Understanding the pathogenic effect of frailty on the risk of acute cellular rejection in liver transplantation: are we already that far?

we have read with interest the study performed by Fozouni et al. on the association between pre-transplant frailty and increased risk of early acute cellular rejection (ACR) after liver transplantation (LT). Chronic systemic inflammation, which is frequently detected in frail patients, was suspected by the Authors as the underlying pathogenic mechanism. This result was somehow unexpected since frail patients are usually clinically perceived as immunocompromised. Moreover, liver cirrhosis itself is associated with a severe immune dysfunction which is characterized by immunodeficiency and systemic inflammation