Clarification of frailty and functional decline is important in the elderly with chronic kidney disease (CKD), especially those with end stage renal disease (ESRD) on dialysis, a rapidly growing population. CKD has become a geriatric disease and is a predictor for cardiovascular events, hospitalizations, and all-cause mortality.  Intervening health events represent trigger points of entry and activation of a cycle of frailty with ensuing repetitive disability/adverse outcomes. CKD can be viewed as a "silent co-morbidity" interacting with the biology of frailty to affect functional outcomes.