Roles of nutrition and physical activity in musculoskeletal complications before and after liver transplantation

Risk Factors and Management of Osteoporosis Post-Transplant

Bone and mineral disorders are common after organ transplantation. Osteoporosis post transplantation is associated with increased morbidity and mortality. Pathogenesis of bone disorders in this particular sub set of the population is complicated by multiple co-existing factors like preexisting bone disease, Vitamin D deficiency and parathyroid dysfunction. Risk factors include post-transplant immobilization, steroid usage, diabetes mellitus, low body mass index, older age, female sex, smoking, alcohol consumption and a sedentary lifestyle. Immunosuppressive medications post-transplant have a negative impact on outcomes, and further aggravate osteoporotic risk. Management is complex and challenging due to the sub-optimal sensitivity and specificity of non-invasive diagnostic tests, and the underutilization of bone biopsy. In this review, we summarize the prevalence, pathophysiology, diagnostic tests and management of osteoporosis in solid organ and hematopoietic stem cell transplant recipients.

Physical activity and aerobic fitness in children after liver transplantation

To determine physical activity (PA), aerobic fitness, muscle strength, health-related quality of life (HRQOL), fatigue, and participation in children after liver transplantation. Children, 6-12 years, at least one year after liver transplantation, participated in this cross-sectional study. Measurements: Time spent in moderate to vigorous PA (MVPA) was measured using an accelerometer, and aerobic fitness (VO_{2 peak} ) was measured by cardiopulmonary exercise testing. Muscle strength was measured by hand-held dynamometry. Fatigue was measured using the multidimensional fatigue scale, and HRQOL with the Pediatric Quality of life Core scales and leisure activities was measured using the Children's Assessment of Participation and Enjoyment. Outcomes (medians and interquartile range (IQR)) were compared to norm values. Twenty-six children participated in this study (14 boys, age 9.7 years, IQR 7.7;11.4). Children spent 0.8 hours/d (IQR 0.6;1.1) on MVPA. One child met the recommendation of at least 1 hour of MVPA every day of the week. Aerobic fitness was similar to norms (VO_{2 peak} 1.4 _L/min , IQR 1.1;1.7, Z-score -0.3). Z-scores of muscle strength ranged between -1.4 and -0.4 and HRQOL and fatigue between -2.3 and -0.4. Participation was similar to published norms (Z-scores between -0.6 and 0.6). Young children after liver transplantation have similar MVPA patterns and aerobic fitness compared to published norms. Despite lower HRQOL, more fatigue, and less muscle strength, these children have similar participation in daily activities. Although children do well, it remains important to stimulate PA in children after liver transplantation in the context of long-term management.

Posttransplant muscle mass measured by urinary creatinine excretion rate predicts long-term outcomes after liver transplantation

Long-term survival in orthotopic liver transplant (OLT) recipients remains impaired because of many contributing factors, including a low pretransplant muscle mass (or sarcopenia). However, influence of posttransplant muscle mass on survival is currently unknown. We hypothesized that posttransplant urinary creatinine excretion rate (CER), an established noninvasive marker of total body muscle mass, is associated with long-term survival after OLT. In a single-center cohort study of 382 adult OLT recipients, mean ± standard deviation CER at 1 year posttransplantation was 13.3 ± 3.7 mmol/24 h in men and 9.4 ± 2.6 mmol/24 h in women. During median follow-up for 9.8 y (interquartile range 6.4-15.0 y), 104 (27.2%) OLT recipients died and 44 (11.5%) developed graft failure. In Cox regression analyses, as continuous variable, low CER was associated with increased risk for mortality (HR = 0.43, 95% CI: 0.26-0.71, P = .001) and graft failure (HR = 0.42, 95% CI: 0.20-0.90, P = .03), independent of age, sex, and body surface area. Similarly, OLT recipients in the lowest tertile had an increased risk for mortality (HR = 2.69; 95% CI: 1.47-4.91, P = .001) and graft failure (HR = 2.77, 95% CI: 1.04-7.39, P = .04), compared to OLT recipients in the highest tertile. We conclude that 1 year posttransplant low total body muscle mass is associated with long-term risk of mortality and graft failure in OLT recipients.

N-Acetylcysteine inhalation improves pulmonary function in patients received liver transplantation

Postoperative pulmonary complications (PPCs) following orthotopic liver transplantation (OLT) are associated with high morbidity and mortality rates. The effect of N-acetylcysteine (NAC) inhalation on the incidence of PPCs and the outcomes of patients undergoing OLT is unknown. This prospective randomized controlled clinical trial was conducted to investigate the effect of NAC inhalation during OLT on PPCs. Sixty patients were randomly assigned to the NAC group (n = 30) or the control group (n = 30) to receive inhaled NAC or sterilized water, respectively, for 30 min before surgery and 3 h after reperfusion. The incidence of early PPCs and outcomes including survival rate were assessed. Biomarkers including tumor necrosis factor (TNF)-α, interleukin (IL)-8, Clara cell secretory protein (CC16), intercellular adhesion molecule (ICAM)-1, and superoxide dismutase (SOD) were measured in exhaled breath condensate (EBC) at T1 (before surgery) and T2 (at the end of operation) as well as in serum at T1, T2, T3 (12 h after operation), and T4 (24 h after operation). A total of 42 patients (20 in the NAC group and 22 in the control group) were enrolled in the final analysis. Atomization inhaled NAC significantly reduced the incidence of PPCs after OLT. The levels of TNF-α, IL-8, CC16, and ICAM-1 in EBC were significantly lower, and SOD activity was higher, at T2 in the NAC group; similar data were found in serum at T2, T3, and T4. In summary, perioperative NAC inhalation may reduce the incidence of PPCs and improve patient outcomes after OLT.

Physical exercise in cirrhotic patients: Towards prehabilitation on waiting list for liver transplantation. A systematic review and meta-analysis

BACKGROUND

Early survival after Liver Transplantation (LT) is reduced among sarcopenic patients. Despite, Adapted Physical Activity (APA) before LT is rarely proposed for the risk to impair portal hypertension and its resulting complications.

OBJECTIVES

To assess the effects of APA program in adults affected by End Stage Liver Disease (ESLD) on hospital stay, 1-year mortality and morbidity after LT, adverse events (Primary outcomes). Secondary outcomes were changes in VO2 peak, muscle morphology, 6minutes walking distance test (6MWD), Body Mass Index (BMI), MELD, CHILD score and Hepatic Venous Pressure Gradient (HVPG).

SEARCH METHODS

MEDLINE, EMBASE, Google Scholar and the Cochrane Library database were explored for randomized clinical trials (RCT).

DATA COLLECTION AND ANALYSIS

Data were collected by one review author on the type of study, participants, treatments used for primary and secondary outcomes. Review Manager 5.2 was used for the analysis.

MAIN RESULTS

Four RCT with 81 patients were included. Primary outcomes: no severe adverse event was observed, but no published data were available on hospital stay or mortality after LT.

SECONDARY OUTCOMES

CHILD, MELD and BMI were not worsened by physical activity. No significant muscle diameter, 6MWD and VO2 peak changes were observed after exercise. Significant reduction in HVPG in the treatment group was observed in a single study (MD-2.5mmHg; 95%CI [-04.76, -0.24]; P=0.03).

AUTHORS' CONCLUSIONS

Knowledge in this field is still at an early stage. Evidence derived from small trials of medium quality on ESLD patients suggests that APA is safe, without increasing portal hypertension. Further research is very likely to have an important impact on our confidence in the intervention effect.

Current therapies in alleviating liver disorders and cancers with a special focus on the potential of vitamin D

Background

Liver dysfunction is a topic of global concern with many advancing therapies being researched. Though vitamin D takes a center place, other therapies especially nutritional are also gaining ground. Vitamin D has gone beyond its role in skeletal disorders by showcasing its associations in other metabolic dysfunctions too.

Result

Epidemiological evidences show a correlation between the status of vitamin D and different forms of cancer. Vitamin D receptors and alterations in gene expression appear decisive in the development of chronic liver disorders. Nutritional status therefore plays a significant role in avoiding the complications related to liver dysfunctions, making it mandatory in maintaining vitamin D sufficiency in the body. Therapies with omega-3 fatty acids, antioxidants, amino acids, steroids also render benefits which could be further explored. Recent research on the progression of certain forms of liver cancer using vitamin D analogs like Seocalcitol EB 1089 has shown good promise.

Conclusion

The anti-inflammatory and immuno- regulatory properties of vitamin D makes its analogs, suitable candidates of better choice for the prevention and treatment of liver disorders and cancer.

A Review of Organ Transplantation: Heart, Lung, Kidney, Liver, and Simultaneous Liver-Kidney

Heart, lung, kidney, liver, and simultaneous liver-kidney transplants share many features. They all follow the same 7-step process, the same 3 immunosuppressant medications, and the same reason for organ transplantation. Organs are transplanted because of organ failure. The similarities end there. Each organ has its unique causes for failure. Each organ also has its own set of criteria that must be met prior to transplantation. Simultaneous liver-kidney transplant criteria vary per transplant center but are similar in nature. Both the criteria required and the 7-step process are described by the United Network of Organ Sharing, which is a private, nonprofit organization, under contract with the US Department of Health and Human Services. Its function is to increase the number of transplants, improve survival rates after transplantation, promote safe transplant practices, and endorse efficiency. The purpose of this article is to review the reasons transplant is needed, specifically heart, lung, kidney, liver, and simultaneous liver-kidney, and a brief overview of the transplant process including criteria used, contraindications, and medications prescribed.

Effects of a respiratory physiotherapeutic program in liver transplantation candidates

BACKGROUND

Candidates for liver transplantation may have malnutrition, fatigue, loss of muscle mass and function. The combination of these factors leads to overall physical disability and physical inactivity.

OBJECTIVE

The aim of the study was to evaluate the effects of a respiratory physiotherapeutic program on liver transplantation candidates.

METHOD

Forty-two patients were evaluated by respiratory muscle strength, surface electromyography of the rectus abdominis and diaphragm, and spirometry. We also applied the SF-36. The patients were divided into two groups: 12 randomly assigned to the control group and 5 in the intervention group. The intervention consisted of an explanatory and illustrative manual to be followed at home with diaphragmatic breathing exercises, diaphragmatic isometric exercise, Threshold IMT, lifting the upper limbs with a bat, and strengthening the abdominals.

RESULTS

Significant difference was found between initial forced expiratory flow (FEF)25-75% (P = .042) and final FEF25-75 in the intervention group. The control group had significant difference (P = .036) in the diaphragm RMS between initial time and end time. In conclusion, the control group showed greater electrical activity of the diaphragm after 3 months.

CONCLUSION

The intervention group benefited from the exercise, thus improving the FEF25-75%.

Long-term dietary habits and interventions in solid-organ transplantation

Diet and nutrition are moving to the forefront of modern primary and preventive care to help address the rising burden of chronic diseases among the general population. Such a movement has yet to occur formally across the field of transplantation. We therefore looked to establish the current base of knowledge regarding diet, nutrition and solid-organ transplantation. A limited number of focused studies looking into the dietary habits of solid-organ transplant patients have been performed and many of the available studies have detailed the nutritional status in the peri-operative period. Frequently described, however, is the heavy incidence of metabolic abnormalities, such as obesity, dyslipidemia and diabetes, occurring after solid-organ transplantation. Optimistically, several studies have noted improvement in several metabolic abnormalities with the use of dietary interventions in the post-transplant period. Despite these positive results, few consensus guidelines for post-transplant diet have been established and nutritional support among transplant programs remains limited. Although there are many hurdles to implementation of detailed dietary recommendations and nutritional support for transplant patients, creating such programs and guidelines could dramatically impact long-term outcomes and burden of chronic metabolic disease for transplant recipients.

Early respiratory complications after liver transplantation

The poor clinical conditions associated with end-stage cirrhosis, pre-existing pulmonary abnormalities, and high comorbidity rates in patients with high Model for End-Stage Liver Disease scores are all well-recognized factors that increase the risk of pulmonary complications after orthotopic liver transplantation (OLT) surgery. Many intraoperative and postoperative events, such as fluid overload, massive transfusion of blood products, hemodynamic instability, unexpected coagulation abnormalities, renal dysfunction, and serious adverse effects of reperfusion syndrome, are other factors that predispose an individual to postoperative respiratory disorders. Despite advances in surgical techniques and anesthesiological management, the lung may still suffer throughout the perioperative period from various types of injury and ventilatory impairment, with different clinical outcomes. Pulmonary complications after OLT can be classified as infectious or non-infectious. Pleural effusion, atelectasis, pulmonary edema, respiratory distress syndrome, and pneumonia may contribute considerably to early morbidity and mortality in liver transplant patients. It is of paramount importance to accurately identify lung disorders because infectious pulmonary complications warrant speedy and aggressive treatment to prevent diffuse lung injury and the risk of evolution into multisystem organ failure. This review discusses the most common perioperative factors that predispose an individual to postoperative pulmonary complications and these complications’ early clinical manifestations after OLT and influence on patient outcome.

Bone density in heart or lung transplant recipients--a longitudinal study

BACKGROUND

Osteoporosis is prevalent among heart or lung transplant (HLT) candidates. Bone loss is common posttransplant, with an associated increase in fracture risk. There is a lack of consensus regarding optimal management of bone health in HLT recipients. We report bone health data in a cohort of HLT recipients before and after transplantation and make recommendations for management.

METHODS

Patients over the age of 20 who had a heart or lung transplant between 2000 and 2011 were identified from the New Zealand HLT Service database, and demographic data, immunosuppressive regimens, bisphosphonate use, and serial bone mineral density (BMD) data were extracted.

RESULTS

Pretransplant BMD was available in 52 heart and 72 lung transplant recipients; 30 and 42, respectively, also had posttransplant BMD data. Pretransplant osteopenia or osteoporosis prevalence were 23% and 8% for heart candidates and 36% and 31% for lung candidates. Posttransplant, BMD decreased significantly at the femoral neck but not at the lumbar spine in the first year, with subsequent stabilization particularly in the presence of bisphosphonate use. Pretransplant BMD was the major predictor for developing osteopenia or osteoporosis after transplantation.

CONCLUSION

A significant proportion of HLT recipients have osteopenia or osteoporosis pretransplant, and this persists posttransplant. Pretransplant BMD is an important predictor of subsequent osteopenia or osteoporosis development, allowing risk stratification and targeted intervention.

Nutritional interventions for liver-transplanted patients

BACKGROUND

Malnutrition is a common problem for patients waiting for orthotopic liver transplantation and a risk factor for post-transplant morbidity. The decision to initiate enteral or parenteral nutrition, to which patients and at which time, is still debated. The effects of nutritional supplements given before or after liver transplantation, or both, still remains unclear.

OBJECTIVES

The aim of this review was to assess the beneficial and harmful effects of enteral and parenteral nutrition as well as oral nutritional supplements administered to patients before and after liver transplantation.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register (March 2012), the Cochrane Central Register of Controlled Trials (Issue 2 of 12, 2012) in The Cochrane Library, MEDLINE (January 1946 to March 2012), EMBASE (January 1974 to March 2012), Science Citation Index Expanded (January 1900 to March 2012), Social Science Citation Index (January 1961 to October 2010), and reference lists of articles. Manufacturers and experts in the field have also been contacted and relevant journals and conference proceedings were handsearched (from 1997 to October 2010).

SELECTION CRITERIA

Randomised clinical trials of parallel or cross-over design evaluating the beneficial or harmful effects of enteral or parenteral nutrition or oral nutritional supplements for patients before and after liver transplantation were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the risk of bias of the trials and extracted data. Dichotomous data were reported as odds ratios (OR) and continuous data as mean differences (MD) along with their corresponding 95% confidence intervals (CI). Meta-analysis was not possible due to clinical heterogeneity of included interventions.

MAIN RESULTS

Thirteen trials met the inclusion criteria. Four publications did not report outcomes pre-defined in the review protocol, or other clinically relevant outcomes and additional data could not be obtained. Nine trials could provide data for the review. Most of the 13 included trials were small and at high risk of bias. Meta-analyses were not possible due to clinical heterogeneity of the interventions.No interventions that were likely to be beneficial were identified.For interventions of unknown effectiveness,postoperative enteral nutrition compared with postoperative parenteral nutrition seemed to have no beneficial or harmful effects on clinical outcomes. Parenteral nutrition containing protein, fat, carbohydrates, and branched-chain amino acids with or without alanyl-glutamine seemed to have no beneficial effect on the outcomes of one and three years survival when compared with a solution of 5% dextrose and normal saline. Enteral immunonutrition with Supportan® seemed to have no effect on occurrence of immunological rejection when compared with enteral nutrition with Fresubin®.There is weak evidence that, compared with standard dietary advice, adding a nutritional supplement to usual diet for patients during the waiting time for liver transplantation had an effect on clinical outcomes after liver transplantation. The combination of enteral nutrition plus parenteral nutrition plus glutamine-dipeptide seemed to be beneficial in reducing length of hospital stay after liver transplantation compared with standard parenteral nutrition (mean difference (MD) -12.20 days; 95% CI -20.20 to -4.00). There is weak evidence that the use of parenteral nutrition plus branched-chain amino acids had an effect on clinical outcomes compared with standard parenteral nutrition, but each was beneficial in reducing length of stay in intensive care unit compared to a standard glucose solution (MD -2.40; 95% CI -4.29 to -0.51 and MD -2.20 days; 95% CI -3.79 to -0.61). There is weak evidence that adding omega-3 fish oil to parenteral nutrition reduced the length of hospital stay after liver transplantation (mean difference -7.1 days; 95% CI -13.02 to -1.18) and the length of stay in intensive care unit after liver transplantation (MD -1.9 days; 95% CI -1.9 to -0.22).For interventions unlikely to be beneficial, there is a significant increased risk in acute rejections in malnourished patients with a history of encephalopathy and treated with the nutritional supplement Ensure® compared with usual diet only (MD 0.70 events per patient; 95% CI 0.08 to 1.32).

AUTHORS' CONCLUSIONS

We were unable to identify nutritional interventions for liver transplanted patients that seemed to offer convincing benefits. Further randomised clinical trials with low risk of bias and powerful sample sizes are needed.

Occupational therapy services to enable liver patients to thrive following transplantation

ABSTRACT Transplantation is the only viable treatment for end-stage liver failure. With advances in biomedicine and surgical technique, survival rates have improved and current research is beginning to focus on patient-related outcomes such as of quality of life (QOL) and life satisfaction. However, attention to the rehabilitation needs of those patients whose lives are saved, is lagging. Pretransplantation, there are serious strains to role function and limitations to mental and physical capacity. Following transplantation, the ability to perform once easy familiar tasks is difficult for a prolonged recovery period. Within a year many people do well, others do not. Little has been done for this latter group. The purpose of this article is to systematically describe the contributions occupational therapy can make to the people struggling with the challenges faced during the transplantation process. The first part presents a framework for understanding the impact of end-stage liver disease, then the transplant, and the subsequent recovery through the combination of two frameworks: the International Classification of Functioning Disability and Health (ICF) and the Model of Human Occupation. The second part of this article will present the implications for occupational therapists throughout seven stages: (1) decline in health, (2) organ failure, (3) referral for transplantation, (4) the waiting period, (5) the transplant surgery, (6) recovery, and (7) return of health. Attention to the needs of transplant recipients who lack the adaptive skills to resume productive lifestyles has the capacity to improve participation outcomes for this population.

Frequency of musculoskeletal complications among the patients receiving solid organ transplantation in a tertiary health-care center

Solid organ transplantation is an important lifesaving procedure mainly performed in patients with end-stage organ failure such as liver cirrhosis, congestive heart failure, and end-stage renal disease. While these complications are among the most preventable adverse effects of solid organ transplantation, these are generally neglected by physicians. Accordingly, this study was performed to evaluate the frequency of musculoskeletal complications among the patients receiving solid organ transplantation in a tertiary health-care center in a developing country. This cohort study was performed from 2000 to 2009, among fifty patients receiving organ transplantation (liver, heart, and lung) attending to a training hospital in Tehran, Iran. The main variables were musculoskeletal complaints and findings that were measured according to patients' self-report and clinical examination. The mean age of the patients was 40.2 ± 10.9 years ranging from 5 to 58 years. Twenty out of 50 patients (40%) had musculoskeletal complaints that the most common complaint was the arthralgia. Also, the mechanical arthritis was the most common clinical finding in clinical examination (24%). Low serum level of vitamin D (74.4%) and high serum alkaline phosphatase level (27.9%) were the most common biochemical abnormalities in understudy population. Finally, it may be concluded that nearly forty percent of patients receiving solid organ transplantation may develop musculoskeletal findings and/or complaints. These complications may be found and treated with regular examinations to reduce the burden of disease.

Haemodynamic effects of physiotherapy programme in intensive care unit after liver transplantation

OBJECTIVE

To determine the haemodynamic effects of intensive care physiotherapy after liver transplantation.

PATIENTS AND METHODS

Thirteen patients were included in the study after liver transplantation. The following physiotherapy programme were applied to the patients in intensive care unit: Respiratory physiotherapy, active joint movements, sitting in bed (first task), sitting at the edge of bed (second task), standing (third task), sitting out of bed (fourth task) and walking (fifth task). Heart rate (HR), mean, systolic and diastolic blood pressures (MBP, SBP, DBP), peripheral oxygen saturation (SpO(2)), respiration rate (RR) were recorded before treatment, after each task, after treatment and at the fifth minute of recovery. Pain level was assessed with Visual Analogue Scale (0-10).

RESULTS

When compared with supine position before treatment, all of the parameters except RR increased after the first task whereas HR, SBP, MBP and pain increased after the second task. After the third task only HR and pain increased. There was no significant difference between the fourth task and pre-treatment values while HR, DBP and pain increased after the fifth task. When measurements of pre-treatment, immediately after treatment and the fifth minute of recovery were compared HR, MBP and pain increased after treatment whereas HR, RR and pain decreased after recovery. There was no significant difference between pre-treatment values and fifth minute of recovery measurements.

CONCLUSION

Returning to initial values after a 5-min period shows that cardiopulmonary changes caused by intensive care physiotherapy after liver transplantation are responded at physiological limits.

Risk of fractures after renal transplantation in the United States

BACKGROUND

Although it is known that the incidence of fracture events is increased in renal transplantation recipients, the timing and the factors associated with risk of fractures are less well understood. The objective of this study was to estimate the time to fracture in renal transplantation recipients and to determine whether risk was associated with patient and transplantation characteristics.

METHODS

Using the U. S. Renal Data System, we retrospectively studied 68,814 patients, who underwent renal transplantation between 1988 and 1998. Fractures were identified from International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes in billing data. Time to first fracture was modeled during the first 5 years posttransplant using the Kaplan-Meier method and Cox proportional hazards models.

RESULTS

Of the patients who underwent transplantation, 22.5% developed a fracture within 5 years. Woman (hazard ratio [HR] 1.36, P<0.0001), patients older than 45 years of age (HR 1.14, P<0.0001) especially older than 65 years (HR 1.69, P<0.0001), and whites (HR 1.28, P<0.0001) were at increased risk of a fracture. Additionally, receipt of a deceased donor kidney (HR 1.30, P<0.0001), increased human leukocyte antigen mismatches (HR 1.09, P<0.014), diabetes (HR 1.88, P<0.0001), pretransplant dialysis (HR 1.08, P<0.0001), and an aggressive induction immunosuppression regimen (HR 1.14, P<0.0001) all significantly increased risk of fracture events during the first 5 years.

CONCLUSIONS

In addition to patient demographic features, donor factors, including suboptimal organ quality and the need for more intense immunosuppression, were associated with an increased risk of fractures during the first 5 years after a renal transplant.

Budd-Chiari syndrome from an advanced practice nurse perspective

PURPOSE

To provide nurse practitioners (NPs) with a case study and literature review of Budd-Chiari syndrome (BCS). This rare liver disease has a multitude of clinical presentations that NPs may encounter in the primary care setting.

DATA SOURCE

A literature search was conducted in Pub-Med and CINAHL using key search words. Information for the case study was obtained from a patient and his gastroenterology specialist, who is a foremost expert in this field.

CONCLUSION

BCS is complex and may be difficult to diagnose because of its atypical clinical presentation. Delayed diagnosis can affect the quality and quantity of a patient's life. Increasing NPs' awareness about this rare condition through a case presentation and review of the literature emphasizes the major factors for accurate diagnosis.

IMPLICATIONS FOR PRACTICE

Knowledge of BCS can assist the NP in identifying this syndrome and making prompt, appropriate referrals.

Acute Inpatient Rehabilitation of 55 Patients After Liver Transplantation

OBJECTIVE

Acute rehabilitation for patients who have had liver transplants is often necessary to restore functional mobility, but no studies, except for case reports, have documented the complications, outcomes, or predictors of success of an acute inpatient rehabilitation program. Our objective was to examine each of these areas related to rehabilitation after liver transplantation.

DESIGN

We performed a chart review of 55 patients who received a liver transplant and were treated on our acute rehabilitation service. We examined several factors, including age, reason for transplant, length of acute hospital stay, length of acute inpatient rehabilitation stay, FIMtrade mark scores, albumin levels, medical complications, and discharge disposition.

RESULTS

Patients undergoing rehabilitation after liver transplantation required multiple medical interventions, including liver biopsy, ultrasound, blood transfusions, and dialysis. Several patients (15%) were transferred to the acute care hospital for medical problems. Both a low albumin and a long length of stay in the acute care hospital correlated with a longer stay in rehabilitation and less efficient rehabilitation. Longer rehabilitation stays correlated positively with FIM gain (P < 0.001, r = 0.534). Significant improvements in FIM scores (P < 0.001) during acute inpatient rehabilitation were noted in patients who were discharged to home. We also found that age, albumin level, and length of stay in the hospital did not predict discharge disposition.

CONCLUSION

Patients who have had liver transplants can achieve significant functional gains in acute rehabilitation. Rehabilitation professionals should be aware of potential complications and factors that may affect the rehabilitation of this patient population.

Insulin-like growth factor-I enhances choleretic action of FK506 in rats

FK506 is an immunosuppressant for organ transplantation in the same clinical settings as cyclosporine (CsA). In the management of liver transplantation, FK506 has advantages over CsA, in terms of rejection and corticosteroid requirements. Recent clinical findings in liver transplant patients indicate that FK506, but not CsA, stimulates choleresis, suggesting that FK506 treatment may accelerate recovery from cholestatic dysfunction through its choleretic action. Recently, we demonstrated in rats that exogenous treatment with insulin-like growth factor I (IGF-I) results in an increase in bile flow and also that FK506 has the potential to increase hepatic production of IGF-I. However, circulating levels of IGF-I in FK506-treated rats were only 30% higher than in nontreated rats. In this study, we evaluated the combined effect of treatment with both IGF-I and FK506 on bile flow in rats to explore the possibility that combination treatment in liver transplant patients could enhance the choleretic action of FK506, benefiting the transplanted liver. Combination treatment of IGF-I with FK506 resulted in a potent and long-lasting increase in bile flow. Overall, this study demonstrated that IGF-I treatment enhanced the choleretic action of FK506, providing potential clinical utility for combination therapy using these two drugs, in treatment after liver transplantation.