Not all risk is in the OR: How frailty and nutrition shape nephrectomy outcomes
When we think of risks in surgery, our minds often go to human factors around the procedure itself, but some powerful predictors of surgical outcomes have nothing to do with the surgeon.
In our latest study, published in the Journal of Robotic Surgery, we found that frailty and malnutrition, two often-overlooked patient factors, significantly worsen outcomes for people undergoing laparoscopic and robotic radical nephrectomy, common surgeries for kidney cancer.
Using data from more than 7,300 patients in the American College of Surgeons’ NSQIP database, we found that frail patients were 1.7 times more likely to experience major complications and had double the risk of death within 30 days of minimally invasive kidney surgery compared to their non-frail counterparts. Our results may have significant implications for how we approach care for these vulnerable populations following surgery.
Why does this matter? Because frailty and nutrition are modifiable. Unlike age or tumor stage, these are things we may be able to improve through prehabilitation programs, nutritional support and tailored planning before surgery. Too often, these things are afterthoughts. Some patients may look fine on paper, with clearance from cardiology, and no red flags; however, they may still be at significant risk if they have diabetes; trouble with everyday activities like walking, cooking or dressing; high blood pressure that needs to be treated with medicine; or drops in protein levels in the blood along with losing weight without trying.
These five factors make up a clinical score for frailty called the mFI-5 that we used in our study, as well as NRI scores (nutritional status and clinical outcomes). Together, the mFI-5 and NRI can help identify vulnerable patients who might benefit from targeted interventions before surgery.
This study is a call to action. If we want to reduce complications, improve recovery and truly put patients at the center of their care, we need to pay attention to additional factors before surgery. The mFI-5 offers a straightforward approach by evaluating specific conditions like diabetes, high blood pressure requiring medication, chronic obstructive pulmonary disorder (COPD) and congestive heart failure, along with limitations to everyday activities. Similarly, the NRI helps identify nutrition risks by measuring protein levels in blood and tracking weight loss patterns.
When these assessments identify high-risk patients, we should implement targeted interventions: optimize chronic disease management, initiate nutritional supplementation for those with low albumin, develop personalized prehabilitation programs, and possibly consider extended recovery pathways. Our data shows these aren’t merely clinical distinctions, they translate to meaningful differences in outcomes, with malnourished patients experiencing nearly five times higher rates of pneumonia (4.24% vs. 0.91%) and more than five times higher risk of transfusion requirements (20.8% vs. 4.47%). It’s time we move beyond identification to systematic intervention.
These findings could have important policy implications. Many patients face social barriers to maintaining good nutrition and exercise habits, including limited access to healthy foods, safe exercise spaces and transportation to medical appointments. Older patients often struggle with consistent follow-up care due to mobility issues, lack of caregiver support or difficulty navigating complex healthcare systems. To address these challenges, healthcare policies could require enhanced preoperative assessments that include mFI-5 and NRI evaluations for surgical patients. Hospitals and healthcare systems would need to allocate resources for staff training and tools to conduct these assessments properly. Insurance policies might need updating to cover these assessments and the interventions they recommend, ensuring that financial barriers don’t prevent patients from receiving optimal care before and after surgery.
By Drs. Gal Saffati, andrology research fellow; David Eugenio Hinojosa-Gonzalez, medical resident, urology; Jeremy Slawin, assistant professor, urology; Wesley Mayer, associate professor, urology at Baylor College of Medicine
