Frailty Screening and Prehabilitation Before Kidney Transplant Listing: A Practical Narrative Review

Frailty is increasingly recognized as a clinically meaningful and potentially modifiable vulnerability among kidney transplant candidates and among patients with advanced chronic kidney disease (CKD) referred for transplant evaluation. Contemporary guidance emphasizes individualized risk-benefit assessment and equity in access to transplantation while acknowledging substantial inter-center variability in evaluation practices. Frailty assessment may improve transparency and consistency compared with subjective impressions, support shared decision-making, and identify targets for prehabilitation and other optimization strategies. However, challenges persist, including heterogeneity in frailty definitions, variability in reported frailty prevalence across transplant-candidate cohorts and instruments, uncertainty regarding optimal tools and thresholds, and operational questions regarding who should measure frailty, when to repeat testing, and how to interpret results without creating unjust barriers to listing. This narrative review summarizes (i) conceptual models of frailty relevant to transplant candidates, (ii) practical frailty assessment options and their feasibility in transplant clinics, (iii) a pragmatic workflow for integrating frailty screening into pre-listing evaluation, and (iv) evidence and implementation considerations for prehabilitation in kidney transplant candidates. Overall, frailty screening is best positioned as a tool for decision-support and targeted optimization rather than a rigid exclusion criterion.