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

More Evidence Highlights Importance of Pretransplant Status

In a large national cohort of patients with chronic liver disease, Bernal and colleagues[4] also examined the association between pretransplant performance status and posttransplant survival in 7053 adults with chronic liver disease undergoing liver transplant in the United Kingdom between 1994 and 2016. Pretransplant functional status was prospectively assessed using a modification of the Eastern Cooperative Oncology Group (ECOG) performance status, which rates the ability to perform personal care or work-related activities on a 5-point scale from 1 (meaning "no restriction") to 5 (meaning "completely reliant on nursing/medical care").

They found that 14% of recipients had an ECOG status of 4 (only capable of limited self-care, mostly confined to bed or a chair), and 3% were status 5. Compared with 5800 recipients with status 1-3, status 4 or 5 recipients had higher pretransplant MELD scores and lower serum sodium levels; more had ascites, and more were hospitalized at the time of transplant (61% vs 6%). Posttransplant survival was worse in patients with increasingly impaired performance status; 90-day and 1-year patient survival fell from 96% and 93%, respectively, in status 1 patients to 83% and 77% in status 5 patients.

On multivariate Cox regression analysis adjusting for factors that included MELD, measures of graft quality, and era of transplantation, performance status remained strongly and independently predictive of posttransplant mortality. Recipient performance status assessed using a simple measure is independently predictive of posttransplant patient survival, with the strongest association seen in those with advanced debility. These findings reinforce the importance of debility as a potentially modifiable determinant of post-liver transplant outcome.

Chapman and colleagues[5] further investigated the impact of malnutrition on clinical outcome after transplant in a retrospective review of data on 390 adult patients. Nutritional status at the time of wait listing, assessed by subjective global assessment and functional muscle assessment by handgrip strength and the 6-minute walk test, allowed categorization of patients as well-nourished, mildly to moderately malnourished, or severely malnourished. Malnutrition was identified in 67% of patients at the time of placement on the transplant waiting list, and there was a progressive decline in nutritional status after a median waiting time of approximately 4 months. Therefore, 77% of patients were malnourished at the time of transplant; of these, 18% were severely malnourished.

Malnutrition at wait-listing was significantly associated with severity of liver disease (higher MELD and Child-Pugh scores), reduced handgrip strength, and results on the 6-minute walk test. Severe malnutrition at transplant was associated with longer length of stay in the intensive care unit (147 hours vs 89 hours), increased hospital length of stay (40 days vs 16 days), and increased incidence of infection (55% vs 34%) compared with well-nourished patients.

Conclusion

These studies validate the high prevalence of malnutrition in patients undergoing transplant and demonstrate the effect of nutritional status and muscle function on early posttransplant morbidity and mortality.

Aggressive strategies to combat malnutrition and deconditioning in the pretransplant period may lead to improved patient outcomes and economic benefits after transplant. Such strategies might include prescription of a high-calorie, high-protein diet and other oral nutrition support therapies as needed at the time of assessment.

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