*Purpose: Frailty, a syndrome distinct from comorbidity and disability, is clinically manifested as a decreased resistance to stressors and is present in up to 35% of end-stage renal disease (ESRD) patients. It is associated with falls, hospitalizations, poor cognitive function, and mortality. Also, frailty is associated with poor post-kidney transplant (KT) outcomes including graft loss and mortality. It is likely frailty is associated with decreased access to KT, given its association with poor outcomes on dialysis and post-KT. Yet, clinicians have difficulty identifying which patients are frail; therefore, we sought to quantify if frail KT candidates had similar access to KT as nonfrail candidates.

*Methods: We studied 7,078 KT candidates (2009-2018) in a three-center prospective cohort study of frailty. Fried frailty (unintentional weight loss, grip strength, walking speed, exhaustion, and activity level) was measured at outpatient KT evaluation. We estimated time to listing and transplant rate by frailty status using Cox proportional hazards and Poisson regression, adjusting for demographic and health factors.

*Results: The mean age was 54 years (SD=13; range 18-89), 40.2% were female, 33.9% were African American, and 21.1% were frail. Frail participants were almost half as likely to be listed for KT (hazard ratio:0.62, 95%CI:0.56-0.69, p<0.001) compared to nonfrail participants, independent of age and other demographic factors. Furthermore, frail candidates were transplanted 35% less frequently than nonfrail candidates (incidence rate ratio:0.65, 95%CI:0.55-0.77, p<0.001).

*Conclusions: Frailty is associated with decreased listing and decreased rate of transplant and is a potentially modifiable risk factor. Thus, assessment at kidney transplant evaluation could improve patient counseling and motivate strategies to improve pre-KT outcomes for frail candidates of all ages.

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