Frailty Assessment in Lung Transplantation: What the 2026 ISHLT Consensus Says About SPPB

The document moves beyond the question of whether frailty matters. Its practical focus is how transplant programs should measure frailty, when assessment should be repeated, and what should happen when frailty is identified.

Moving beyond subjective assessment of frailty

One of the clearest messages in the consensus statement is that frailty should not be judged by subjective observation alone.

The authors note that subjective assessment—the so-called “eyeball test”—can vary according to age, sex, body habitus, and the individual clinician. It may also fail to identify milder forms of frailty that are still associated with poor outcomes.

The consensus therefore recommends incorporating objective frailty measures into the multidisciplinary evaluation and selection process for lung transplantation. It also recommends that transplant programs select measures that have been rigorously studied in lung transplant populations and can reliably support clinical decision-making.

SPPB is one of the most studied physical frailty measures

The consensus divides frailty assessment broadly into physical frailty measures and cumulative deficit measures.

Among physical frailty instruments, the Short Physical Performance Battery (SPPB) and the Fried Frailty Phenotype (FFP) are described as the most frequently studied in lung transplant populations.

The SPPB assesses lower-extremity performance through three components: standing balance, gait speed, and repeated chair stands. The total score ranges from 0 to 12, with higher scores indicating better physical performance. The consensus describes the SPPB as an objective and sensitive measure that can be completed in approximately 5 to 10 minutes.

Importantly, the evidence base is not limited to a single outcome. Studies in lung transplant candidates and recipients have examined the SPPB in relation to response to prehabilitation and rehabilitation, disability and health-related quality of life, waitlist death or delisting, hospital and ICU outcomes, readmission, and post-transplant survival.

The consensus does not name a single best tool

The prominence of the SPPB should not be interpreted as a recommendation that every transplant program use the SPPB as its only frailty measure.

The ISHLT statement explicitly avoids recommending one instrument for all programs. Different tools capture different aspects of frailty, and each transplant program has its own clinical goals, resources, and workflow.

For example, the FFP combines objective measures such as gait speed and grip strength with self-reported domains such as weight loss, exhaustion, and physical activity. The Lung Transplant Frailty Score (LT-FS) was developed specifically for lung transplantation and may provide stronger prediction for some outcomes, but depending on the model it requires additional clinical variables, grip strength, body composition, or research biomarkers.

The practical question is therefore not which tool is universally “best,” but which validated measure fits the purpose of the program.

Universal screening changes the role of frailty assessment

The consensus recommends that all transplant programs perform frailty screening on all lung transplant candidates.

This is an important shift. Frailty assessment is not intended only for patients who appear old, weak, or visibly impaired. Universal screening can reduce the bias of selective clinical judgment and provide a standardized basis for candidate evaluation, counseling, intervention, and program planning.

The statement also links frailty assessment to several different program goals, including listing decisions, pre-transplant intervention, expectations for the post-operative course, program performance, and resource planning.

SPPB appears repeatedly among the physical frailty measures that can support these goals.

Frailty is dynamic and may be reversible

Another important message is that frailty should not automatically be treated as a fixed contraindication to transplantation.

In some patients, physical frailty may be driven substantially by advanced lung disease itself and can improve after transplantation. The consensus cites evidence that physical frailty resolved after transplant in a large proportion of surviving recipients who had been frail before surgery.

This is why the document emphasizes the potential reversibility of frailty and the need to consider whether a patient can improve with treatment, rehabilitation, or transplantation.

Frailty assessment therefore becomes more useful when it is treated as a longitudinal measure rather than a one-time label.

Screening should lead to prehabilitation and reassessment

When frailty is identified, the consensus places exercise-based prehabilitation at the center of management.

It recommends that all lung transplant candidates, including those receiving mechanical support, be considered for exercise interventions during the evaluation process. Exercise should include lower-limb strength or resistance training and endurance activity as tolerated, with at least three sessions per week and daily activity encouraged.

Nutritional assessment and individualized nutritional support are also recommended alongside exercise, particularly because malnutrition and sarcopenia can contribute to frailty.

The document further recommends repeating frailty assessments when the result is likely to influence clinical decision-making or when there has been a meaningful change in clinical status.

This makes repeatable measurement especially relevant: the value of frailty assessment lies not only in identifying risk, but also in following change over time.

The implementation challenge is standardization and repeatability

Physical frailty assessments such as the SPPB can be completed relatively quickly and with good repeatability, but implementation still requires trained staff, standardized administration, measurement, documentation, and space for physical testing.

For transplant programs, the challenge is therefore not simply to recognize the importance of frailty. It is to build a process that can be used consistently across candidate evaluation, prehabilitation, waiting-list follow-up, hospitalization, and post-transplant care.

A useful frailty assessment must be practical enough to repeat when the clinical question changes.

A potential role for automated SPPB

AndanteFit is an automated system designed to measure and score the three SPPB components—balance, gait speed, and the five-times chair stand—using an instrumented and standardized process. It is designed to reduce manual timing and documentation and to complete an SPPB assessment in approximately three minutes.

The potential value of automation is not simply that the test becomes faster. Standardized automation can help reduce operator-dependent measurement steps and make repeated assessments easier to collect in a consistent format across different staff members and time points.

The 2026 ISHLT consensus does not evaluate or recommend AndanteFit. It does, however, make clear that objective frailty assessment should become part of lung transplant care and that physical performance measures such as the SPPB have an established evidence base in this population.

From that perspective, automated SPPB can be considered one possible implementation approach for programs seeking a practical way to integrate standardized and repeated physical function assessment into lung transplant clinical and research workflows.