The word frailty comes from the Latin term fragilitas, which refers to something weak, something that can be easily broken, ruined ordestroyed.

Frailty may vary depending on whether you are referring to an object or material, meaninglittle flexibility in its concrete form or inability tochange its shape, or to the symbolic meaning, inthis case, in relation to abstract concepts, such asemotional, psychological or social weakness.

At present, in the field of medicine, frailty may be defined as a complex biological disorderwith decreased endurance and functional reserve, resulting in a greater vulnerability to adversehealth conditions. Frailty is not necessarily adisability disorder, but they are not exclusive.

This concept has been widely studied in the elderly population as an apparent state of frailtyunder stress, mainly associated with aging, whichaffects homeostasis.¹

In order to understand the starting points of this disorder, it is critical to identify theindividuals at risk in advance so that interventionefforts are targeted at the most affectedcomponents.

This concept can be clearly implemented in adults and also in children with chronicconditions, as is the case of children with liverdisease, whose severe alterations may involvetheir nutrition, endocrine system, immune status, and cognitive development.

The risk assessment of patients with endstage liver disease typically includes signs and symptoms, i.e., ascites, hepatosplenomegaly, deepjaundice, anemia, gastrointestinal bleeding, andbiochemical alterations, such as reduced albuminlevels, low serum sodium levels, decreasedcoagulation factors, etc.

In 1988, the United States National Institutes of Health included guidelines for cadaveric liverdonation for children with severe liver disease toreduce the morbidity and mortality of transplantwaiting list patients.

In February 2002, the United Network for Organ Sharing (UNOS) implemented the Pediatric End Stage Liver Disease (PELD) severity scoringsystem for organ allocation. The PELD scorereplaced urgency status and waiting list times.

The PELD score was rapidly implemented in different transplantation centers worldwide, including Argentina, where it has been used for

several years now to establish organ allocation.

The PELD score was designed to reduce subjectivity and benefit waiting list patients whohad a high probability of dying with a fast organdonation.

The system improved organ donation for high-risk patients; however, the PELD scorewas used in only 52% of cadaveric organtransplantation cases because a high percentageof such transplants in the US and Argentinawere carried out through the request of a way ofexception.

Since the PELD/MELD (Model for end-stage liver disease) scoring system minimizes waitinglist times, many patients fail to reach a high scorein time to receive an organ, leading to chronicimpairment, especially in the pediatric populationbecause of their nutritional status, neurocognitivedevelopment, and quality of life.

An interesting study about frailty in children with liver disease has been recently published; it assessed different factors that account for areduced physiological function or homeostasisrupture. That study had a prospective, cross-sectional, multicenter design (17 livertransplantation centers) and assessed 71 children (5-17 years of age), 36 with compensated chronicliver disease and 35 with end-stage liver disease; all listed for liver transplantation.²

The study population was assessed based on the classic frailty phenotype proposed by Fried and using validated pediatric tools todetermine each of the five classic alteration types:slowness, weakness, exhaustion, diminishedphysical activity, and shrinkage. After performingtests, scores were obtained; a score closer to 10indicated a greater frailty status.

Results showed that subjects with end-stage liver disease had significantly higher frailty scores (median 5; IQR 4.7) than subjects with chronicliver disease (median 3; IQR 2.4); (P < 0.0001).

Those findings suggest that frailty scores capture a different factor of poor health inchildren assessed for transplant that is notconsidered by routine laboratory measures ornutritional tests for children with liver disease.

The elements that contributed to higher frailty scores in children with liver disease wereexhaustion (fatigue), diminished physical activity, and a high prevalence of peripheral strengthimpairment. This last factor is very relevant in children with liver disease because it provides justification for future studies on psoas musclearea, whose reduction is known as sarcopenia, now considered a biological correlate of frailtyand strength impairment.³

The problems of Lurz study were it was conducted in a small cohort and the tools usedwere targeted at children as of 5 years old, whereas most children requiring a transplant areyounger. In the near future, probably, differentquestionnaires like the PedsQL may be usedadditionally to assess different conditions, suchas fatigue, in younger children.

Such new open patient assessment is a good opportunity to establish a new chronic diseaseinterpretation and, in addition, to understandtheir actual impairment status and plan strategiesaimed at reducing risks.

Most likely, only very few people have been able to define the meaning of frailty as precisely as Jorge Luis Borges, who, in his "Poem of the Gifts,"wrote: "Let no one reduce to tears or reproach, thisstatement of the mastery of God, who, with magnificentirony, gave me at once both books and night".