In a national cohort of patients starting renal replacement therapy, Bao and colleagues1 classified 73% as frail using a modification of criteria proposed by Fried et al2 in their seminal delineation of a frailty phenotype. Bao et al1(p1071) describe frailty as “extremely common among patients starting dialysis in the United States” and, more generally, as a “clinical syndrome highly prevalent in the population with end-stage renal disease (ESRD).” While we fully support the recognition of frailty and understanding of contributors to frailty as valuable research objectives, the article by Bao et al1 provides a case in point that assignment of frailty classification is very dependent on the particular criteria and operational measures that are applied. In particular, reliance on a patient-reported measure of physical functioning (PF) as a substitute for performance-based measures of weakness and slowness specified in the frailty phenotype validated by Fried et al2 may yield a different picture of the prevalence of “frailty.”
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