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

## TL;DR

This paper reviews how assessing frailty in kidney transplant candidates can help guide decisions and improve outcomes through prehabilitation.

## Contribution

The paper provides a practical framework for integrating frailty screening and prehabilitation into kidney transplant evaluations.

## Key findings

- Frailty assessment can improve decision-making and consistency in kidney transplant candidate evaluations.
- Frailty screening should support optimization strategies rather than serve as a strict exclusion criterion.
- Practical workflows and tools for frailty screening and prehabilitation are feasible in transplant clinics.

## Abstract

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.