Two significant policy changes, one in the way people are put forward for kidney transplants and the other in the way in which kidneys are distributed to people on the waiting list, make the question of whether someone is too frail to receive a transplant all the more relevant, particularly in Rhode Island. An executive order signed by President Donald Trump1 stresses that efforts to treat kidney disease need to concentrate on providing more people with kidney transplants and increasing the number of organs transplanted rather than discarded. An effort to decrease waiting times for kidneys in large metropolitan areas2 potentially means that younger, more desirable kidneys will be shipped out of New England, leaving longer waiting times and less desirable organs for transplantation in our region. The net effect of these changes may mean that potential older or more frail recipients could be faced with accepting kidneys from older or less desirable donors or spend more time on the waiting list and never receive a credible kidney offer. This raises the specter of poor outcomes from marginally functioning kidneys transplanted into marginally functioning recipients or increased rates of death on the waiting list. While organ allocation policies are beyond the ability of transplant nephrologists in Rhode Island to change, we will need to assess patients more closely for signs of frailty and work with referring doctors to reverse frailty when possible so that patients can take advantage of a kidney transplant even if the organ isn't ideal. This article will review the concept of frailty; how to asses it in general and in the context of a transplant evaluation; the risk of frailty in transplant outcomes and the benefits of transplant in reversing frailty; whether markers of frailty can be improved and whether that improves transplant outcomes.
Keywords: chronic kidney disease; donor waitlists; frailty assessment; kidney transplant.