Baseline 6-min walk distance predicts survival in lung transplant candidates

Lung Transplantation: A Viable Option for Connective Tissue Disease?

Interstitial lung disease (ILD) and pulmonary hypertension (PH) caused by connective tissue disease (CTD) are one of the main causes of morbidity and death in patients. Although the International Society for Heart & Lung Transplant suggested that ILD and PH related to CTD are rare indications for lung transplantation in 2006, many lung transplantation centers are concerned that the multisystem involvement of CTD will affect survival outcomes after lung transplantation, and CTD is regarded as a relative contraindication for lung transplantation. However, long-term and short-term survival after lung transplantation in CTD patients is similar compared with survival in common indications for lung transplantation such as idiopathic pulmonary fibrosis (IPF), and no higher incidence of complications after transplantation in many lung transplant centers. This suggests that lung transplantation may be beneficial in CTD patients with disease that progresses to end-stage lung disease, and CTD should not be considered a contraindication for lung transplantation. In the future, more prospective studies are needed to analyze the risk factors of lung transplantation in CTD patients to improve survival rates and reduce the risk of complications. This narrative review summarizes the selection and evaluation of candidates for CTD before lung transplantation and describes the clinical outcomes in CTD after lung transplantation in large-capacity lung transplantation center. The purpose of this review is to help rheumatologists decide when to refer patients with CTD-related lung involvement to a lung transplantation center and the conditions to consider before transplantation and to provide confidence to lung transplant experts.

Disseminating education to solid organ transplant recipients to promote engagement in physical activity

Objective

To evaluate the dissemination of education through a workshop to promote engagement in physical activity (PA) among solid organ transplant (SOT) recipients.

Methods

The in-person workshop consisted of expert-led lectures on topics related to physical activity (day 1) and sports and fitness training with volunteer coaches (day 2). There were separate streams for children/adolescents and adults. RE-AIM (Reach, Efficacy, Adoption, Implementation, and Maintenance) framework was used to evaluate the impact of the workshop. Presenters and participants completed evaluations of the workshop using a 5-point Likert scale. A subgroup of adults completed a self-reported PA questionnaire at baseline and 4-weeks after the workshop.

Results

103 individuals (71 SOT recipients, 32 caregivers) attended the workshop (ages 4 to 71+ years). Sessions were highly rated (median = 5) for both quality and content on both days. There was no significant change (p = 0.16) in PA. However, 56% of SOT recipients reported changing their level of PA.

Conclusion

An educational-workshop with hands-on training was an efficient and well-received method for disseminating awareness about the benefits of PA in SOT recipients.

Innovation

Dissemination of evidence-based knowledge through a novel educational-workshop in a real-world setting has the potential to inform the decisions about PA behavior among SOT recipients.

A qualitative exploration of people living with idiopathic pulmonary fibrosis experience of a virtual pulmonary rehabilitation programme

BACKGROUND

Pulmonary rehabilitation (PR) is recommended in the treatment of people with idiopathic pulmonary fibrosis (IPF). Little is known about the experiences of people with IPF of PR. Due to Covid-19 there has been a rapid shift of PR services to remote/virtual delivery.

OBJECTIVE

To explore people living with IPFs experience of a virtual PR (VPR) programme.

METHODS

All patients with a diagnosis of IPF in a stable phase of the disease were invited to participate in virtual PR: a 10 week exercise programme delivered twice-weekly for one hour. One-to-one semi- structured interviews were conducted within one week following the programme. All interviews were recorded, transcribed and analysed using Braun and Clarke thematic analysis by two independent assessors.

RESULTS

N=13 participants took part in the semi-structured interviews, mean (standard deviation (SD)) age 69.5(10.4) years; 7M:6F. Mean (SD) FEV1 2.6(0.3)L, FVC 2.9(0.4)L. Four key themes were identified: 1) The impact of VPR on health and outlook, (2) The reality of VPR, (3) Being active after VPR and (4) Living with IPF during the COVID-19 Pandemic. Participants reported high levels of enjoyment and engagement with the programme regardless of the health benefits experienced. Most participants expressed a desire for a longer programme. Participants expressed different levels of maintenance with exercise since finishing the programme, specific motivators and strategies for maintenance included lung transplant, the maintenance of benefits from the programme and social support. COVID-19 and the restrictions imposed had some negative impacts on some participants lives, engaging with PR helped overcome some of these.

CONCLUSION

Despite the progressive nature of IPF, all participants expressed high levels of enjoyment with the programme. Future research should explore strategies for maintenance post PR and the optimum duration of PR for people with IPF.

Relationship of Exercise Capacity, Physical Function, and Frailty Measures With Clinical Outcomes and Healthcare Utilization in Lung Transplantation: A Scoping Review

Measures of exercise capacity, frailty, and physical function are commonly used in lung transplant candidates and recipients to evaluate their physical limitations and the effects of exercise training and to select candidates for transplantation. It is unclear how these measures are related to clinical outcomes and healthcare utilization before and after lung transplantation. The purpose of this scoping review was to describe how measures of exercise capacity, physical function, and frailty are related to pre- and posttransplant outcomes.

Statistical Evaluation of Absolute Change versus Responder Analysis in Clinical Trials

In clinical trials, the primary analysis is often either a test of absolute/relative change in a measured outcome or a corresponding responder analysis. Though each of these tests may be reasonable, determining which test is most suitable for a particular research study is still an open question. These tests may require different sample sizes, define different clinically meaningful differences, and most importantly, lead to different study conclusions. This paper aims to compare a typical non-inferiority test using absolute change as the study endpoint to the corresponding responder analysis in terms of sample size requirements, statistical power, and hypothesis testing results. From numerical analysis, using absolute change as an endpoint generally requires a larger sample size; therefore, when the sample size is the same, the responder analysis has higher power. The cut-off value and non-inferiority margin are critical which can meaningfully impact whether the two types of endpoints yield conflicting conclusions. Specifically, an extreme cut-off value is more likely to cause different conclusions. However, this impact decreases as population variance increases. One important reason for conflicting conclusions is that the population distribution is not normal. To eliminate conflicting results, researchers should pay attention to the population distribution and cut-off value selection.

Early Postoperative Management of Lung Transplant Recipients

The early postoperative period after lung transplantation is a critical time. Prompt recognition and treatment of primary graft dysfunction can alter long-term allograft function. Cardiovascular, gastrointestinal, renal, and hematologic derangements are common and require close management to limit their negative sequelae.

Development of a Mitochondrial Myopathy-Composite Assessment Tool

BACKGROUND

'Mitochondrial Myopathy' (MM) refers to genetically-confirmed Primary Mitochondrial Disease (PMD) that predominantly impairs skeletal muscle function. Validated outcome measures encompassing core MM domains of muscle weakness, muscle fatigue, imbalance, impaired dexterity, and exercise intolerance do not exist. The goal of this study was to validate clinically-meaningful, quantitative outcome measures specific to MM.

METHODS

This was a single centre study. Objective measures evaluated included hand-held dynamometry, balance assessments, Nine Hole Peg Test (9HPT), Functional Dexterity Test (FDT), 30 second Sit to Stand (30s STS), and 6-minute walk test (6MWT). Results were assessed as z-scores, with < -2 standard deviations considered abnormal. Performance relative to the North Star Ambulatory Assessment (NSAA) of functional mobility was assessed by Pearson's correlation.

RESULTS

In genetically-confirmed MM participants [n = 59, mean age 21.6 ± 13.9 (range 7 - 64.6 years), 44.1% male], with nuclear gene aetiologies, n = 18/59, or mitochondrial (mtDNA) aetiologies, n = 41/59, dynamometry measurements demonstrated both proximal [dominant elbow flexion (-2.6 ± 2.1, mean z-score ± standard deviation, SD), hip flexion (-2.5 ± 2.3), and knee flexion (-2.8 ± 1.3)] and distal muscle weakness [wrist extension (-3.4 ± 1.7), palmar pinch (-2.5 ± 2.8), and ankle dorsiflexion (-2.4 ± 2.5)]. Balance [Tandem Stance (TS) Eyes Open (-3.2 ± 8.8, n = 53) and TS Eyes Closed (-2.6 ± 2.7, n = 52)] and dexterity [FDT (-5.9 ± 6.0, n = 44) and 9HPT (-8.3 ± 11.2, n = 53)] assessments also revealed impairment. Exercise intolerance was confirmed by strength-based 30s STS test (-2.0 ± 0.8, n = 38) and mobility-based 6MWT mean z-score (-2.9 ± 1.3, n = 46) with significant decline in minute distances (slope -0.9, p = 0.03, n = 46). Muscle fatigue was quantified by dynamometry repetitions with strength decrement noted between first and sixth repetitions at dominant elbow flexors (-14.7 ± 2.2%, mean ± standard error, SEM, n = 21). All assessments were incorporated in the MM-Composite Assessment Tool (MM-COAST). MM-COAST composite score for MM participants was 1.3± 0.1(n = 53) with a higher score indicating greater MM disease severity, and correlated to NSAA (r = 0.64, p < 0.0001, n = 52) to indicate clinical meaning. Test-retest reliability of MM-COAST assessments in an MM subset (n = 14) revealed an intraclass correlation coefficient (ICC) of 0.81 (95% confidence interval: 0.59-0.92) indicating good reliability.

CONCLUSIONS

We have developed and successfully validated a MM-specific Composite Assessment Tool to quantify the key domains of MM, shown to be abnormal in a Definite MM cohort. MM-COAST may hold particular utility as a meaningful outcome measure in future MM intervention trials.

Telerehabilitation for Lung Transplant Candidates and Recipients During the COVID-19 Pandemic: Program Evaluation

BACKGROUND

The COVID-19 pandemic resulted in a rapid shift from center-based rehabilitation to telerehabilitation for chronic respiratory disease and lung transplantation due to infection control precautions. Clinical experience with this delivery model on a large scale has not been described.

OBJECTIVE

The aim of this study is to describe usage and satisfaction of providers and lung transplant (LTx) candidates and recipients and functional outcomes following the broad implementation of telerehabilitation with remote patient monitoring during the first wave of the COVID-19 pandemic.

METHODS

This study was a program evaluation of providers, LTx candidates, and early LTx recipients who used a web-based, remote monitoring app for at least four weeks between March 16 and September 1, 2020, to participate in telerehabilitation. Within-subjects analysis was performed for physical activity, Self-efficacy For Exercise (SEE) scale score, aerobic and resistance exercise volumes, 6-minute walk test results, and Short Physical Performance Battery (SPPB) results.

RESULTS

In total, 78 LTx candidates and 33 recipients were included (57 [51%] males, mean age 58 [SD 12] years, 58 [52%] with interstitial lung disease, 34 [31%] with chronic obstructive pulmonary disease). A total of 50 (64%) LTx candidates and 17 (51%) LTx recipients entered ≥10 prescribed exercise sessions into the app during the study time frame. In addition, 35/42 (83%) candidates agreed the app helped prepare them for surgery and 18/21 (85%) recipients found the app helpful in their self-recovery. The strongest barrier perceived by physiotherapists delivering the telerehabilitation was patient access to home exercise and monitoring equipment. Between the time of app registration and ≥4 weeks on the waiting list, 26 LTx candidates used a treadmill, with sessions increasing in mean duration (from 16 to 22 minutes, P=.002) but not speed (from 1.7 to 1.75 mph, P=.31). Quadriceps weight (pounds) for leg extension did not change (median 3.5, IQR 2.4-5 versus median 4.3, IQR 3-5; P=.08; n=37). On the Rapid Assessment of Physical Activity questionnaire (RAPA), 57% of LTx candidates scored as active, which improved to 87% (P=.02; n=23). There was a decrease in pretransplant 6-minute walk distance (6MWD) from 346 (SD 84) meters to 307 (SD 85) meters (P=.002; n=45) and no change in the SPPB result (12 [IQR 9.5-12] versus 12 [IQR 10-12]; P=.90; n=42). A total of 9 LTx recipients used a treadmill that increased in speed (from 1.9 to 2.7 mph; P=.003) between hospital discharge and three months posttransplant. Quadriceps weight increased (3 [IQR 0-3] pounds versus 5 [IQR 3.8-6.5] pounds; P<.001; n=15). At three months posttransplant, 76% of LTx recipients scored as active (n=17), with a high total SEE score of 74 (SD 11; n=12). In addition, three months posttransplant, 6MWD was 62% (SD 18%) predicted (n=8).

CONCLUSIONS

We were able to provide telerehabilitation despite challenges around exercise equipment. This early experience will inform the development of a robust and equitable telerehabilitation model beyond the COVID-19 pandemic.

Extracorporeal Membrane Oxygenation as a Bridge to Lung Transplant

Extracorporeal membrane oxygenation (ECMO) is a cardiopulmonary technology capable of supporting cardiac and respiratory function in the presence of end-stage lung disease. Initial experiences using ECMO as a bridge to lung transplant (ECMO-BTLT) were characterized by high rates of ECMO-associated complications and poor posttransplant outcomes. More recently, ECMO-BTLT has garnered success in preserving patients' physiologic condition and candidacy prior to lung transplant due to technological advances and improved management. Despite recent growth, clinical practice surrounding use of ECMO-BTLT remains variable, with little data to inform optimal patient selection and management. Although many questions remain, the use of ECMO-BTLT has shown promising outcomes suggesting that ECMO-BTLT can be an effective strategy to ensure that complex and rapidly decompensating patients with end-stage lung disease can be safely transplanted with good outcomes. Further studies are needed to refine and inform practice patterns, management, and lung allocation in this high-risk and fragile patient population.

Pediatric lung transplant: Correlation of pretransplant condition with post-transplant outcomes

BACKGROUND

It is generally accepted that patients who have greater functional capacity are better candidates for lung transplantation. Accurate assessment of physical condition is important in identifying appropriate candidates for transplant. The focus of this study was to determine which measures of pretransplant physical condition correlate with positive post-transplant outcomes in children undergoing lung transplant.

METHODS

A retrospective chart review was done on 44 patients, ages 5 to 21 years. The pretransplant data collected included functional status, 6MWT, ambulatory status, and mechanical support. Post-transplant outcome data included time on the ventilator, days in the ICU, length of hospitalization, and 12-month survival.

RESULTS

Results were analyzed using Fisher exact and Kruskal-Wallis tests. Patients with limited ambulation had more days in the ICU compared to the most ambulatory group (P = .043). Patients independent or needing some help with ADL had less time on the ventilator compared to patients needing total help. (P = .014). Patients with 6MWT result greater than 500' had fewer ICU days (P = .044) and marginally better 12-month survival (P = .057). The 12-month survival of children needing invasive ventilatory support pretransplant was not significantly worse than those who did not; however, they required significantly more time on the ventilator (P = .004), days in ICU (P = .013), and longer hospitalization.

DISCUSSION

This study demonstrated that pretransplant physical condition affects post-transplant outcomes in children. Measures associated with positive post-transplant outcomes were identified and could be beneficial in determining which patients are optimal candidates for lung transplant.

Exercise training for lung transplant candidates and recipients: a systematic review

Exercise intolerance and impaired quality of life (QoL) are characteristic of lung transplant candidates and recipients. This review investigated the effects of exercise training on exercise capacity, QoL and clinical outcomes in pre- and post-operative lung transplant patients.A systematic literature search of PubMed, Nursing and Allied Health, Cochrane (CENTRAL), Scopus and CINAHL databases was conducted from inception until February, 2020. The inclusion criteria were assessment of the impact of exercise training before or after lung transplantation on exercise capacity, QoL or clinical outcomes.21 studies met the inclusion criteria, comprising 1488 lung transplant candidates and 1108 recipients. Studies consisted of five RCTs, two quasi-experimental and 14 single-arm cohort or pilot studies. Exercise training improved or at least maintained exercise capacity and QoL before and after lung transplantation. The impact on clinical outcomes was less clear but suggested a survival benefit. The quality of evidence ranged from fair to excellent.Exercise training appears to be beneficial for patients before and after lung transplantation; however, the evidence for direct causation is limited by the lack of controlled trials. Well-designed RCTs are needed, as well as further research into the effect of exercise training on important post-transplant clinical outcomes, such as time to discharge, rejection, infection, survival and re-hospitalisation.

Changes in 6-minute walking distance in lung transplant candidates while participating in a home-based pre-habilitation program-A retrospective chart review

Home-based exercise programs may offer a less costly alternative to providing exercise pre-transplant to a large number of patients. We describe the changes in 6-minute walk distance (6MWD) in lung transplant candidates who participated in a home-based exercise program and their relationship to post-transplant outcomes. Retrospectively, we investigated 159 individuals while awaiting transplantation who performed the surgery between 2011 and 2015. Primary outcome was 6MWD at time of assessment for transplant, last test prior to transplant and one-month post-transplant. 6MWD decreased by 28 ± 93.9 m between the time of assessment and the last 6MWD prior to transplantation (P < .001). Forty-one patients (25.8%) increased their 6MWD (mean + 85.8 ± 42.8 m); 72 patients (45.3%) decreased their 6MWD (mean -109.8 ± 71.2 m); and 46 patients (28.9%) had no change in 6MWD (-1.5 ± 15.7 m). There was a moderate correlation (r = .528; P < .001) between the last 6MWD prior to transplant and 6MWD post-transplant. Change in 6MWD prior to transplant weakly correlated with length of time on mechanical ventilation (r = -.185; P = .034). When adjusted for covariates, change in 6MWD prior to transplant was not associated with length of time on mechanical ventilation, total hospital LOS, or intensive care unit LOS. The majority of the patients were able to either increase or maintain their 6MWD while participating in a home-based pre-habilitation program during the waiting list period. Prospective research is needed to evaluate the effects of home-based pre-habilitation program for lung candidates.

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.

The impaired diaphragmatic function after bilateral lung transplantation: A multifactorial longitudinal study

BACKGROUND

Lung transplantation is a complex but effective treatment of end-stage pulmonary disease. Among the post-operative complications, phrenic nerve injury, and consequent diaphragmatic dysfunction are known to occur but are hitherto poorly described. We aimed to investigate the effect of lung transplantation on diaphragmatic function with a multimodal approach.

METHODS

A total of 30 patients were studied at 4 time points: pre-operatively, at discharge after surgery, and after approximately 6 and subsequently 12 months post surgery. The diaphragmatic function was studied in terms of geometry (assessed by the radius of the diaphragmatic curvature delineated on chest X-ray), weakness (considering changes in forced vital capacity when the patient shifted from upright to supine position), force (maximal pressure during sniff), mobility (excursion of the dome of the diaphragm delineated by ultrasound), contractility (thickening fraction assessed by ultrasound), electrical activity (latency and area of compound muscle action potential during electrical stimulation of phrenic nerve), and kinematics (relative contribution of the abdominal compartment to tidal volume).

RESULTS

Despite good clinical recovery (indicated by spirometry and 6 minutes walking test), a reduction of the diaphragmatic function was detected at discharge; it persisted 6 months later to recover fully 1 year after transplantation. Diaphragmatic dysfunction was demonstrated in terms of force, weakness, electrical activity, and kinematics. Our data suggest that the dysfunction was caused by phrenic nerve neurapraxia or moderate axonotmesis, potentially as a consequence of the surgical procedure (i.e., the use of ice and pericardium manipulation).

CONCLUSIONS

The occurrence of diaphragmatic dysfunction in patients with a good clinical recovery indicates that the evaluation of diaphragmatic function should be included in the post-operative assessment after lung transplantation.

Remote Therapy to Improve Outcomes in Lung Transplant Recipients: Design of the INSPIRE-III Randomized Clinical Trial

BACKGROUND

Impaired functional capacity and emotional distress are associated with lower quality of life (QoL) and worse clinical outcomes in post lung transplant patients. Strategies to increase physical activity and reduce distress are needed.

METHODS

The Investigational Study of Psychological Interventions in Recipients of Lung Transplant-III study is a single site, parallel group randomized clinical trial in which 150 lung transplant recipients will be randomly assigned to 3 months of telephone-delivered coping skills training combined with aerobic exercise (CSTEX) or to a Standard of Care plus Education control group. The primary endpoints are a global measure of distress and distance walked on the 6-Minute Walk Test. Secondary outcomes include measures of transplant-specific QoL, frailty, health behaviors, and chronic lung allograft dysfunction-free survival.

RESULTS

Participants will be evaluated at baseline, at the conclusion of 3 months of weekly treatment, at 1-year follow-up, and followed annually thereafter for clinical events for up to 4 years (median = 2 y). We also will determine whether functional capacity, distress, and health behaviors (eg, physical activity, medication adherence, and volume of air forcefully exhaled in 1 second (FEV1), mediate the effects of the CSTEX intervention on clinical outcomes.

CONCLUSIONS

Should the CSTEX intervention result in better outcomes compared with the standard of care plus post-transplant education, the remotely delivered CSTEX intervention can be made available to all lung transplant recipients as a way of enhancing their QoL and improving clinical outcomes.

A Comparison of Frailty Measures at Listing to Predict Outcomes After Lung Transplantation

BACKGROUND

Sarcopenia may be an important predictive factor of outcomes after lung transplantation (LTx). Serum albumin and the 6-minute walk distance (6MWD) have been shown to be a marker of LTx outcomes. We measured sarcopenia, albumin, and 6MWD in a cohort of LTx patients and analyzed the utility of these as markers of outcomes for LTx patients.

METHODS

We retrospectively identified LTx recipients from 2013-2018 at our institution who underwent computed tomographic imaging during their listing evaluation. From that image, we measured skeletal muscle cross-sectional surface area at the third lumbar vertebral level, and sarcopenia was diagnosed by established cutoffs. Associations between sarcopenia, albumin, 6MWD, and survival, and hospital length of stay, complications, readmissions, and discharge destination were evaluated.

RESULTS

Sarcopenia was found in 72% (95 of 132) of patients, 18% (24 of 131) of patients were hypoalbuminemic, and 41% had a low 6MWD. Survival was not associated with presence of sarcopenia (hazard ratio [HR], 1.06; 95% confidence interval [CI], 0.46-2.42) or low 6MWD (HR, 0.86; 95% CI, 0.410-1.83). Hospital length of stay, complications, readmissions, and discharge destination were not influenced by sarcopenia or 6MWD. In contrast, hypoalbuminemia was independently associated with decreased survival (HR, 2.25; 95% CI, 1.04-4.85) and a higher grade of postoperative complications (P = .04).

CONCLUSIONS

Sarcopenia is prevalent in LTx patients. Neither sarcopenia nor 6MWD predicted mortality or short-term outcomes after LTx. This is in contrast to albumin levels, which were inversely associated with survival and complications. Albumin shows promise as an important predictor of mortality and short-term outcomes after LTx.

Impaired cardiac autonomic response in lung transplant patients: A retrospective cohort study

BACKGROUND

Cardiac autonomic dysfunction (AD) is associated with adverse prognosis in lung disease; however, its implications in lung transplantation have not been previously described. This study evaluated the prevalence of AD in lung transplant (LTx) candidates, its determinants, prognostic implications, and prevalence post-transplant.

METHODS

Retrospective one-year study of 103 LTx candidates with AD assessed using heart rate (HR) from the six-minute walk test (6MWT). Impaired chronotropic response index (CRI) was defined as <80% age-adjusted HR during 6MWT. Abnormal HR recovery (HRR) was categorized as reduction in HR ≤ 12 beats/minute after the first minute of 6MWT cessation.

RESULTS

Abnormal CRI and HRR were observed in 94% and 76% of patients, respectively. A lower CRI was associated with obstructive lung disease and lower estimated aerobic capacity. CRI was independently associated with 6MW distance [12 m per 10% CRI, P = 0.03], but not with post-transplant cardiovascular events, hospital stay, or one-year mortality. At 3 months post-transplant, no improvement was observed in CRI (99%, n = 66/67, P = 0.25) or HRR (88%, n = 36/41, P = 0.12).

CONCLUSION

Cardiac AD was prevalent in LTx candidates and recipients, with chronotropic incompetence a modest contributor to exercise intolerance pretransplant. Further study may help determine whether direct autonomic measures such as HR variability may be more prognostic of LTx outcomes.

A 1-Month Physical Therapy-Based Outpatient Program for Adults Awaiting Lung Transplantation: A Retrospective Analysis of Exercise Capacity, Symptoms, and Quality of Life

Purpose

Rehabilitation can improve health outcomes in candidates for lung transplantation. The purpose of this study was to retrospectively evaluate the effect of a one-month physical therapy (PT)-based outpatient program on exercise capacity, symptoms, quality of life and examine predictors of functional outcome changes in adults awaiting lung transplantation.

Methods

Participants (n=141) completed a 23-session exercise and educational program over one month. Outcomes included 6-minute walk distance (6MWD), San Diego Shortness of Breath Questionnaire (SOBQ), Center for Epidemiological Studies-Depression Scale (CESD), and Ferrans and Powers Quality of Life Index Pulmonary Version III (QOL).

Results

Participants were older (median age 63) with restrictive (59%) or obstructive (24%) disease. Moderate-to-large improvements in 6MWD were observed (69 m, p < 0.001, d = 0.72), independent of demographics, symptoms, and QOL. Lower initial 6MWD and lower oxygen utilization were associated with greater 6MWD improvements, with largest gains occurring in initial 6MWD < 305 m. Small-to-moderate improvements were observed on CESD (p < 0.001, d = 0.26) and in overall QOL (p < 0.001, d = 0.27), with a non-significant improvement observed on SOBQ (p = 0.248, d = 0.13).

Conclusions

Completion of a one-month PT-based outpatient rehabilitation program was associated with improved exercise capacity, depressive symptoms and QOL.

Evolution of Functional Exercise Capacity in Lung Transplant Patients With and Without Bronchiolitis Obliterans Syndrome: A Longitudinal Case-Control Study

INTRODUCTION

Bronchiolitis Obliterans Syndrome (BOS) is a debilitating disease with limited treatment options that threatens both the quality of life and long-term survival of lung transplant (LTx) recipients. This retrospective longitudinal case-control study was performed to compare the long-term functional evolution of LTx recipients with and without BOS.

METHODS

Twenty-four LTx recipients with BOS (BOS=Cases) and 24 without BOS (NON-BOS=Controls) were selected and individually matched according to age, gender, diagnosis and LTx characteristics. Measurements of 6-minute walking distance (6MWD), symptoms of dyspnea (BORG CR-10 scale), and comprehensive pulmonary function testing were performed before LTx and at annual follow-up assessments after LTx.

RESULTS

Peak FEV₁ after LTx was similar in both groups [FEV₁ (% predicted) 101±25 vs. 101±31, p=0.96] and BOS diagnosis in cases was established 3.6±2.5 years after LTx. At the final follow-up assessment (6.5±3.2 years after LTx) FEV₁ (% predicted) was 86±34 in NON-BOS vs. 44±17 in BOS (p<0.001). Evolution of 6MWD was different between groups (group by time interaction: p=0.002). Borg dyspnea scores were also significantly different between groups at the final evaluation (NON-BOS 3.3±1.7 vs. BOS 5.0±2.2; p=0.024).

CONCLUSIONS

We observed gradual reductions in functional exercise capacity and increasing symptoms of dyspnea in patients who developed BOS after LTx. As such, prospective studies seem warranted to explore whether rehabilitative interventions might be useful to improve symptoms and slow down deterioration of exercise capacity in these patients from the onset of BOS.

Pre-transplant weight loss and clinical outcomes after lung transplantation

BACKGROUND

Patients with greater adiposity before lung transplantation are at an increased risk for worse post-transplant outcomes. Few studies have addressed whether pre-transplant weight loss mitigates this risk. In this study we examined the association between pre-transplant weight loss and post-transplant clinical outcomes.

METHODS

We conducted a retrospective cohort study of patients who received a lung transplant at the Duke University Hospital from May 1, 2005 to April 30, 2015. The sample included adult transplant recipients with restrictive, obstructive, and vascular diseases. Cox proportional hazards models were used to examine mortality and chronic lung allograft dysfunction (CLAD)-free survival, and negative binomial regression analyses were used to examine length of stay (LOS). Weight loss was assessed from change in body mass index (BMI).

RESULTS

The cohort consisted of 810 patients. Initially, 403 (50%) were overweight and 109 (13%) were obese by BMI criteria. Greater pre-transplant weight loss was associated with dose-response improvements in survival (hazard ratio [HR] 0.83 [0.72 to 0.97], p = 0.018), with modest (0% to 3%, HR 0.91), moderate (7% to 10%, HR 0.83), and high (>15%, HR 0.71) levels of weight loss conferring longer survival, independent of initial weight (p = 0.533 for interaction). Weight loss was also associated with improved CLAD-free survival (HR 0.84 [0.71 to 0.99], p = 0.034) and shorter LOS (b = ‒0.17, p < 0.001).

CONCLUSIONS

Weight loss before transplantation was associated with improved short- and long-term clinical outcomes, independent of initial weight. Survival improved proportionally to percentage of weight lost. The mechanisms by which weight loss improve clinical outcomes warrant further exploration.

Physical Activity, Sedentary Time, and Associated Factors in Recipients of Solid-Organ Transplantation

BACKGROUND

Short-term survival after solid-organ transplantation has substantially improved, and the focus has shifted to long-term survival, including the role of physical activity (PA). Knowledge about PA and sedentary time in recipients of solid-organ transplantation is limited, and identification of the levels and associated factors is necessary for intervention development.

OBJECTIVE

The objectives of this study were to investigate the level of PA and sedentary time in recipients of solid-organ transplantation and to identify factors associated with these behaviors.

DESIGN

The design consisted of a cross-sectional survey.

METHODS

Questionnaires on PA level, sedentary time, and potential associated factors were used for recipients of solid-organ transplantation (kidney, liver, lung, and heart [N = 656]). Multiple regression analyses with a variable selection procedure were used.

RESULTS

Fewer than 60% of the recipients fulfilled the PA guideline. Factors significantly associated with a lower level of PA included being a woman, younger age (nonlinear), not actively working or being retired, physical limitations, and low expectations and self-confidence. Factors significantly associated with less sedentary time included exercise self-efficacy and not actively working or being retired. Significantly associated with more sedentary time were a high education level, fear of negative effects, physical limitations, and the motivator "health and physical outcomes." The type of transplantation did not significantly influence either of the outcome measures.

LIMITATIONS

The design did not allow for causal inferences to be made. The studied associated factors were limited to individual and interpersonal factors. Self-reported measures of PA and sedentary time were used.

CONCLUSIONS

In intervention development directed at increasing the level of PA and reducing sedentary time in recipients of solid-organ transplantation, attention should be paid to physical limitations, fear of negative effects, low expectations and self-confidence, health and physical outcomes, and exercise self-efficacy.

Depressive Symptoms, Exercise Capacity, and Clinical Outcomes After Lung Transplantation

OBJECTIVE

Depressive symptoms are common among lung transplant recipients and have been associated with worse clinical outcomes. However, few studies have examined the association between depressive symptoms assessed at multiple time points or behavioral mechanisms by which posttransplant depressive symptoms may confer greater clinical risk. We therefore examined the associations between depressive symptoms, exercise capacity, chronic lung allograft dysfunction (CLAD), and mortality prospectively in a large sample of lung transplant recipients.

METHODS

Between July 2009 and February 2016, 251 lung transplant recipients were assessed before transplantation and again approximately 3 weeks and 3 months after transplant. Depressive symptoms were assessed using the Centers for Epidemiologic Studies of Depression scale. Functional exercise capacity was assessed using the 6-minute walk test. Cox proportional hazards models were used to examine the associations between depressive symptoms, exercise capacity, CLAD, and mortality.

RESULTS

During a median (range) follow-up of 4.5 (0.1 to 6.3) years, 53 participants (21%) died. Greater depressive symptoms (hazard ratio [HR] = 1.39 [95% CI = 1.05 to 1.84], p = .021) and poorer exercise capacity (HR = 0.58 [95% CI = 0.38 to 0.90], p = .021) assessed 3 months after transplant were both independently associated with mortality. Although greater depressive symptoms were associated with lower exercise capacity (β = -0.14, p = .039), exercise capacity did not mediate the association between depressive symptoms and mortality. In secondary analyses, depressive symptoms were independently predictive of CLAD (HR = 1.29 [95% CI = 1.01 to 1.65], p = .045) and the composite outcome of CLAD and mortality in a clustered event model (HR = 1.30 [1.09 to 1.56], p = .005).

CONCLUSIONS

Depressive symptoms are associated with mortality and CLAD after lung transplantation, independent of exercise capacity.

Depression, social support, and clinical outcomes following lung transplantation: a single-center cohort study

Depressive symptoms are common among lung transplant candidates and have been associated with poorer clinical outcomes in some studies. Previous studies have been plagued by methodologic problems, including small sample sizes, few clinical events, and uncontrolled confounders, particularly perioperative complications. In addition, few studies have examined social support as a potential protective factor. We therefore examined the association between pretransplant depressive symptoms, social support, and mortality in a large sample of lung transplant recipients. As a secondary aim, we also examined the associations between psychosocial factors, perioperative outcomes [indexed by hospital length of stay (LOS)], and mortality. We hypothesized that depression would be associated with longer LOS and that the association between depression, social support, and mortality would be moderated by LOS. Participants included lung transplant recipients, transplanted at Duke University Medical Center from January 2009 to December 2014. Depressive symptoms were evaluated using the Beck Depression Inventory (BDI-II) and social support using the Perceived Social Support Scale (PSSS). Medical risk factors included forced vital capacity (FVC), partial pressure of carbon dioxide (PCO₂ ), donor age, acute rejection, and transplant type. Functional status was assessed using six-minute walk distance (6MWD). We also controlled for demographic factors, including age, gender, and native disease. Transplant hospitalization LOS was examined as a marker of perioperative clinical outcomes. Participants included 273 lung recipients (174 restrictive, 67 obstructive, 26 cystic fibrosis, and six "other"). Pretransplant depressive symptoms were common, with 56 participants (21%) exhibiting clinically elevated levels (BDI-II ≥ 14). Greater depressive symptoms were associated with longer LOS [adjusted b = 0.20 (2 days per 7-point higher BDI-II score), P < 0.01]. LOS moderated the associations between depressive symptoms (P = 0.019), social support (P < 0.001), and mortality, such that greater depressive symptoms and lower social support were associated with greater mortality only among individuals with longer LOS. For individuals with LOS ≥ 1 month, clinically elevated depressive symptoms (BDI-II ≥ 14) were associated with a threefold increased risk of mortality (HR = 2.97). Greater pretransplant depressive symptoms and lower social support may be associated with greater mortality among a subset of individuals with worse perioperative outcomes.

Relationship between pre-transplant physical function and outcomes after kidney transplant

BACKGROUND

Performance-based measures of physical function predict morbidity following non-transplant surgery. Study objectives were to determine whether physical function predicts outcomes after kidney transplant and assess how physical function changes post-transplant.

METHODS

We conducted a prospective study involving living donor kidney transplants recipients at our center from May 2012 to February 2014. Physical function was measured using the Short Physical Performance Battery (SPPB [balance, chair stands, gait speed]) and grip strength testing. Initial length of stay (LOS), 30- day rehospitalizations, allograft function, and quality of life (QOL) were assessed.

RESULTS

The majority of the 140 patients in our cohort had excellent pre-transplant physical function. In general, balance scores were more predictive of post-transplant outcomes than the SPPB. Decreased pre-transplant balance was independently associated with longer LOS and increased rehospitalizations but not with post-transplant QOL; 35% of patients experienced a clinically meaningful (≥ 1.0 m/s) improvement in gait speed 4 months post-transplant.

CONCLUSIONS

Decreased physical function may be associated with longer LOS and rehospitalizations following kidney transplant. Further studies are needed to confirm this association. The lack of relationship between pre-transplant gait speed and outcomes in our cohort may represent a ceiling effect. More comprehensive measures, including balance testing, may be required for risk stratification.

Prediction of Poor Short-Term Prognosis and Unmet Needs in Advanced Chronic Obstructive Pulmonary Disease: Use of the Two-Minute Walking Distance Extracted from a Six-Minute Walk Test

OBJECTIVES

Prognostic challenges hinder the identification of patients with advanced chronic obstructive pulmonary disease (COPD) for timely palliative interventions. We postulate that a two-minute derivative (two-minute walking distance [2MWD]) of a standard six-minute walk test (6MWT) can identify frail subjects with poorer survival for early palliative intervention. The primary outcome of interest is mortality at 18 months. Secondary objectives include evaluation of the relationship between the 2MWD and ability to self-care, dyspnea-related disabilities, nutrition, forced expiratory volume in first second (FEV₁), quality of life (QoL), and comorbidity burden.

DESIGN AND SETTING

One hundred twenty-four subjects with stage 3 and 4 COPD were recruited and followed up. Ability to self-care, dyspnea-related disabilities, airflow limitation, nutrition, and QoL were measured by using modified Barthel index (MBI), Modified Medical Research Council (MMRC) dyspnea scale, FEV₁ (% predicted), BODE [BMI(B), FEV₁(O), MMRC(D), 6MWT(E)] index, updated ADO [Age(A), MMRC(D), FEV₁(O)] index, Subjective Global Assessment (SGA), and St. George's Respiratory Questionnaire (SGRQ), respectively. Survival data were prospectively collected and analyzed.

RESULTS

The 2MWD correlates highly with BODE and predicts updated ADO independent of age, co-morbidities, long-term oxygen therapy (LTOT), body mass index, and FEV₁. Log-rank test performed with Kaplan-Meier plots demonstrates that 2MWD ≤80 m significantly predicts survival time (p < 0.05). Cox proportional hazard regression shows a 3.6-time greater probability of 18-month mortality (hazard ratio [HR] 3.57; 95% confidence interval [CI] 1.26-10.13; p < 0.05). In addition, 2MWD strongly predicted MBI and MMRC, independent of age, co-morbidities, LTOT, body mass index, and FEV₁. Subjects with 2MWD ≤80 m have a poorer ability to self-care (median MBI 90 vs. 100), lower FEV₁ (32.9% ± 9.8% vs. 38.1% ± 9.4%), poorer QoL (mean SGRQ 46.6 ± 16.2 vs. 36.6 ± 13.3), and greater dyspnea-related disability (mean MMRC 1.7 ± 0.7 vs. 0.9 ± 0.6), and they are more malnourished (40.4% vs. 9.7%; RR 1.51) (all p < 0.001).

CONCLUSION

2MWD ≤80 m identifies subjects with higher mortality, greater functional dependence, poorer in nutrition, greater dyspnea, and lower QoL. Incorporation of 2MWD into composite prognostic indices can enhance predictive accuracy and identify patients requiring early proactive palliative interventions.

Effects of pulmonary rehabilitation in lung transplant candidates: a systematic review

OBJECTIVES

The aim of this systematic review of randomised controlled trials (RCTs), and quasi-experimental and retrospective studies is to investigate the effects of pulmonary rehabilitation (PR) in patients with advanced chronic disease on the waiting list for lung transplantation.

SETTING

PR performed for inpatient or outpatient lung transplant candidates.

INTERVENTION

PR programme including aerobic exercise training and/or resistance exercise training.

PRIMARY AND SECONDARY OUTCOMES

Quality of life and exercise capacity (primary outcomes). Survival rate after transplant surgery; pulmonary function; respiratory muscle strength; psychological aspects; upper and lower extremity muscle strength and adverse effects (secondary outcomes). Two review authors independently selected the studies, assessed study quality and extracted data. Studies in any language were included.

RESULTS

This was a systematic review and studies were searched on the Cochrane Library, MEDLINE, EMBASE, CINAHL and PEDro. Experimental and retrospective studies evaluating the effects of PR in candidates for lung transplantation (>18 years old) with any lung diseases were included. 2 RCTs, and two quasi-experimental and two retrospectives studies, involving 1305 participants were included in the review. 5 studies included an enhancement reported in quality of life using the Short Form 36 questionnaire and showed improvements in some domains. All studies included exercise capacity evaluated through 6 min walk test and in five of them, there were improvements in this outcome after PR. Owing to the different characteristics of the studies, it was not possible to perform a meta-analysis.

CONCLUSIONS

Studies included in this review showed that PR is an effective treatment option for patients on the waiting list for lung transplantation and can improve quality of life and exercise capacity in those patients. Although individual studies reported positive effects of PR, this review shows that there is a need for more studies of a high methodological quality addressing PR effects in lung transplant candidates.

TRIAL REGISTRATION NUMBER

PROSPERO CDR42015025110.

Survival and outcomes after lung transplantation for non-scleroderma connective tissue-related interstitial lung disease

BACKGROUND

Patients with non-scleroderma connective tissue-related lung disease (NS-CTLD), including rheumatoid arthritis, idiopathic inflammatory myopathies, Sjögren syndrome, mixed connective tissue disease, and systemic lupus erythematosus, may be at risk for worse outcomes after lung transplantation because of immune dysregulation or extrapulmonary manifestations of their underlying disease. We compared survival, acute and chronic rejection, and extrapulmonary organ dysfunction after transplantation in patients with NS-CTLD and idiopathic pulmonary fibrosis (IPF).

METHODS

This was a retrospective cohort study of patients with NS-CTLD and IPF who were listed in the Scientific Registry of Transplant Recipients and underwent lung transplantation from May 5, 2005, to March 1, 2016.

RESULTS

Patients with NS-CTLD (n = 275) were younger, a higher percentage female and non-white than patients with IPF (n = 6,346). NS-CTLD patients did not have worse adjusted survival (hazard ratio, 1.14, 95% confidence interval [CI], 0.92-1.42; p = 0.24). They were not more likely to have an episode of acute cellular rejection (odds ratio, 0.96; 95% CI, 0.72-1.28; p = 0.77) or to develop bronchiolitis obliterans syndrome (odds ratio, 0.82; 95% CI, 0.60-1.12; p = 0.21). Patients with NS-CTLD were not more likely to require plasmapheresis or dialysis or to develop a lymphoproliferative malignancy or liver disease after transplantation.

CONCLUSIONS

We found no significant differences in survival, acute or chronic rejection, or extrapulmonary organ dysfunction in patients who underwent lung transplantation for NS-CTLD compared with IPF. In appropriately selected candidates, NS-CTLD should not be considered a contraindication to lung transplantation.

Physical rehabilitation for lung transplant candidates and recipients: An evidence-informed clinical approach

Physical rehabilitation of lung transplant candidates and recipients plays an important in optimizing physical function prior to transplant and facilitating recovery of function post-transplant. As medical and surgical interventions in lung transplantation have evolved over time, there has been a demographic shift of individuals undergoing lung transplantation including older individuals, those with multiple co-morbidites, and candidates with respiratory failure requiring bridging to transplantation. These changes have an impact on the rehabilitation needs of lung transplant candidates and recipients. This review provides a practical approach to rehabilitation based on research and clinical practice at our transplant centre. It focuses on functional assessment and exercise prescription during an uncomplicated and complicated clinical course in the pre-transplant, early and late post-transplant periods. The target audience includes clinicians involved in pre- and post-transplant patient care and rehabilitation researchers.

Lung transplantation at Duke

Lung transplantation represents the gold-standard therapy for patients with end-stage lung disease. Utilization of this therapy continues to rise. The Lung Transplant Program at Duke University Medical Center was established in 1992, and since that time has grown to one of the highest volume centers in the world. The program to date has performed over 1,600 lung transplants. This report represents an up-to-date review of the practice and management strategies employed for safe and effective lung transplantation at our center. Specific attention is paid to the evaluation of candidacy for lung transplantation, donor selection, surgical approach, and postoperative management. These evidence-based strategies form the foundation of the clinical transplantation program at Duke.

The utility of preoperative six-minute-walk distance in lung transplantation

RATIONALE

The use of 6-minute-walk distance (6MWD) as an indicator of exercise capacity to predict postoperative survival in lung transplantation has not previously been well studied.

OBJECTIVES

To evaluate the association between 6MWD and postoperative survival following lung transplantation.

METHODS

Adult, first time, lung-only transplantations per the United Network for Organ Sharing database from May 2005 to December 2011 were analyzed. Kaplan-Meier methods and Cox proportional hazards modeling were used to determine the association between preoperative 6MWD and post-transplant survival after adjusting for potential confounders. A receiver operating characteristic curve was used to determine the 6MWD value that provided maximal separation in 1-year mortality. A subanalysis was performed to assess the association between 6MWD and post-transplant survival by disease category.

MEASUREMENTS AND MAIN RESULTS

A total of 9,526 patients were included for analysis. The median 6MWD was 787 ft (25th-75th percentiles = 450-1,082 ft). Increasing 6MWD was associated with significantly lower overall hazard of death (P < 0.001). Continuous increase in walk distance through 1,200-1,400 ft conferred an incremental survival advantage. Although 6MWD strongly correlated with survival, the impact of a single dichotomous value to predict outcomes was limited. All disease categories demonstrated significantly longer survival with increasing 6MWD (P ≤ 0.009) except pulmonary vascular disease (P = 0.74); however, the low volume in this category (n = 312; 3.3%) may limit the ability to detect an association.

CONCLUSIONS

6MWD is significantly associated with post-transplant survival and is best incorporated into transplant evaluations on a continuous basis given limited ability of a single, dichotomous value to predict outcomes.

Lung transplantation: overall approach regarding its major aspects

Lung transplantation is a well-established treatment for patients with advanced lung disease. The evaluation of a candidate for transplantation is a complex task and involves a multidisciplinary team that follows the patient beyond the postoperative period. Currently, the mean time on the waiting list for lung transplantation in the state of São Paulo, Brazil, is approximately 18 months. For Brazil as a whole, data from the Brazilian Organ Transplant Association show that, in 2014, there were 67 lung transplants and 204 patients on the waiting list for lung transplantation. Lung transplantation is most often indicated in cases of COPD, cystic fibrosis, interstitial lung disease, non-cystic fibrosis bronchiectasis, and pulmonary hypertension. This comprehensive review aimed to address the major aspects of lung transplantation: indications, contraindications, evaluation of transplant candidates, evaluation of donor candidates, management of transplant recipients, and major complications. To that end, we based our research on the International Society for Heart and Lung Transplantation guidelines and on the protocols used by our Lung Transplant Group in the city of São Paulo, Brazil.

Psychosocial Predictors of Mortality Following Lung Transplantation

Lung transplantation has become an increasingly common treatment for patients with end-stage lung disease. Few studies have examined psychosocial risk factors for mortality in transplant recipients, despite evidence suggesting that elevated levels of negative affect are associated with greater mortality following major cardiac surgery. We therefore examined the relationship between negative affect early after lung transplantation and long-term survival in a sample of 132 lung transplant recipients (28 cystic fibrosis, 64 chronic obstructive pulmonary disease, 26 idiopathic pulmonary fibrosis, 14 other) followed for up to 13.5 years (median 7.4 years) following transplantation. Patients underwent both medical and psychosocial assessments 6 months following transplantation, which included the Beck Depression Inventory-II (BDI-II), Spielberger Anxiety Inventory, and General Health Questionnaire (GHQ). Over the course of follow-up, 80 (61%) participants died. Controlling for demographic factors, native lung disease, disease severity, family income, education level, social support, and frequency of posttransplant rejection, elevated symptoms of depression (BDI-II: HR = 1.31, p = 0.011) and distress (GHQ: HR = 1.28, p = 0.003) were associated with increased mortality. Higher levels of depression and general distress, but not anxiety, measured 6 months following lung transplantation are associated with increased mortality, independent of background characteristics and medical predictors.

Six-minute-walk distance and accelerometry predict outcomes in chronic obstructive pulmonary disease independent of Global Initiative for Chronic Obstructive Lung Disease 2011 Group

RATIONALE

The 2011 combined Global Initiative for Chronic Obstructive Lung Disease (GOLD) assessment incorporates symptoms, exacerbation history, and spirometry in discriminating risk of exacerbations in patients with chronic obstructive pulmonary disease (COPD). Six-minute-walk distance (6MWD) and accelerometry also have been used to assess disease severity in COPD. The association between these measures and the risks of hospitalization and mortality in the context of GOLD 2011 is unknown.

OBJECTIVES

To describe changes in exercise tolerance and physical activity over time in patients with COPD and to test the hypothesis that lower baseline 6MWD or accelerometry step count is associated with increased risk of COPD-related hospitalization or all-cause mortality, independent of GOLD 2011 group.

METHODS

Physical function and medical outcomes were prospectively assessed in 326 patients with moderate to severe COPD in INSPIRE-II, a randomized controlled trial of a coping skills training intervention. Cox models were used to determine if GOLD 2011 group, 6MWD, or accelerometry steps were associated with risk of COPD-related hospitalization or all-cause mortality.

MEASUREMENTS AND MAIN RESULTS

Physical function declined over time in GOLD group D but remained stable in groups A, B, and C. GOLD classification was associated with time to death or first COPD-related hospitalization. Baseline 6MWD was more strongly associated with time to death or first COPD-related hospitalization (hazard ratio, 0.50 [95% confidence interval, 0.34, 0.73] per 150 m, P=0.0003) than GOLD 2011 classification. A similar relationship was observed for accelerometry steps (hazard ratio, 0.80 [95% confidence interval, 0.70, 0.92] per 1,000 steps, P=0.002).

CONCLUSIONS

Exercise tolerance and daily physical activity are important predictors of hospitalization and mortality in COPD, independent of GOLD 2011 classification. Physical function may represent a modifiable risk factor that warrants increased attention as a target for interventions to improve clinically meaningful outcomes in COPD.

Pretransplant frailty is associated with decreased survival after lung transplantation

BACKGROUND

Frailty is a condition of increased vulnerability to adverse health outcomes. Although frailty is an important prognostic factor for many conditions, the effect of frailty on mortality in lung transplantation is unknown. Our objective was to assess the association of frailty with survival after lung transplantation.

METHODS

We performed a retrospective cohort analysis of all adult lung transplant recipients at our institution between 2002 and 2013. Frailty was assessed using the frailty deficit index, a validated instrument that assesses cumulative deficits for up to 32 impairments and measures the proportion of deficits present (with frailty defined as >0.25). We examined the association between frailty and survival, adjusting for age, sex, and bilateral (vs single) lung transplant using Cox proportional hazard regression models.

RESULTS

Among 144 lung transplant patients, 102 (71%) completed self-reported questionnaires necessary to assess the frailty deficit index within 1 year before lung transplantation. Frail patients (n = 46) had an increased risk of death, with an adjusted hazard ratio (HR) of 2.24 (95% confidence interval [CI], 1.22-4.19; p = 0.0089). Frailty was not associated with an increased duration of mechanical ventilation (median, 2 vs 2 days; p = 0.26), intensive care unit length of stay (median, 7.5 vs 6 days; p = 0.36) or hospital length of stay after transplantation (median, 14 vs 10.5 days; p = 0.26).

CONCLUSIONS

Pre-transplant frailty was independently associated with decreased survival after lung transplantation. Pre-transplant frailty may represent an important area for intervention to improve candidate selection and lung transplant outcomes.

Overweight-mortality paradox and impact of six-minute walk distance in lung transplantation

Overweight–mortality paradox and impact of six-minute walk distance (SMWD) in lung transplantation

Predicting 6-minute walking distance in recipients of lung transplantation: longitudinal study of 108 patients

BACKGROUND

Exercise capacity, muscle function, and physical activity levels remain reduced in recipients of lung transplantation. Factors associated with this deficiency in functional exercise capacity have not been studied longitudinally.

OBJECTIVE

The study aims were to analyze the longitudinal change in 6-minute walking distance and to identify factors contributing to this change.

DESIGN

This was a longitudinal historical cohort study.

METHODS

Data from patients who received a lung transplantation between March 2003 and March 2013 were analyzed for the change in 6-minute walking distance and contributing factors at screening, discharge, and 6 and 12 months after transplantation. Linear mixed-model and logistic regression analyses were performed with data on characteristics of patients, diagnosis, waiting list time, length of hospital stay, rejection, lung function, and peripheral muscle strength.

RESULTS

Data from 108 recipients were included. Factors predicting 6-minute walking distance were measurement moment, diagnosis, sex, quadriceps muscle and grip strength, forced expiratory volume in 1 second (percentage of predicted), and length of hospital stay. After transplantation, 6-minute walking distance increased considerably. This initial increase was not continued between 6 and 12 months. At 12 months after lung transplantation, 58.3% of recipients did not reach the cutoff point of 82% of the predicted 6-minute walking distance. Logistic regression demonstrated that discharge values for forced expiratory volume in 1 second and quadriceps or grip strength were predictive for reaching this criterion.

LIMITATIONS

Study limitations included lack of knowledge on the course of disease during the waiting list period, type and frequency of physical therapy after transplantation, and number of missing data points.

CONCLUSIONS

Peripheral muscle strength predicted 6-minute walking distance; this finding suggests that quadriceps strength training should be included in physical training to increase functional exercise capacity. Attention should be paid to further increasing 6-minute walking distance between 6 and 12 months after transplantation.

An official systematic review of the European Respiratory Society/American Thoracic Society: measurement properties of field walking tests in chronic respiratory disease

This systematic review examined the measurement properties of the 6-min walk test (6MWT), incremental shuttle walk test (ISWT) and endurance shuttle walk test (ESWT) in adults with chronic respiratory disease.

Studies that report the evaluation or use of the 6MWT, ISWT or ESWT were included. We searched electronic databases for studies published between January 2000 and September 2013.

The 6-min walking distance (6MWD) is a reliable measure (intra-class correlation coefficients ranged from 0.82 to 0.99 in seven studies). There is a learning effect, with greater distance walked on the second test (pooled mean improvement of 26 m in 13 studies). Reliability was similar for ISWT and ESWT, with a learning effect also evident for ISWT (pooled mean improvement of 20 m in six studies). The 6MWD correlates more strongly with peak work capacity (r=0.59–0.93) and physical activity (r=0.40–0.85) than with respiratory function (r=0.10–0.59). Methodological factors affecting 6MWD include track length, encouragement, supplemental oxygen and walking aids. Supplemental oxygen also affects ISWT and ESWT performance. Responsiveness was moderate to high for all tests, with greater responsiveness to interventions that included exercise training.

The findings of this review demonstrate that the 6MWT, ISWT and ESWT are robust tests of functional exercise capacity in adults with chronic respiratory disease.

A functional assessment of patients two years after lung transplantation in Poland

THE AIM OF THE STUDY

The aim of the study was to assess the long-term results of lung transplantation (LT) in Poland two years after the procedure.

MATERIAL AND METHODS

The study included patients who underwent LT between December 2004 and December 2009 in the Silesian Center for Heart Diseases in Zabrze. Various lung functions (forced vital capacity - FVC; forced expiratory volume in 1 second - FEV1), the quality of life (SF-36 questionnaire), the level of perceived dyspnea (Medical Research Council - MRC; basic dyspnea index - BDI), and the patient's mobility (the 6-minute walking test - 6MWT) were assessed before and approximately 24 months after LT. Among 35 patients who underwent LT, 20 patients were referred to our study (mean age: 46.6 ± 9.03 years).

RESULTS

After LT, a statistically significant increase was observed in the distance achieved in the 6MWT (323.8 vs. 505.8 m), FVC (1.64 vs. 2.88 L), and FEV1 (1.37 vs. 2.09 L). An improvement in perceived dyspnea in MRC and BDI questionnaires was observed in patients with chronic obstructive pulmonary disease (COPD) after LT. The assessment of the quality of life, excluding perceived pain, showed the most significant improvement in the physical cumulative score (PCS; 25 vs. 45 points), especially in patients with idiopathic pulmonary fibrosis.

CONCLUSIONS

Lung transplantation in Poland, in patients who live longer than 2 years after the procedure, significantly improves the mobility, lung function, perceived dyspnea, and the quality of life.

Impact of pulmonary rehabilitation on quality of life and functional capacity in patients on waiting lists for lung transplantation

OBJECTIVE:

To investigate the impact of a pulmonary rehabilitation program on the functional capacity and on the quality of life of patients on waiting lists for lung transplantation.

METHODS:

Patients on lung transplant waiting lists were referred to a pulmonary rehabilitation program consisting of 36 sessions. Before and after the program, participating patients were evaluated with the six-minute walk test and the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36). The pulmonary rehabilitation program involved muscle strengthening exercises, aerobic training, clinical evaluation, psychiatric evaluation, nutritional counseling, social assistance, and educational lectures.

RESULTS:

Of the 112 patients initially referred to the program, 58 completed it. The mean age of the participants was 46 ± 14 years, and females accounted for 52%. Of those 58 patients, 37 (47%) had pulmonary fibrosis, 13 (22%) had pulmonary emphysema, and 18 (31%) had other types of advanced lung disease. The six-minute walk distance was significantly greater after the program than before (439 ± 114 m vs. 367 ± 136 m, p = 0.001), the mean increase being 72 m. There were significant point increases in the scores on the following SF-36 domains: physical functioning, up 22 (p = 0.001), role-physical, up 10 (p = 0.045); vitality, up 10 (p < 0.001); social functioning, up 15 (p = 0.001); and mental health, up 8 (p = 0.001).

CONCLUSIONS:

Pulmonary rehabilitation had a positive impact on exercise capacity and quality of life in patients on lung transplant waiting lists.

Neurobehavioral functioning and survival following lung transplantation

BACKGROUND

Neurobehavioral functioning is widely recognized as being an important consideration in lung transplant candidates, but little is known about whether these factors are related to clinical outcomes. The present study examined the relationship of neurobehavioral functioning, including measures of executive function and memory, depression, and anxiety, to long-term survival among lung transplant recipients.

METHODS

The sample was drawn from 201 patients who underwent transplantation at Duke University and Washington University who participated in a dual-site clinical trial investigating medical and psychosocial outcomes in transplant candidates with end-stage lung disease. All patients completed the Beck Depression Inventory-II (BDI-II) and Spielberger State-Trait Anxiety Inventory at baseline and again after 12 weeks, while a subset of 86 patients from Duke University also completed neurocognitive testing. Patients were followed for survival up to 12 years after completing baseline assessments.

RESULTS

One hundred eleven patients died over a mean follow-up of 10.8 years (SD=0.8). Baseline depression, anxiety, and neurocognitive function were examined as predictors of posttransplant survival, controlling for age, 6-min walk distance, FEV, and native disease; education and cardiovascular risk factors were also included in the model for neurocognition. Lower executive function (hazard ratio [HR]=1.09, P=.012) and memory performance (HR=1.11, P=.030) were independently associated with greater mortality following lung transplant. Although pretransplant depression and anxiety were not predictive of mortality, patients who scored>13 on the BDI-II at baseline and after 3 months pretransplant had greater mortality (HR=1.85 [95% CI, 1.04, 3.28], P=.036).

CONCLUSIONS

Neurobehavioral functioning, including persistently elevated depressive symptoms and lower neurocognitive performance, was associated with reduced survival after lung transplantation.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT00113139; URL: www.clinicaltrials.gov.

Pulmonary rehabilitation in lung transplant candidates

BACKGROUND

While awaiting lung transplantation, candidates may participate in pulmonary rehabilitation to improve their fitness for surgery. However, pulmonary rehabilitation outcomes have not been systematically evaluated in lung transplant candidates.

METHODS

This investigation was a retrospective cohort study of 345 pre-transplant pulmonary rehabilitation participants who received a lung transplant between January 2004 and June 2009 and had available pre-transplant exercise data. Data extracted included: 6-minute walk tests at standard intervals; exercise training details; health-related quality-of-life (HRQL) measures; and early post-transplant outcomes. Paired t-tests were used to examine changes in the 6MW distance (6MWD), exercise training volume and HRQL during the pre-transplant period. We evaluated the association between pre-transplant 6MWD and transplant hospitalization outcomes.

RESULTS

The final 6MWD prior to transplantation was only 15 m less than the listing 6MWD (n = 200; p = 0.002). Exercise training volumes increased slightly from the start of the pulmonary rehabilitation program until transplant: treadmill, increase 0.69 ml/kg/min (n = 238; p < 0.0001); biceps resistance training, 18 lbs. × reps (n = 286; p < 0.0001); and quadriceps resistance training, 15 lbs. × reps (n = 278; p < 0.0001). HRQL measures declined. A greater final 6MWD prior to transplant correlated with a shorter length of stay in the hospital (n = 207; p = 0.003).

CONCLUSIONS

Exercise capacity and training volumes are well preserved among lung transplant candidates participating in pulmonary rehabilitation, even in the setting of severe, progressive lung disease. Participants with greater exercise capacity prior to transplantation have more favorable early post-transplant outcomes.