The potential of prehabilitation to enhance recovery in sarcopenic and frail older kidney transplant candidates: A narrative review

BACKGROUND: Older adults represent the fastest-growing segment on kidney transplant (KT) waiting lists. In this population, the high prevalence of sarcopenia and frailty impairs the ability to adapt and respond to metabolic stress, contributing to poorer postoperative outcomes. Given that many adverse events occur in the early postoperative period, the optimal window for intervention is prior to surgery. Prehabilitation, defined as a structured intervention delivered before surgery, aims to enhance postoperative recovery. METHODS: In the context of older adults candidates to KT, we constructed a detailed narrative review on: the development of sarcopenia and frailty as a result of ageing and chronic kidney disease pathophysiologic process; sarcopenia and frail influence on post-operative outcomes, and prehabilitation as a strategy to improve recovery. RESULTS: Age-related anabolic resistance and hormonal, cellular and metabolic disarrangements resulting from the pathophysiologic process of kidney failure, aggravated by dialysis side effects, result in sarcopenia and frailty. Frail/sarcopenic older adults are more vulnerable to post-operative complications and recovery is prolonged. Published prehabilitation studies for candidates to KT mostly comprised of in-situ exercise-only interventions; prehabilitated patients demonstrated improvement of physical function as compared to baseline and just one study assessed post-operative outcomes. The limited results from these studies reflect the absence of a multimodal approach with a comprehensive and personalized medical, dietetic and psychosocial intervention in addition to exercise, necessary to accomplish success. Based on renal, ageing and surgical scientific literature, a suggested multimodal prehabilitation program is proposed. CONCLUSION: Although the optimal structure of prehabilitation remains to be established, individualized multimodal interventions appear to hold promise for optimizing patients during the KT waiting period.