*Purpose: Frailty predicts adverse post-kidney transplant (KT) outcomes, yet impacts of frailty assessments on center-level outcomes remain unclear. We tested whether transplant centers assessing frailty as part of clinical practice have better pre- and post-KT outcomes in adult patients (18+) and older patients (65+).

*Methods: We conducted a survey of US transplant centers (11/2017-4/2018); 132 centers (response rate=65.3%) reported frequencies of frailty assessment at evaluation and KT. Center characteristics and clinical outcomes for patients during 2017-2019 were gleaned from the SRTR datasets. Poisson regression was used to estimate incidence rate ratios (IRRs) of waitlist mortality and transplantation in candidates and all-cause mortality and death-censored graft loss in recipients by frequency of frailty assessment.

*Results: Assessing frailty at evaluation was associated with lower waitlist mortality rate (always IRR=0.91,95%CI:0.84-0.99;sometimes=0.89,95%CI:0.83-0.96) and KT rate (always=0.94,95%CI:0.91-0.97;sometimes=0.88,95%CI:0.85-0.90); the associations with waitlist mortality rate (always=0.86,95%CI:0.74-0.99;sometimes=0.83,95%CI:0.73-0.94) and KT rate (always=0.82,95%CI:0.77-0.88;sometimes=0.92,95%CI:0.87-0.98) were stronger in older patients. Always assessing frailty at KT was associated with lower graft loss rate (IRR=0.71,95%CI:0.54-0.92) but not with mortality (IRR=0.93,95%CI:0.76-1.13).

*Conclusions: Assessing frailty at evaluation is associated with lower KT rate but better waitlist survival rate, particularly in older candidates; centers always assessing frailty at admission are likely to have better graft survival rate. Transplant centers may utilize frailty assessments as a tool to better allocate health care resources for patients identified as frail, particularly for older patients.

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