Malnutrition & Frailty in Organ Transplant Candidates & Recipients

By Allison Nitsch, MD, FACP, CEDS

Malnutrition may affect 52-90% of those with advanced lung, liver or kidney disease who are waiting for organ transplants. Malnutrition can be caused by numerous factors in this patient population, including a decrease in food intake, medication side effects and the increased metabolic demands associated with advanced disease. When an organ transplant candidate experiences both malnutrition and frailty, the risk of hospital readmission, infection and even death increases. Medical interventions, including nutritional support and rehabilitation, can improve outcomes.

How common is malnutrition in organ transplant candidates?

Malnutrition is common among patients awaiting organ transplants and is often observed in those with advanced heart, lung, liver or kidney disease. Studies estimate that a significant portion of transplant candidates are malnourished or at risk of malnutrition before surgery, including up to1,2-4:

  • 90% of those with heart failure
  • 80% of liver transplant candidates
  • 60% of lung transplant candidates
  • 52% of those with chronic kidney disease requiring dialysis

Because poor nutritional status is linked to worse surgical outcomes and recovery, identifying and treating malnutrition is key in pre-transplantation care.

What causes malnutrition in advanced organ disease?

Malnutrition is common among individuals with advanced organ disease and organ failure because various physiological and treatment-related factors can disrupt normal nutrition. Reduced food intake, restrictive therapeutic diets and medication side effects can make it hard for patients to get enough calories and nutrients.

At the same time, nutrient losses and increased metabolic demands to sustain organ function can add to weight loss and muscle wasting.

People with advanced organ disease are also more likely to face socioeconomic barriers, such as limited access to food and difficulties in food preparation.

Organ failure and malnutrition

Those with advanced organ disease already face numerous challenges. Below is a breakdown of the causes and signs of malnutrition within various disease states, including heart disease, end-stage liver disease, kidney disease and lung disease.

Heart disease

More than 50% of people with heart failure are malnourished, with some estimates reaching up to 90%.4,5 In addition to malnutrition, about 15% of patients are also severely cachectic.4

Malnutrition in patients with heart failure is caused by multiple factors including4:

  • Inflammation
  • Hypercatabolism
  • Dyspnea
  • Reduced exercise tolerance
  • Loss of adipose tissue and skeletal muscle.

Patients with heart failure are often in an inflammatory and hypercatabolic state, experiencing skeletal and cardiac muscle breakdown that releases amino acids, which in turn impair skeletal and cardiac physiological and metabolic functions.

Heart disease is frequently treated with medications like diuretics, antiarrhythmics, beta-blockers and statins, which can cause nausea or gastrointestinal discomfort. These side effects may decrease appetite and lead to reduced food intake over time.

Patients with heart disease are also commonly prescribed reduced-sodium diets, which can decrease food palatability, inadvertently lowering food intake and contributing to nutrient deficiencies.

End-stage liver disease

Malnutrition is very common among patients with end-stage liver disease (ESLD), affecting 80% of transplant candidates.2 The prevalence of malnutrition is higher in individuals with cirrhosis overall, with rates reaching up to 90%.4

Factors in ESLD that contribute to malnutrition include4:

  • Altered metabolism
  • Malabsorption
  • Hypercatabolism (muscle breakdown)
  • Increased resting energy expenditure (REE)
  • Poor appetite and early satiety
  • Nausea and/or vomiting
  • Micronutrient deficiency

When the liver is damaged, there is also a decrease in the production of bile salts, which alters the absorption of fats and fat-soluble vitamins, and leads to a decrease in essential and polyunsaturated fatty acids.4

There is also a decrease in albumin production in the liver. This hypoalbuminemia causes intestinal edema that impairs nutrient absorption.4

Inflammation linked to liver disease can induce a hypercatabolic state and boost REE, leading to a net negative energy balance.6

Medications commonly used to treat liver disease, such as diuretics and lactulose, can cause gastrointestinal side effects like nausea, bloating and diarrhea. These symptoms may also lead to malnutrition by decreasing appetite.

Kidney disease

A meta-analysis estimated the global prevalence of malnutrition in dialysis patients between 28% and 52%. Estimates of malnutrition prevalence among patients with chronic kidney disease (CKD) stages 3-5 were 11-54%.4

Patients on dialysis are at higher risk for malnutrition due to ongoing poor appetite related to4:

  • Inflammation
  • Increased REE
  • Nutrient losses
  • Metabolic acidosis
  • Malabsorption

When renal function declines, the body’s ability to filter and excrete urea is compromised, raising blood urea nitrogen. This disrupted protein metabolism is closely linked to abnormal energy expenditure and affects REE.7

The combined effects of kidney failure, chronic inflammation, metabolic acidosis and physical inactivity can create a catabolic environment that worsens muscle loss.7

CKD also is associated with elevated levels of appetite-suppressing hormones and decreased levels or downregulation of appetite-stimulating hormones.1 Over time, low caloric intake can lead to protein-energy malnutrition and micronutrient deficiency deficiencies.1

For patients on dialysis, the procedure can lead to a direct loss of nutrients from the body, resulting in deficiencies in protein, vitamins and electrolytes.8

Medications used to treat kidney disease, such as phosphate binders and iron supplements, cause gastrointestinal symptoms like nausea, constipation, and stomach discomfort. These side effects may lead to reduced appetite and decreased food intake in patients with CKD.

Lung disease

The prevalence of malnutrition among patients with end-stage lung disease awaiting a transplant is estimated to be 30-60%.3,4

Malnutrition in patients with lung disease is caused by multiple factors including4:[BB1] 

  • Hypercatabolism
  • Increased resting energy expenditure
  • Inflammation
  • Decrease in fat-free mass
  • Co-occurring gastrointestinal disease (gastroesophageal reflux disease, dysphagia, ineffective esophagus, gastroparesis and restrictive scleroderma)
  • Dysgeusia (altered taste)

Inflammatory lung disease can produce a hypermetabolic state. Increased REE can promote muscle breakdown, leading to weight loss and muscle wasting even with what seems like adequate food intake.9

Medications used to treat chronic lung diseases, like bronchodilators and antibiotics, can cause side effects such as nausea, dry mouth and gastrointestinal upset. These symptoms may affect appetite and make eating less appealing for patients with advanced respiratory illness.

Frailty: A dangerous combination of malnutrition, sarcopenia and cachexia

Frailty is a medical condition characterized by decreased function and health, common among older adults but also affecting people at any age. It impacts many patients who are seeking or receiving an organ transplant, including4,10-12:

  • Up to 54% of lung transplant recipients
  • Up to 43% of liver transplant recipients
  • Up to 20% of kidney transplant recipients
  • Up to 16% of heart transplant recipients

Frail patients have decreased strength, function, physical performance and resilience due to insufficient protein intake, a sedentary lifestyle, inflammation, hypercatabolism and muscle breakdown.

Contributors to frailty

Malnutrition

Malnutrition, or inadequate nutrition, decreases body fat and reduces muscle stores, leading to unintentional weight loss. Alongside sarcopenia and cachexia, malnutrition contributes to muscle wasting in patients with advanced organ disease and organ failure, increasing their risk of frailty.

Sarcopenia

Sarcopenia is a progressive, age-related decline in skeletal muscle mass. Features of sarcopenia include reduced muscle quality and quantity along with decreased physical performance. Along with malnutrition, it contributes to diminished muscle strength and muscle wasting.

Cachexia

Cachexia, also known as wasting syndrome, is a metabolic disorder characterized by significant weight loss. It involves rapid protein breakdown, fatigue, anorexia and early satiety. Along with malnutrition, it leads to substantial and uncontrolled fat loss.

Poor recipient outcomes due to malnutrition and frailty

Readmission and longer length of stay

Malnutrition can increase the risk of readmission due to complications. A single study on malnutrition in lung transplant recipients indicates a higher chance of returning to the ICU within 60 days after transplantation for patients who are malnourished compared to those who are not.4

This same study also indicated a longer length of stay for malnourished patients compared to non-malnourished patients.4 Frailty in kidney transplant recipients is also associated with a longer length of stay and early hospital readmission.4

Increased risk of infection

Infection is also more common in transplant recipients who have malnutrition. About 53% of patients with ESLD and severe malnutrition develop an infection within 90 days after transplantation, compared to 32.5% of patients without malnutrition.4

Muscle wasting is also linked to an increased risk of postoperative infection, with studies showing that 27% of heart transplant recipients with muscle wasting experience an infection compared to 8.3% of those without.4

Decreased function

Those with malnutrition can also experience decreased function after receiving a transplant. Patients with liver disease identified as high-risk for malnutrition have worse clinical outcomes, including reduced liver function and lower quality of life.4

Frailty in kidney transplant patients is linked to delayed graft function, intolerance to immunosuppression and impaired function.4

Increased mortality risk

Malnutrition can increase the risk of death in transplant candidates, whether they are on the waiting list or are postoperative. Patients with liver cirrhosis and malnutrition have an estimated 3.79 times higher risk of mortality while on the transplant waiting list and within 12 months after transplantation compared to those without malnutrition.4

Those with end-stage heart failure and moderate or severe malnutrition after surgery also experienced an 18% higher mortality rate in the first year.4

For those who have received a lung transplant, frailty increases the risk of wait-list and postoperative mortality. Frailty is also independently linked to a twofold increase in the risk of death in kidney transplant patients.4 Mortality in frail heart transplant recipients reaches as high as 26% at 12 months, and in frail liver transplant patients it is as high as 16% at five years.13,14

Treating malnutrition in advanced organ disease

Medical stabilization

In many cases, patients with advanced organ disease require medical stabilization to safely begin nutritional rehabilitation. Careful monitoring and treatment in a medical setting can help manage complications, stabilize vital functions and ensure that nutrition support is introduced safely as patients prepare for possible transplantation or other advanced therapies.

Nutritional rehabilitation

Nutritional rehabilitation is an important part of treating malnutrition in patients with advanced organ disease. Individualized nutrition plans can help restore energy and protein intake, support muscle mass and address vitamin or mineral deficiencies that develop as illness progresses.

Supportive care

Supportive care that helps manage the underlying organ disease is also essential. Treatments that improve heart, lung, liver and kidney function can help reduce symptoms that interfere with eating and allow the body to better use nutrients during recovery.

Find help for severe malnutrition

If you are experiencing malnutrition related to advanced organ disease, seeking specialized medical care early can make a meaningful difference. Poor nutritional status can sometimes make patients ineligible for organ transplantation or increase the risk of complications after surgery. Comprehensive treatment, including nutritional support and careful medical management, can improve their strength and overall health while preparing for organ transplantation.

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References

  1. Iorember, F. M. (2018). Malnutrition in chronic kidney disease. Frontiers in Pediatrics, 6, 161. https://doi.org/10.3389/fped.2018.00161
  2. Jadeja, Y., & Kher, V. (2012). Protein energy wasting in chronic kidney disease: An update with focus on nutritional interventions to improve outcomes. Indian Journal of Endocrinology and Metabolism, 16(2), 246. https://doi.org/10.4103/2230-8210.93743
  3. Calañas-Continente, A. J., Pluvins, C. C., Gomariz, E. M., Martínez, R. L., Ugalde, P. F., Puerta, M. J. M., & Luna, F. S. (2002). Prevalence of malnutrition among candidates for lung transplantation. Nutricion Hospitalaria, 17(4), 197–203. https://pubmed.ncbi.nlm.nih.gov/12395609
  4. Lorden, H., Engelken, J., Sprang, K., Rolfson, M., Mandelbrot, D., & Parajuli, S. (2023). Malnutrition in solid organ transplant patients: A review of the literature. Clinical Transplantation, 37(11), e15138. https://doi.org/10.1111/ctr.15138
  5. Vest, A. R., DiDomenico, R. J., Lichtenstein, L., Slater, T., Ekpo, E., Damluji, A. A., Bohula, E., & Alviar, C. L. (2026). Malnutrition and cachexia in inpatients with acute cardiac conditions: A scientific statement from the American Heart Association. Circulation, 153(18). https://doi.org/10.1161/cir.0000000000001405
  6. Müller, M. (1994). Are patients with liver cirrhosis hypermetabolic? Clinical Nutrition, 13(3), 131–144. https://doi.org/10.1016/0261-5614(94)90092-2
  7. Li, Z., Zhang, S., Xiao, X., & Sun, Y. (2025). Resting energy expenditure and kidney disease: A narrative review. Frontiers in Nutrition, 12, Article 1683191. https://doi.org/10.3389/fnut.2025.1683191
  8. Laville, M., & Fouque, D. (2000). Nutritional aspects in hemodialysis. Kidney International, 58, S133–S139. https://doi.org/10.1046/j.1523-1755.2000.07617.x
  9. Collins, P. F., Yang, I. A., Chang, Y., & Vaughan, A. (2019). Nutritional support in chronic obstructive pulmonary disease (COPD): An evidence update. Journal of Thoracic Disease, 11, S2230–S2237. https://doi.org/10.21037/jtd.2019.10.41
  10. Hage, R., & Schuurmans, M. M. (2023). Frailty as a prognostic indicator in lung transplantation: A Comprehensive analysis. Transplantology, 5(1), 1–11. https://doi.org/10.3390/transplantology5010001
  11. Kim, S., Sakowitz, S., Hadaya, J., Curry, J., Chervu, N. L., Bakhtiyar, S. S., Mallick, S., Cho, N. Y., & Benharash, P. (2023). Association of frailty with postoperative outcomes following thoracic transplantation: A national analysis. JTCVS Open, 16, 1038–1048. https://doi.org/10.1016/j.xjon.2023.10.011
  12. Proietti, M., & Cesari, M. (2020). Frailty: What is it? Advances in Experimental Medicine and Biology, 1216, 1–7. https://doi.org/10.1007/978-3-030-33330-0_1
  13. Macdonald, P. S., Gorrie, N., Brennan, X., Aili, S. R., De Silva, R., Jha, S. R., Fritis-Lamora, R., Montgomery, E., Wilhelm, K., Pierce, R., Lam, F., Schnegg, B., Hayward, C., Jabbour, A., Kotlyar, E., Muthiah, K., Keogh, A. M., Granger, E., Connellan, M., . . . Jansz, P. C. (2020). The impact of frailty on mortality after heart transplantation. Journal of Heart and Lung Transplantation, 40(2), 87–94. https://doi.org/10.1016/j.healun.2020.11.007
  14. Lai, J. C., Shui, A. M., Duarte‐Rojo, A., Ganger, D. R., Rahimi, R. S., Huang, C., Yao, F., Kappus, M., Boyarsky, B., McAdams‐Demarco, M., Volk, M. L., Dunn, M. A., Ladner, D. P., Segev, D. L., Verna, E. C., & Feng, S. (2022). Frailty, mortality, and health care utilization after liver transplantation: From the Multicenter Functional Assessment in Liver Transplantation (FrAILT) Study. Hepatology, 75(6), 1471–1479. https://doi.org/10.1002/hep.32268

ACUTE Earns Prestigious Center of Excellence Designation from Anthem
In 2018, the ACUTE Center for Eating Disorders & Severe Malnutrition at Denver Health was honored by Anthem Health as a Center of Excellence for Medical Treatment of Severe and Extreme Eating Disorders. ACUTE is the first medical unit ever to achieve this designation in the field of eating disorders. It comes after a rigorous review process.

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