Frailty in Kidney Transplant Candidates: Bridging Evidence to Practice

I read with great interest the article by Pérez-Sáez and Pascual1 on frailty in kidney transplant (KT) candidates, which provides a comprehensive overview of this critical issue. The authors highlight the dynamic nature of frailty, its impact on KT outcomes, and the potential role of prehabilitation. Although the review is thorough, I would like to raise several points for further discussion and consideration. First, the authors provide valuable insights into frailty assessment in KT, yet critical questions remain unresolved. Although the physical frailty phenotype demonstrates superior prognostic value over the FRAIL scale,2 how can we standardize frailty metrics across transplant centers? In clinical practice, time constraints often favor simpler tools like FRAIL, but its failure to capture sarcopenia risks underdiagnosing frail males with preserved self-reported function. Should transplant programs prioritize physical frailty phenotype despite its resource demands or develop hybrid models combining grip strength measurements with brief questionnaires? Second, the authors discuss the sex-frailty paradox, noting that women are more likely to be frail but exhibit lower mortality rates than men. This raises an important clinical question: should sex-specific frailty interventions be developed? For instance, women may benefit more from interventions targeting sarcopenia and physical activity, whereas men might require a greater focus on managing comorbidities.3 Tailoring interventions to address these differences could optimize outcomes and reduce disparities in access to transplantation. Third, the review underscores the potential reversibility of frailty through prehabilitation. However, the evidence supporting its impact on post-KT outcomes remains limited. Given the logistical challenges of implementing structured prehabilitation programs, particularly for patients on dialysis, could home-based or telehealth interventions be a viable alternative? Studies in other surgical populations have demonstrated the efficacy of remote prehabilitation programs in improving functional status and reducing postoperative complications.4 Exploring such models in KT candidates could address barriers related to time, geography, and patient adherence. Fourth, although the authors rightly argue against excluding frail patients from KT solely based on frailty scores, how should clinicians balance the risks of transplantation with the potential benefits in this population? For older or severely frail candidates, would a shared decision-making model incorporating patient preferences and quality-of-life considerations be more appropriate? Such an approach could help align clinical decisions with patient goals, particularly in cases where the benefits of KT are uncertain.5 In conclusion, this review provides a strong foundation for addressing frailty in KT candidates. However, further research is needed to refine frailty assessment tools, explore innovative prehabilitation strategies, and develop personalized interventions.