COMMENTARY

'Prehabilitation' May Be Key to Obtaining Improved Liver Transplantation Outcomes

The Liver Meeting 2017: American Association for the Study of Liver Diseases (AASLD)

William F. Balistreri, MD

Disclosures

December 07, 2017

Predicting Outcomes in Frail Transplant Recipients

Malnutrition, which affects 40%-80% of patients awaiting liver transplantation, is associated with increased morbidity and mortality after transplant surgery. Muscle wasting with sarcopenia and functional decline are also increasingly recognized as correlates of excess liver transplant waiting list mortality in patients with cirrhosis.

Frailty and compromised functional status are independent determinants of mortality in patients with chronic liver disease and waiting list mortality. However, their association with posttransplant outcomes are less well characterized. These measures, which are not quantified by the Model for End-Stage Liver Disease (MELD) score, have recently been incorporated into proposed frailty measures. For example, a liver frailty index was shown to predict mortality, independent of the MELD score, in adults listed for liver transplantation.[1]

In outpatients listed for liver transplant, Lai and colleagues[2] previously reported that candidate measures of physical frailty (ie, gait speed, chair stands, 30-second balance, hand grip strength, instrumental activities of daily living, weight loss, exhaustion, and physical activity) predicted waiting list mortality.[2] These observations emphasized the value of routine assessment of frailty to enhance the care of patients awaiting liver transplantation. These proposed measures also should be the target of pretransplant interventions.

At this year's Liver Meeting, Lai and colleagues[3] reported data on 214 adult liver transplant recipients who had been assessed using the Liver Frailty Index. At approximately 3 months pretransplant, the median Liver Frailty Index score was 3.7; 21% of the patients were frail. The median frailty index scores worsened at 3 months after liver transplant but improved at 6 and 12 months posttransplant. Among patients who were robust before undergoing transplant, 61% remained so after transplant. In contrast, among those who were frail before transplant, only 4% became robust at any time posttransplant.

In univariable analysis, each point improvement in the pretransplant Liver Frailty Index score (in other words, becoming less frail) was associated with increased odds of being robust after liver transplant at 3 months, 6 months, and 1 year. Patients who were frail before transplant had higher posttransplant length of stay and a trend toward more days in the intensive care unit and 90-day readmissions.

The investigators made a plea for institution of "prehabilitation" programs, including exercise and nutritional therapy, along with serial candidate performance assessment. These aggressive interventions are aimed at preventing or slowing the progression of frailty and sarcopenia before transplant. Intervening early after transplant will optimize transplant outcomes.

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