Outcomes for Frail Dialysis Patients Not Referred for Transplantation: A Cohort Study

BACKGROUND: Frailty is highly prevalent in kidney failure, but it is unclear whether frailty impacts health outcomes for those initiating dialysis who are not referred for transplantation. Our objective was to determine if frailty is associated with death or development of a permanent contraindication to transplantation among eligible non-referred patients following dialysis initiation. METHODS: We analyzed all incident adult dialysis patients from January 2009 to December 2018 (last follow-up December 2020) who lacked an identifiable absolute contraindication to transplant, but were not referred to our institution. Frailty was captured using the Clinical Frailty Scale (CFS) and categorized by severity. Time to death or development of a permanent contraindication to transplantation was analyzed using an adjusted Cox Proportional Hazards Regression model. Associations with the composite outcome were reported using hazard ratios (HR) and 95% confidence intervals (CI). RESULTS: A total of 401 patients were included, 14% had a CFS of 6-8; 90% of patients with CFS 6-8 either died or developed a permanent contraindication to transplant and none received a transplant during follow-up. Among patients with CFS 6-8, 27% died or developed a permanent contraindication at 1 year; increasing to 81% by 5 years. After adjusting for patient characteristics, frailty was associated with the composite outcome (CFS 4-5: HR 1.71, 95% CI 1.17-2.21; CFS 6-8: HR 2.34, 95% CI 1.42-3.37). CONCLUSIONS: Among patients not referred for transplantation, a higher frailty severity was associated with death or development of a contraindication, particularly after the first year following dialysis initiation. Future studies should explore whether alternative approaches to the timing of transplant referral in frail patients are associated with improved outcomes and focus on novel strategies to reduce frailty severity or better support frail patients who may otherwise be eligible for transplantation.