Low Health Literacy Is Associated With Frailty and Reduced Likelihood of Liver Transplant Listing: A Prospective Cohort Study

Frailty as a determinant of liver transplant outcomes: A call for integrative strategies

Frailty has emerged as a pivotal determinant of post-liver transplant (LT) outcomes, yet its integration into clinical practice remains inconsistent. Defined by functional impairments and reduced physiologic reserve, frailty transcends traditional metrics like the model for end-stage liver disease (MELD) score, demonstrating increasing predictive value for mortality beyond the immediate post-operative period. Recent findings suggest that frail recipients experience significantly higher mortality within the first 12 months following transplantation—a period when traditional monitoring often wanes. This raises critical questions about the adequacy of current assessment and follow-up protocols. The observed dissociation between MELD scores and long-term survival underscores the limitations of existing selection criteria. Frailty, as a dynamic and modifiable condition, represents an opportunity for targeted intervention. Prehabilitation programs focusing on nutritional optimization, physical rehabilitation, and psychosocial support could enhance resilience in transplant candidates, reducing their risk profile and improving post-transplant outcomes. Furthermore, these findings call for an expanded approach to post-transplant monitoring. Extending surveillance for frail recipients beyond standard timelines may facilitate early detection of complications, mitigating their impact on survival. Incorporating frailty into both pre- and post-transplant protocols could redefine how transplant centers evaluate and manage risk. This editorial advocates for a paradigm shift: Frailty must no longer be viewed as a secondary consideration but as a core element in LT care. By addressing frailty comprehensively, we can move toward more personalized, effective strategies that improve survival and quality of life for LT recipients.

Frailty serves as an adverse predictor for mortality in liver transplant candidates: A systematic review and meta-analysis

BACKGROUND

Physical frailty increases susceptibility to stressors and has been associated with increased mortality among liver transplant candidates. However, evidence about this population's frailty prevalence and mortality is inconsistent and needs to be clarified. This study aimed to quantitatively synthesize the prevalence of frailty and the role of frailty on mortality in liver transplant candidates.

METHODS

All eligible studies published in Embase, PubMed, Scopus, and Web of Science from inception until March 5, 2024, were included. The pooled prevalence and hazard ratio (HR) corresponding to 95 % confidence intervals (CI) in mortality estimates were conducted. The random-effects model was used for the calculations.

RESULTS

A total of 17 studies containing 4509 patients with liver transplant waitlist candidates were included. The prevalence of frailty in liver transplant waitlist candidates was 32 % (95 % CI = 25-38; p < 0.01). In this population, frailty was associated with an increased hazard ratio for mortality (8 studies) (HR = 2.49; 95 % CI = 1.77-3.51; p < 0.01). Furthermore, subgroup analysis showed that frailty was associated with a higher mortality in the USA (HR = 4.03; 95 % CI = 1.77-3.51; p < 0.01) compared with the non-USA area (HR = 2.03; 95 % CI = 1.51-2.72; p < 0.01).

CONCLUSION

Our results suggest that frailty is prevalent in patients awaiting liver transplants, which strongly predicts waitlist mortality among this population. These findings highlight the importance of frailty in the decision of transplantation and in designing studies that consider frailty. Reducing the severity or impact of frailty on this population may improve prognosis.

Association of Limited Health Literacy With Frailty, Health-Related Quality of Life, and Health Care Utilization Among Older Adults With Cancer: The Cancer and Aging Resilience Evaluation Registry

PURPOSE

Limited health literacy-ability to obtain, process, and understand health information-can hinder communication, access to medical treatment, and identification and management of comorbidities. Older adults have high rates of poor health literacy, but its role in aging-related outcomes among older adults with cancer is understudied.

METHODS

We included 876 older adults age 60 years and older with cancer from the Cancer and Aging Resilience Evaluation Registry completing self-reported geriatric assessment, including health literacy, at first visit to medical oncology. The exposure was limited health literacy. Outcomes were frailty, physical/mental health-related quality of life (HRQOL), and health care utilization. We used modified Poisson regression to examine the association of exposure on outcomes adjusting for age, race-ethnicity, sex, and cancer type/stage.

RESULTS

Median age at enrollment was 68; 57.8% were male; 20.2% were non-Hispanic Black. The most prevalent cancers were advanced-stage (46.8% stage IV) colorectal (26.9%) and pancreatic (19.0%). Those with limited health literacy were older (70 v 68 years; P < .001), male (63.0% v 55.1%; P = .026), non-Hispanic Black (28.8% v 16.1%; P < .001), ≤high school educated (62.3% v 28.1%; P < .001), and retired/disabled (86.3% v 71.2%; P < .001). In multivariable analysis, limited health literacy was associated with higher prevalence of frailty (prevalence ratio [PR], 2.64 [95% CI, 2.15 to 3.26]), impaired physical (PR, 1.90 [95% CI, 1.59 to 2.27]) and mental (PR, 2.08 [95% CI, 1.76 to 2.47]) HRQOL, and hospitalization in the last year (PR, 1.28 [95% CI, 1.10 to 1.48]) versus adequate health literacy.

CONCLUSION

Older adults with cancer and limited health literacy had higher adjusted prevalence of frailty, impaired physical and mental HRQOL, and recent hospitalization. Interventions to address limited health literacy should be explored in this vulnerable and growing cancer population.

Health literacy and cumulative social disadvantage are associated with survival and transplant in patients with hepatocellular carcinoma: a prospective study

OBJECTIVE

To investigate how individual social determinants of health (SDOH) and cumulative social disadvantage (CSD) affect survival and receipt of liver transplant (LT) in patients with hepatocellular carcinoma (HCC).

METHODS

We enrolled 139 adult patients from two Indianapolis hospital systems between June 2019 and April 2022. Structured questionnaires collected SDOH and social risk factor data. We compared SDOH and CSD by race, gender and disease aetiology, assigning one point per adverse SDOH. Multivariable competing risk survival analysis assessed associations between SDOH, CSD, survival and LT receipt.

RESULTS

Black patients experienced higher CSD than white patients in the cohort (5.4±2.5 vs 3.2±2.1, p<0.001). Black patients were significantly more likely to have household incomes

CONCLUSIONS

There are significant racial and aetiology-related differences in SDOH burden. Low health literacy and high CSD are linked to worse outcomes in HCC patients. Health literacy screening and targeted interventions for those with high CSD could improve LT access and survival rates.

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Key Words

• ECONOMIC EVALUATION
• HEPATOCELLULAR CARCINOMA
• LIVER
• LIVER TRANSPLANTATION

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MESH Headings

• Humans
• Carcinoma, Hepatocellular/surgery
• Carcinoma, Hepatocellular/mortality
• Male
• Female
• Liver Neoplasms/surgery
• Liver Neoplasms/mortality
• Liver Transplantation/statistics & numerical data
• Middle Aged
• Health Literacy/statistics & numerical data
• Prospective Studies
• Social Determinants of Health/statistics & numerical data
• Aged
• Risk Factors
• Socioeconomic Factors
• Adult
• United States/epidemiology
• Survival Analysis

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Grants

• K23 MD018090 NIMHD NIH HHS
• NMIHD

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Affiliation(s)

Lauren D. Nephew Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA Indiana University Simon Comprehensive Cancer Center, Indianapolis, Indiana, USA
Susan M Rawl Indiana University Simon Comprehensive Cancer Center, Indianapolis, Indiana, USA Indiana University School of Nursing, Indianapolis, Indiana, USA
Allie Carter Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
Nicole Garcia Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
Patrick O Monahan Indiana University Simon Comprehensive Cancer Center, Indianapolis, Indiana, USA Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
John Holden Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
Marwan Ghabril Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
Eleazar Montalvan-Sanchez Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
Kavish Patidar Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
Archita P Desai Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
Eric Orman Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
Naga Chalasani Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA

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Neighborhood-level Social Determinants of Health and Waitlist Mortality for Liver Transplantation: The Liver Outcomes and Equity Index

BACKGROUND AND AIMS

To examine neighborhood-level disparities in waitlist mortality for adult liver transplantation (LT), we developed novel area-based social determinants of health (SDOH) index using a national transplant database.

METHODS

ZIP Codes of individuals listed for or received LT in the Scientific Registry of Transplant Recipients database between June 18, 2013, and May 18, 2019, were linked to 36 American Community Survey (ACS) variables across 5 SDOH domains for index development. A step-wise principal component analysis was used to construct the Liver Outcomes and Equity (LOEq) index. We then examined the association between LOEq quintiles (Q1 = worst and Q5 = best neighborhood SDOH) and waitlist mortality with competing risk regression among listed adults in the study period and acuity circle (AC) era.

RESULTS

The final LOEq index consisted of 13 ACS variables. Of 59 298 adults waitlisted for LT, 30% resided in LOEq Q5 compared with only 14% in Q1. Q1 neighborhoods with worse SDOH were disproportionately concentrated in transplant regions with low median Model for End-Stage Liver Disease at transplant (MMAT) and shorter wait times. Five years cumulative incidence of waitlist mortality was 33% in Q1 in high MMAT regions versus 16% in Q5 in low MMAT regions. Despite this allocation advantage, LOEq Q1-Q4 were independently associated with elevated risk of waitlist mortality compared with Q5, with highest increased hazard of waitlist deaths of 19% (95% CI, 11%-26%) in Q1. This disparity persisted in the AC era, with 24% (95% CI, 10%-40%) increased hazard of waitlist deaths for Q1 versus Q5.

CONCLUSIONS

Neighborhood SDOH independently predicts waitlist mortality in adult LT.

Mental health and quality of life in patients with chronic liver disease: a single-center structural equation model

BACKGROUND

Chronic liver disease (CLD) is one of the leading disease burdens in Pakistan. Until now, there has only been limited focus in the country on providing health services through tertiary services in urban cities, whereas there is almost no research in Pakistan on the mental health and quality of life of CLD patients. This study aimed to understand which predictors influence the mental health and quality of life of CLD patients in order to advise better policy protection.

METHODS

Data was collected from CLD patients at the Pakistan Kidney and Liver Institute and Research Centre, Lahore, Pakistan. A total of 850 respondents were part of the final sample. The age of respondents ranged from 18 to 79 years and included the following diagnosis: (i) Chronic Viral Hepatitis (n = 271), (ii) Cirrhosis (n = 259), (iii) Hepatocellular Carcinoma (n = 193), and (iv) Non-viral Liver Disease (n = 127).

RESULTS

Mean results reveal that females as well as illiterate patients need more support for mental health and communication with their physician; whereas men need more support to develop coping strategies. Structural equation modelling results reveal that the severity of symptoms (β = 0.24, p < 0.001), coping strategies (β=-0.51, p < 0.001), and doctor communication (β=-0.35, p < 0.001) predict mental health. Quality of life is associated with the severity of symptoms (β=-0.36, p < 0.001), coping strategies (β = 0.26, p < 0.05), and doctor communication (β = 0.09, p < 0.05).

CONCLUSIONS

A 'bio-psycho-social-spiritual' model is recommended for Pakistan's CLD patients which includes the integration of social officers to provide support in four key areas to secure mental health and quality of life of patients.

Low Health Literacy, Lack of Knowledge, and Self-Control Hinder Healthy Lifestyles in Diverse Patients with Steatotic Liver Disease

INTRODUCTION

In parallel with the obesity and diabetes epidemics, steatotic liver disease (SLD) has emerged as a major global public health concern. The mainstay of therapy is counseling on weight loss and increased exercise. However, such lifestyle modifications infrequently lead to success. We aimed to identify barriers to diet and lifestyle modification in patients with SLD.

METHODS

Patients with SLD completed a 14-item questionnaire that assigned barriers to healthy eating to three categories: lack of knowledge, lack of self-control, and lack of time, with a higher summary score indicating more perceived barriers. We administered assessments of health literacy and physical activity. We analyzed the data using descriptive statistics and ordinal regression analysis.

RESULTS

We included 151 participants with a median age of 64; 54% were female and 68.2% were Hispanic. Median BMI was 31.9 kg/m2. Most respondents, 68.2%, had low health literacy and were either underactive, 29.1% or sedentary, 23.2%. Lack of self-control was the strongest barrier to achieving a healthy lifestyle, followed by lack of knowledge. Lack of time was not significant barrier. Patients with the most significant barriers were more likely to have obesity, low health literacy, and be sedentary.

DISCUSSION

Lack of self-control and knowledge are the greatest barriers to adopting a healthy lifestyle in patients with SLD. Future clinical interventions should integrate education that targets various health literacy levels with behavioral approaches to improve a sense of agency.

A randomized, controlled, prehabilitation intervention to maximize early recovery (PRIMER) in liver transplantation

Frailty and impaired functional status are associated with adverse outcomes on the liver transplant (LT) waitlist and after transplantation. Prehabilitation prior to LT has rarely been tested. We conducted a 2-arm patient-randomized pilot trial to evaluate the feasibility and efficacy of a 14-week behavioral intervention to promote physical activity prior to LT. Thirty patients were randomized 2:1 to intervention (n = 20) versus control (n = 10). The intervention arm received financial incentives and text-based reminders linked to wearable fitness trackers. Daily step goals were increased by 15% in 2-week intervals. Weekly check-ins with study staff assessed barriers to physical activity. The primary outcomes were feasibility and acceptability. Secondary outcomes included mean end-of-study step counts, short physical performance battery, grip strength, and body composition by phase angle. We fit regression models for secondary outcomes with the arm as the exposure adjusting for baseline performance. The mean age was 61, 47% were female, and the median Model for End-stage Liver Disease sodium (MELD-Na) was 13. One-third were frail or prefrail by the liver frailty index, 40% had impaired mobility by short physical performance battery, nearly 40% had sarcopenia by bioimpedance phase angle, 23% had prior falls, and 53% had diabetes. Study retention was 27/30 (90%; 2 unenrolled from intervention, 1 lost to follow-up in control arm). Self-reported adherence to exercise during weekly check-ins was about 50%; the most common barriers were fatigue, weather, and liver-related symptoms. End-of-study step counts were nearly 1000 steps higher for intervention versus control: adjusted difference 997, 95% CI, 147-1847; p = 0.02. On average, the intervention group achieved daily step targets 51% of the time. A home-based intervention with financial incentives and text-based nudges was feasible, highly accepted, and increased daily steps in LT candidates with functional impairment and malnutrition.

Factors associated with poor health literacy in older adults: A systematic review

OBJECTIVES

To identify factors associated with poor health literacy in older adults.

METHODS

A systematic literature review was conducted, employing the descriptors "Aged" and "Health Literacy".

PROSPERO - CRD

42022350140.

RESULTS

Out of 23,500 articles screened, 176 were selected. Several factors associated with poor health literacy in older adults were identified, such as sociodemographic (e.g., advanced age, low educational level, non-white population, and others), social (e.g., poor family/social support, loneliness, social isolation, few social activities, and others), economic (e.g., lower income and/or lower socioeconomic status) and health aspects (e.g., poor health, chronic conditions, mental health challenges, hospitalizations, frailty, physical inactivity, cognitive impairment, and others).

CONCLUSIONS

The factors associated with poor health literacy in older adults identified in this review could contribute to future research, support interventions to improve health literacy, and assist professionals in planning educational activities and public policies.

Mitigating Health Disparities in Transplantation Requires Equity, Not Equality

Despite decades of research and evidence-based mitigation strategies, disparities in access to transplantation persist for all organ types and in all stages of the transplant process. Although some strategies have shown promise for alleviating disparities, others have fallen short of the equity goal by providing the same tools and resources to all rather than tailoring the tools and resources to one's circumstances. Innovative solutions that engage all stakeholders are needed to achieve equity regardless of race, sex, age, socioeconomic status, or geography. Mitigation of disparities is paramount to ensure fair and equitable access for those with end-stage disease and to preserve the trust of the public, upon whom we rely for their willingness to donate organs. In this overview, we present a summary of recent literature demonstrating persistent disparities by stage in the transplant process, along with policies and interventions that have been implemented to combat these disparities and hypotheses for why some strategies have been more effective than others. We conclude with future directions that have been proposed by experts in the field and how these suggested strategies may help us finally arrive at equity in transplantation.

Patient randomised controlled trial of technology enabled strategies to promote treatment adherence in liver transplantation: rationale and design of the TEST trial

BACKGROUND AND AIMS

Liver transplantation is a life-saving procedure for end-stage liver disease. However, post-transplant medication regimens are complex and non-adherence is common. Post-transplant medication non-adherence is associated with graft rejection, which can have long-term adverse consequences. Transplant centres are equipped with clinical staff that monitor patients post-transplant; however, digital health tools and proactive immunosuppression adherence monitoring has potential to improve outcomes.

METHODS AND ANALYSIS

This is a patient-randomised prospective clinical trial at three transplant centres in the Northeast, Midwest and South to investigate the effects of a remotely administered adherence programme compared with usual care. The programme monitors potential non-adherence largely levering text message prompts and phenotypes the nature of the non-adhere as cognitive, psychological, medical, social or economic. Additional reminders for medications, clinical appointments and routine self-management support are incorporated to promote adherence to the entire medical regimen. The primary study outcome is medication adherence via 24-hour recall; secondary outcomes include additional medication adherence (ASK-12 self-reported scale, regimen knowledge scales, tacrolimus values), quality of life, functional health status and clinical outcomes (eg, days hospitalised). Study implementation, acceptability, feasibility, costs and potential cost-effectiveness will also be evaluated.

ETHICS AND DISSEMINATION

The University of Pennsylvania Review Board has approved the study as the single IRB of record (protocol # 849575, V.1.4). Results will be published in peer-reviewed journals and summaries will be provided to study funders.

TRIAL REGISTRATION NUMBER

NCT05260268.

Measuring Medication Use, Obstacles, and Knowledge in Individuals With Cirrhosis

BACKGROUND & AIMS

Although patient knowledge is modifiable, there are no widely accepted tools to measure patient understanding during cirrhosis care. We aimed to develop and validate "My Cirrhosis Coach" (MCC), a personalized, self-administered questionnaire to evaluate cirrhosis-related medication use, obstacles, and understanding.

METHODS

Adults with cirrhosis were prospectively enrolled at 3 tertiary centers from July 2016 through July 2020. Psychometrics including confirmatory factor analysis was used to develop and validate a final questionnaire. Content validity was measured via the content validity index and expert performance. Discriminant validity was assessed by comparing scores between groups hypothesized to have varying performance.

RESULTS

The MCC was tested in a diverse cohort (n = 713) with cirrhosis and its complications including ascites (45%) and hepatic encephalopathy (33%) with median Model for End-Stage Liver Disease-Sodium 10 (interquartile range, 9-15). A 6-factor model of the MCC fit the data well (root mean square error of approximation, 0.22; comparative fit index, 0.96; standardized root mean squared residual, 0.104; final domains: Medication Use & Accessibility, Medication Obstacles, Lactulose Use, Diuretic Use, Beta Blocker Use, and Dietary Sodium Use). The MCC had excellent content validity (content validity index, 81%-94%) and accuracy (91%-100%) ratings by experts. Mean domain scores ranged from 1.1 to 2.6 (range, 0-3; 3 indicating better performance). Those with a cirrhosis complication scored higher in the relevant medication domain (ie, diuretic use score in ascites). Compared with outpatients, inpatients scored higher in all knowledge domains except salt use and reported more medication obstacles. Scores differed by income, education level, and having an adult at home.

CONCLUSIONS

In a large, diverse cohort, we validated the MCC, which can serve to standardize medication use and knowledge measurement in clinical practice and education-based studies in cirrhosis.

Community-level social vulnerability and individual socioeconomic status on liver transplant referral outcome

BACKGROUND

Recent endeavors emphasize the importance of understanding early barriers to liver transplantation (LT) by consistently collecting data on patient demographics, socioeconomic factors, and geographic social deprivation indices.

METHODS

In this retrospective single-center cohort study of 1657 adults referred for LT evaluation, we assessed the association between community-level vulnerability and individual socioeconomic status measures on the rate of waitlisting and transplantation. Patients' addresses were linked to Social Vulnerability Index (SVI) at the census tract-level to characterize community-level vulnerability. Descriptive statistics were used to describe patient characteristics. Multivariable cause-specific HRs were used to assess the association between community-level vulnerability, individual measures of the socioeconomic status, and LT evaluation outcomes (waitlist and transplantation).

RESULTS

Among the 1657 patients referred for LT during the study period, 54% were waitlisted and 26% underwent LT. A 0.1 increase in overall SVI correlated with an 8% lower rate of waitlisting (HR 0.92, 95% CI 0.87-0.96, p < 0.001), with socioeconomic status, household characteristics, housing type and transportation, and racial and ethnic minority status domains contributing significantly to this association. Patients residing in more vulnerable communities experienced a 6% lower rate of transplantation (HR 0.94, 95% CI 0.91- 0.98, p = 0.007), with socioeconomic status and household characteristic domain of SVI significantly contributing to this association. At the individual level, both government insurance and employment status were associated with lower rates of waitlisting and transplantation. There was no association with mortality prior to waitlisting or mortality while on the waitlist.

CONCLUSION

Our findings indicate that both individual and community measures of the socioeconomic status (overall SVI) are associated with LT evaluation outcomes. Furthermore, we identified individual measures of neighborhood deprivation associated with both waitlisting and transplantation.

HBV screening among West Africans living in the US: Influences of stigma, health literacy, and self-efficacy

BACKGROUND

Applying theoretically informed constructs using an adaptation of the "Theory of Planned Behavior," this study assessed social-cognitive and sociocultural determinants of HBV screening among West Africans living in the US to inform solutions to testing gaps.

METHODS

We developed and administered a theory-based survey in both English (41%) and French (59%) from September 2021 to April 2022 to a sample of West African-born individuals (n = 162). Predictors of HBV screening included: attitudes, perceived behavioral control or self-efficacy, and subjective norms along with health literacy (HL), language proficiency, and stigma of HBV infection. We hypothesized that these constructs would predict HBV testing. We also conducted path analytic modeling to better understand both direct and indirect effects of key factors on HBV screening status.

RESULTS

West Africans who completed the survey in English were younger with less education and lower income, whereas those who completed the survey in French reported higher HBV-related stigma. In a bivariate analysis of factors associated with HBV screening by language, less education was associated with lower HBV screening in English speakers. Adequate HL, higher self-efficacy, and higher English language proficiency were independently associated with HBV screening. Path analysis to better understand the interplay between social-cognitive and sociocultural factors revealed HL and stigma both had indirect effects on screening, mediated by differences in self-efficacy.

CONCLUSIONS

This study identified HL and stigma as key indirect factors that influence HBV screening by way of self-efficacy in West Africans in the US. This work is a first step to identifying barriers that can lead to the development of an evidence-based intervention aimed at increasing HBV screening of West Africans to address health disparities.

Frailty as a predictor of poor outcomes among patients awaiting liver transplant: a systematic review and meta-analysis

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.

Frailty and solid-organ transplant candidates: a scoping review

BACKGROUND

There is currently no consensus as to a standardized tool for frailty measurement in any patient population. In the solid-organ transplantation population, routinely identifying and quantifying frailty in potential transplant candidates would support patients and the multidisciplinary team to make well-informed, individualized, management decisions. The aim of this scoping review was to synthesise the literature regarding frailty measurement in solid-organ transplant (SOT) candidates.

METHODS

A search of four databases (Cochrane, Pubmed, EMBASE and CINAHL) yielded 3124 studies. 101 studies (including heart, kidney, liver, and lung transplant candidate populations) met the inclusion criteria.

RESULTS

We found that studies used a wide range of frailty tools (N = 22), including four 'established' frailty tools. The most commonly used tools were the Fried Frailty Phenotype and the Liver Frailty Index. Frailty prevalence estimates for this middle-aged, predominantly male, population varied between 2.7% and 100%. In the SOT candidate population, frailty was found to be associated with a range of adverse outcomes, with most evidence for increased mortality (including post-transplant and wait-list mortality), post-operative complications and prolonged hospitalisation. There is currently insufficient data to compare the predictive validity of frailty tools in the SOT population.

CONCLUSION

Overall, there is great variability in the approach to frailty measurement in this population. Preferably, a validated frailty measurement tool would be incorporated into SOT eligibility assessments internationally with a view to facilitating comparisons between patient sub-groups and national and international transplant services with the ultimate goal of improved patient care.

Area Deprivation Index and Gut-Brain Axis in Cirrhosis

INTRODUCTION

Neighborhood deprivation has been associated with chronic diseases and with gut microbial alterations. Although cirrhosis is associated with gut microbiome changes and hepatic encephalopathy (HE), their association is unclear.

METHODS

Demographics and cirrhosis details (model for end-stage liver disease [MELD], prior HE, and medications) were recorded from outpatients with cirrhosis. Area deprivation index (ADI), which ranks neighborhoods by socioeconomic disadvantage, was recorded as state decile and national percentile (high = worse for both) and dichotomized on the median. Patients underwent cognitive testing to diagnose minimal HE (MHE). Stool microbiota was analyzed using 16S ribosomal RNA for α/β-diversity. Multivariable analysis was used to evaluate the factors independently associated with MHE.

RESULTS

A total of 321 people with cirrhosis (60 years, 78% men, 75% non-Hispanic White, 24% non-Hispanic African American, 4% Hispanic) were included. 45% had prior HE and 56% MHE. For ADI, the national percentile was 49.1 ± 21.8 while the state decile was 6.1 ± 2.3. ADI was not associated with race, ethnicity, MELD, or HE-related variables on regression. Regarding microbiota, α-diversity was lower in MHE and prior HE patients but similar across ADI rankings. Low vs high ADIs were associated with different β-diversity in univariable but not multivariable analyses. Multivariable analyses showed positive associations with MELD, prior HE, and lactate producers ( Lactobacillus and Lacticaseibacillus ) and negative associations with short-chain fatty acid producers ( Blautia , Lachnoclostridium , and Anaerobutyricum ) with MHE.

DISCUSSION

Cirrhosis-related variables may be more influential in determining gut microbiome composition and cognitive impairment than ADI. Therefore, the focus should be on improving cirrhosis care, regardless of ADI, but studies evaluating other measures of social determinants are needed in cirrhosis.

Revision Total Hip Arthroplasty in Solid Organ Transplant Patients: A Propensity Score-Matched Cohort Study for Aseptic and Infected Revisions

Background

Previous studies have demonstrated that solid organ transplant (SOT) patients undergoing primary total hip arthroplasty (THA) are at an increased risk of postoperative complications. The purpose of this study is to use a large, national database to investigate revision THA (rTHA) outcomes in SOT patients.

Methods

Nationwide Readmissions Database (NRD) from 2010-2018 was used, and ICD-9 and ICD-10 codes were used to identify all patients who underwent rTHA, including those with history of SOT. Propensity score matching (PSM) was used to analyze rTHA outcomes in SOT patients comparted to matched controls. Separate analysis performed for patients undergoing rTHA for prosthetic joint infection (PJI) vs other causes.

Results

A total of 414,756 rTHA, with 1837 of those being performed in SOT patients, were identified. Of these, 65,961 and 276 were performed for PJI in non-SOT and SOT patients, respectively. For non-PJI patients, SOT patients had higher 90-day all-cause readmission rates (24.0% vs 19.4%, P = .03) but lower rate for readmission related to rTHA (6.0% vs 9.2%, P = .03), but no difference readmission for specific rTHA complications, mortality (0.6% vs 1.3%, P = .20), or revision rTHA. Of PJI patients, SOT patients had no difference in overall 90-day readmission (38.6 vs 31.3%, P = .280), readmission for specific rTHA complications, re-revision, or mortality (4.7% vs 6.0%, P = .63).

Conclusions

SOT patients undergoing rTHA for aseptic reasons are higher risk of overall readmission but lower risk of readmission related to rTHA than appropriately matched controls. SOT PJI patients undergoing had similar rates of readmission, mortality, and revision surgery compared to matched non-SOT PJI patients.

Limited health literacy increases the risk of frailty among community-dwelling older adults: Longitudinal findings from the Korean Frailty and Aging Cohort Study

AIM

Despite the growing recognition of the importance of health literacy, there is a lack of knowledge on the longitudinal association between health literacy and frailty. The present study explored whether limited health literacy increases the risk of developing pre-frailty and frailty among older adults.

METHODS

Data were drawn from the Korean Frailty and Aging Cohort Study, a nationwide, population-based prospective cohort study of community-dwelling older Koreans. A baseline sample of 2808 adults aged 70-84 years was analyzed for the cross-sectional models, and 2278 participants in the 2-year follow-up assessment were included for the longitudinal analyses. Multinomial logistic regression models were used to evaluate the relative risk ratios of pre-frailty or frailty, where a robust group served as the reference category.

RESULTS

The findings showed that baseline limited health literacy was associated with an approximately 1.4-fold increased risk of developing pre-frailty after 2 years, even after adjusting for sociodemographic characteristics, health behaviors and health status. However, the longitudinal association between health literacy and frailty was not significant after adjusting for health-related factors.

CONCLUSIONS

Our findings point to the importance of promoting health literacy among older adults, and provide preliminary evidence that can inform the development of tailored public health strategies. Geriatr Gerontol Int 2022; 22: 325-331.

A scoping review of inequities in access to organ transplant in the United States

BACKGROUND

Organ transplant is the preferred treatment for end-stage organ disease, yet the majority of patients with end-stage organ disease are never placed on the transplant waiting list. Limited access to the transplant waiting list combined with the scarcity of the organ pool result in over 100,000 deaths annually in the United States. Patients face unique barriers to referral and acceptance for organ transplant based on social determinants of health, and patients from disenfranchised groups suffer from disproportionately lower rates of transplantation. Our objective was to review the literature describing disparities in access to organ transplantation based on social determinants of health to integrate the existing knowledge and guide future research.

METHODS

We conducted a scoping review of the literature reporting disparities in access to heart, lung, liver, pancreas and kidney transplantation based on social determinants of health (race, income, education, geography, insurance status, health literacy and engagement). Included studies were categorized based on steps along the transplant care continuum: referral for transplant, transplant evaluation and selection, living donor identification/evaluation, and waitlist outcomes.

RESULTS

Our search generated 16,643 studies, of which 227 were included in our final review. Of these, 34 focused on disparities in referral for transplantation among patients with chronic organ disease, 82 on transplant selection processes, 50 on living donors, and 61 on waitlist management. In total, 15 studies involved the thoracic organs (heart, lung), 209 involved the abdominal organs (kidney, liver, pancreas), and three involved multiple organs. Racial and ethnic minorities, women, and patients in lower socioeconomic status groups were less likely to be referred, evaluated, and added to the waiting list for organ transplant. The quality of the data describing these disparities across the transplant literature was variable and overwhelmingly focused on kidney transplant.

CONCLUSIONS

This review contextualizes the quality of the data, identifies seminal work by organ, and reports gaps in the literature where future research on disparities in organ transplantation should focus. Future work should investigate the association of social determinants of health with access to the organ transplant waiting list, with a focus on prospective analyses that assess interventions to improve health equity.

Redefining Success After Liver Transplantation: From Mortality Toward Function and Fulfillment

Liver transplantation (LT), the only cure for end-stage liver disease, is a lifesaving, costly, and limited resource. LT recipients (LTRs) are aging with an increasing burden of medical comorbidities. Patient and graft survival rates exceed 70% at 5 years; however, patient-centered health outcomes beyond survival have received relatively little attention. LTRs must have strong self-management skills to navigate health systems, adhere to clinical monitoring, and take complex, multidrug regimens. All of these tasks require formidable cognitive abilities for active learning and problem solving. Yet, LTRs are at higher risk for impaired cognition as a result of the high prevalence of pretransplant hepatic encephalopathy, multiple chronic conditions, alcohol use, physical frailty, sarcopenia, and older age. Cognitive impairment after transplant may persist and has been causally linked to poor self-management skills, worse physical function, and inferior health outcomes in other health care settings, yet its impact after LT is largely unknown. There is a need to study potentially modifiable, posttransplant targets including caregiver support, physical activity, sleep, and treatment adherence to inform future health system responses to promote the long-term health and well-being of LTRs. Prospective, longitudinal data collection that encompasses key sociodemographic, cognitive-behavioral, psychosocial, and medical factors is needed to improve risk prediction and better inform patient and caregiver expectations. Interventions with proactive monitoring, reducing medical complexity, and improved care coordination can be tailored to optimize posttransplant care. We propose a research agenda focused on understudied, potentially modifiable risk factors to improve the long-term health of LTRs. Our conceptual model accounts for cognitive function, caregiver and patient self-management skills, health behaviors, and patient-centered outcomes beyond mortality. We propose actionable health-system, patient, and caregiver-directed interventions to fill knowledge gaps and improve outcomes.

Revision total knee arthroplasty outcomes in solid organ transplant Patients, a matched cohort study of aseptic and infected revisions

BACKGROUND

Previous studies have demonstrated that solid organ transplant (SOT) patients undergoing primary total knee arthroplasty (TKA) are at an increased risk of postoperative complications. The purpose of this study is to utilize a large, national database to investigate revision TKA (rTKA) outcomes in SOT patients.

METHODS

This was a retrospective review utilizing the Nationwide Readmissions Database (NRD) and ICD-9 codes to identify patients who underwent rTKA from 2010-2014 with a history of at least one SOT. Propensity-score-matching (PSM) was used to compare rTKA outcomes in SOT patients compared to matched patients without SOT.

RESULTS

A total of 303,867 rTKAs, with 464 of those being performed in SOT patients, were included in the study. Of these, 71,903 and 182 were performed for PJI in non-SOT and SOT patients, respectively. rTKA was performed most frequently in kidney transplant patients (53.0%) followed by liver transplant patients (34.3%). For non-PJI patients, SOT patients had a higher 90-day readmission rate than matched non-SOT rTKA patients (23.2% vs 12.6%, p = 0.006). However, there were no differences in 90-day readmission rates for specific rTKA complications, subsequent revision rTKA, or mortality. Among patients undergoing rTKA for PJI, there was no difference in overall 90-day readmission rate, readmission for specific rTKA complications, subsequent revision rTKA, or mortality.

CONCLUSIONS

While the increased medical comorbidities associated with SOT place patients at increased risk for complications following rTKA, it appears that SOT alone does not do so when patients are matched based on overall medical comorbidity.

Equitable Access to Liver Transplant: Bridging the Gaps in the Social Determinants of Health

The COVID-19 pandemic and social justice movement have highlighted the impact of social determinants of health (SDOH) and structural racism in the United States on both access to care and patient outcomes. With the evaluation for liver transplantation being a highly subjective process, there are multiple ways for SDOH to place vulnerable patients at a disadvantage. This policy corner focuses on three different methods to reverse the deleterious effects of SDOH-identify and reduce implicit bias, expand and optimize telemedicine, and improve community outreach.

Prehabilitation-Driven Changes in Frailty Metrics Predict Mortality in Patients With Advanced Liver Disease

INTRODUCTION

Frailty is a predictor of morbidity and mortality in cirrhosis. Although evidence for prehabilitation is promising, the data for liver transplant (LT) candidates are limited. The primary aim of this study was to evaluate the effect of a novel prehabilitation strategy on changes in frailty metrics and survival in LT candidates. The secondary aim was to determine liver-related and extrahepatic conditions associated with frailty.

METHODS

In this ambispective cohort study, all patients underwent frailty assessment using the liver frailty index (LFI), 6-minute walk test, and gait speed test performed by a dedicated physical therapist. Home-based exercise prescription was individualized to each patient's baseline physical fitness.

RESULTS

We included 517 patients (59% men, median age 61 years, and a model for end-stage liver disease score of 12) evaluated during 936 PT visits. Frailty metrics were affected by age, sex, and liver-related parameters, but not by model for end-stage liver disease. Patients with nonalcoholic fatty liver disease and alcohol-related cirrhosis had worse frailty metrics by all tools. We demonstrated the feasibility of prehabilitation in improving both LFI and 6-minute walk test, particularly in adherent patients. A median LFI improvement of 0.3 in frail patients was associated with improved survival in univariate analysis. Compliance with physical therapist visits (hazards ratio = 0.35 [0.18-0.67] for 2 visits and hazards ratio = 0.54 [0.31-0.94] for ≥3 visits) was independently associated with increased survival.

DISCUSSION

Prehabilitation improves frailty metrics in LT candidates and is associated with a survival advantage. Our findings provide a framework for the standardized prehabilitation program in LT candidates while prioritizing compliance, adherence, and on-training LFI goal accomplishment.

Health Literacy and Frailty in Community-Dwelling Older Adults: Evidence from a Nationwide Cohort Study in South Korea

Health literacy is closely associated with poor health outcomes and mortality. However, only a handful of studies have examined the association between health literacy and frailty status. The current study used data from a nationwide sample of Korean adults aged 70-84 collected from 10 cities, each of which represents a different region of South Korea (n = 1521). We used the propensity score matching (PSM) method to minimize the potential selection bias and confounding factors that are present in observational studies. After PSM, demographic and health-related characteristics between the limited health literacy (n = 486) and the nonlimited health literacy (n = 486) groups were not significantly different. Multinomial logistic regression analyses were conducted for the PSM-matched sample to examine the association between health literacy and frailty outcomes, where the robust group was set as a reference. Limited health literacy significantly increased the risk of pre-frailty (RRR = 1.45, p = 0.02) and frailty (RRR = 2.03, p = 0.01) after adjusting for demographic and health-related factors. Our findings underscore the need to foster health literacy programs and provide preliminary evidence to inform tailored intervention programs so that we might attenuate the risk of frailty in the older population.

Transjugular intrahepatic portosystemic shunt (TIPS) procedure: an assessment of the quality and readability of online information

Purpose

Transjugular intrahepatic portosystemic shunt (TIPS) procedure is an established procedure carried out by interventional radiologists to achieve portal decompression and to manage the complications of portal hypertension. The aim of this study was to evaluate the quality and readability of information available online for TIPS procedure.

Methods

Websites were identified using the search terms “TIPS procedure”, “TIPSS procedure”, “transjugular intrahepatic portosystemic shunt procedure”, with the first 25 pages from the three most popular search engines (Google, Bing and Yahoo) being selected for evaluation with a total of 225. Each Website was grouped by authorship into one of five categories: (1) Physician, (2) Academic, (3) For-profit, (4) Non-profit (including government and public health), or (5) Other (discussion/social media). Readability of each Website was assessed using the Flesch-Reading Ease score, Flesch–Kincaid grade level, Gunning-Fog Index, Coleman–Liau and SMOG index. Quality was calculated using the DISCERN instrument, the Journal of the American Medical Association (JAMA) benchmark criteria and the presence of Health on the Net (HON) code certification.

Results

After disregarding duplicate and non-accessible Websites a total of 81 were included. The mean DISCERN score assessing the quality of information provided by Websites was “good” (59.3 ± 10.2) with adherence to the JAMA Benchmark being 54.3%. Websites with HON-code certification were statistically significantly higher in terms of DISCERN (p = 0.034) and JAMA scores (p = 0.003) compared to HON-code negative sites. The readability scores of Websites ranged from 10 to 12th grade across calculators. Thirty-two out of the 81 Websites were targeted towards patients (39.5%), 46 towards medical professionals (56.8%) and 3 were aimed at neither (3.7%). The medical professional aimed Websites were statistically significantly more difficulty to read across all readability formulas (all p < 0.001).

Conclusion

While quality of online information available to patients is “good”, the average readability for information on the internet for TIPS is set far above the recommended 7th-grade level. Academic Websites were of the highest quality, yet most challenging for the general public to read. These findings call for the production of high-quality and comprehensible content around TIPS procedure, where physicians can reliably direct their patients for information.

The Stanford Integrated Psychosocial Assessment for Transplant Is Associated With Outcomes Before and After Liver Transplantation

The Stanford Integrated Psychosocial Assessment for Transplant (SIPAT) is a standardized psychosocial evaluation tool used in liver transplantation (LT) evaluation. We assessed the impact of the SIPAT score and subdomains on transplant waitlisting decisions and post-LT outcomes including immunosuppression (IS) nonadherence, biopsy-proven rejection, andmortality/graft failure. We conducted a single-center observational cohort study of 1430 patients evaluated for LT. Patients were divided in 2 groups based on a SIPAT cutoff score of <21 or ≥21 (higher SIPAT scores indicate higher psychosocial risk). Regression models assessed relationships between total SIPAT score and domain scores and waitlisting decisions, IS nonadherence, allograft rejection, and death/graft failure. Elevated total SIPAT and SIPAT domain scores were associated not being added to the waitlist (total SIPAT core ≥21 adjusted odds ratio [aOR], 1.78 [95% confidence interval, CI, 1.36-2.33]; readiness score ≥5 aOR, 2.01 [95% CI, 1.36-2.76]; social support score ≥4aOR, 1.50 [95% CI, 1.15-1.94]; psychopathology score ≥7 aOR, 1.45 [95% CI, 1.07-1.94]; lifestyle/substance abuse score ≥12 aOR, 1.72 [95%CI, 1.23-2.39]) and were more likely to experience IS nonadherence as measured by the tacrolimus coefficient of variation (CoV) (total SIPAT score ≥21 aOR, 2.92 [95% CI, 1.69-5.03]; readiness score ≥5 aOR, 3.26 [95% CI, 1.63-6.52]; psychopathology score ≥7 aOR, 1.88 [95% CI, 1.00-3.50]; lifestyle substance abuse score ≥12 aOR, 3.03 [95% CI, 1.56-5.86]). SIPAT readinessscore ≥5 was associated with biopsy-proven allograft rejection (aOR, 2.66; 95% CI, 1.20-5.91). The SIPAT score was independently associated with LT listing decisions and IS nonadherence, and the readiness domain was associated with the risk of allograft rejection. These findings offer insights into higher risk recipients who require additional support before and aftertransplantation.