Frailty in end-stage kidney disease: A multidimensional approach to risk stratification and personalized care

Background: Frailty is increasingly recognized as a critical determinant of outcomes in end-stage kidney disease (ESKD), affecting up to 70% of dialysis patients and 20% of kidney transplant candidates. Objective: This review synthesizes current evidence on frailty in ESKD, focusing on definition, assessment, outcomes, modality differences, interventions, and implementation strategies. Key Findings: Frailty in ESKD results from complex interactions between uremia-related factors, comorbidities, and aging processes. While the Fried Frailty Phenotype remains the most widely used assessment tool, the clinical frailty scale (CFS) offers practical advantages in clinical settings. Frailty independently predicts mortality (2.6-fold increased risk), hospitalization, falls, and post-transplant complications. Comparative studies suggest that while frailty prevalence is similar between hemodialysis and peritoneal dialysis patients (approximately 40–43%), some frail patients still derive survival benefit from kidney transplantation despite increased perioperative risks. Multimodal interventions combining nutritional support, exercise training, and cognitive rehabilitation show promise in attenuating frailty progression. Conclusion: Incorporating frailty assessment into routine nephrology care enables risk stratification and personalized management strategies. The CFS represents a practical tool for resource-limited settings.