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D'Arcangelo F, Zanetto A, Ferrarese A, Gambato M, Lanari J, Piano S, Germani G, Senzolo M, Russo FP, Angeli P, Cillo U, Burra P. Frailty and sarcopenia in patients with cirrhosis awaiting liver transplantation: evidence from a single-centre, prospective cohort study. Updates Surg 2024:10.1007/s13304-024-01962-9. [PMID: 39102178 DOI: 10.1007/s13304-024-01962-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 07/30/2024] [Indexed: 08/06/2024]
Abstract
Sarcopenia and frailty are common complications in patients with cirrhosis evaluated for liver transplantation (LT). Although the negative impact of sarcopenia on patient's outcome has been well studied, the prognostic role of frailty is not as clear. We assessed the prevalence of sarcopenia and frailty and the clinical impact of frailty in a prospective cohort of cirrhosis patients with and without hepatocellular carcinoma (HCC) listed for LT. Patients with cirrhosis were prospectively recruited at the time of admission into the waiting list. Clinical and lab values were collected. Physical frailty was assessed by liver frailty index (LFI) and patients were categorized into robust (< 3.2); pre-frail (between 3.2 and 4.5), and frail (> 4.5). Skeletal muscle mass was evaluated via skeletal muscle index (SMI) obtained from last CT scan before LT; sarcopenia was defined by SMI < 50 cm2/m2 in males and < 39 cm2/m2 in females. 105 patients were included, of which 42 (40%) had hepatocellular carcinoma (HCC). In patients without HCC (63.5% males, median age 61 years), 36.5% were frail, 50.8% were pre-frail and 12.7% were robust. Frail patients were older than non-frail patients (63 vs. 56; p = 0.008) and had more severe liver disease (Child C: 65% vs. 37.5%; p = 0.02). Prevalence of sarcopenia in patients without HCC was 63%, with similar value of median SMI between frail and not frail patients (p = 0.454). Patients with HCC (78.6% males, 65 years old) were 21.4% frail, 61.9% pre-frail, and 16.7% robust. Frail patients had more severe liver disease (Child C: 77% vs. 18.2%; p = 0.004), whereas age was comparable to non-frail patients; among patients without HCC, during a median follow-up of 263 days, 17% died (of which 72% were frail) and 10 patients were delisted due to clinical improvement (none of whom were frail). Among those with HCC, during a median follow-up of 289 days, 4 (9%) patients died of which 50% were frail. Frailty and sarcopenia are common complications in patients with cirrhosis awaiting LT. Frailty appears to be associated with an increased risk of mortality during wait-list time especially in those with decompensated cirrhosis. At univariate analysis Meld score, Child score and presence of frailty were found to be associated with shorter survival, however, at multivariate analysis presence of frailty and Child C vs. A/B were the only independent predictor of death. Larger cohorts are required to confirm these results.
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Affiliation(s)
- Francesca D'Arcangelo
- Multivisceral Transplant Unit, Gastroenterology, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Via Giustiniani 2, 35128, Padua, PD, Italy
| | - Alberto Zanetto
- Multivisceral Transplant Unit, Gastroenterology, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Via Giustiniani 2, 35128, Padua, PD, Italy.
| | - Alberto Ferrarese
- Multivisceral Transplant Unit, Gastroenterology, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Via Giustiniani 2, 35128, Padua, PD, Italy
| | - Martina Gambato
- Multivisceral Transplant Unit, Gastroenterology, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Via Giustiniani 2, 35128, Padua, PD, Italy
| | - Jacopo Lanari
- Hepato-Biliary-Pancreatic and Liver Transplant Unit, Padua University Hospital, Padua, Italy
| | - Salvatore Piano
- Unit of Internal Medicine and Hepatology, Department of Medicine - DIMED, University and Hospital of Padova, Padua, Italy
| | - Giacomo Germani
- Multivisceral Transplant Unit, Gastroenterology, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Via Giustiniani 2, 35128, Padua, PD, Italy
| | - Marco Senzolo
- Multivisceral Transplant Unit, Gastroenterology, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Via Giustiniani 2, 35128, Padua, PD, Italy
| | - Francesco Paolo Russo
- Multivisceral Transplant Unit, Gastroenterology, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Via Giustiniani 2, 35128, Padua, PD, Italy
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology, Department of Medicine - DIMED, University and Hospital of Padova, Padua, Italy
| | - Umberto Cillo
- Hepato-Biliary-Pancreatic and Liver Transplant Unit, Padua University Hospital, Padua, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit, Gastroenterology, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Via Giustiniani 2, 35128, Padua, PD, Italy
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Gabrielli F, Biagi F, Avossa A, Falcini M, Nascimbeni F, Andreone P, Gitto S. Frailty after Liver Transplantation: A Complex Unexplored Issue. J Clin Med 2024; 13:4537. [PMID: 39124803 PMCID: PMC11313396 DOI: 10.3390/jcm13154537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Revised: 07/30/2024] [Accepted: 07/31/2024] [Indexed: 08/12/2024] Open
Abstract
Frailty is a multidimensional syndrome predominantly studied in the elderly, characterized by reduced resistance to stressors due to diminished physiological reserve and resilience. Advances in surgical techniques and immunosuppressive drugs have improved long-term survival rates in solid organ transplant recipients, yet the 10-year survival is satisfying. However, liver transplant recipients have a noteworthy risk of developing frailty status. After liver transplant, frailty can be favored by socioeconomic, cultural, and health-related factors, leading to increased risks of hospitalization, morbidity, and mortality. Various tools for frailty assessment exist, but none are universally validated for post-transplant patients. The integration of socioeconomic and psychological factors into frailty evaluation could improve quality of life and long-term outcomes for transplant recipients. Multidisciplinary approaches, including psychosocial support, are essential for managing frailty and enhancing the overall care of transplanted patients. This narrative review aims to comprehensively address the principal frailty risk factors associated with liver transplantation.
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Affiliation(s)
- Filippo Gabrielli
- Internal and Metabolic Medicine, Department of Medical and Surgical Sciences for Children & Adults, AOU of Modena, University of Modena and Reggio Emilia, 41126 Modena, Italy; (F.G.)
- Department of Surgical Sciences, University of Bologna, 40126 Bologna, Italy
| | - Filippo Biagi
- Internal Medicine, University Hospital Careggi and Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy
| | - Alessandra Avossa
- Internal Medicine, University Hospital Careggi and Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy
| | - Margherita Falcini
- Internal Medicine, University Hospital Careggi and Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy
| | - Fabio Nascimbeni
- Internal and Metabolic Medicine, Department of Medical and Surgical Sciences for Children & Adults, AOU of Modena, University of Modena and Reggio Emilia, 41126 Modena, Italy; (F.G.)
| | - Pietro Andreone
- Internal and Metabolic Medicine, Department of Medical and Surgical Sciences for Children & Adults, AOU of Modena, University of Modena and Reggio Emilia, 41126 Modena, Italy; (F.G.)
- Postgraduate School of Allergology and Clinical Immunology, University of Modena and Reggio Emilia, 41126 Modena, Italy
| | - Stefano Gitto
- Internal Medicine, University Hospital Careggi and Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy
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Geng D, Wang Y, Wu X, Hu X. Impact of pre-existing frailty on survival outcomes in solid-organ transplant candidates and recipients: A meta-analysis. Ageing Res Rev 2024; 99:102364. [PMID: 38838786 DOI: 10.1016/j.arr.2024.102364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 04/24/2024] [Accepted: 06/01/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND There is controversy surrounding the association between preexisting frailty and increased mortality in candidates and recipients of solid-organ transplants. This meta-analysis aimed to evaluate the impact of preexisting frailty on survival outcomes in solid-organ transplant candidates and recipients. METHODS A systematic search was conducted in the PubMed, Web of Sciences, and Embase databases until October 2, 2023. Two reviewers independently selected the eligible studies according to the PECOS criteria: Participants (candidates and recipients of solid-organ transplants), Exposure (frailty), Comparison (no-frailty), Outcomes (waitlist or posttransplant mortality), and Study design (retrospective or prospective cohort studies). The pooled effects were summarized by pooling the adjusted hazard ratio (HR) with 95 % confidence intervals (CI) for the frail patients than those without frailty. RESULTS Sixteen studies with 10091 patients met the eligibility criteria. Depending on the frailty tools used, the prevalence of frailty in solid-organ transplant candidates/recipients ranged from 4.6 % to 45.1 %. Frailty was significantly associated with an increased risk of waitlist mortality (HR 2.44; 95 % CI 1.84-3.24) and posttransplant mortality (HR 2.23; 95 % CI 1.61-3.09) in solid-organ transplant candidates and recipients, respectively. Subgroup analyses showed that the association of preexisting frailty with waitlist mortality and posttransplant mortality appeared to stronger in kidney transplant candidates (HR 2.70; 95 % CI 1.93-3.78) and lung transplantation recipients (HR 2.52; 95 % CI 1.23-5.15). CONCLUSION Frailty is a significant predictor of reduced survival in solid-organ transplant candidates and recipients. Assessment of frailty has the potential to identify patients who are suitable for transplantation.
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Affiliation(s)
- Donghua Geng
- Department of General Surgery, Shengjing Hospital of China Medical University, Shenyang 110004, China
| | - Yuxin Wang
- Department of Vascular and Thyroid Surgery, The First Affiliated Hospital, China Medical University, Shenyang 110001, China
| | - Xinyue Wu
- Department of Vascular and Thyroid Surgery, The First Affiliated Hospital, China Medical University, Shenyang 110001, China
| | - Xinhua Hu
- Department of Vascular and Thyroid Surgery, The First Affiliated Hospital, China Medical University, Shenyang 110001, China.
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Wang M, Shui AM, Ruck J, Huang CY, Verna EC, King EA, Ladner DP, Ganger D, Kappus M, Rahimi R, Tevar AD, Duarte-Rojo A, Lai JC. Clinically relevant cut-points for changes in the Liver Frailty Index are associated with waitlist mortality in patients with cirrhosis. Liver Transpl 2024:01445473-990000000-00406. [PMID: 38900010 DOI: 10.1097/lvt.0000000000000418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 04/25/2024] [Indexed: 06/21/2024]
Abstract
Physical frailty is a critical determinant of mortality in patients with cirrhosis and can be objectively measured using the Liver Frailty Index (LFI), which is potentially modifiable. We aimed to identify LFI cut-points associated with waitlist mortality. Ambulatory adults with cirrhosis without HCC awaiting liver transplantation from 9 centers from 2012 to 2021 for ≥3 months with ≥2 pre-liver transplantation LFI assessments were included. The primary explanatory variable was the change in LFI from first to second assessments per 3 months (∆LFI); we evaluated clinically relevant ∆LFI cut-points at 0.1, 0.2, 0.3, and 0.5. The primary outcome was waitlist mortality (death or delisting for being too sick), with transplant considered as a competing event. Among 1029 patients, the median (IQR) age was 58 (51-63) years; 42% were female; and the median lab Model for End-Stage Liver Disease-Sodium at first assessment was 18 (15-22). For each 0.1 improvement in ∆LFI, the risk of overall mortality decreased by 6% (cause-specific hazard ratio: 0.94, 95% CI: 0.92-0.97, p < 0.001). ∆LFI was associated with waitlist mortality at cut-points as low as 0.1 (cause-specific hazard ratio: 0.63, 95% CI: 0.46-0.87) and 0.2 (HR: 0.61, 95% CI: 0.42-0.87). An improvement in LFI per 3 months as small as 0.1 in the pre-liver transplantation period is associated with a clinically meaningful reduction in waitlist mortality. These data provide estimates of the reduction in mortality risk associated with improvements in LFI that can be used to assess the effectiveness of interventions targeting physical frailty in patients with cirrhosis.
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Affiliation(s)
- Melinda Wang
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Amy M Shui
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Jessica Ruck
- Department of Surgery, John Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Chiung-Yu Huang
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Elizabeth C Verna
- Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York, New York, USA
| | - Elizabeth A King
- Department of Surgery, John Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Daniela P Ladner
- Northwestern University Transplant Outcomes Transplant Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern Medicine, Chicago, Illinois, USA
| | - Daniel Ganger
- Northwestern University Transplant Outcomes Transplant Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern Medicine, Chicago, Illinois, USA
| | - Matthew Kappus
- Division of Gastroenterology and Hepatology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Robert Rahimi
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Baylor Scott and White Health, Dallas, Texas, USA
| | - Amit D Tevar
- Department of Surgery and Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Andres Duarte-Rojo
- Northwestern University Transplant Outcomes Transplant Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern Medicine, Chicago, Illinois, USA
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
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Harris SJ, Stine JG. Frailty in liver transplantation: Exploring prescribing exercise as medicine to improve patient outcomes. Liver Int 2024. [PMID: 38899635 DOI: 10.1111/liv.15986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 05/08/2024] [Accepted: 05/14/2024] [Indexed: 06/21/2024]
Abstract
Liver transplantation (LT) represents a curative avenue for individuals with advanced chronic liver disease. Given the inherent illness severity of LT candidates, identifying patients at greater risk for adverse outcomes before and after transplantation is paramount. Approximately 50% of cirrhotic patients are frail and have considerable functional impairment. Various measures have been used to assess frailty, including performance-based tests and functional status evaluations. Frailty carries significant prognostic implications and predicts both mortality and pre- and post-LT complications. Contributing factors to frailty in this population include sarcopenia, malnutrition, inflammation, and psychosocial factors. Recognizing the prevalence of frailty among LT candidates, exercise interventions have been developed to improve physical frailty and offer potential to improve patient outcomes. While many interventions have demonstrated efficacy without notable adverse events, the absence of a universally accepted standard for exercise prescription underscores the variability in intervention elements and patient adherence. Given the safety profile of exercise interventions, there remains a critical need for standardized protocols and guidelines to optimize exercise regimens for LT candidates. This review delves into the landscape of frailty among LT candidates, elucidating its etiological underpinnings, impact on outcomes, utilization of exercise interventions, and the efficacy of exercise programs in reducing the burden frailty in those awaiting LT.
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Affiliation(s)
- Sara J Harris
- College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Jonathan G Stine
- Division of Gastroenterology and Hepatology, Department of Medicine, Penn State Health - Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
- Fatty Liver Program, Penn State Health - Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
- Liver Center, Penn State Health - Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
- Department of Public Health Sciences, The Pennsylvania State University - College of Medicine, Hershey, Pennsylvania, USA
- Cancer Institute, Penn State Health - Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
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Campos-Varela I, Castells L, Quiroga S, Vargas V, Simon-Talero M. Frailty and sarcopenia in patients with acute-on-chronic liver failure: Assessment and risk in the liver transplant setting. Ann Hepatol 2024; 29:101515. [PMID: 38851394 DOI: 10.1016/j.aohep.2024.101515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/17/2023] [Accepted: 05/31/2024] [Indexed: 06/10/2024]
Abstract
Frailty and sarcopenia are well-recognized factors related to worse outcomes in patients with cirrhosis, including liver transplant (LT) candidates. Implications of pre-LT functional and muscle deterioration also affect post-LT outcomes. Patients with cirrhosis and acute-on-chronic liver failure (ACLF) have a lower survival rate, both before and after LT. There is a need to better identify those patients with ACLF who would benefit from LT. This review aims to present the available data about frailty and sarcopenia in patients with ACLF in the LT setting. An exhaustive review of the published literature was conducted. Data regarding frailty and sarcopenia in LT candidates with ACLF are scarce and heterogeneous. Studies evaluating frailty and sarcopenia in critically ill patients outside the liver literature are also presented in this review to enrich the knowledge of this field in expansion. Frailty and sarcopenia seem to contribute to worse outcomes in LT candidates with ACLF, both before and after LT. Sarcopenia evaluation may be the most prudent approach for those very sick patients. Skeletal muscle index assessed by computed tomography is recommended to evaluate sarcopenia. The role of muscle ultrasound and bioelectrical impedance analysis is to be determined. Frailty and sarcopenia are crucial factors to consider on a case-by-case basis in LT candidates with ACLF to improve patient outcomes.
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Affiliation(s)
- Isabel Campos-Varela
- Liver Unit, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain.
| | - Lluis Castells
- Liver Unit, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Sergi Quiroga
- Radiology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Victor Vargas
- Liver Unit, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Macarena Simon-Talero
- Liver Unit, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
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LaHue SC, Fuentealba M, Roa Diaz S, Seetharaman S, Garcia T, Furman D, Lai JC, Newman JC. Association of biological aging with frailty and post-transplant outcomes among adults with cirrhosis. GeroScience 2024; 46:3287-3295. [PMID: 38246968 PMCID: PMC11009173 DOI: 10.1007/s11357-024-01076-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 01/13/2024] [Indexed: 01/23/2024] Open
Abstract
Frailty is classically associated with advanced age but is also an important predictor of clinical outcomes in comparatively young adults with cirrhosis. We examined the association of biological aging with frailty and post-transplant outcomes in a pilot of adults with cirrhosis undergoing liver transplantation (LT). Frailty was measured via the Liver Frailty Index (LFI). The primary epigenetic clock DNA methylation (DNAm) PhenoAge was calculated from banked peripheral blood mononuclear cells; we secondarily explored two first-generation clocks (Hannum; Horvath) and two additional second-generation clocks (GrimAge; GrimAge2). Twelve adults were included: seven frail (LFI ≥ 4.4, mean age 55 years) and five robust (LFI < 3.2, mean age 55 years). Mean PhenoAge age acceleration (AgeAccel) was + 2.5 years (P = 0.23) for frail versus robust subjects. Mean PhenoAge AgeAccel was + 2.7 years (P = 0.19) for subjects who were readmitted or died within 30 days of discharge post-LT versus those without this outcome. When compared with first-generation clocks, the second-generation clocks demonstrated greater average AgeAccel for subjects with frailty or poor post-LT outcomes. Measuring biological age using DNAm-derived epigenetic clocks is feasible in adults undergoing LT. While frail and robust subjects had the same average chronological age, average biological age as measured by second-generation epigenetic clocks tended to be accelerated among those who were frail or experienced a poor post-LT outcome. These results suggest that frailty in these relatively young subjects with cirrhosis may involve similar aging mechanisms as frailty classically observed in chronologically older adults and warrant validation in a larger cohort.
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Affiliation(s)
- Sara C LaHue
- Department of Neurology, School of Medicine, University of California, San Francisco, CA, USA.
- Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, 505 Parnassus Ave, Box 0114, San Francisco, CA, 94143, USA.
- Buck Institute for Research On Aging, Novato, CA, USA.
| | | | - Stephanie Roa Diaz
- Buck Institute for Research On Aging, Novato, CA, USA
- Division of Geriatrics, Department of Medicine, School of Medicine, University of California, San Francisco, CA, USA
| | - Srilakshmi Seetharaman
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, CA, USA
| | - Thelma Garcia
- Buck Institute for Research On Aging, Novato, CA, USA
- Division of Geriatrics, Department of Medicine, School of Medicine, University of California, San Francisco, CA, USA
| | - David Furman
- Buck Institute for Research On Aging, Novato, CA, USA
- Instituto de Investigaciones en Medicina Traslacional, Universidad Austral, Consejo Nacional de Investigaciones Científicas y Técnicas, 1629, Pilar, Argentina
- Stanford 1000 Immunomes Project, Stanford University School of Medicine, Stanford, CA, USA
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, CA, USA
| | - John C Newman
- Buck Institute for Research On Aging, Novato, CA, USA
- Division of Geriatrics, Department of Medicine, School of Medicine, University of California, San Francisco, CA, USA
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Xie R, Jing X, Yang C. The prevalence and characteristics of frailty in cirrhosis patients: a meta-analysis and systematic review. Front Med (Lausanne) 2024; 11:1353406. [PMID: 38745743 PMCID: PMC11092890 DOI: 10.3389/fmed.2024.1353406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 03/08/2024] [Indexed: 05/16/2024] Open
Abstract
Objectives This study aimed to assess the prevalence of frailty in cirrhosis patients and the distribution of age, sex, and body mass index (BMI) in cirrhotic patients with frailty. Methods We performed a thorough literature search using PubMed, Embase, Web of Science, and the Cochrane Library from inception to 29 February 2024. The estimated prevalence with a 95% confidence interval (CI) was calculated with a random effect model. Subgroup analysis and sensitivity analysis were performed to assess the heterogeneity and characterize the distribution of age, sex, and body mass index (BMI) in cirrhotic patients. Publication bias was assessed by the funnel plot, Begg's test, and Egger's test. Results The 16 included studies, which were all observational, reported a prevalence of frailty in 8,406 cirrhosis patients ranging from 9 to 65%, and the overall estimated prevalence was 27% (95% CI: 21-33%; I2 = 97.7%, P < 0.001). This meta-analysis indicated that the estimated prevalence of frailty in cirrhosis patients was high, and compared to the non-frail cohort, the frail cohort tended to have a higher mean age, with a mean age of 63.3 (95% CI: 59.9, 66.7; Z = 36.48; P < 0.001), and a larger proportion of male patients with worse liver function, with a mean of 73.5% (95% CI: 71.4, 75.5%; Z = 7.65; P < 0.001), ND in the frail cohort, 54.8% (95% CI: 43.1, 66.5%; P < 0.001) and 23.4% (95% CI: 13.2, 33.7%; P < 0.001) were classified into Child-Pugh B and C, respectively. Meanwhile, the patients in the non-frail cohort are more likely to have a higher BMI, with a mean of 28.4 (95% CI: 24.1, 32.7; Z = 13.07; P < 0.001). Conclusion The current study suggests that cirrhosis patients have a high prevalence of frailty. Compared with the non-frail cohort, the frail patients tend to be male, older, and have a lower BMI with worse liver function.
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Affiliation(s)
- Ruiyu Xie
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Hebei Key Laboratory of Gastroenterology, Hebei Institute of Gastroenterology, Hebei Clinical Research Center for Digestive Diseases, Shijiazhuang, Hebei, China
| | - Xiaotong Jing
- Department of Hematology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Chuanjie Yang
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Hebei Key Laboratory of Gastroenterology, Hebei Institute of Gastroenterology, Hebei Clinical Research Center for Digestive Diseases, Shijiazhuang, Hebei, China
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9
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Benmassaoud A, Martel M, Carli F, Geraci O, Daskalopoulou SS, Sebastiani G, Bessissow A. Prehabilitation in patients awaiting liver transplantation. Transplant Rev (Orlando) 2024; 38:100835. [PMID: 38367398 DOI: 10.1016/j.trre.2024.100835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 01/30/2024] [Accepted: 01/31/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND Frailty, malnutrition and sarcopenia lead to a significant increase in morbidity and mortality before and after liver transplantation (LT). Prehabilitation attempts to optimize physical fitness of individuals before major surgeries. To date, little is known about its impact on patients awaiting LT. AIMS The aim of our scoping review was to describe whether prehabilitation in patients awaiting LT is feasible and safe, and whether it leads to a change in clinical parameters before or after transplantation. METHODS We performed a systematic review of the literature from 1946 to November 2023 to identify prospective studies and randomized controlled trials of adult LT candidates who participated in an exercise training program. RESULTS Out of 3262 citations initially identified, six studies were included. Studies were heterogeneous in design, patient selection, intervention, duration, and outcomes assessed. All studies were self-described as pilot or feasibility studies and had a sample size ranging from 13 to 33. Two studies were randomized controlled trials. Two study restricted to patients with cirrhosis who were eligible for liver transplantation or on the transplant list. Exercise programs lasted between 6 and 12 weeks. In terms of feasibility, proportion of eligible patients that were recruited was between 54 and 100%. Program completion ranged between 38 and 90%. Interventions appeared safe with 9 (9.2%) adverse events noted. In the intervention group, improvements were generally noted in peak oxygen consumption and workload, 6-min walking distance, and muscle strength. One study suggested a decrease in post-transplant hospital length of stay. CONCLUSIONS Overall, it appears that prehabilitation with exercise training is feasible, and safe in patients awaiting LT. Higher quality and larger studies are needed to confirm its impact on pre- and post-transplantation-related outcomes.
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Affiliation(s)
- Amine Benmassaoud
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Canada; Research Institute of the McGill University Health Centre, Montreal, Canada.
| | - Myriam Martel
- Research Institute of the McGill University Health Centre, Montreal, Canada
| | - Franco Carli
- Department of Anesthesia, McGill University Health Centre
| | - Olivia Geraci
- Research Institute of the McGill University Health Centre, Montreal, Canada
| | - Stella S Daskalopoulou
- Research Institute of the McGill University Health Centre, Montreal, Canada; Division of General Internal Medicine, McGill University Health Centre
| | - Giada Sebastiani
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Canada; Research Institute of the McGill University Health Centre, Montreal, Canada
| | - Amal Bessissow
- Research Institute of the McGill University Health Centre, Montreal, Canada; Division of General Internal Medicine, McGill University Health Centre
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10
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Cruz C, Prado CM, Gillis C, Martindale R, Bémeur C, Lai JC, Tandon P. Nutritional aspects of prehabilitation in adults with cirrhosis awaiting liver transplant. Hepatology 2024:01515467-990000000-00825. [PMID: 38546288 DOI: 10.1097/hep.0000000000000818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 01/20/2024] [Indexed: 04/21/2024]
Abstract
Malnutrition, sarcopenia (low muscle mass), and physical frailty have gained increasing recognition in candidates for liver transplant (LT) as these conditions can impact postoperative functional capacity. Multidimensional prehabilitation programs have been proposed as a safe intervention in adults awaiting LT but the nutritional pillar of prehabilitation has been understudied. This review summarizes the nutritional recommendations for prehabilitation for individuals with cirrhosis awaiting LT. Three major aspects of nutritional prehabilitation are discussed: (1) Assess: Evaluate nutritional status and assess for malnutrition, sarcopenia, and frailty to guide the nutritional prehabilitation intervention intensity, increasing across universal, targeted, and specialist levels; (2) Intervene: Prescribe a nutritional prehabilitation intervention to meet established nutrition guidelines in cirrhosis with a targeted focus on improving nutritional status and muscle health; (3) Reassess: Follow-up based on the required intensity of nutritional care with as needed intervention adjustment. Topics covered in the review include nutritional care levels for prehabilitation, energy prescriptions across body mass index strata, detailed considerations around protein intake (amount, distribution, and quality), carbohydrate and fat intake, other nutritional considerations, and the potential role of dietary supplements and nutraceuticals. Future research is warranted to more accurately evaluate energy needs, evaluate emerging dietary supplementation strategies, and establish the role of nutraceuticals alongside food-based interventions. While the general principles of nutritional prehabilitation are ready for immediate application, future large-scale randomized controlled trials in this space will help to quantify the benefit that can be gained by transitioning the LT approach from passive "transplant waitlist time" to active "transplant preparation time."
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Affiliation(s)
- Christofer Cruz
- Department of Medicine, Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Alberta, Canada
| | - Carla M Prado
- Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, Alberta, Canada
| | - Chelsia Gillis
- School of Human Nutrition, McGill University, Montreal, Quebec, Canada
- Department of Nutrition, Université de Montréal, Montreal, Quebec, Canada
| | - Robert Martindale
- Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Chantal Bémeur
- Department of Nutrition, Université de Montréal, Montreal, Quebec, Canada
| | - Jennifer C Lai
- Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Puneeta Tandon
- Department of Medicine, Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Alberta, Canada
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11
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Perdiguero GG, Spina JC, Martínez J, Savluk L, Saidman J, Bonifacio M, Bakken S, Padilla M, Gallego-Clemente E, Moreno-González V, De Santibañes M, Marciano S, De Santibañes E, Gadano A, Pekolj J, Abraldes JG, Mauro E. Enhancing ACLF prediction by integrating sarcopenia assessment and frailty in liver transplant candidates on the waiting list. JHEP Rep 2024; 6:100985. [PMID: 38384670 PMCID: PMC10879792 DOI: 10.1016/j.jhepr.2023.100985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 12/04/2023] [Accepted: 12/12/2023] [Indexed: 02/23/2024] Open
Abstract
Background & Aims Malnutrition, sarcopenia, and frailty are prevalent in cirrhosis. We aimed to assess the correlation between assessment tools for malnutrition, sarcopenia, and frailty in patients on the liver transplant (LT) waiting list (WL), and to identify a predictive model for acute-on-chronic liver failure (ACLF) development. Methods This prospective single-center study enrolled consecutive patients with cirrhosis on the WL for LT (May 2019-November 2021). Assessments included subjective global assessment, CT body composition, skeletal muscle index (SMI), ultrasound thigh muscle thickness, sarcopenia HIBA score, liver frailty index (LFI), hand grip strength, and 6-minute walk test at enrollment. Correlations were analyzed using Pearson's correlation. Competing risk regression analysis was used to assess the predictive ability of the liver- and functional physiological reserve-related variables for ACLF. Results A total of 132 patients, predominantly with decompensated cirrhosis (87%), were included. Our study revealed a high prevalence of malnutrition (61%), sarcopenia (61%), visceral obesity (20%), sarcopenic visceral obesity (17%), and frailty (10%) among participants. Correlations between the assessment tools for sarcopenia and frailty were poor. Sarcopenia by SMI remained prevalent when frailty assessments were not usable. After a median follow-up of 10 months, 39% of the patients developed ACLF on WL, while 28% experienced dropouts without ACLF. Multivariate analysis identified MELD-Na, SMI, and LFI as independent predictors of ACLF on the WL. The predictive model MELD-Na-sarcopenia-LFI had a C-statistic of 0.85. Conclusions The poor correlation between sarcopenia assessment tools and frailty underscores the importance of a comprehensive evaluation. The SMI, LFI, and MELD-Na independently predicted ACLF development in WL. These findings enhance our understanding of the relationship between sarcopenia, frailty, and ACLF in patients awaiting LT, emphasizing the need for early detection and intervention to improve WL outcomes. Impact and implications The relationship between sarcopenia and frailty assessment tools, as well as their ability to predict acute-on-chronic liver failure (ACLF) in patients on the liver transplant (LT) waiting list (WL), remains poorly understood. Existing objective frailty screening tests have limitations when applied to critically ill patients. The correlation between sarcopenia and frailty assessment tools was weak, suggesting that they may capture different phenotypes. Sarcopenia assessed by skeletal muscle index, frailty evaluated using the liver frailty index, and the model for end-stage liver disease-Na score independently predicted the development of ACLF in patients on the WL. Our findings support the integration of liver frailty index and skeletal muscle index assessments at the time of inclusion on the WL for LT. This combined approach allows for the identification of a specific patient subgroup with an increased susceptibility to ACLF, underscoring the importance of early implementation of targeted treatment strategies to improve outcomes for patients awaiting LT.
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Affiliation(s)
| | - Juan Carlos Spina
- Liver Transplant Unit, Hospital Italiano de Bs. As., Buenos Aires, Argentina
- Radiology Department, Hospital Italiano de Bs As, Buenos Aires, Argentina
| | - Jorge Martínez
- Liver Unit, Hospital Italiano de Bs. As., Buenos Aires, Argentina
| | - Lorena Savluk
- Liver Transplant Unit, Hospital Italiano de Bs. As., Buenos Aires, Argentina
- Radiology Department, Hospital Italiano de Bs As, Buenos Aires, Argentina
| | - Julia Saidman
- Radiology Department, Hospital Italiano de Bs As, Buenos Aires, Argentina
| | | | - Sofia Bakken
- Liver Transplant Unit, Hospital Italiano de Bs. As., Buenos Aires, Argentina
- Radiology Department, Hospital Italiano de Bs As, Buenos Aires, Argentina
| | - Marlene Padilla
- Liver Unit, Hospital Italiano de Bs. As., Buenos Aires, Argentina
| | | | | | | | - Sebastián Marciano
- Liver Unit, Hospital Italiano de Bs. As., Buenos Aires, Argentina
- Liver Transplant Unit, Hospital Italiano de Bs. As., Buenos Aires, Argentina
| | | | - Adrían Gadano
- Liver Unit, Hospital Italiano de Bs. As., Buenos Aires, Argentina
- Liver Transplant Unit, Hospital Italiano de Bs. As., Buenos Aires, Argentina
| | - Juan Pekolj
- Liver Transplant Unit, Hospital Italiano de Bs. As., Buenos Aires, Argentina
| | - Juan G. Abraldes
- Division of Gastroenterology, University of Alberta, CEGIIR, Edmonton, Canada
| | - Ezequiel Mauro
- Liver Unit, Hospital Italiano de Bs. As., Buenos Aires, Argentina
- Liver Transplant Unit, Hospital Italiano de Bs. As., Buenos Aires, Argentina
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12
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Ruiz-Margáin A, Macías-Rodríguez RU, Flores-García NC, Román Calleja BM, Fierro-Angulo OM, González-Regueiro JA. Assessing nutrition status, sarcopenia, and frailty in adult transplant recipients. Nutr Clin Pract 2024; 39:14-26. [PMID: 38097210 DOI: 10.1002/ncp.11107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/15/2023] [Accepted: 11/15/2023] [Indexed: 01/13/2024] Open
Abstract
The assessment of nutrition status, sarcopenia, and frailty holds significant relevance in the context of adult transplantation, as these factors are associated with an unfavorable prognosis; thus, transplant candidates must undergo a full nutrition assessment. Screening tools may be used to prioritize patients, this can be done using the Nutrition Risk Screening 2002 or Royal Free Hospital-Nutritional Prioritizing Tool. Subsequently, a thorough nutrition-focused physical examination should be conducted to evaluate clinical signs of nutrition deficiencies, fat and muscle loss, and fluid overload; dietary history and current intake must also be assessed. Apart from physical examination, specific testing for sarcopenia and frailty are recommended. For sarcopenia assessment, specifically for muscle quantification, the gold standard is the cross-sectional measurement of the muscle at L3 obtained from a computed tomography scan or magnetic resonance imaging; dual-energy x-ray absorptiometry is also a good tool especially when appendicular skeletal muscle index is calculated. Other more readily available options include phase angle from bioelectrical impedance or bioimpedance spectroscopy. In the sarcopenia assessment, muscle function evaluation is required, handgrip strength stands as the primary test for this purpose; this test is also part of the subjective global assessment and is included in some frailty scores. Finally, for frailty assessment, the Short Physical Performance Battery is useful for evaluating physical frailty, and for a multidimensional evaluation, the Fried frailty phenotype can be used. Specifically for liver transplant candidates, the use of Liver Frailty Index is recommended.
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Affiliation(s)
- Astrid Ruiz-Margáin
- Division of Hepatology, Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Ricardo U Macías-Rodríguez
- Division of Hepatology, Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Nayelli C Flores-García
- Division of Hepatology, Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Berenice M Román Calleja
- Division of Hepatology, Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Oscar M Fierro-Angulo
- Division of Hepatology, Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - José A González-Regueiro
- Division of Hepatology, Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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13
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Wang M, Shui AM, Ruck J, King E, Rahimi R, Kappus M, Volk ML, Ganger DR, Ladner DP, Duarte-Rojo A, Huang CY, Verna EC, Lai JC. The liver frailty index is a predictor of healthcare utilization after liver transplantation in older adults. Clin Transplant 2024; 38:e15219. [PMID: 38064281 PMCID: PMC11042074 DOI: 10.1111/ctr.15219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 11/15/2023] [Accepted: 11/26/2023] [Indexed: 01/31/2024]
Abstract
BACKGROUND Older adults have higher healthcare utilization after liver transplantation (LT), yet objective risk stratification tools in this population are lacking. We evaluated the Liver Frailty Index (LFI) as one potential tool. METHODS Ambulatory LT candidates ≥65 years without hepatocellular carcinoma (HCC) who underwent LT from 1/2012 to 6/2022 at 8 U.S. centers were included. Estimates of the difference in median using quantile regression were used to assess the adjusted association between LFI and hospitalized days within 90 days post-LT. RESULTS Of 131 LT recipients, median (interquartile range [IQR]) (1st -3rd quartiles) age was 68 years (66-70); median pre-LT MELD-Na was 19 (15-24). Median LFI was 4.1 (3.6-4.7); 27% were frail (LFI≥4.5). Median hospitalized days within 90 days post-LT was 11 (7-20). Compared with non-frail patients, frail patients were hospitalized for a median of 5 days longer post-LT (95% CI .30-9.7, p = .04). Each .5 unit increase in pre-LT LFI was associated with an increase of 1.16 days (95%CI .42-2.69, p = .02) in hospitalized days post-LT. CONCLUSION Among older adults undergoing LT, frailty was associated with more hospitalized days within 90 days after LT. The LFI can identify older adults who might benefit from pre-LT or early post-LT programs which may reduce post-LT healthcare utilization, such as early rehabilitation or post-hospital discharge programs.
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Affiliation(s)
- Melinda Wang
- Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Amy M. Shui
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, California, USA
| | - Jessica Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth King
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Robert Rahimi
- Division of Gastroenterology and Hepatology, Department of Medicine, Baylor Scott and White Health, Dallas, Texas, USA
| | - Matthew Kappus
- Division of Gastroenterology, Department of Medicine, Duke University Hospital, Durham, North Carolina, USA
| | - Michael L. Volk
- Division of Gastroenterology and Nutrition, Department of Medicine, Loma Linda University, Loma Linda, California, USA
| | - Daniel R. Ganger
- Division of Gastroenterology and Nutrition, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Daniela P. Ladner
- Division of Organ Transplantation, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Andres Duarte-Rojo
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Chiung-Yu Huang
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, California, USA
| | - Elizabeth C. Verna
- Center for Liver Division of Digestive and Liver Diseases, Diseases and Transplantation, Columbia University Medical Center, New York, New York, USA
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
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14
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Duarte-Rojo A, Bux R, Sliwa J. Untangling frailty, sarcopenia, and physical fitness in cirrhosis. Clin Liver Dis (Hoboken) 2024; 23:e0213. [PMID: 38841195 PMCID: PMC11152786 DOI: 10.1097/cld.0000000000000213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 04/01/2024] [Indexed: 06/07/2024] Open
Affiliation(s)
- Andres Duarte-Rojo
- Division of Gastroenterology and Hepatology, Northwestern Feinberg School of Medicine; Chicago, Illinois, USA
- Comprehensive Transplant Center, Northwestern Medicine, Chicago, Illinois, USA
| | - Rehaan Bux
- Comprehensive Transplant Center, Northwestern Medicine, Chicago, Illinois, USA
| | - James Sliwa
- Shirley Ryan Ability Lab, Department of Physical Medicine & Rehabilitation, Northwestern Feinberg School of Medicine, Chicago, Illinois, USA
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15
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Giammarino AM, Ghani M, Satapathy SK. A brief review of sarcopenia and frailty in the early post-liver transplant period. Clin Liver Dis (Hoboken) 2024; 23:e0215. [PMID: 38912000 PMCID: PMC11191939 DOI: 10.1097/cld.0000000000000215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 04/07/2024] [Indexed: 06/25/2024] Open
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16
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Thuluvath AJ, Verna EC. Deciphering an expanding array of clinical and research frailty measures. Clin Liver Dis (Hoboken) 2024; 23:e0180. [PMID: 38872786 PMCID: PMC11168841 DOI: 10.1097/cld.0000000000000180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 03/01/2024] [Indexed: 06/15/2024] Open
Affiliation(s)
- Avesh J. Thuluvath
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
- Department of Surgery, Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York, New York, USA
| | - Elizabeth C. Verna
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
- Department of Surgery, Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York, New York, USA
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17
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Ruck JM, Shui AM, Jefferis AA, Rojo AD, Rahimi RS, Ganger DR, Verna EC, Kappus M, Ladner DP, Segev DL, Volk M, Tevar A, King EA, Lai JC. Association of body mass index with post-liver transplant outcomes. Clin Transplant 2024; 38:e15205. [PMID: 38041450 PMCID: PMC10918560 DOI: 10.1111/ctr.15205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 08/18/2023] [Accepted: 11/19/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND Patients with obesity have inferior outcomes after general surgery procedures, but studies evaluating post-liver transplant (LT) outcomes have been limited by small sample sizes or lack of granularity of outcomes. We evaluated the relationship between obesity and post-LT outcomes, including those observed in other populations to be obesity-related. METHODS Included were 1357 LT recipients prospectively enrolled in the ambulatory pre-LT setting at 8 U.S. CENTERS Recipient were categorized by body mass index (BMI, kg/m2 ): non-obese (BMI < 30), class 1 obesity (BMI 30-<35), and classes 2-3 obesity (BMI ≥ 35). Post-transplant complications were compared by BMI using Chi-square and rank-sum testing, logistic regression, Kaplan-Meier curves, and Cox regression. RESULTS Classes 2-3 obesity was associated with higher adjusted odds than non-obesity of venous thrombosis [adjusted odds ratio (aOR) 2.06, 95% CI 1.01-4.23, p = .047] and wound dehiscence (aOR 2.45, 95% CI 1.19-5.06, p = .02). Compared with non-obese recipients, post-LT hospital stay was significantly longer for recipients with classes 2-3 obesity [p = .01; median (Q1-Q3) 9 (6-14) vs. 8 (6-12) days) or class 1 obesity [p = .002; 9 (6-14) vs. 8 (6-11) days]. Likelihood of ICU readmission, infection, discharge to a non-home facility, rejection, 30-day readmission, and 1-year readmission were similar across BMI categories (all p > .05). CONCLUSION Compared to non-obese recipients, obese recipients had similar post-LT survival but longer hospital stay and higher likelihood of wound dehiscence and venous thrombosis. These findings underscore that obesity alone should not preclude LT, but recipients with obesity should be monitored for obesity-related complications such as wound dehiscence and venous thrombosis.
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Affiliation(s)
- Jessica M. Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Amy M. Shui
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Alexis A. Jefferis
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Andres Duarte Rojo
- Center for Liver Diseases, Thomas A. Starzl Transplantation Institute, Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Robert S. Rahimi
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Baylor Scott and White Health, Dallas, Texas, USA
| | - Daniel R. Ganger
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern Medicine, Chicago, Illinois, USA
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Elizabeth C. Verna
- Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York, New York, USA
| | - Matthew Kappus
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Daniela P. Ladner
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Division of Transplantation, Department of Surgery, Northwestern Medicine, Chicago, Illinois, USA
| | - Dorry L. Segev
- Department of Surgery, New York University Grossman School of Medicine and Langone Health, New York, New York, USA
- Department of Population Health, New York University Grossman School of Medicine and Langone Health, New York, New York, USA
| | - Michael Volk
- Division of Gastroenterology & Hepatology, and Transplantation Institute, Loma Linda University Health, Loma Linda, California, USA
| | - Amit Tevar
- Department of Medicine, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Elizabeth A. King
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jennifer C. Lai
- Department of Medicine, University of California San Francisco School of Medicine, San Francisco, California, USA
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18
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Musto JA, Lucey MR. Prognostic models in alcohol-related liver disease and alcohol-related hepatitis. Best Pract Res Clin Gastroenterol 2023; 67:101867. [PMID: 38103931 DOI: 10.1016/j.bpg.2023.101867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 08/18/2023] [Indexed: 12/19/2023]
Abstract
Alcohol-associated liver disease (ALD) and alcohol-associated hepatitis (AH) are dynamic disorders whose prognosis can be challenging to determine. A number of prognostic models have been developed to determine likelihood of death, when to refer for liver transplant (LT) and the role for glucocorticoids. Often these models were created with a specific application in mind but were found to have additional applications with further study. Those prognostic models that have stood the test of time are easy to use, have clear interpretations and employ objective parameters. These parameters most often include total bilirubin, INR and creatinine among other data points. Ideally, these models could be utilized at all phases of disease but in most, it is important for clinicians to consider drinking history and how it might alter the determined scores. Herein we provide a brief review of prognostic models in ALD and AH and provide practical tips and considerations to successfully make use of these tools in a clinical setting.
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Affiliation(s)
- Jessica Ann Musto
- Department of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
| | - Michael Ronan Lucey
- Department of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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19
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Kurian J, Matevish LE, Feizpour C, Shah JA, Hwang C, Hanish SI, Mufti AR, Neill-Fogus S, Vagefi PA, Patel MS. Liver Transplantation in Elderly Recipients: Is Age Just a Number? Am Surg 2023; 89:5737-5743. [PMID: 37142265 DOI: 10.1177/00031348231173998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
BACKGROUND The proportion of older patients on the liver transplant waitlist continues to increase. With limited existing data to guide liver transplant evaluation of elderly patients, we aimed to study selection practices and outcomes of patients ≥70 years old. We hypothesized that 1-year patient and graft survival would not differ between appropriately selected elderly patients and those who are younger. METHODS All patients referred for liver transplantation between 2018 and 2020 were stratified into elderly (age ≥70) and young (age <70) cohorts. Evaluation data pertaining to medical, surgical, and psychosocial risk assessment were reviewed. Recipient characteristics and post-operative outcomes, primarily 1-year graft and patient survival, were compared, with a median follow-up of 16.4 months. RESULTS 322 patients underwent transplant out of 2331 referred. Elderly patients represented 230 of these referrals and 20 underwent transplant. The most common reasons for denial of elderly patients were multiple medical comorbidities (49%), cardiac risk (15%) and psychosocial barriers (13%). The median MELD of elderly recipients was lower (19 vs 24, P = .02), and proportion of hepatocellular carcinoma was higher (60% vs 23%, P < .001). There was no difference in 1-year graft (elderly 90.9% vs young 93.3%, P = .72) or patient survival (elderly 90.9% vs young 94.7%, P = .88). DISCUSSION Liver transplant outcomes and survival are not affected by advanced age in carefully evaluated and selected recipients. Age should not be considered an absolute contraindication for liver transplant referral. Efforts should be made to develop guidelines for risk stratification and donor-recipient matching that optimize outcomes in elderly patients.
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Affiliation(s)
- Joshua Kurian
- Division of Surgical Transplantation, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Lauren E Matevish
- Division of Surgical Transplantation, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Cyrus Feizpour
- Division of Surgical Transplantation, The University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jigesh A Shah
- Division of Surgical Transplantation, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Christine Hwang
- Division of Surgical Transplantation, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Steven I Hanish
- Division of Surgical Transplantation, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Arjmand R Mufti
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Susan Neill-Fogus
- Division of Surgical Transplantation, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Parsia A Vagefi
- Division of Surgical Transplantation, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Madhukar S Patel
- Division of Surgical Transplantation, The University of Texas Southwestern Medical Center, Dallas, TX, USA
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Affiliation(s)
- Michael R Lucey
- From the Department of Medicine, Division of Gastroenterology and Hepatology (M.R.L.), the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition (K.N.F.), and the Department of Surgery, Division of Transplantation (D.P.F.), University of Wisconsin, Madison
| | - Katryn N Furuya
- From the Department of Medicine, Division of Gastroenterology and Hepatology (M.R.L.), the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition (K.N.F.), and the Department of Surgery, Division of Transplantation (D.P.F.), University of Wisconsin, Madison
| | - David P Foley
- From the Department of Medicine, Division of Gastroenterology and Hepatology (M.R.L.), the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition (K.N.F.), and the Department of Surgery, Division of Transplantation (D.P.F.), University of Wisconsin, Madison
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Duarte-Rojo A, Bloomer PM, Grubbs RK, Stine JG, Ladner D, Hughes CB, Dunn MA, Jakicic JM. Use of a Mobile-Assisted Telehealth Regimen to Increase Exercise in Transplant Candidates: A Home-Based Prehabilitation Pilot and Feasibility Trial. Clin Transl Gastroenterol 2023; 14:e00601. [PMID: 37477616 PMCID: PMC10684184 DOI: 10.14309/ctg.0000000000000601] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 05/01/2023] [Indexed: 07/22/2023] Open
Abstract
INTRODUCTION Physical fitness assessed by the Liver Frailty Index (LFI) and 6-minute walk test (6MWT) informs the prognosis of liver transplant candidates, although there are limited data on its reversibility after prehabilitation. On a home-based exercise trial, we aimed to improve LFI and 6MWT and to investigate trial feasibility and intervention adherence. METHODS Liver transplant candidates with cirrhosis wore a personal activity tracker and used Exercise and Liver FITness app for 14 weeks, including a 2-week technology acclimation run-in. The 12-week intervention consisted of Exercise and Liver FITness app plus personal activity tracker and 15-/30-minute weekly calls with a physical activity coach aiming to complete ≥2 video-training sessions/week, or ≥500 step/d baseline increase for ≥8 weeks. We defined feasibility as ≥66% of subjects engaging in the intervention phase and adherence as ≥50% subjects meeting training end point. RESULTS Thirty-one patients (61 ± 7 years, 71% female, model for end-stage liver disease 17 ± 5, ∼33% frail) consented and 21 (68%) started the intervention. In the 15 subjects who completed the study, LFI improved from 3.84 ± 0.71 to 3.47 ± 0.90 ( P = 0.03) and 6MWT from 318 ± 73 to 358 ± 64 m ( P = 0.005). Attrition reasons included death (n = 4) and surgery (n = 2). There was 57% adherence, better for videos than for walking, although daily steps significantly increased (3,508 vs baseline: 1,260) during best performance week. One adverse event was attributed to the intervention. DISCUSSION Our clinical trial meaningfully improved LFI by 0.4 and 6MWT by 41 m and met feasibility/adherence goals. In-training daily step increase supported physical self-efficacy and intervention uptake, but maintenance remained a challenge despite counseling.
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Affiliation(s)
- Andres Duarte-Rojo
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, USA
- Comprehensive Transplant Center, Northwestern Medicine, Feinberg School of Medicine, Chicago, Illinois, USA
- Division Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Pamela M. Bloomer
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Rachel K. Grubbs
- Division Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jonathan G. Stine
- Division of Gastroenterology and Hepatology, Department of Medicine, The Pennsylvania State University- Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Daniela Ladner
- Comprehensive Transplant Center, Northwestern Medicine, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Christopher B. Hughes
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Michael A. Dunn
- Division Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - John M. Jakicic
- Division of Physical Activity and Weight Management, University of Kansas, Kansas, KA, USA
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22
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Puchades L, Herreras J, Ibañez A, Reyes É, Crespo G, Rodríguez-Perálvarez M, Cortés L, Serrano T, Fernández-Yunquera A, Montalvá E, Berenguer M. Waiting time dictates impact of frailty: A Spanish multicenter prospective study. JHEP Rep 2023; 5:100840. [PMID: 37767462 PMCID: PMC10520529 DOI: 10.1016/j.jhepr.2023.100840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 06/30/2023] [Accepted: 07/01/2023] [Indexed: 09/29/2023] Open
Abstract
Background & Aims Frailty is prevalent in liver transplant (LT) candidates. It is considered an independent predictor of adverse outcomes pre- and post-transplant according to data obtained in the United States. We aimed to externally validate the liver frailty index (LFI) in a multicenter cohort of LT candidates. Methods Outpatients with cirrhosis were prospectively recruited from five Spanish centers (2018-2020). Patients were defined as "frail" by an optimal cut-off of LFI ≥4.5. Patients were followed for at least 6 months to study associations of pre-LT frailty with pre- and post-transplant mortality, length of hospital and intensive care unit (ICU) stays, risk of early (<30 days) and late (30-90 days) post-transplant complications, retransplantation and cardiovascular events. Results Of 212 patients included, 45 patients (21%) were frail pre-LT, and the median LFI was 3.9 (IQR 3.5-4.4). After a median waiting time of 78 days, 2% died or were delisted for clinical worsening. The LFI at baseline was not predictive of mortality/delisting in LT candidates in univariable or multivariable analyses after adjusting for age and MELD-Na score (hazard ratio 1.48; p = 0.586). In contrast, compared to non-frail patients, frail LT candidates had a significantly higher length of hospital stay (9 vs. 13 days; p = 0.001) and rate of early (<30 days) post-transplant complications (55% vs. 100%; p = 0.021). Conclusions In the context of a short LT waiting time, frailty does not impact pretransplant mortality and/or delisting. In contrast, LT frailty is predictive of higher post-transplant complication rates and length of hospital stay. Whether strategies aimed at pre- and/or re-habilitation are beneficial in settings with short waiting times needs to be confirmed in prospective studies. Impact and implications Literature is scarce on the actual impact of physical frailty on adverse outcomes in the liver transplant scenario outside North America. Evidence-based justification to extend the use of objective frailty tools in the decision-making processes in other liver transplant settings is needed. This study is the first to evaluate the predictive value of the liver frailty index in outpatients in the European liver transplant setting, showing that in a low MELD, high access system, frailty does not impact pretransplant mortality and/or delisting but is predictive of higher complication rates and longer post-transplant length of stay. In practical ways, physicians should consider physical frailty as a vital sign to be measured systematically and routinely during clinic visits; researchers are encouraged to initiate prospective studies to evaluate the benefit of applying strategies aimed at pre- and or re-habilitation in liver transplant settings with short waiting times.
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Affiliation(s)
- Lorena Puchades
- Medical Research Institute Hospital La Fe, Hepatology and Liver Transplantation group, Valencia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Julia Herreras
- Medical Research Institute Hospital La Fe, Hepatology and Liver Transplantation group, Valencia, Spain
| | - Ana Ibañez
- Departament de Finances Empresarials, Facultat d’Economia, University of Valencia, Valencia, Spain
| | - Érick Reyes
- Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Gonzalo Crespo
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
- Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Manuel Rodríguez-Perálvarez
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
- Department of Hepatology and Liver Transplantation, Hospital Universitario Reina Sofía, University of Córdoba, IMIBIC, Córdoba, Spain
| | - Luis Cortés
- Liver Transplantation Unit, Department of Gastroenterology, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Trinidad Serrano
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
- Liver Transplantation Unit, Department of Gastroenterology, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Ainhoa Fernández-Yunquera
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
- Department of Gastroenterology, Gregorio Marañón University General Hospital, Madrid, Spain
| | - Eva Montalvá
- Medical Research Institute Hospital La Fe, Hepatology and Liver Transplantation group, Valencia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
- Liver Transplantation Unit, Department of General Surgery, La Fe University Hospital, Valencia, Spain
| | - Marina Berenguer
- Medical Research Institute Hospital La Fe, Hepatology and Liver Transplantation group, Valencia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
- Department of Gastroenterology, Hepatology Unit, La Fe University Hospital, University of Valencia, Medicine Department, Valencia, Spain
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23
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Choi WM. Pretransplant Frailty on Postoperative Morbidity and Mortality after Liver Transplantation: Bystander or Upstander? Gut Liver 2023; 17:670-671. [PMID: 37712189 PMCID: PMC10502495 DOI: 10.5009/gnl230316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/16/2023] Open
Affiliation(s)
- Won-Mook Choi
- Department of Gastroenterology, Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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24
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Casas-Deza D, Bernal-Monterde V, Betoré-Glaria E, Julián-Gomara AB, Yagüe-Caballero C, Sanz-París A, Fernández-Bonilla EM, Fuentes-Olmo J, Arbones-Mainar JM. Liver Disease Undernutrition Screening Tool Questionnaire Predicts Decompensation and Mortality in Cirrhotic Outpatients with Portal Hypertension. Nutrients 2023; 15:3780. [PMID: 37686812 PMCID: PMC10489934 DOI: 10.3390/nu15173780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 08/23/2023] [Accepted: 08/28/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Numerous scores are designed to predict outcomes of patients with liver cirrhosis. Our study aimed to evaluate the ability of the Liver Disease Undernutrition Screening Tool (LDUST) in predicting mortality and decompensation in outpatients with clinically significant portal hypertension (CSPH). We hypothesized that LDUST could help identify patients in need of nutritional supplementation and intervention. METHODS A prospective study of 57 CSPH patients (36.8% female, mean age: 63.5 ± 9.9 years) with a median follow-up of 41 months was conducted. Baseline liver function, nutrition, and sarcopenia were assessed, alongside LDUST. During follow-up, the occurrence of liver decompensation, hospital admission, need for emergency care, and mortality were evaluated. RESULTS A total of 56.1% of patients were Child A, and the most frequent etiology was alcohol (50.9%). Malnutrition risk according to LDUST raised mortality (HR: 25.96 (1.47-456.78)), decompensation (HR 9.78 (2.08-45.89)), and admission (HR 4.86 (1.09-21.61)) risks in multivariate Cox analysis. Combining LDUST with Child and MELD scores improved their decompensation prediction (0.936 vs. 0.811 and 0.866 vs. 0.700). CONCLUSIONS The LDUST has a solid ability to predict complications in cirrhosis outpatients with CSPH, and its integration with Child and MELD models enhances their predictive power. LDUST implementation could identify individuals necessitating early nutritional support.
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Affiliation(s)
- Diego Casas-Deza
- Gastroenterology and Hepatology Department, Miguel Servet University Hospital, 50009 Zaragoza, Spain; (V.B.-M.); (E.B.-G.); (A.B.J.-G.); (C.Y.-C.); (E.M.F.-B.); (J.F.-O.)
- Instituto de Investigación Sanitaria de Aragón (IISA), 50009 Zaragoza, Spain; (A.S.-P.); (J.M.A.-M.)
| | - Vanesa Bernal-Monterde
- Gastroenterology and Hepatology Department, Miguel Servet University Hospital, 50009 Zaragoza, Spain; (V.B.-M.); (E.B.-G.); (A.B.J.-G.); (C.Y.-C.); (E.M.F.-B.); (J.F.-O.)
- Instituto de Investigación Sanitaria de Aragón (IISA), 50009 Zaragoza, Spain; (A.S.-P.); (J.M.A.-M.)
| | - Elena Betoré-Glaria
- Gastroenterology and Hepatology Department, Miguel Servet University Hospital, 50009 Zaragoza, Spain; (V.B.-M.); (E.B.-G.); (A.B.J.-G.); (C.Y.-C.); (E.M.F.-B.); (J.F.-O.)
| | - Ana Belén Julián-Gomara
- Gastroenterology and Hepatology Department, Miguel Servet University Hospital, 50009 Zaragoza, Spain; (V.B.-M.); (E.B.-G.); (A.B.J.-G.); (C.Y.-C.); (E.M.F.-B.); (J.F.-O.)
- Instituto de Investigación Sanitaria de Aragón (IISA), 50009 Zaragoza, Spain; (A.S.-P.); (J.M.A.-M.)
| | - Carmen Yagüe-Caballero
- Gastroenterology and Hepatology Department, Miguel Servet University Hospital, 50009 Zaragoza, Spain; (V.B.-M.); (E.B.-G.); (A.B.J.-G.); (C.Y.-C.); (E.M.F.-B.); (J.F.-O.)
- Instituto de Investigación Sanitaria de Aragón (IISA), 50009 Zaragoza, Spain; (A.S.-P.); (J.M.A.-M.)
| | - Alejandro Sanz-París
- Instituto de Investigación Sanitaria de Aragón (IISA), 50009 Zaragoza, Spain; (A.S.-P.); (J.M.A.-M.)
- Endocrinology and Nutrition Department, Miguel Servet University Hospital, 50009 Zaragoza, Spain
| | - Eva María Fernández-Bonilla
- Gastroenterology and Hepatology Department, Miguel Servet University Hospital, 50009 Zaragoza, Spain; (V.B.-M.); (E.B.-G.); (A.B.J.-G.); (C.Y.-C.); (E.M.F.-B.); (J.F.-O.)
| | - Javier Fuentes-Olmo
- Gastroenterology and Hepatology Department, Miguel Servet University Hospital, 50009 Zaragoza, Spain; (V.B.-M.); (E.B.-G.); (A.B.J.-G.); (C.Y.-C.); (E.M.F.-B.); (J.F.-O.)
- Instituto de Investigación Sanitaria de Aragón (IISA), 50009 Zaragoza, Spain; (A.S.-P.); (J.M.A.-M.)
| | - Jose M. Arbones-Mainar
- Instituto de Investigación Sanitaria de Aragón (IISA), 50009 Zaragoza, Spain; (A.S.-P.); (J.M.A.-M.)
- Instituto Aragonés de Ciencias de la Salud (IACS), 50009 Zaragoza, Spain
- Centro de Investigación Biomédica en Red Fisiopatología de la Obesidad y Nutrición (CiberOBN), Instituto de Salud Carlos III, 28029 Madrid, Spain
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25
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Hogen R, Witt MH, Dhanireddy K. The sex disparity in liver transplantation. Curr Opin Organ Transplant 2023; 28:254-258. [PMID: 37307525 DOI: 10.1097/mot.0000000000001081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
PURPOSE OF THE REVIEW This review describes the sex disparity in liver transplantation (LT) and explains its underlying causes. RECENT FINDINGS There is a small but persistent sex disparity in transplant rate and waitlist mortality that disappears once women are listed as Status 1. Allocation systems that could replace the Model for End Stage Liver Disease (MELD)-Na with scores less reliant on serum creatine and muscle mass have the potential to alleviate part of the sex disparity. Women perform worse on frailty assessments and are more likely to have nonalcoholic steatohepatitis (NASH). A diagnosis of NASH is compounding risk factor for frailty. SUMMARY Women remain disadvantaged in their access to LT despite multiple evolutions of the allocation system. An allocation system that relies less heavily on serum creatinine could partially alleviate the sex disparity. As NASH becomes more prevalent and frailty becomes more important in listing decisions, we may also need to carefully consider differences in the manifestations of frailty between the genders.
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Affiliation(s)
- Rachel Hogen
- Tampa General Hospital, Transplant Institute, Abdominal Organ Transplantation, Tampa, Florida, USA
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26
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Terrault NA, Francoz C, Berenguer M, Charlton M, Heimbach J. Liver Transplantation 2023: Status Report, Current and Future Challenges. Clin Gastroenterol Hepatol 2023; 21:2150-2166. [PMID: 37084928 DOI: 10.1016/j.cgh.2023.04.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 03/29/2023] [Accepted: 04/04/2023] [Indexed: 04/23/2023]
Abstract
Liver transplantation offers live-saving therapy for patients with complications of cirrhosis and stage T2 hepatocellular carcinoma. The demand for organs far outstrips the supply, and innovations aimed at increasing the number of usable deceased donors as well as alternative donor sources are a major focus. The etiologies of cirrhosis are shifting over time, with more need for transplantation among patients with alcohol-associated liver disease and nonalcoholic/metabolic fatty liver disease and less for viral hepatitis, although hepatitis B remains an important indication for transplant in countries with high endemicity. The rise in transplantation for alcohol-associated liver disease and nonalcoholic/metabolic fatty liver disease has brought attention to how patients are selected for transplantation and the strategies needed to prevent recurrent disease. In this review, we present a status report on the most pressing topics in liver transplantation and future challenges.
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Affiliation(s)
- Norah A Terrault
- Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles, California.
| | - Claire Francoz
- Liver Intensive Care and Liver Transplantation Unit, Hepatology, Hospital Beaujon, Clichy, France
| | - Marina Berenguer
- Hepatology and Liver Transplantation Unit, Hospital Universitario la Fe - IIS La Fe Valencia; CiberEHD and University of Valencia, Valencia, Spain
| | - Michael Charlton
- Transplantation Institute, University of Chicago, Chicago, Illinois
| | - Julie Heimbach
- William von Liebig Center for Transplantation, Mayo Clinic Rochester, Minnesota
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27
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Wang M, Shui AM, Barry F, Verna E, Kent D, Yao F, Seetharaman S, Berry K, Grubbs RK, George G, Huang CY, Duarte-Rojo A, Lai JC. The tele-liver frailty index (TeLeFI): development of a novel frailty tool in patients with cirrhosis via telemedicine. Am J Transplant 2023; 23:966-975. [PMID: 37061188 PMCID: PMC10330470 DOI: 10.1016/j.ajt.2023.04.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 03/23/2023] [Accepted: 04/10/2023] [Indexed: 04/17/2023]
Abstract
Frailty is a critical determinant of outcomes in cirrhosis patients. The increasing use of telemedicine has created an unmet need for virtual frailty assessment. We aimed to develop a telemedicine-enabled frailty tool (tele-liver frailty index). Adults with cirrhosis in the liver transplant setting underwent ambulatory frailty testing with the liver frailty index (LFI) in-person, then virtual administration of (1) validated surveys (eg, SARC-F and Duke Activity Status Index [DASI]), (2) chair stands, and (3) balance. Two models were selected and internally validated for predicting LFI ≥4.4 using: (1) Bayesian information criterion (BIC), (2) C-statistics, and (3) ease of use. Of 145 patients, the median (interquartile range) LFI was 3.7 (3.3-4.2); 15% were frail. Frail (vs not frail) patients reported significantly greater impairment on all virtually assessed instruments. We selected 2 parsimonious models: (1) DASI + chair/bed transfer (SARC-F) (BIC 255, C-statistics 0.78), and (2) DASI + chair/bed transfer (SARC-F) + virtually assessed chair stands (BIC 244, C-statistics 0.79). Both models had high C-statistics (0.76-0.78) for predicting frailty. In conclusion, the tele-liver frailty index is a novel tool to screen frailty in liver transplant patients via telemedicine pragmatically and may be used to identify patients who require in-person frailty assessment, more frequent follow-up, or frailty intervention.
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Affiliation(s)
- Melinda Wang
- Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Amy M Shui
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, California, USA
| | - Fawzy Barry
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Elizabeth Verna
- Department of Medicine, Division of Digestive & Liver Diseases, Columbia University College of Physicians & Surgeons, New York, New York, USA
| | - Dorothea Kent
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Frederick Yao
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Srilakshmi Seetharaman
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Kacey Berry
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Rachel K Grubbs
- Division Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Geena George
- Department of Medicine, Division of Digestive & Liver Diseases, Columbia University College of Physicians & Surgeons, New York, New York, USA
| | - Chiung-Yu Huang
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, California, USA
| | - Andres Duarte-Rojo
- Division Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA.
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Kim DG, Hwang S, Lee KW, Choi GS, You YK, Ryu JH, Kim BW, Nah YW, Kim DS, Cho JY, Kang KJ, Hong G, Yu HC, Ju MK, Suh SW, Kim KW, Choi D, Jeong J, Choi SJN, Moon JI, Lee JG, Kim MS, Choi D, Joo DJ. Physical Performance Decline During the Early Posttransplantation Period Affects Survival After Living Donor Liver Transplantation. Transplantation 2023; 107:1545-1553. [PMID: 36740738 DOI: 10.1097/tp.0000000000004517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patient physical performance has been emphasized in liver transplant recipients; however, evidence for living donor liver transplantation (LDLT) patients is lacking. This study investigated the impact of physical performance decline during the early posttransplantation period on survival and risk factors for this decline in LDLT recipients. METHODS From national registry data, 2703 LDLT patients were divided into 2 groups based on the change in their Karnofsky performance status (KPS) between 1 and 6 mo posttransplantation: declined KPS (n = 188) and control (n = 2515). Multivariable analyses were conducted to control for confounders, including posttransplantation complications. RESULTS Estimated 5-y patient survival rates were 91.6% in the declined KPS group and 96.3% in the control group, favoring the latter ( P = 0.003). The survival hazard of KPS decline was significant in a baseline covariates-adjusted Cox model (hazard ratio [HR], 2.60; 95% confidence interval [CI], 1.37-4.95) and an adjusted model accounting for posttransplantation complications (HR, 3.38; 95% CI, 1.70-6.72). In subgroup analyses, KPS decline independently reduced survival in patients without complications (HR, 3.95; 95% CI, 1.67-9.34), and the trend was similar in patients with complications, although significance was marginal (HR, 3.02; 95% CI, 0.98-9.27). We found that only posttransplantation complications, such as rejection, infection, bile duct complication, and vascular complication, were significant risk factors for KPS decline after LDLT. CONCLUSIONS Physical performance decline during the early posttransplantation period independently reduced survival rates, and posttransplantation complications were the only significant risk factors for physical performance decline in LDLT recipients.
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Affiliation(s)
- Deok-Gie Kim
- Department of Surgery, The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, South Korea
| | - Shin Hwang
- Department of Surgery, College of Medicine University of Ulsan, Asan Medical Center, Seoul, South Korea
| | - Kwang-Woong Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Gyu-Seong Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Young Kyoung You
- Department of Surgery, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Je Ho Ryu
- Department of Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Pusan, South Korea
| | - Bong-Wan Kim
- Department of Liver Transplantation and Hepatobiliary Surgery, Ajou University School of Medicine, Suwon, South Korea
| | - Yang Won Nah
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea
| | - Dong-Sik Kim
- Department of Surgery, Korea University College of Medicine, Seoul, South Korea
| | - Jai Young Cho
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Koo Jeong Kang
- Department of Surgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, South Korea
| | - Geun Hong
- Department of Surgery, EWHA Womans University College of Medicine, Seoul, South Korea
| | - Hee Chul Yu
- Department of Surgery, Jeonbuk National University Medical School, Jeonju, South Korea
| | - Man Ki Ju
- Department of Surgery, Gangnam Severance Hospital, Yonsei University college of Medicine, Seoul, South Korea
| | - Suk-Won Suh
- Department of Surgery, College of Medicine, Chung-Ang University, Seoul, South Korea
| | - Kwan Woo Kim
- Department of Surgery, Dong-A University Hospital, Pusan, South Korea
| | - Dongho Choi
- Department of Surgery, College of Medicine, Hanyang University, Seoul, South Korea
| | - Jaehong Jeong
- Department of Surgery, School of Medicine, Soonchunhyang University, Pusan, South Korea
| | - Soo Jin Na Choi
- Department of Surgery Chonnam National University Medical School and Hospital, Gwangju, Korea
| | - Ju Ik Moon
- Department of Surgery, Konyang University Hospital, Konyang University College of Medicine, Daejeon, Korea
| | - Jae Geun Lee
- Department of Surgery, The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, South Korea
| | - Myoung Soo Kim
- Department of Surgery, The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, South Korea
| | - Donglak Choi
- Department of Surgery, Catholic University of Daegu, Daegu, South Korea
| | - Dong Jin Joo
- Department of Surgery, The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, South Korea
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Ravaioli F, De Maria N, Di Marco L, Pivetti A, Casciola R, Ceraso C, Frassanito G, Pambianco M, Pecchini M, Sicuro C, Leoni L, Di Sandro S, Magistri P, Menozzi R, Di Benedetto F, Colecchia A. From Listing to Recovery: A Review of Nutritional Status Assessment and Management in Liver Transplant Patients. Nutrients 2023; 15:2778. [PMID: 37375682 DOI: 10.3390/nu15122778] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 06/04/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023] Open
Abstract
Liver transplantation (LT) is a complex surgical procedure requiring thorough pre- and post-operative planning and care. The nutritional status of the patient before, during, and after LT is crucial to surgical success and long-term prognosis. This review aims to assess nutritional status assessment and management before, during, and after LT, with a focus on patients who have undergone bariatric surgery. We performed a comprehensive topic search on MEDLINE, Ovid, In-Process, Cochrane Library, EMBASE, and PubMed up to March 2023. It identifies key factors influencing the nutritional status of liver transplant patients, such as pre-existing malnutrition, the type and severity of liver disease, comorbidities, and immunosuppressive medications. The review highlights the importance of pre-operative nutritional assessment and intervention, close nutritional status monitoring, individualised nutrition care plans, and ongoing nutritional support and monitoring after LT. The review concludes by examining the effect of bariatric surgery on the nutritional status of liver transplant recipients. The review offers valuable insights into the challenges and opportunities for optimising nutritional status before, during, and after LT.
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Affiliation(s)
- Federico Ravaioli
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Nicola De Maria
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Lorenza Di Marco
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Alessandra Pivetti
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Riccardo Casciola
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Carlo Ceraso
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Gabriella Frassanito
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Martina Pambianco
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Maddalena Pecchini
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Chiara Sicuro
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Laura Leoni
- Division of Metabolic Diseases and Clinical Nutrition, Department of Specialistic Medicines, University Hospital of Modena and Reggio Emilia, Largo del Pozzo 71, 41125 Modena, Italy
| | - Stefano Di Sandro
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Paolo Magistri
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Renata Menozzi
- Division of Metabolic Diseases and Clinical Nutrition, Department of Specialistic Medicines, University Hospital of Modena and Reggio Emilia, Largo del Pozzo 71, 41125 Modena, Italy
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Antonio Colecchia
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
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Thul J, Pruett TL, Teigen LM. CT-derived psoas muscle area and density are associated with length of stay and discharge disposition after liver transplantation. Clin Nutr ESPEN 2023; 55:434-439. [PMID: 37202080 DOI: 10.1016/j.clnesp.2023.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 04/24/2023] [Accepted: 04/27/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND & AIMS Prolonged length of stay (LOS) and discharge disposition following liver transplantation are associated with postoperative complications and increased healthcare utilization. This study evaluated the relationship between CT-derived psoas muscle measurements and hospital LOS, intensive care unit (ICU) LOS, and discharge disposition after liver transplant. The psoas muscle was chosen given its ease of measurement with any radiological software. A secondary analysis assessed the relationship between the American Society for Parenteral and Enteral Nutrition and the Academy of Nutrition and Dietetics (ASPEN/AND) malnutrition diagnosis criteria and CT-derived psoas muscle measures. METHODS CT-derived measures of psoas muscle density (mHU) and cross-sectional area at the level of the third lumbar vertebrae were obtained from preoperative CT scans of liver transplant recipients. Cross-sectional area measures were corrected for body size to generate a psoas area index variable (cm2/m2; PAI). RESULTS Each 1-unit increase in PAI was associated with a reduced hospital LOS of 4 days (R2 = 0.07). Each 5-unit increase in mean Hounsfield units (mHU) was associated with a reduced hospital and ICU LOS of 5 and 1.6 days, respectively (R2 = 0.22 and 0.14, respectively). Mean PAI and mHU were higher in patients who discharged to home. PAI was reasonably identified through ASPEN/AND malnutrition criteria, but there was no difference in mHU between those with and without malnutrition. CONCLUSION Measures of psoas density were associated with both hospital and ICU LOS and discharge disposition. PAI was associated with hospital LOS and discharge disposition. CT-derived measures of psoas density may be a valuable complement to preoperative liver transplant nutrition assessment using traditional ASPEN/AND malnutrition criteria.
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Affiliation(s)
- Jessica Thul
- MHealth Fairview, University of Minnesota Medical Center, Minneapolis, MN, 55455, USA.
| | - Timothy L Pruett
- Department of Surgery, University of Minnesota, Minneapolis, MN, 55455, USA.
| | - Levi M Teigen
- Department of Food Science and Nutrition, University of Minnesota, St. Paul, MN, 55108, USA.
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Tandon P, Zanetto A, Piano S, Heimbach JK, Dasarathy S. Liver transplantation in the patient with physical frailty. J Hepatol 2023; 78:1105-1117. [PMID: 37208097 PMCID: PMC10825673 DOI: 10.1016/j.jhep.2023.03.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/23/2023] [Accepted: 03/26/2023] [Indexed: 05/21/2023]
Abstract
Frailty is a decline in functional reserve across multiple physiological systems. A key component of frailty is sarcopenia, which denotes a loss of skeletal muscle mass and impaired contractile function that ultimately result in physical frailty. Physical frailty/sarcopenia are frequent and contribute to adverse clinical outcomes before and after liver transplantation. Frailty indices, including the liver frailty index, focus on contractile dysfunction (physical frailty), while cross-sectional image analysis of muscle area is the most accepted and reproducible measure to define sarcopenia. Thus, physical frailty and sarcopenia are interrelated. The prevalence of physical frailty/sarcopenia is high in liver transplant candidates and these conditions have been shown to adversely impact clinical outcomes including mortality, hospitalisations, infections, and cost of care both before and after transplantation. Data on the prevalence of frailty/sarcopenia and their sex- and age-dependent impact on outcomes are not consistent in patients on the liver transplant waitlist. Physical frailty and sarcopenic obesity are frequent in the obese patient with cirrhosis, and adversely affect outcomes after liver transplantation. Nutritional interventions and physical activity remain the mainstay of management before and after transplantation, despite limited data from large scale trials. In addition to physical frailty, there is recognition that a global evaluation including a multidisciplinary approach to other components of frailty (e.g., cognition, emotional, psychosocial) also need to be addressed in patients on the transplant waitlist. Recent advances in our understanding of the underlying mechanisms of sarcopenia and contractile dysfunction have helped identify novel therapeutic targets.
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Affiliation(s)
- Puneeta Tandon
- Division of Gastroenterology (Liver Unit), Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Alberto Zanetto
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padova University Hospital, Italy
| | - Salvatore Piano
- Unit of Internal Medicine and Hepatology, Department of Medicine - DIMED, University and Hospital of Padova, Padova, Italy
| | - Julie K Heimbach
- William J von Liebig Transplant Center Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
| | - Srinivasan Dasarathy
- Division of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH 44195, USA
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Artru F, Goldberg D, Kamath PS. Should patients with acute-on-chronic liver failure grade 3 receive higher priority for liver transplantation? J Hepatol 2023; 78:1118-1123. [PMID: 37208098 DOI: 10.1016/j.jhep.2022.12.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 12/21/2022] [Indexed: 05/21/2023]
Abstract
In this debate, the authors consider whether patients with acute-on-chronic liver failure grade 3 (ACLF-3) should receive higher liver transplant priority, with reference to the following clinical case: a 62-year-old male with a history of decompensated alcohol-associated cirrhosis, with recurrent ascites and hepatic encephalopathy, and metabolic comorbidities (type 2 diabetes mellitus, arterial hypertension and a BMI of 31 kg/m2). A few days following evaluation for liver transplantation (LT), the patient was admitted to the intensive care unit and placed on mechanical ventilation for neurological failure, FiO2 of 0.3 with a SpO2 of 98%, and started on norepinephrine at 0.62 μg/kg/min. He had been abstinent since the diagnosis of cirrhosis a year prior. Laboratory results at admission were: leukocyte count 12.1 G/L, international normalised ratio 2.1, creatinine 2.4 mg/dl, sodium 133 mmol/L, total bilirubin 7 mg/dl, lactate 5.5 mmol/L, with a MELD-Na score of 31 and a CLIF-C ACLF score of 67. On the 7th day after admission, the patient was placed on the LT waiting list. On the same day, he had massive variceal bleed with hypovolemic shock requiring terlipressin, transfusion of three red blood cell units, and endoscopic band ligation. On day 10, the patient was stabilised with a low dose of norepinephrine 0.03 μg/kg/min, with no new sepsis or bleeding. However, the patient was still intubated for grade 2 hepatic encephalopathy and on renal replacement therapy with a lactate level of 3.1 mmol/L. The patient is currently categorised as having ACLF-3, with five organ failures (liver, kidney, coagulation, circulation, and respiration). Based on the severity of his liver disease and multiorgan failure, the patient is at an exceedingly high risk of death without LT. Is it appropriate to perform LT in such a patient?
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Affiliation(s)
- Florent Artru
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - David Goldberg
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA.
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Rau M. [Sarcopenia in chronic liver diseases]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2023:10.1007/s00108-023-01526-w. [PMID: 37219562 DOI: 10.1007/s00108-023-01526-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 04/25/2023] [Indexed: 05/24/2023]
Abstract
BACKGROUND Sarcopenia is a progressive and generalized disorder of the skeletal musculature that involves the loss of skeletal muscle mass and function. Patients with chronic liver disease frequently have sarcopenia in advanced stages of the disease; however, there is an increased prevalence of sarcopenia not only in liver cirrhosis but also in earlier stages of disease, e.g., in non-alcoholic fatty liver disease (NAFLD). RESULTS Sarcopenia is an independent prognostic risk factor for morbidity and mortality in patients with liver cirrhosis. The pathogenesis of sarcopenia is multifactorial and in chronic liver diseases a lower oral energy intake, altered ammonia metabolism, hormonal imbalances and a chronic low-grade inflammatory state are important. When the screening test is positive, determination of the muscle strength, e.g., measurement of hand grip strength, is recommended for the diagnostic approach. Lower muscle strength leads to further measurement of muscle mass to confirm the diagnosis of sarcopenia. In patients with chronic liver disease abdominal imaging by computed tomography or magnetic resonance imaging is particularly suitable for this. The severity of sarcopenia is classified by the physical performance. Therapeutic strategies for the treatment of sarcopenia include nutritional therapy as well as exercise therapy. CONCLUSION Patients with chronic liver diseases frequently have sarcopenia. This is an independent prognostic risk factor. Therefore, sarcopenia should be considered in the diagnostics and therapeutic approaches.
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Affiliation(s)
- Monika Rau
- Schwerpunkt Hepatologie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland.
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McAdams-DeMarco MA, Thind AK, Nixon AC, Woywodt A. Frailty assessment as part of transplant listing: yes, no or maybe? Clin Kidney J 2023; 16:809-816. [PMID: 37151416 PMCID: PMC10157764 DOI: 10.1093/ckj/sfac277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Indexed: 12/31/2022] Open
Abstract
Frailty, characterized by a decreased physiological reserve and an increased vulnerability to stressors, is common among kidney transplant (KT) candidates and recipients. In this review, we present and summarize the key arguments for and against the assessment of frailty as part of KT evaluation. The key arguments for including frailty were: (i) sheer prevalence and far-reaching consequences of frailty on KT, and (ii) the ability to conduct a more holistic and objective evaluation of candidates, removing the inaccuracy associated with 'eye-ball' assessments of transplant fitness. The key argument against were: (i) lack of agreement on the definition of frailty and which tools should be used in renal populations, (ii) a lack of clarity on how, by whom and how often frailty assessments should be performed, and (iii) a poor understanding of how acute stressors affect frailty. However, it is the overwhelming opinion that the time has come for frailty assessments to be incorporated into KT listing. Although ongoing areas of uncertainty exist and further evidence development is needed, the well-established impact of frailty on clinical and experiential outcomes, the invaluable information obtained from frailty assessments, and the potential for intervention outweigh these limitations. Proactive and early identification of frailty allows for individualized and improved risk assessment, communication and optimization of candidates.
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Affiliation(s)
- Mara A McAdams-DeMarco
- Department of Surgery, NYU Grossman School of Medicine and NYU Langone Health, New York, USA
- Department of Population Health, NYU Grossman School of Medicine, New York, USA
| | - Amarpreet K Thind
- Division of Immunology and Inflammation, Department of Medicine, Centre for Inflammatory Disease, Imperial College London, London, UK
- Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, Manchester, UK
| | - Andrew C Nixon
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
- Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
| | - Alexander Woywodt
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
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35
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Henson JB, Cabezas M, McElroy LM, Muir AJ. Rates of employment after liver transplant: A nationwide cohort study. Hepatol Commun 2023; 7:e0061. [PMID: 36802369 PMCID: PMC9949776 DOI: 10.1097/hc9.0000000000000061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 12/23/2022] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND Employment outcomes after liver transplant (LT) over the past decade have not been described. METHODS LT recipients ages 18-65 from 2010-2018 were identified in Organ Procurement and Transplantation Network data. Employment within two years post-transplant was assessed. RESULTS Of 35,340 LT recipients, 34.2% were employed post-LT, including 70.4% who were working pre-transplant, compared to only 18.2% not working preLT. Younger age, male sex, educational attainment, and functional status were associated with returning to employment. CONCLUSION Returning to employment is an important goal for many LT candidates and recipients, and these findings can be used to guide their expectations.
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Affiliation(s)
- Jacqueline B. Henson
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Melanie Cabezas
- Division of Gastroenterology, Department of Medicine, University of South Florida Health, Tampa, Florida, USA
| | - Lisa M. McElroy
- Division of Abdominal Transplant, Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Andrew J. Muir
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
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36
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Ufere NN, El-Jawahri A, Ritchie C, Lai JC, Schwarze ML. Promoting Prognostic Understanding and Health Equity for Patients With Advanced Liver Disease: Using "Best Case/Worst Case". Gastroenterology 2023; 164:171-176. [PMID: 36702571 DOI: 10.1053/j.gastro.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Nneka N Ufere
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, and, Harvard Medical School, Boston, Massachusetts, and, The Mongan Institute, Boston, Massachusetts
| | - Areej El-Jawahri
- Harvard Medical School, Boston, Massachusetts, and, The Mongan Institute, Boston, Massachusetts, and, Division of Hematology and Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Christine Ritchie
- Harvard Medical School, Boston, Massachusetts, and, The Mongan Institute, Boston, Massachusetts, and, Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, California
| | - Margaret L Schwarze
- Division of Vascular Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Promoting Prognostic Understanding and Health Equity for Patients With Advanced Liver Disease: Using "Best Case/Worst Case". Clin Gastroenterol Hepatol 2023; 21:250-255. [PMID: 36697145 DOI: 10.1016/j.cgh.2022.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Indexed: 01/27/2023]
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Moosavi SA, Mashhadiagha A, Taherifard E, Fallahzadeh MA, Motazedian N, Sayadi M, Azarpira N, Rahimi RS. Frailty as a predictor of poor outcomes among patients awaiting liver transplant: a systematic review and meta-analysis. GASTROENTEROLOGY AND HEPATOLOGY FROM BED TO BENCH 2023; 16:364-377. [PMID: 38313349 PMCID: PMC10835093 DOI: 10.22037/ghfbb.v16i4.2795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 02/07/2023] [Indexed: 02/06/2024]
Abstract
Aim This review sought to evaluate the significance of a functional assessment for liver transplant candidates, i.e., frailty, in the pre-transplant setting and its association with mortality and morbidities. Background Liver transplantation (LT) remains the treatment of choice for patients with end-stage liver disease. Due to the shortage of organs for LT, a careful selection of suitable recipients is essential. Frailty, a measure of physiologic reserve and increased vulnerability to stressors, was initially used in geriatrics and then introduced to the field of transplantation for better patient selection. Methods PubMed, Scopus, and Web of Science databases were reviewed up until January 2023. The search terms included: "frail*", "liver", and "transplant*". A Meta-analysis was conducted for the hazard ratios (HRs) obtained from the COX regression models. Fifty-five studies were included in this review; ten were included in the meta-analysis. Results The prevalence of frailty varied from 2.82% to 70.09% in the studies. Meta-analysis showed that overall frailty had a significant association with mortality (pooled adjusted HR [95%CI]: 2.66 [1.96-3.63]). Subgroup analyses revealed that both the Liver Frailty Index and Fried Frailty Index were significantly associated with mortality. Furthermore, these studies have demonstrated that this population's frailty is associated with ascites, hepatic encephalopathy, and esophageal varices. Conclusion According to emerging evidence, frailty is associated with increased morbidity and mortality of the patients on the LT waiting list. Further randomized trials are required to determine the efficacy and safety of variable interventions in the frail population.
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Affiliation(s)
- Seyed Ali Moosavi
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
- These authors contributed equally
| | - Amirali Mashhadiagha
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
- These authors contributed equally
| | - Erfan Taherifard
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Nasrin Motazedian
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mehrab Sayadi
- Cardiovascular Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Negar Azarpira
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Robert S Rahimi
- Baylor University Medical Center, Baylor Scott & White Health, Dallas, Texas, United States
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Goffaux A, Delorme A, Dahlqvist G, Lanthier N. Improving the prognosis before and after liver transplantation: Is muscle a game changer? World J Gastroenterol 2022; 28:5807-5817. [PMID: 36353207 PMCID: PMC9639652 DOI: 10.3748/wjg.v28.i40.5807] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/30/2022] [Accepted: 10/11/2022] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation (LT) is currently the only curative treatment option for selected patients with end stage liver disease or hepatocellular carcinoma. Improving waiting list-mortality, post-transplant morbidity and mortality and refining the selection of the patients remain our current central objectives. In this field, different concepts dealing with nutrition and the muscle such as sarcopenia, malnutrition, frailty or myosteatosis have emerged as possible game changers. For more than a decade, many prospective studies have demonstrated that sarcopenia and frailty are major predictive factors of mortality in the waiting list but also after LT. Malnutrition is also a well-known risk factor for morbidity and mor-tality. Muscle composition is a newer concept giving insight on muscle quality which has also been shown to be linked to poorer outcomes. Each of these terms has a precise definition as well as pathophysiological mechanisms. The bi-directional liver-muscle axis makes sense in this situation. Defining the best, easy to use in clinical practice tools to assess muscle quality, quantity, and function in this specific population and developing quality prospective studies to identify interventional strategies that could improve these parameters as well as evaluate the effect on mortality are among the important challenges of today.
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Affiliation(s)
- Alexis Goffaux
- Laboratory of Hepato-Gastroenterology, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels 1200, Belgium
- Service d’Hépato-Gastroentérologie, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels 1200, Belgium
| | - Alicia Delorme
- Service d’Hépato-Gastroentérologie, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels 1200, Belgium
| | - Géraldine Dahlqvist
- Service d’Hépato-Gastroentérologie, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels 1200, Belgium
| | - Nicolas Lanthier
- Laboratory of Hepato-Gastroenterology, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels 1200, Belgium
- Service d’Hépato-Gastroentérologie, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels 1200, Belgium
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Sim JH, Kwon HM, Kim KW, Ko YS, Jun IG, Kim SH, Kim KS, Moon YJ, Song JG, Hwang GS. Associations of sarcopenia with graft failure and mortality in patients undergoing living donor liver transplantation. Liver Transpl 2022; 28:1345-1355. [PMID: 35243771 DOI: 10.1002/lt.26447] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 02/08/2022] [Accepted: 02/28/2022] [Indexed: 01/13/2023]
Abstract
Recent studies have reported that sarcopenia influences morbidity and mortality in surgical patients. However, few studies have investigated the associations of sarcopenia with short-term and long-term graft failure in recipients after living donor liver transplantation (LDLT). In this study, we investigated the associations between sarcopenia and graft failure/mortality in patients undergoing LDLT. We retrospectively examined 2816 recipients who underwent LDLT between January 2008 and January 2018. Cox regression analysis was performed to evaluate the associations between sarcopenia and graft failure/mortality in recipients at 60 days, 180 days, and 1 year and overall. Sarcopenia in the recipient was significantly associated with 60-day graft failure (adjusted hazard ratio [HR], 1.98; 95% confidence interval [CI], 1.09-3.61; p = 0.03), 180-day graft failure (HR, 1.85; 95% CI, 1.19-2.88; p = 0.01), 1-year graft failure (HR, 1.45; 95% CI, 1.01-2.17; p = 0.05), and overall graft failure (HR, 1.42; 95% CI, 1.08-1.87; p = 0.01). In addition, recipient sarcopenia was associated with 180-day mortality (HR, 1.88; 95% CI, 1.17-3.01; p = 0.01), 1-year mortality (HR, 1.53; 95% CI, 1.01-2.29; p = 0.04), and overall mortality (HR, 1.43; 95% CI, 1.08-1.90; p = 0.01). Preoperative sarcopenia was associated with high rates of graft failure and mortality in LDLT recipients. Therefore, preoperative sarcopenia may be a strong predictor of the surgical prognosis in LDLT recipients.
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Affiliation(s)
- Ji-Hoon Sim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hye-Mee Kwon
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kyung-Won Kim
- Department of Radiology, Asan Image Metrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - You-Sun Ko
- Department of Radiology, Asan Image Metrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - In-Gu Jun
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung-Hoon Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kyoung-Sun Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Young-Jin Moon
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jun-Gol Song
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Gyu-Sam Hwang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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