Dietitian Blog, MNT Guidelines | Jan 24 2022

Kidney transplant and frailty: What’s the connection?

Nurse helping elderly woman walk with a walker


In the United States, approximately 91,000 Americans are on the list waiting for a kidney transplant.  This organ can be transplanted from a living or deceased donor with the number of kidneys needed significantly outweighing the number available. Transplantation is the preferred modality for end stage kidney disease because of the benefits with quality of life, life expectancy and the decreased financial burden on the healthcare system. With an aging population, the concept of frailty is a newer measure that can be considered as part of the transplant evaluation process. How does this influence nutrition and care from the registered dietitian nutritionist (RDN)?  

What is the Fried Frailty Index? 

Frailty encompasses a decline often seen with aging that is reflected in an individual’s physical, cognitive, physiological, and immune function. In the transplant candidate this measure is linked with mortality, risk for delayed graft function, longer hospitalizations, and readmissions. Five assessment areas are included as part of the Fried Frailty Index, the most commonly used scale for measuring frailty.   

These areas include: 

  • slowness  
  • exhaustion  
  • physical inactivity  
  • unintentional weight loss  
  • weakness 

Role of frailty and nutrition 

Due to the metabolic abnormalities associated with chronic kidney disease, the presence of anorexia, metabolic acidosis, sarcopenia and chronic inflammation can all influence measures of frailty. The good news is that frailty can be improved as part of the pre-transplant process with multiple prospective studies showing a benefit with more tailored nutrition. While research continues within this area, several specific interventions have the potential to benefit the kidney transplant candidate and go hand in hand with the recent Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines from the National Kidney Foundation. Prevention of undernutrition and therefore weight loss, can be achieved by adequate intake of calories and protein. Diet quality can also impact the nutrition status of these individuals and healthier eating patterns with fruits, vegetables, whole grain sources in place of ultra-processed foods is recommended.   

Patient application 

The nutrition care process can help identify at-risk transplant candidates and decrease concerns for frailty. Depending on the facility, the role of the RDN may include administration of the Fried Frailty Index or a different frailty measure in coordination with the nutrition assessment. Understanding of each of the components as well as their importance is beneficial not only to better individualize medical nutrition therapy care but also to improve overall health outcomes and graft survival.  

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Health Resources and Service Administration. Organ Donation Statistics.  Available at: Accessed December 11, 2021. 
Gandolfini I, Regolisti G, Bazzocchi A, et al. Frailty and sarcopenia in older patients receiving kidney transplantation. Front Nutr. 2019;6:169. 
Perez-Saez M, Morgado-Perez A, Faura A, et al. The FRAILMar study protocol: frailty in patients with advanced chronic kidney disease awaiting kidney transplantation. A randomized clinical trial of multimodal prehabilitation. Front Med. 2021;8:675049. 
Ikizler TA, Burrowes JD, Byham-Gray LD, et al. KDOQI Nutrition in CKD Guideline Work Group. KDOQI clinical practice guideline for nutrition in CKD: 2020 update. Am J Kidney Dis. 2020;76(3)(suppl 1):S1-S107 
Lochlainn M, Cox N, Wilson T, et al. Nutrition and frailty: opportunities for prevention and treatment. Nutrients. 2021;13:2349. 
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About Stacey Phillips

Stacey Phillips, MS, RD is a clinical dietitian working with general medicine, oncology, CKD, renal transplant recipients and living kidney donor patients. Outside of her work, Stacey is passionate about improving the resources available to individuals with chronic kidney disease and actively participates on several renal dietitian committees.

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