Dynamic Frailty Before Kidney Transplantation—Time of Measurement Matters

Background Frail kidney transplant (KT) recipients have higher risk of adverse post-KT outcomes. Yet, there is interest in measuring frailty at KT evaluation and then using this information for post-KT risk stratification. Given long wait times for KT, frailty may improve or worsen between evaluation and KT. Patterns, predictors, and post-KT adverse outcomes associated with these changes are unclear. Methods 569 adult KT candidates were enrolled in a cohort study of frailty (11/2009-09/2017) at evaluation and followed-up at KT. Patterns of frailty transitions were categorized as: 1) binary state change (frail/nonfrail); 2) 3-category state change (frail/intermediate/nonfrail); and 3) raw score change (-5 to 5). Adjusted Cox proportional hazard and logistic regression models were used to test whether patterns of frailty transitions were associated with adverse post-KT outcomes. Results Between evaluation and KT, 22.0% became more frail, while 24.4% became less frail. Black race (RRR=1.98, 95%CI:1.07-3.67) was associated with frail-to-nonfrail transition; diabetes (RRR=2.56, 95%CI:1.22-5.39) was associated with remaining stably frail. Candidates who became more frail between 3-category states (HR=2.27, 95%CI:1.11-4.65) or frailty scores (HR=2.36, 95%CI:1.12-4.99) had increased risk of post-KT mortality and had higher odds of length of stay (LOS) ≥2 weeks (3-category: OR=2.02, 95%CI:1.20-3.40; scores: OR=1.92, 95%CI:1.13-3.25). Conclusions Almost half of KT candidates experienced change in frailty between evaluation and KT, and those transitions were associated with mortality and longer LOS. Monitoring changes in frailty from evaluation to admission may improve post-KT risk stratification. *NMC and AD contributed equally to this manuscript. Contact Information: Nadia M. Chu, PhD, MPH, Department of Surgery 615, N. Wolfe St, Baltimore, MD 21205, (215) 200-5327 email: nchu8@jhu.edu. Alternate Corresponding Author: mara@jhu.edu. AUTHORSHIP Participated in data analysis: NMC, AD, HY; participated in research design: MMD, DLS; participated in writing of the paper NMC, AD; participated in performance of the research: MMD, DLS; participated in critical revision of the paper: NMC, AD, HY, CEH, JMGW, MMD, DLS; participated in approval of paper: NMC, MMD, DLS. STATEMENT OF COMPETING FINANCIAL INTERESTS Disclosures: None FUNDING This study was supported by the National Institute of Diabetes and Digestive and Kidney Disease (NIDDK) grant numbers: K24DK101828 (PI: Segev) and K23DK115908 (PI: Garonzik Wang), as well as the National Institute on Aging (NIA) grant numbers: F32AG053025 (PI: Haugen), R01AG042504 (PI: Segev), K01AG043501 (PI: McAdams-DeMarco), and R01AG055781 (PI: McAdams-DeMarco). Mara A. McAdams-DeMarco was also supported by the Johns Hopkins University Claude D. Pepper Older Americans Independence Center (P30AG021334). Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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