated in the writing of the article and review of the article. P.M. participated in the writing of the article and review of the article.

Correspondence: Arika L. Hoffman, MD, University of Nebraska Medical Center, 983285 Nebraska Medical Center, Omaha, NE 68198-3285. (

The medical field has long recognized that advanced age carries an increased risk of morbidity and mortality after surgery. It is the impact of frailty on surgical outcomes that drives most of the research in patients who do not pass the “eyeball test.” Frailty is characterized as an increased vulnerability to stressors associated with a decreased reserve across multiple physiologic systems and is a better predictor of morbidity and mortality than chronological age.1,2 Limited compensatory mechanisms lead to functional impairment and adverse health outcomes, such as disability, falls, decreased mobility, hospitalization, and death.3

In this issue of Transplantation, McAdams-DeMarco et al4 expand on their previous work which demonstrated that frail patients with end-stage renal disease are more than twice as likely to experience a decline in health-related quality of life (HRQOL) while awaiting kidney transplant (KT). This results in worse HRQOL compared with their nonfrail peers at the time of transplant. Additionally, the authors previously demonstrate that frail KT patients have a more than twofold adjusted risk of mortality after transplantation.5 Although a study by Garonzik-Wang et al6 showed that frailty is independently linked to a twofold increased risk for delayed graft function. However, McAdams-DeMarco et al4 most recent work shows that frail KT recipients experienced a greater improvement in physical HRQOL and kidney disease-specific HRQOL than their nonfrail counterparts, despite the fact that frail KT recipients had worse HRQOL before KT. This current research is an excellent contribution to frailty in the posttransplant kidney population and supports their previous work which suggested that frailty changes with transplantation.7

How then does the transplant community incorporate frailty into an assessment and evaluation of transplant candidates? Is it feasible to perform a formal frailty assessment during evaluation and/or yearly during waitlist management appointments? The current study assessed frailty at the time of transplant and used 5 phenotypic components: shrinking (self-report of unintentional weight loss of more than 10 lbs in the past year), weakness, exhaustion (self-reported), low activity, and slow walking speed.4 The article does not discuss average waitlist time or if frailty was assessed at any other time during the patient’s pretransplant course. The mean time on dialysis was only 3.26 years, and the mean age was 52 years (SD, 14.1 years). More than a third of the patient population studied was considered frail. Previously, research had shown that frailty was associated with difficulty with activities of daily living, less than high school education, and no residual kidney function.7

Frailty assessment is valuable in the evaluation of the transplant candidate, and how we identify the functionally impaired patients who are still appropriate for kidney transplantation has yet to be answered. In a retrospective study, the same group identified that 2 specific components of the frailty phenotype, exhaustion and slow walking speed, were associated with increased mortality in KT recipients.7 There is no consensus on measuring frailty, despite multiple studies showing its importance in postsurgical patients. In a field where resources are limited, it is imperative that we develop guidelines to determine which frail patients should be listed for transplant. Most measurements of frailty fall into 1 of 3 categories: accumulation of deficits, phenotypic measurements, or morphometric age. Most frailty research in KT recipients uses phenotypic measurements which are a combination of self- reported and measured components. A frailty index is based off of an accumulation of deficits model and is most commonly developed from The Canadian Study of Health and Aging Frailty Index. A modified frailty index using 11 variables, gathered during a routine review of systems, has been used in multiple studies to predict 30-day morbidity and mortality in patients undergoing liver transplantation, spine surgery, and vascular surgery.8,9 Englesbe et al10 demonstrated that sarcopenia, a condition associated with frailty, strongly correlated with mortality after liver transplantation. Using body morphometry as a marker of frailty is objective and can be standardized. It is possible that objective measures could lead to specific therapy and optimization, although there have been no studies to showing frailty is reversible with exercise and nutritional interventions prior to surgery. From this study, we now understand that certain frail patients have improved HRQOL after kidney transplantation. Future research can aim to determine which frailty measurements are easily integrated into the evaluation process to help shape and inform listing decisions.

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