Personalized adapted physical activity before liver transplantation: acceptability and results. Transplantation. 2015;99:145-150. [PMID: 25531893 DOI: 10.1097/tp.0000000000000245]

Prehabilitation in patients with cirrhosis awaiting liver transplantation: protocol of a feasibility study

INTRODUCTION

Patients with cirrhosis awaiting liver transplantation (LT) are often frail, and malnourished. The period of time on the waitlist provides an opportunity to improve their physical fitness. Prehabilitation appears to improve the physical fitness of patients before major surgery. Little is known about prehabilitation in patients with cirrhosis. The aim of this feasibility study will be to investigate the feasibility, safety, and effectiveness of a multimodal prehabilitation programme in this patient population.

METHODS AND ANALYSIS

This is an open-label single-arm feasibility trial recruiting 25 consecutive adult patients with cirrhosis active on the LT waiting list of the McGill University Health Centre (MUHC). Individuals will be excluded based on criteria developed for the safe exercise training in patients with cirrhosis. Enrolled individuals will participate in a multimodal prehabilitation programme conducted at the PeriOperative Programme complex of the MUHC. It includes exercise training with a certified kinesiologist (aerobic and resistance training), nutritional optimisation with a registered dietician and psychological support with a nurse specialist. The exercise training programme is divided into an induction phase with three sessions per week for 4 weeks followed by a maintenance phase with one session every other week for 20 weeks. Aerobic training will be individualised based on result from cardiopulmonary exercise testing (CPET) and will include a high-intensity interval training on a cycle ergometer. Feasibility, adherence and acceptability of the intervention will be assessed. Adverse events will be reviewed before each visit. Changes in exercise capacity (6-minute walk test, CPET, liver frailty index), nutritional status and health-related quality of life will be assessed during the study. Post-transplantation outcomes will be recorded.

ETHICS AND DISSEMINATION

The research ethics board of the MUHC has approved this study (2021-7646). Our findings will be submitted for presentation at national and international conferences, and for peer-reviewed publication.

TRIAL REGISTRATION NUMBER

NCT05237583.

Prehabilitation in patients awaiting liver transplantation

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.

Approaching the Sarcopenic Patient with Nonalcoholic Steatohepatitis-related Cirrhosis

Sarcopenia is a well-known complication of chronic liver disease (CLD), and it is almost always observed in patients with cirrhosis, at least in those with decompensated disease. Since nonalcoholic fatty liver disease (NAFLD), recently renamed metabolic dysfunction-associated steatotic liver disease (MASLD), is becoming the leading cause of end-stage liver disease, a new scenario characterized by the frequent coexistence of NAFLD, obesity, and sarcopenia is emerging. Although it is not yet resolved whether the bidirectional relationship between sarcopenia and NAFLD subtends causal determinants, it is clear that the interaction of these two conditions is associated with an increased risk of poor outcomes. Notably, during the course of CLD, deregulation of the liver-muscle-adipose tissue axis has been described. Unfortunately, owing to the lack of properly designed studies, specific therapeutic guidelines for patients with sarcopenia in the context of NAFLD-related CLD have not yet been defined. Strategies aimed to induce the loss of fat mass together with the maintenance of lean body mass seem most appropriate. This can be achieved by properly designed diets integrated with specific nutritional supplementations and accompanied by adequate physical exercise. Future studies aiming to add to the knowledge of the correct assessment and approach to sarcopenia in the context of NAFLD-related CLD are eagerly awaited.

The influence of prehabilitation in patients with liver cirrhosis before liver transplantation: a randomized clinical trial

BACKGROUND

The high prevalence of liver cirrhosis in Slovakia leads to a great need for transplant treatment. The outcome of liver transplantation is influenced by several factors.

AIM

The main objective of this study is to test the effectiveness of prehabilitation compared to standard of care.

DESIGN

Prospective, double-arm, randomized, open-registry study.

SETTING

Patient in F. D. Roosevelt Teaching Hospital, Slovakia, Banská Bystrica.

POPULATION

The participants consisted of patients with liver cirrhosis (55 men, 25 women).

METHODS

The patients were randomized to the active prehabilitation group (N.=39) or the standard of care group (SOC) (N.=41). SOC represents the standard of care for patients prior to liver transplantation, consisting of a formal oral interview lasting 30 minutes. In addition to SOC, each patient with decompensated liver cirrhosis also underwent a prehabilitation intervention that included rehabilitation and nutrition support. Patients completed the exercises under the supervision of a physician during hospitalisation.

RESULTS

After one month, the liver frailty index improved in the prehabilitation group (P=0.05). No improvement in MELD (Model of End Stage Liver Disease) was found in the group that underwent the prehabilitation program (P=0.28), and no improvement was found in the Child-Pugh score after one month (P=0.13). In the prehabilitation groups compared with the SOC group, differences were not found in the MELD score (P=0.11). Better clinical outcomes according to the Child-Pugh score was found for the prehabilitation group compared with the SOC group (P=0.02). According to LFI, there was no difference between the groups (P=0.26). Very low adherence was found after three months. Only three patients in the SOC group and six patients in the prehabilitation group came to the check-up. Due to low adherence after 3 months in patients with liver cirrhosis, it is not possible to make an adequate comparison between groups after three months.

CONCLUSIONS

Despite the great effort to maintain adherence, it was not possible to draw a conclusion about the effectiveness of prehabilitation in patients before liver transplantation compared to standard of care because the main problem in Slovak patients with liver cirrhosis is low adherence. More studies are needed to identify the barriers that lead to low adherence in patients with liver cirrhosis.

CLINICAL REHABILITATION IMPACT

A promising result was found due to improvement of the Liver Frailty Index and the Child-Pugh Score after one month in the prehabilitation group.

'Effects of a home-based bimodal lifestyle intervention in frail patients with end-stage liver disease awaiting orthotopic liver transplantation': study protocol of a non-randomised clinical trial

INTRODUCTION

Patients with end-stage liver disease awaiting orthotopic liver transplantation (OLT) are generally classified as frail due to disease-related malnutrition and a progressive decline in musculoskeletal and aerobic fitness, which is associated with poor pre-OLT, peri-OLT and post-OLT outcomes. However, frailty in these patients may be reversable with adequate exercise and nutritional interventions.

METHODS AND ANALYSIS

Non-randomised clinical trial evaluating the effect of a home-based bimodal lifestyle programme in unfit patients with a preoperative oxygen uptake (VO2) at the ventilatory anaerobic threshold ≤13 mL/kg/min and/or VO2 at peak exercise ≤18 mL/kg/min listed for OLT at the University Medical Center Groningen (UMCG). The programme is patient tailored and comprises high-intensity interval and endurance training, and functional exercises three times per week, combined with nutritional support. Patients will go through two training periods, each lasting 6 weeks.The primary outcome of this study is the impact of the programme on patients' aerobic fitness after the first study period. Secondary outcomes include aerobic capacity after the second study period, changes in sarcopenia, anthropometry, functional mobility, perceived quality of life and fatigue, incidence of hepatic encephalopathy and microbiome composition. Moreover, number and reasons of intercurrent hospitalisations during the study and postoperative outcomes up to 12 months post OLT will be recorded. Finally, feasibility of the programme will be assessed by monitoring the participation rate and reasons for non-participation, number and severity of adverse events, and dropout rate and reasons for dropout.

ETHICS AND DISSEMINATION

This study was approved by the Medical Research Ethics Committee of the UMCG (registration number NL83612.042.23, August 2023) and is registered in the Clinicaltrials.gov register (NCT05853484). Good Clinical Practice guidelines and the principles of the Declaration of Helsinki will be applied. Results of this study will be submitted for presentation at (inter)national congresses and publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05853484.

Exercise and Nutrition Interventions for Prehabilitation in Hepato-Pancreato-Biliary Cancers: A Narrative Review

Gastrointestinal (GI) cancers constitute over 25% of global cancer cases annually, with hepato-pancreato-biliary (HPB) cancers presenting particularly poor prognosis and challenging surgical treatments. While advancements in clinical care have improved post-operative outcomes over time, surgery for HPB cancers remains associated with high morbidity and mortality rates. Patients with HPB cancer are often older, diagnosed at later stages, and have a higher prevalence of co-morbid conditions, leading to reduced life expectancy, suboptimal post-operative recovery, and increased recurrence risk. Exercise and nutrition interventions have emerged as safe non-pharmacological strategies to enhance clinical outcomes among cancer survivors, but their potential in the pre-operative period for patients with HPB cancer remains underexplored. This narrative review evaluates existing evidence on exercise and nutritional interventions during pre-operative prehabilitation for HPB cancer populations, focusing on clinically relevant post-operative outcomes related to frailty and malnutrition. We conducted a literature search in PubMed and Google Scholar databases to identify studies utilizing a prehabilitation intervention in HPB cancer populations with exercise and nutritional components. The currently available evidence suggests that incorporating exercise and nutrition into prehabilitation programs offers a critical opportunity to enhance post-operative outcomes, mitigate the risk of comorbidities, and support overall survivorship among HPB cancer populations. This review underscores the need for further research to optimize the timing, duration, and components of pre-operative prehabilitation programs, emphasizing patient-centered, multidisciplinary approaches in this evolving field.

European Society of Organ Transplantation (ESOT) Consensus Statement on Prehabilitation for Solid Organ Transplantation Candidates

There is increasingly growing evidence and awareness that prehabilitation in waitlisted solid organ transplant candidates may benefit clinical transplant outcomes and improve the patient's overall health and quality of life. Lifestyle changes, consisting of physical training, dietary management, and psychosocial interventions, aim to optimize the patient's physical and mental health before undergoing surgery, so as to enhance their ability to overcome procedure-associated stress, reduce complications, and accelerate post-operative recovery. Clinical data are promising but few, and evidence-based recommendations are scarce. To address the need for clinical guidelines, The European Society of Organ Transplantation (ESOT) convened a dedicated Working Group "Prehabilitation in Solid Organ Transplant Candidates," comprising experts in physical exercise, nutrition and psychosocial interventions, to review the literature on prehabilitation in this population, and develop recommendations. These were discussed and voted upon during the Consensus Conference in Prague, 13-15 November 2022. A high degree of consensus existed amongst all stakeholders including transplant recipients and their representatives. Ten recommendations were formulated that are a balanced representation of current published evidence and real-world practice. The findings and recommendations of the Working Group on Prehabilitation for solid organ transplant candidates are presented in this article.

From Listing to Recovery: A Review of Nutritional Status Assessment and Management in Liver Transplant Patients

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.

Six-Minute walk distance predicts outcomes in liver transplant candidates

A 6-minute walk test is a simple tool for assessing submaximal exercise capacity. We sought to determine whether a 6-minute walk distance (6MWD) predicts outcomes in patients with cirrhosis. The Pulmonary Vascular Complications of Liver Disease 2 study is a multicenter, prospective cohort study that enrolled adults with portal hypertension during liver transplantation evaluation. We excluded subjects with an incident or prevalent portopulmonary hypertension. The 6-minute walk test was performed using standardized methods. Cox proportional hazards modeling and multivariable linear regression analysis were performed to determine the relationship between baseline 6MWD and outcomes. The study sample included 352 subjects. The mean 6MWD was 391±101 m. For each 50-meter decrease in 6MWD, there was a 25% increase in the risk of death (HR 1.25, 95% CI [1.11, 1.41], p < 0.001) after adjustment for age, gender, body mass index, MELD-Na, and liver transplant as a time-varying covariate. In a multistate model, each 50-meter decrease in 6MWD was associated with an increased risk of death before the liver transplant ( p < 0.001) but not after the transplant. 6MWD was similar to MELD-Na in discriminating mortality. Each 50-meter decrease in 6MWD was associated with an increase in all-cause ( p < 0.001) and transplant-free hospitalizations ( p < 0.001) in multivariable models for time-to-recurrent events. Shorter 6MWD was associated with worse Short Form-36 physical ( p < 0.001) and mental component scores ( p = 0.05). In conclusion, shorter 6MWD is associated with an increased risk of death, hospitalizations, and worse quality of life in patients evaluated for liver transplantation. The 6-minute walk distance may be a useful adjunct for risk assessment in patients undergoing liver transplant evaluation.

Osteosarcopenia in NAFLD/MAFLD: An Underappreciated Clinical Problem in Chronic Liver Disease

Chronic liver disease (CLD), including non-alcoholic fatty liver disease (NAFLD) and its advanced form, non-alcoholic steatohepatitis (NASH), affects a significant portion of the population worldwide. NAFLD is characterised by fat accumulation in the liver, while NASH is associated with inflammation and liver damage. Osteosarcopenia, which combines muscle and bone mass loss, is an emerging clinical problem in chronic liver disease that is often underappreciated. The reductions in muscle and bone mass share several common pathophysiological pathways; insulin resistance and chronic systemic inflammation are the most crucial predisposing factors and are related to the presence and gravity of NAFLD and to the worsening of the outcome of liver disease. This article explores the relationship between osteosarcopenia and NAFLD/MAFLD, focusing on the diagnosis, prevention and treatment of this condition in patients with CLD.

Therapeutic Physical Exercise Programs in the Context of NASH Cirrhosis and Liver Transplantation: A Systematic Review

In recent years, various physical exercise interventions have been developed with a view to reducing comorbidity and morbidity rates among patients with chronic diseases. Regular physical exercise has been shown to reduce hypertension and mortality in patients with type 2 diabetes. Diabetes and obesity are often associated with the development of nonalcoholic fatty liver disease, which can lead to liver fibrosis and then (in some cases) nonalcoholic steatohepatitis cirrhosis. We searched the literature for publications on personalized physical exercise programs in cirrhotic patients before and after liver transplantation. Eleven studies in cirrhotic patients and one study in liver transplant recipients were included in the systematic review, the results of which were reported in compliance with the preferred reporting items for systematic reviews and meta-analyses guidelines. The personalized physical exercise programs lasted for 6 to 16 weeks. Our review evidenced improvements in peak oxygen consumption and six-minute walk test performance and a reduction in the hepatic venous pressure gradient. In cirrhotic patients, personalized physical exercise programs improve quality of life, are not associated with adverse effects, and (for transplant recipients) might reduce the 90-day hospital readmission rate. However, none of the literature data evidenced reductions in the mortality rates before and after transplantation. Further prospective studies are needed to evaluate the benefit of long-term physical exercise programs in cirrhotic patients before and after liver transplantation.

Prehabilitation in Adult Solid Organ Transplant Candidates

Purpose of Review

To highlight the importance of biological age in the context of prehabilitation and to present relevant research regarding prehabilitation prior to solid organ transplantation.

Recent Findings

Studies on the effect of prehabilitation have been performed in kidney-, lung-, liver-, and heart transplant patient populations. Prior to kidney transplantation, exercise interventions have been shown to improve cardiopulmonary- and physical fitness and result in a decreased length of hospital stay postoperatively. Among lung transplant candidates, various methods of prehabilitation have been studied including home-based, outpatient and in-patient programs, consisting of physical training, psychological support, education, and nutritional interventions. Overall, prehabilitation seems to improve or maintain quality of life and exercise capacity in this patient population. Patients undergoing liver transplantation seem to benefit from prehabilitation as well. Not only does it seem safe and feasible, but significant improvements in aerobic and functional capacity have also been found. Regarding heart transplant candidates, both inpatient and outpatient, supervised prehabilitation programs show promising results with improvements in exercise capacities and quality of life.

Summary

Prehabilitation is an effective and safe intervention for improving functional outcomes of solid organ transplant patients. Future studies should evaluate whether prehabilitation translates into improved pre- and post-transplant clinical outcomes.

Effects of an active lifestyle on the physical frailty of liver transplant candidates

BACKGROUND

Liver transplantation is the most important therapeutic intervention for end-stage liver disease (ELD). The prioritization of these patients is based on the model for end-stage liver disease (MELD), which can successfully predict short-term mortality. However, despite its great validity and value, it cannot fully incorporate several comorbidities of liver disease, such as sarcopenia and physical frailty, variables that can sufficiently influence the survival of such patients. Subsequently, there is growing interest in the importance of physical frailty in regard to mortality in liver transplant candidates and recipients, as well as its role in improving their survival rates.

AIM

To evaluate the effects of an active lifestyle on physical frailty on liver transplant candidates.

METHODS

An observational study was performed within the facilities of the Department of Transplant Surgery of Aristotle University of Thessaloniki. Twenty liver transplant candidate patients from the waiting list of the department were included in the study. Patients that were bedridden, had recent cardiovascular incidents, or had required inpatient treatment for more than 5 d in the last 6 mo were excluded from the study. The following variables were evaluated: Activity level via the International Physical Activity Questionnaire (IPAQ); functional capacity via the 6-min walking test (6MWT) and cardiopulmonary exercise testing; and physical frailty via the Liver Frailty Index (LFI).

RESULTS

According to their responses in the IPAQ, patients were divided into the following two groups based on their activity level: Active group (A, 10 patients); and sedentary group (S, 10 patients). Comparing mean values of the recorded variables showed the following results: MELD (A: 12.05 ± 5.63 vs S: 13.99 ± 3.60; P > 0.05); peak oxygen uptake (A: 29.78 ± 6.07 mL/kg/min vs S: 18.11 ± 3.39 mL/kg/min; P < 0.001); anaerobic threshold (A: 16.71 ± 2.17 mL/kg/min vs S: 13.96 ± 1.45 mL/kg/min; P < 0.01); 6MWT (A: 458.2 ± 57.5 m vs S: 324.7 ± 55.8 m; P < 0.001); and LFI (A: 3.75 ± 0.31 vs S: 4.42 ± 0.32; P < 0.001).

CONCLUSION

An active lifestyle can be associated with better musculoskeletal and functional capacity, while simultaneously preventing the evolution of physical frailty in liver transplant candidates. This effect appears to be independent of the liver disease severity.

Current Approaches in the Allocation of Liver Transplantation

In recent decades, important advances have been made in the field of liver transplantation. One of the major problems remaining in this area is the small number of donors. Thus, recent data bring multiple updates of the indications and contraindications of this therapeutic method. The main goal is to increase the number of patients who can benefit from liver transplantation, a therapeutic method that can improve life expectancy and the quality of life of patients with end-stage liver disease. Another goal in the management of these patients is represented by the optimal care of those on the waiting list during that period. A multidisciplinary team approach is necessary to obtain the best results for both the donor and the recipient.

The role of prehabilitation on short-term outcomes after liver transplantation: A review of the literature and expert panel recommendations

BACKGROUND

Prehabilitation programs as part of ERAS protocols are being increasingly used in multiple surgeries, improving postoperative outcomes. Data regarding prehabilitation programs in patients awaiting liver transplantation and their outcomes is scarce.

OBJECTIVES

To identify whether prehabilitation programs based on exercise training conducted prior to liver transplantation improve short-term postoperative outcomes, and to provide expert panel recommendations.

DATA SOURCES

Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central.

METHODS

Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Studies included those evaluating postoperative outcomes, as well as those evaluating functional outcomes.

PROSPERO ID

CRD42021236305.

RESULTS

Of the 170 studies screened, only one assessed the primary objective. Most studies focus on the preoperative impact of exercise training on aerobic capacity, muscle mass and/or strength, showing positive effects and no significant adverse events, but are underpowered and with heterogenous designs and interventions. The non-randomized observational study which assessed relevant postoperative outcomes, showed a non-significant trend towards reduced 90-day readmission rate and shorter length of stay in the prehabilitation group.

CONCLUSIONS

Prehabilitation prior to liver transplantation is unlikely to be harmful, and likely to have short term benefits on functional status. We cautiously recommend prehabilitation on the basis of absence of harm and possibility of benefit (Quality of Evidence; Very Low | Grade of Recommendation; Low).

Physical Effects, Safety and Feasibility of Prehabilitation in Patients Awaiting Orthotopic Liver Transplantation, a Systematic Review

Prehabilitation improves surgical outcomes in patients undergoing surgery. However, patients preparing for orthotopic liver transplantation (OLT) are physically “frail” and suffer from comorbidities that generally hamper physical activity. This systematic review aims to evaluate the physical effects, safety and feasibility of prehabilitation in OLT candidates. Relevant articles were searched, in Embase, Web of Science, Cochrane, Medline and Google Scholar, to December 2021. Studies reporting on specified preoperative exercise programs, including adult OLT candidates with end-stage liver disease, with a model for end-stage liver disease (MELD) score ≥12 or Child-Pugh classification B/C, were included. This resulted in 563 potentially eligible studies, out of which eight were selected for inclusion, consisting of 1,094 patients (male sex 68%; mean age 51–61 years; mean MELD score 12-21). Six of the included studies were classified as low-quality by the GRADE system, and three studies had high risk for ineffectiveness of the training program according to the i-CONTENT tool. Significant improvement was observed in VO2 peak, 6-minute walking distance, hand grip strength, liver frailty index and quality of life. Feasibility ranged from an adherence of 38%–90% in unsupervised-to &gt;94% in supervised programs. No serious adverse events were reported. In conclusion, prehabilitation in patients awaiting OLT appears to improve aerobic capacity, and seems feasible and safe. However, larger clinical trials are required to accurately examine the preoperative and postoperative effects of prehabilitation in this specific patient population.

EXERCISE IN THE PHYSICAL REHABILITATION OF CIRROTICS: A RANDOMIZED PILOT STUDY

ABSTRACT Background: Physical exercise delays the sarcopenic process and can reverse the loss of muscle strength, improve quality of life and prognosis in cirrhotic patients. Objective: The aim was to verify the effects of face-to-face versus home aerobic exercise on the variables fatigue, respiratory and peripheral muscle strength, functional capacity and quality of life in patients with compensated cirrhosis. Methods: Patients were selected by convenience, stratified and randomized into supervised face-to-face exercise (n=13) and home exercise without daily supervision (n=12). Patients were submitted to a program of aerobic physical exercises, with progressive duration of 30 to 50 minutes, twice a week for twelve weeks. Before starting the program and every four weeks, all patients in both groups were assessed for fatigue (fatigue severity scale), respiratory (Pimáx and Pemáx) and peripheral (concentric quadriceps peak torque) muscle strength, functional capacity (6-minute walking distance) and quality of life (Short Form-36 Health Survey questionnaire). Results: The face-to-face group showed reduced fatigue (P<0.001), increased inspiratory (P<0.001), expiratory (P<0.001) and peripheral (P<0.001) muscle strength of the 6MWD (P<0.001) and improved quality of life. The home group showed no significant improvement in these variables. Conclusion: A face-to-face program of moderate aerobic exercise in patients with compensated cirrhosis reduces fatigue, improves functional capacity and quality of life and increases respiratory and peripheral muscle strength. Home physical exercises do not cause the same adaptive effects in this population.

The Effect of Diet and Exercise Interventions on Body Composition in Liver Cirrhosis: A Systematic Review

Alterations in body composition, in particular sarcopenia and sarcopenic obesity, are complications of liver cirrhosis associated with adverse outcomes. This systematic review aimed to evaluate the effect of diet and/or exercise interventions on body composition (muscle or fat) in adults with cirrhosis. Five databases were searched from inception to November 2021. Controlled trials of diet and/or exercise reporting at least one body composition measure were included. Single-arm interventions were included if guideline-recommended measures were used (computed tomography/magnetic resonance imaging, dual-energy X-ray absorptiometry, bioelectrical impedance analysis, or ultrasound). A total of 22 controlled trials and 5 single-arm interventions were included. Study quality varied (moderate to high risk of bias), mainly due to lack of blinding. Generally, sample sizes were small (n = 6–120). Only one study targeted weight loss in an overweight population. When guideline-recommended measures of body composition were used, the largest improvements occurred with combined diet and exercise interventions. These mostly employed high protein diets with aerobic and or resistance exercises for at least 8 weeks. Benefits were also observed with supplementary branched-chain amino acids. While body composition in cirrhosis may improve with diet and exercise prescription, suitably powered RCTs of combined interventions, targeting overweight/obese populations, and using guideline-recommended body composition measures are needed to clarify if sarcopenia/sarcopenic obesity is modifiable in patients with cirrhosis.

Investigation of movement-related behaviors and energy compensation in people living with liver disease: A scoping review

The importance of integrated movement behaviours (MB, i.e., physical activity [PA], sedentary behaviour, and sleep) and their interdependence for health has been recently discussed in the literature. The proposition that the amount of time spent in any one of these behaviours may impact the amount of time spent in another is supported by the ActivityStat hypothesis. The aim of this review is to (1) to assess whether individuals with liver disease display MB and/or energy (i.e., total energy expenditure [EE], basal EE, resting EE, and activity EE) compensation throughout the day and/or days; and (2) to examine whether a prescribed PA intervention triggers compensatory responses. Documents were included if they focused on people living with liver disease; analysed MB and/or EE components; were data-based; and were published in English. Fifteen documents were included in the final synthesis. The one finding that addressed research question 1 showed no compensatory response. As for research question 2, most of the findings suggest no compensation effects in response to a PA intervention. There is insufficient evidence to support the ActivityStat hypothesis in people living with liver disease. Further research should be conducted to test this hypothesis using standardized methodological procedures.

A decline in functional status while awaiting liver transplantation is predictive of increased post-transplantation mortality

BACKGROUND

Functional status (FS) is dynamic and changes over time. We examined how changes in FS while awaiting liver transplantation influence post-transplant outcomes.

METHODS

Data on adult liver transplants performed in the United States during the MELD era were obtained through September 2020. Patient and graft survival were compared between groups with no change or improved FS, and those with worsening FS.

RESULTS

Of the 90,210 transplant recipients included in the analysis, 39,193 (43%) had worsening FS, which was associated with longer waiting-list time (187 vs. 329 days, p < 0.001) and worse patient survival after liver transplant (1858 vs. 1727 days, p < 0.001). A consistent and dose-dependent relationship was observed for each 10-point decrease in Karnofsky Performance Score and post-transplant survival. Multivariable regression analysis confirmed that a decline in FS was associated with worse patient survival (HR 1.15, p < 0.001). Similar findings were observed for graft survival.

CONCLUSION

A decline in FS on the waiting-list is associated with significantly greater post-liver transplant mortality in recipients. These results should be taken into consideration when allocating organs and determining transplant candidacy. Strategies to optimize FS prior to transplantation should be prioritized as even subtle decreases in FS are associated with inferior post-transplantation outcomes.

Effects of supervised exercise on aerobic capacity and quality of life in patients with chronic liver disease and patients who underwent liver transplantation: a systematic review and meta-analysis

Chronic liver disease and liver transplantation are risk factors for poor physical health and quality of life. This meta-analysis aimed to examine whether supervised exercise improves the physical health and quality of life in patients with chronic liver disease and liver transplant. Articles were searched in four databases (MEDLINE, Cochrane, Embase, and the Web of Science) from 1 January 1990 to 6 July 2021. Studies that assessed the change in aerobic capacity and quality of life following supervised exercise in patients with chronic liver disease or in those who had undergone liver transplantation were included in this meta-analysis. The two independent reviewers extracted data and the methodological quality of the included studies was assessed by the Cochrane Handbook for Systematic Reviews of Interventions. The extracted data were statistically analyzed using review management software (RevMan 5.3). The meta-analysis included 11 studies, comprising 159 patients. We observed that aerobic capacity measured as VO2 peak and 6-min walking test improved in patients with chronic liver disease and liver transplant after supervised exercise. Among the parameters of Short-form-36 (SF-36) used for measuring the quality of life, only physical functioning improved after supervised exercise. The other parameters of SF-36 including role-physical, bodily pain, general health, vitality, social functioning, role-emotional, and mental health were not significantly improved after supervised exercise. Supervised exercise seems essential for patients with chronic liver disease and liver transplant. It was found to be helpful in enhancing the aerobic capacity and physical function in these patients.

Sarcopenia in hepatocellular carcinoma: Current knowledge and future directions

Liver cancer is the second most occurring cancer worldwide and is one of the leading causes of cancer-related deaths. Hepatocellular carcinoma (HCC) is the most common (80%-90%) type among malignant liver cancers. Sarcopenia occurs very early in HCC and can predict and provide an opportunity to improve muscle health before engaging in the treatment options such as loco-regional, systemic, and transplant management. Multiple prognostic stating systems have been developed in HCC, such as Barcelona Clinic Liver Cancer, Child-Pugh score and Albumin-Bilirubin grade. However, the evaluation of patients' performance status is a major limitation of these scoring systems. In this review, we aim to summarize the current knowledge and recent advances about the role of sarcopenia in cirrhosis in general, while focusing specifically on HCC. Additionally, the role of sarcopenia in predicting clinical outcomes and prognostication in HCC patients undergoing loco-regional therapies, liver resection, liver transplantation and systematic therapy has been discussed. A literature review was performed using databases PubMed/MEDLINE, EMBASE, Cochrane, Web of Science, and CINAHL on April 1, 2021, to identify published reports on sarcopenia in HCC. Sarcopenia can independently predict HCC-related mortality especially in patients undergoing treatments such as loco-regional, surgical liver transplantation and systemic therapies. Basic research is focused on evaluating a balance of anabolic and catabolic pathways responsible for muscle health. Early clinical studies have shown promising results in methods to improve sarcopenia in HCC which can potentially increase prognosis in these patients. As sarcopenia occurs very early in HCC, it can predict and provide an opportunity to improve muscle health before engaging in the treatment options such as loco-regional, systemic, and transplant management. Further, sarcopenia measurement can obviate the confounding caused by the abdominal ascites in these patients. The use of sarcopenia can add to the existing scoring systems to better prognosticate the HCC.

Adding Branched-Chain Amino Acids to an Enhanced Standard-of-Care Treatment Improves Muscle Mass of Cirrhotic Patients With Sarcopenia: A Placebo-Controlled Trial

INTRODUCTION

The effect of branched-chain amino acid (BCAA) supplementation on muscle mass in patients with cirrhosis and sarcopenia is unknown.

METHODS

This is a pilot, prospective, randomized, and double-blind study of a cohort of 32 patients with cirrhosis and sarcopenia diagnosed by computed tomography scan who underwent a nutritional and physical activity intervention for 12 weeks. They were divided into 2 groups (placebo: 17 patients; BCAA: 15 patients). The study protocol was registered at ClinicalTrials.gov (NCT04073693).

RESULTS

Baseline characteristics were similar in both groups. After treatment, only the BCAA group presented a significant improvement in muscle mass (43.7 vs 46 cm2/m2; P = 0.023). Seventeen patients (63%) presented improvement in muscle mass overall, which was more frequent in the BCAA group (83.3 vs 46.7%; P = 0.056). Regarding frailty, there was a significant improvement in the Liver Frailty Index in the global cohort (n = 32) after the 12 weeks (4.2 vs 3.9; P < 0.001). This difference was significant in both groups: in the placebo group (4.2 vs 3.8; P < 0.001) and in the BCAA group (4.2 vs 3.9; P < 0.001). After treatment, the BCAA group had a higher increase in zinc levels than the placebo group (Δzinc: 12.3 vs 5.5; P = 0.026). In addition, there was a trend for greater improvement of albumin levels in the BCAA group (Δalbumin: 0.19 vs 0.04; P = 0.091).

DISCUSSION

BCAA supplementation improves muscle mass in cirrhotic patients with sarcopenia.

Exercise physiology in cirrhosis and the potential benefits of exercise interventions: A review

Reduction in muscle mass is a highly prevalent phenomenon in cirrhosis and is now well-documented to be associated with significant morbidity and mortality. Research into muscle loss in cirrhosis remains limited by an ongoing poor understanding of its relationship with muscle function, physical activity, and aerobic capacity. Alterations in exercise physiology have been documented in studies of individuals with cirrhosis that provide important information on physical function that is not captured by simple quantification of muscle mass. Despite expert consensus recommending regular exercise in end-stage liver disease to maintain muscle mass and function, there is little evidence guiding clinicians as to which form of exercise or delivery mechanism is most effective. It also remains unproven whether any specific intervention can alter clinically relevant outcomes. This review article summarizes the available literature regarding the changes in exercise physiology observed in cirrhosis, the associated impact on physical capacity, and the results of existing trials that examine the potential benefits of exercise delivery in patients with cirrhosis, particularly pertaining to their impact on exercise physiology.

Frailty and Sarcopenia in Acute-on-Chronic Liver Failure

In patients with cirrhosis, sarcopenia is a critical reduction in skeletal muscle mass and frailty represents a status of global physical dysfunction caused by under nutrition, muscle wasting, and functional impairment. Both are prevalent conditions in liver transplant candidates and have shown to be independent predictors of adverse outcome. Evidence supports their incorporation into clinical practice both as a prognostic factor guiding clinical decision making and as a tool to identify candidates for physical and nutritional interventions. The wide heterogeneity of instruments used for sarcopenia and frailty measurement, the absence of a single suitable instrument for sarcopenia and frailty assessment in the outpatient versus inpatient acute-on-chronic clinical scenario, and the lack of strong evidence showing a beneficial effect of sarcopenia and frailty improvement on outcomes before and after transplantation are some of the questions that remain unanswered.

Wearables, Physical Activity, and Exercise Testing in Liver Disease

Physical inactivity is a major cause of deterioration in all forms of advanced liver disease. It is especially important as a driver of the components of the metabolic syndrome, with nonalcoholic fatty liver disease rapidly becoming the dominant cause of liver-related death worldwide. Growing realization of the health benefits of moderate-to-vigorous physical activity has captured the interest of persons who desire to improve their health, including those at risk for chronic liver injury. They are increasingly adopting wearable activity trackers to measure the activity that they seek to improve. Improved physical activity is the key lifestyle behavior that can improve cardiorespiratory fitness, which is most accurately measured with cardiopulmonary exercise testing (CPET). CPET is showing promise to identify risk and predict outcomes in transplant hepatology. Team effort among engaged patients, social support networks, and clinicians supported by web-based connectivity is needed to fully exploit the benefits of physical activity tracking.

Changing Trends in Liver Transplantation: Challenges and Solutions

Despite improvements in postliver transplant outcomes through refinements in perioperative management and surgical techniques, several changing trends in liver transplantation have presented challenges. Mortality on the waitlist remains high. In the United States, Europe, and the United Kingdom, there is an increasing need for liver transplantation, primarily as a result of increased incidence of nonalcoholic steatohepatitis-related cirrhosis and cancer indications. Meanwhile, donor suitability has decreased, as donors are often older and have more comorbidities. Despite a mismatch between organ need and availability, many organs are discarded. Notwithstanding this, many solutions have been developed to overcome these challenges. Innovative techniques in allograft preservation, viability assessment, and reconditioning have allowed the use of suboptimal organs with adequate results. Refinements in surgical procedures, including live donor liver transplantations, have increased the organ pool and are decreasing the time and mortality on the waitlist. Despite many challenges, a similar number of solutions and prospects are on the horizon. This review seeks to explore the changing trends and challenges in liver transplantation and highlight possible solutions and future directions.

Impact of exercise training on the sarcopenia criteria in non-alcoholic fatty liver disease: a systematic review and meta-analysis

Sarcopenia is a highly prevalent complication of non-alcoholic fatty liver disease (NAFLD). We aimed to conduct a systematic review and meta-analyses to elucidate the exercise training (ET)'s efficacy on NAFLD adult patients' sarcopenia criteria. We identified relevant randomized controlled trials (RCT) in electronic databases PubMed, CINAHL, and Scopus. We selected seven RCT from 66 screened studies. The ET programs included endurance or combined (endurance and resistance) training. No study performed resistance training alone. The physical function improved with endurance or combined training (mean differences [MD] 8.26 mL/Kg*min [95% CI 5.27 to 11.24 mL/Kg*min], p < 0.0001); Muscle mass showed no evidence of the beneficial effects of endurance or combined training (MD 1.01 Kg [95% CI -1.78 to 3.80 Kg], p = 0.48). None of the selected studies evaluated muscle strength. Endurance and combined training increase physical function criteria but do not improve muscle mass criteria on sarcopenia in NAFLD patients. These results must be interpreted with caution for the small number of patients included in the RCTs analyzed, the different characteristics of the ET carried out, the non-use of resistance training, which prevents assess its effect on sarcopenia despite the evidence that recommends it and does not assessment muscle strength criteria in RCT include. Future research should include muscle strength assessments and resistance training to evaluate the effects in this condition. Exercise training is beneficial for sarcopenia in NAFLD but is necessary more experimental evidence to define the best type of training that positively affects the three criteria of sarcopenia. PROSPERO reference number CRD42020191471.

Sarcopenia in chronic liver disease: mechanisms and countermeasures

Sarcopenia, a condition of low muscle mass, quality, and strength, is commonly found in patients with cirrhosis and is associated with adverse clinical outcomes including reduction in quality of life, increased mortality, and posttransplant complications. In chronic liver disease (CLD), sarcopenia is most commonly defined through the measurement of the skeletal muscle index of the third lumbar spine. A major contributor to sarcopenia in CLD is the imbalance in muscle protein turnover, which likely occurs due to a decrease in muscle protein synthesis and an elevation in muscle protein breakdown. This imbalance is assumed to arise due to several factors including accelerated starvation, hyperammonemia, amino acid deprivation, chronic inflammation, excessive alcohol intake, and physical inactivity. In particular, hyperammonemia is a key mediator of the liver-gut axis and is known to contribute to mitochondrial dysfunction and an increase in myostatin expression. Currently, the use of nutritional interventions such as late-evening snacks, branched-chain amino acid supplementation, and physical activity have been proposed to help the management and treatment of sarcopenia. However, little evidence exists to comprehensively support their use in clinical settings. Several new pharmacological strategies, including myostatin inhibition and the nutraceutical Urolithin A, have recently been proposed to treat age-related sarcopenia and may also be of use in CLD. This review highlights the potential molecular mechanisms contributing to sarcopenia in CLD alongside a discussion of existing and potential new treatment strategies.

Impact of exercise training on the sarcopenia criteria in non-alcoholic fatty liver disease: a systematic review and meta-analysis

Sarcopenia is a highly prevalent complication of non-alcoholic fatty liver disease (NAFLD). We aimed to conduct a systematic review and meta-analyses to elucidate the exercise training (ET)'s efficacy on NAFLD adult patients' sarcopenia criteria. We identified relevant randomized controlled trials (RCT) in electronic databases PubMed, CINAHL, and Scopus. We selected seven RCT from 66 screened studies. The ET programs included endurance or combined (endurance and resistance) training. No study performed resistance training alone. The physical function improved with endurance or combined training (mean differences [MD] 8.26 mL/Kg*min [95% CI 5.27 to 11.24 mL/Kg*min], p < 0.0001); Muscle mass showed no evidence of the beneficial effects of endurance or combined training (MD 1.01 Kg [95% CI -1.78 to 3.80 Kg], p = 0.48). None of the selected studies evaluated muscle strength. Endurance and combined training increase physical function criteria but do not improve muscle mass criteria on sarcopenia in NAFLD patients. These results must be interpreted with caution for the small number of patients included in the RCTs analyzed, the different characteristics of the ET carried out, the non-use of resistance training, which prevents assess its effect on sarcopenia despite the evidence that recommends it and does not assessment muscle strength criteria in RCT include. Future research should include muscle strength assessments and resistance training to evaluate the effects in this condition. Exercise training is beneficial for sarcopenia in NAFLD but is necessary more experimental evidence to define the best type of training that positively affects the three criteria of sarcopenia. PROSPERO reference number CRD42020191471.

Prevalence and Nonpharmacological Interventions for Sarcopenia among Cirrhotic Patients

Sarcopenia is the most common feature of hepatic cirrhosis characterized by progressive loss of muscle mass and function and increases permanently the mortality and morbidity rates among those patients. The incidence of sarcopenia in cirrhotic patients ranged 40-70% associating with impaired quality of life and augmented rates of infection. Based on these issues, this review is aimed at determining the prevalence and main causes of sarcopenia among cirrhotic patients and recognizing the recent diagnostic and physical treatment modalities that prevent risk factors for sarcopenia in those patients. No ideal modality is currently demonstrated for diagnosing sarcopenia in hepatic diseases, particularly cirrhosis; however, recent studies reported different diagnostic modalities for muscle function in different individuals including handgrip strength, skeletal muscle index, six-min walk test, liver frailty index, short physical performance battery, and radiological assessments for quadriceps and psoas muscles. Exercise training and therapeutic nutrition are strongly recommended for controlling sarcopenia in cirrhotic patients. The exercise program is designed and carried out on a frequent basis within an extensive scheduled time aimed at improving functional performance, aerobic capacity, and healthy conditions. Finally, a combination of exercise training and therapeutic nutrition is powerfully recommended to control sarcopenia in cirrhosis.

Nutrition in Chronic Liver Disease: Consensus Statement of the Indian National Association for Study of the Liver

Malnutrition and sarcopenia are common in patients with chronic liver disease and are associated with increased risk of decompensation, infections, wait-list mortality and poorer outcomes after liver transplantation. Assessment of nutritional status and management of malnutrition are therefore essential to improve outcomes in patients with chronic liver disease. This consensus statement of the Indian National Association for Study of the Liver provides a comprehensive review of nutrition in chronic liver disease and gives recommendations for nutritional screening and treatment in specific clinical scenarios of malnutrition in cirrhosis in adults as well as children with chronic liver disease and metabolic disorders.

The inter- and intrarater reliability and feasibility of dietetic assessment of sarcopenia and frailty in potential liver transplant recipients: A mixed-methods study

Sarcopenia and frailty are associated with poorer outcomes in potential liver transplant (LT) recipients. We examined the reliability and feasibility of dietitians assessing sarcopenia and frailty. Seventy-five adults referred for LT underwent assessments of muscle mass (abdominal CTs), physical function (handgrip strength; HGS, short physical performance battery; SPPB), and frailty (Liver Frailty Index; LFI). Inter- and intrarater reliability and agreement were assessed in subsets of patients using intraclass correlation coefficients (ICCs) and Bland-Altman plots. CTs were analyzed by a dietitian and two independent experts, two dietitians assessed function and frailty. Feasibility assessed system, patient, and profession factors (staff survey). Inter- and intrarater reliability for CT-defined low muscle were excellent (ICCs > 0.97). Reliability between dietitians was excellent for HGS (0.968, 95% CI, 0.928-0.986), SPPB (0.932, 95% CI, 0.798-0.973), and LFI (0.938, 95% CI 0.861-0.973). Bland-Altman analysis indicated excellent agreement for HGS. All transplant clinicians valued sarcopenia and frailty in LT assessments and considered the dietitian appropriate to perform them. Seven saw no barriers to implementation into practice, while five queried test standardization, learning from repeat testing, and resource cost. Dietetic assessments of sarcopenia and frailty are reliable, feasible, and valued measures in the assessment of potential LT recipients.

Cardiovascular Acute Effects of Traditional vs. Paired Set Resistance Training in Patients With Liver Cirrhosis

Purpose: This study compared the acute effects of two different resistance training methods on heart rate variability, blood pressure, and rating of perceived exertion in patients with liver cirrhosis. Methods: Ten patients with Child-Pugh A (seven women and three men) participated in two experimental sessions, in random order: The traditional set condition consisted of three sets of six exercises performed in a sequential manner, while the paired set condition consisted of alternating sets between two exercises (three pairs of exercises). Ten repetitions were performed for each set with 70% of a 10 repetition maximum load and with 2 min rest between sets. Blood pressure and heart rate variability were assessed pre-workout and for 60 min post-workout. The rating of perceived exertion was assessed at the end of the third set for each exercise. Results: Significant alterations in heart rate variability were observed when considering the lowest value obtained during recovery, in which the SDNN was reduced in both the traditional set and paired set conditions, as well as the root mean square of standard deviation for the traditional set condition (p < .05). Additionally, for the paired set condition, there was a significant reduction in the HFnu band and a significant increase in the LFnu band (p < .05). Effect size showed reductions in diastolic and mean blood pressure until 30 min in a small magnitude for traditional sets. Conclusion: Similar cardiovascular responses were observed between methods eliciting normal physiological responses within safe limits for patients with liver cirrhosis.

NAFLD and liver transplantation: Disease burden, current management and future challenges

Non-alcoholic fatty liver disease (NAFLD), specifically its progressive form non-alcoholic steatohepatitis (NASH), represents the fastest growing indication for liver transplantation in Western countries. Diabetes mellitus, morbid obesity and cardiovascular disease are frequently present in patients with NAFLD who are candidates for liver transplantation. These factors require specific evaluation, including a detailed pre-surgical risk stratification, in order to improve outcomes after liver transplantation. Moreover, in the post-transplantation setting, the incidence of cardiovascular events and metabolic complications can be amplified by immunosuppressive therapy, which is a well-known driver of metabolic alterations. Indeed, patients with NASH are more prone to developing early post-transplant complications and, in the long-term, de novo malignancy and cardiovascular events, corresponding to higher mortality rates. Therefore, a tailored multidisciplinary approach is required for these patients, both before and after liver transplantation. Appropriate candidate selection, lifestyle modifications and specific assessment in the pre-transplant setting, as well as pharmacological strategies, adjustment of immunosuppression and a healthy lifestyle in the post-transplant setting, play a key role in correct management.

Exercise interventions in solid organ transplant candidates: A systematic review

INTRODUCTION

Exercise training may be recommended to solid organ transplant (SOT) candidates to improve fitness and tolerance before surgery. We aimed to determine the acceptance, safety, and effectiveness of exercise interventions in SOT candidates.

METHODS

Online databases were searched. Studies of any design were included. Outcomes of interest were acceptance, safety, exercise capacity, and health-related quality of life.

RESULTS

Twenty-three articles were included. Acceptance ranged from 16% to 100%. In the fifteen studies that assessed adverse events, none mentioned any adverse events occurring during the study. Five out of seven studies reported an increase in maximal exercise capacity post-exercise in the intervention group (range of mean change: 0.45 to 2.9 mL/kg). Eight out of fourteen studies reported an increase in 6-minute walking distance in the intervention group after the training period (range of mean change: 40-105 m). Two articles showed an improvement in the mental composite scores as well as in the physical composite scores post-exercise in the intervention group.

CONCLUSION

There was a lack of significant findings among most randomized controlled trials. Exercise training is acceptable and safe for selective SOT candidates. The effects of exercise training on exercise capacity and quality of life in SOT candidates are unclear.

Anxiety and depression on the liver transplant waiting list: a case for psychological prehabilitation?

Introduction:

Anxiety and depression in patients awaiting liver transplantation are associated with worse clinical outcomes. However, optimising patient mental health is not routinely addressed in pre-transplant care.

Aims:

To understand the prevalence of anxiety and depression in patients awaiting transplantation and their access to pharmacological and psychological therapies.

Methods:

Patients awaiting transplantation were offered screening for anxiety and depression using the Hospital Anxiety and Depression Screening (HADS) tool. Data pertaining to patient demographics and previous treatment for anxiety and depression were recorded and analysed.

Findings:

Over 50% of patients recorded abnormal scores for anxiety and depression. Of the 19 patients screened, 42% had received treatment for either disorder, and most found the intervention unhelpful due to lack of follow-up appointments and limited understanding of their underlying chronic liver disease. There was a significant association between female sex and screening positive for depression.

Conclusion:

Anxiety and depression are prevalent in patients awaiting liver transplantation. The integration of a psychologist into the transplantation multidisciplinary team may improve patient outcomes.

Sport and Exercise in Improving Outcomes After Solid Organ Transplantation: Overview From a UK Meeting

Outcomes after solid organ transplantation continue to improve, but premature loss of life remains a major concern, with death from cerebrovascular disease and cardiovascular disease accounting for around 20% late deaths. There are multiple contributory factors including preexisting, and the posttransplant development of, cardiometabolic conditions (such as hypertension, diabetes mellitus, hyperlipidemia, and obesity). There is accumulating evidence that the regular engagement in exercise is an important factor affecting outcomes before, during, and after transplantation; yet most waitlist candidates and recipients have reduced levels of physical activity. The mechanisms whereby physical activity is associated with better outcomes and a reduction in risk factors for cardiovascular disease are incompletely understood. Attempts to increase physical activity in the transplant population, as in the general population, have had limited success. Use of concepts from Nudge theory provides an evidence-based approach that may help increase physical activity and so reduce premature mortality. Both National and International Transplant Games provide a vehicle for increasing physical activity in this population and may also help to reduce premature death by providing a forum for mutual support for recipients and their families as well as an excellent forum for highlighting the success and impact of organ donation.

Resistance Training Increases Muscle Strength and Muscle Size in Patients With Liver Cirrhosis

BACKGROUND & AIMS

Cirrhosis is often complicated by reduced muscle mass and strength, which limits the ability to perform daily activities and affects quality of life. Resistance training can increase muscle strength and mass in elderly and chronically ill patients. We performed a randomized controlled trial to investigate whether resistance training increases muscle strength and size in patients with compensated cirrhosis.

METHODS

We performed a prospective study of 39 patients with cirrhosis (Child-Pugh class A or B) seen at an outpatient clinic in Denmark from January 2015 through March 2017. Participants protein intake and activity levels were registered daily. Participants were randomly assigned (1:1) to a group that performed 36 1-hour sessions of physical exercise (supervised progressive resistance training for 1 hour, 3 times weekly for 12 weeks) or a control group (no change in daily activity level). Maximal muscle strength was measured as the peak torque in isokinetic knee extension and muscle size was measured as the cross-sectional area of the quadriceps muscle, assessed by magnetic resonance imaging of the thigh.

RESULTS

The exercise group increased their muscle strength by 13% (from a mean 119 Nm to 134 Nm)-an 11 Nm greater gain in mean strength than that of the control group (P = .05). The exercise group increased their quadriceps cross-sectional area by 10% (from a mean 58.5 cm² to 64.6 cm²)-a 4.4 cm² greater gain than that of the control group (P < .01). The exercise group had significant increases in whole-body lean mass and body cell mass, and significant increases in 6-minute walking distance and the mental component summary of the short form-36 questionnaire. Adverse events were minor and equal between groups.

CONCLUSIONS

In a randomized trial of patients with compensated cirrhosis, we found that 12 weeks of supervised progressive resistance training increased muscle strength and size and had beneficial effects on general performance measures, compared with patients who did not change their daily activity routine (control subjects). ClinicalTrials.gov no: NCT02343653.

Exercise and physical activity in cirrhosis: opportunities or perils

Reduced exercise capacity and impaired physical performance are observed in nearly all patients with liver cirrhosis. Physical activity and exercise are physiological anabolic stimuli that can reverse dysregulated protein homeostasis or proteostasis and potentially increase muscle mass and contractile function in healthy subjects. Cirrhosis is a state of anabolic resistance, and unlike the beneficial responses to exercise reported in physiological states, there are few systematic studies evaluating the response to exercise in cirrhosis. Hyperammonemia is a mediator of the liver-muscle axis with net skeletal muscle ammonia uptake in cirrhosis causing signaling perturbations, mitochondrial dysfunction with decreased ATP content, modifications of contractile proteins, and impaired ribosomal function, all of which contribute to anabolic resistance in cirrhosis and have the potential to impair the beneficial responses to exercise. English language-publications in peer-reviewed journals that specifically evaluated the impact of exercise in cirrhosis were reviewed. Most studies evaluated responses to endurance exercise, and readouts included peak or maximum oxygen utilization, grip strength, and functional capacity. Endurance exercise for up to 12 wk is clinically tolerated in well-compensated cirrhosis. Data on the safety of resistance exercise are conflicting. Nutritional supplements enhance the benefits of exercise in healthy subjects but have not been evaluated in cirrhosis. Whether the beneficial physiological responses with endurance exercise and increase in muscle mass with resistance exercise that occur in healthy subjects also occur in cirrhotics is not known. Specific organ-system responses, changes in body composition, or improved long-term clinical outcomes with exercise in cirrhosis need evaluation.

Assessment of Malnutrition, Sarcopenia and Frailty in Patients with Cirrhosis: Which Tools Should We Use in Clinical Practice?

Malnutrition is a common comorbidity in patients with cirrhosis. Its prognostic value is indisputable as it greatly affects the evolution of liver diseases. It has a major impact on both morbi-mortality before and after liver transplantation. Being now integrated in the definition of malnutrition and recognized as a new entity in the international classification of diseases, physicians have taken great interest in sarcopenia. Its negative consequences on the fate of patients with cirrhosis are well-demonstrated. The concept of frailty has recently been enlarged to chronic liver diseases as symptoms of impaired global physical functioning. In this article, we will discuss the definitions of malnutrition and emphasize its links with sarcopenia and frailty. We will show the relevance of frailty and sarcopenia in the course of liver diseases. The emerging role of muscle depletion on the cardiorespiratory system will also be highlighted. The importance of body composition will be demonstrated and the main tools reviewed. Finally, we adapted the definition of malnutrition to patients with cirrhosis based on the assessment of sarcopenia together with reduced food intakes.

Peri-transplant management of nonalcoholic fatty liver disease in liver transplant candidates

The incidence of non-alcoholic fatty liver disease (NAFLD) is rapidly growing, affecting 25% of the world population. Non-alcoholic steatohepatitis (NASH) is the most severe form of NAFLD and affects 1.5% to 6.5% of the world population. Its rising incidence will make end-stage liver disease (ESLD) due to NASH the number one indication for liver transplantation (LT) in the next 10 to 20 years, overtaking Hepatitis C. Patients with NASH also have a high prevalence of associated comorbidities such as type 2 diabetes, obesity, metabolic syndrome, cardiovascular disease, and chronic kidney disease (CKD), which must be adequately managed during the peritransplant period for optimal post-transplant outcomes. The focus of this review article is to provide a comprehensive overview of the unique challenges these patients present in the peritransplant period, which comprises the pre-transplant, intraoperative, and immediate postoperative periods.

Clinical impact of sarcopenia assessment in patients with hepatocellular carcinoma undergoing treatments

Changes in body composition are associated with poor outcomes in cancer patients including hepatocellular carcinoma (HCC). Sarcopenia, defined as the loss of skeletal muscle mass, quality and function, has been associated with a higher rate of complications and recurrences in patients with cirrhosis and HCC. The assessment of patient general status before HCC treatment, including the presence of sarcopenia, is a key-point for achieving therapy tolerability and to avoid short- and long-term complications leading to poor patients' survival. Thus, we aimed to review the current literature evaluating the role of sarcopenia assessment related to HCC treatments and to critically provide the clinicians with the most recent and valuable evidence. As a result, sarcopenia can be predictive of poor outcomes in patients undergoing liver resection, transplantation and systemic therapies, offering the chance to clinicians to improve the muscular status of these patients, especially those with high-grade sarcopenia at high risk of mortality. Further studies are needed to clarify the predictive value of sarcopenia in other HCC treatment settings and to evaluate its role as an additional staging tool for identifying the most appropriate treatment. Besides, interventional studies aiming at increasing the skeletal muscle mass for reducing complications and increasing the survival in patients with HCC are needed.

Review article: impact of exercise on physical frailty in patients with chronic liver disease

BACKGROUND

Physical frailty is common in chronic liver disease and the setting of liver transplantation. It is associated with poor quality of life, increased hospitalisation and mortality. Despite this, the impact of exercise in these patients remains poorly understood.

AIM

To summarise the impact of physical exercise on physical frailty in patients with chronic liver disease until after liver transplantation.

METHODS

A MEDLINE and PubMed search was undertaken using the terms; "physical activity", "functional capacity", "exercise", "prehabilitation", "frailty", "liver cirrhosis", "liver failure", "liver transplantation" "chronic liver disease" and "end-stage liver disease" from January 1990 to June 2019.

RESULTS

Eleven studies (five randomised controlled, five observational, one case study) demonstrated that exercise improves VO₂ peak, anaerobic threshold, 6-minute walk distance, muscle mass/function and quality of life in patients with compensated and decompensated cirrhosis. Improvements were most significant with a combination of aerobic and resistance exercises at moderate-high intensity. The studies were small (n = 1-50) and mainly focused on supervised, hospital-based exercises, excluding patients with significant liver failure (MELD > 12). Seven studies (four randomised controlled and three observational) demonstrated that predominantly supervised (only one home-based) aerobic exercise after liver transplantation improves aerobic capacity, muscle mass/strength and quality of life. There was marked heterogeneity in timing, intensity and type of exercises.

CONCLUSION

Exercise improves key components of physical frailty (functional/aerobic capacity, sarcopenia) and quality of life in chronic liver disease and after liver transplantation. Understanding the type, compliance, intensity and duration of exercise and its impact on hard clinical outcomes should be the focus of future large controlled clinical trials.

Frailty, Sarcopenia, and Malnutrition in Cirrhotic Patients

Sarcopenia, frailty, and malnutrition are prevalent complications in patients with end-stage liver disease (ESLD) and are associated with increased risk of morbidity and mortality. It is valuable to measure nutritional status, sarcopenia, and frailty over time in order to create interventions tailored to individuals with ESLD. Evaluating sarcopenia and frailty in patients with ESLD is challenging. Further work is needed to perfect these assessments so that clinicians can incorporate these assessments into their decision-making and management plans for cirrhotic patients.

A North American Expert Opinion Statement on Sarcopenia in Liver Transplantation

Loss of muscle mass and function, or sarcopenia, is a common feature of cirrhosis and contributes significantly to morbidity and mortality in this population. Sarcopenia is a main indicator of adverse outcomes in this population, including poor quality of life, hepatic decompensation, mortality in patients with cirrhosis evaluated for liver transplantation (LT), longer hospital and intensive care unit stay, higher incidence of infection following LT, and higher overall health care cost. Although it is clear that muscle mass is an important predictor of LT outcomes, many questions remain, including the best modality for assessing muscle mass, the optimal cut-off values for sarcopenia, the ideal timing and frequency of muscle mass assessment, and how to best incorporate the concept of sarcopenia into clinical decision making. For these reasons, we assembled a group of experts to form the North American Working Group on Sarcopenia in Liver Transplantation to use evidence from the medical literature to address these outstanding questions regarding sarcopenia in LT. We believe sarcopenia assessment should be considered in all patients with cirrhosis evaluated for liver transplantation. Skeletal muscle index (SMI) assessed by computed tomography constitutes the best-studied technique for assessing sarcopenia in patients with cirrhosis. Cut-off values for sarcopenia, defined as SMI < 50 cm² /m² in male and < 39 cm² /m² in female patients, constitute the validated definition for sarcopenia in patients with cirrhosis. Conclusion: The management of sarcopenia requires a multipronged approach including nutrition, exercise, and additional pharmacological therapy as deemed necessary. Future studies should evaluate whether recovery of sarcopenia with nutritional management in combination with an exercise program is sustainable as well as how improvement in muscle mass might be associated with improvement in clinical outcomes.