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Himebauch AS, Yehya N, Schaubel DE, Josephson MB, Berg RA, Kawut SM, Christie JD. Poor functional status at the time of waitlist for pediatric lung transplant is associated with worse pretransplant outcomes. J Heart Lung Transplant 2023; 42:1735-1742. [PMID: 37437825 PMCID: PMC10776805 DOI: 10.1016/j.healun.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 06/14/2023] [Accepted: 07/04/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND Whether functional status is associated with survival to pediatric lung transplant is unknown. We hypothesized that completely dependent functional status at waitlist registration, defined using Lansky Play Performance Scale (LPPS), would be associated with worse outcomes. METHODS Retrospective cohort study of pediatric lung transplant registrants utilizing United Network for Organ Sharing's Standard Transplant Analysis and Research files (2005-2020). Primary exposure was completely dependent functional status, defined as LPPS score of 10-40. Primary outcome was waitlist removal for death/deterioration with cause-specific hazard ratio (CSHR) regression. Subdistribution hazard regression (SHR, Fine and Gray) was used for the secondary outcome of waitlist removal due to transplant/improvement with a competing risk of death/deterioration. Confounders included: sex, age, race, diagnosis, ventilator dependence, extracorporeal membrane oxygenation, year, and listing center volume. RESULTS A total of 964 patients were included (63.5% ≥ 12 years, 50.2% cystic fibrosis [CF]). Median waitlist days were 95; 20.1% were removed for death/deterioration and 68.2% for transplant/improvement. Completely dependent functional status was associated with removal due to death/deterioration (adjusted CSHR 5.30 [95% CI 2.86-9.80]). This association was modified by age (interaction p = 0.0102), with a larger effect for age ≥12 years, and particularly strong for CF. In the Fine and Gray model, completely dependent functional status did not affect the risk of removal due to transplant/improvement with a competing risk of death/deterioration (adjusted SHR 1.08 [95% CI 0.77-1.49]). CONCLUSIONS Pediatric lung transplant registrants with the worst functional status had worse pretransplant outcomes, especially for adolescents and CF patients. Functional status at waitlist registration may be a modifiable risk factor to improve survival to lung transplant.
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Affiliation(s)
- Adam S Himebauch
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Nadir Yehya
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Douglas E Schaubel
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Maureen B Josephson
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Steven M Kawut
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Medicine, Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason D Christie
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Medicine, Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Remelli F, Scaramuzzo G, Capuzzo M, Maietti E, Berselli A, Denti M, Zani G, Squadrani E, La Rosa R, Volta CA, Volpato S, Spadaro S. Frailty trajectories in ICU survivors: A comparison between the clinical frailty scale and the Tilburg frailty Indicator and association with 1 year mortality. J Crit Care 2023; 78:154398. [PMID: 37531923 DOI: 10.1016/j.jcrc.2023.154398] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 07/03/2023] [Accepted: 07/24/2023] [Indexed: 08/04/2023]
Abstract
PURPOSE To test the agreement of the Clinical Frailty Scale (CFS) and the Tilburg Frailty Indicator (TFI), their association with 3, 6 months and 1-year mortality and the trajectory of frailty in a mixed population of ICU survivors. MATERIAL AND METHODS This is a prospective, multicenter, longitudinal study on ICU survivors ≥18 years old with an ICU stay >72 h. For each patient, sociodemographic and clinical data were collected. Frailty was assessed during ICU stay and at 3, 6, 12 months after ICU discharge, through both CFS and TFI. RESULTS 124 patients with a mean age of 66 years old were enrolled. The baseline prevalence of frailty was 15.3% by CFS and 44.4% by TFI. Baseline CFS and TFI correlated but showed low agreement (Cohen's K = 0.23, p < 0.001). Baseline CFS score, but not TFI, was significantly associated to 1 year mortality. Moreover, CFS score during the follow-up was independently associated 1-year mortality (OR = 1.43; 95% CI: 1.18-1.73). CONCLUSIONS CFS and TFI identify different populations of frail ICU survivors. Frail patients before ICU according to CFS have a significantly higher mortality after ICU discharge. The CFS during follow-up is an independent negative prognostic factor of long-term mortality in the ICU population.
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Affiliation(s)
| | - Gaetano Scaramuzzo
- Department of Translational Medicine, University of Ferrara, Italy; Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria of Ferrara, Italy.
| | - Maurizia Capuzzo
- Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria of Ferrara, Italy
| | - Elisa Maietti
- Department of Biomedical and Neuromotor Science, University of Bologna, Italy
| | - Angela Berselli
- Anesthesia and Intensive Care, Azienda Ospedaliera Carlo Poma, Mantova, Italy
| | - Marianna Denti
- Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria of Ferrara, Italy
| | - Gianluca Zani
- Anesthesia and Intensive Care, Ospedale Santa Maria delle Croci, Ravenna, Italy
| | - Eleonora Squadrani
- Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria of Ferrara, Italy
| | - Riccardo La Rosa
- Department of Translational Medicine, University of Ferrara, Italy
| | - Carlo Alberto Volta
- Department of Translational Medicine, University of Ferrara, Italy; Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria of Ferrara, Italy
| | - Stefano Volpato
- Department of Medical Science, University of Ferrara, Italy; Geriatrics and Orthogeriatrics Unit, Azienda Ospedaliero-Universitaria of Ferrara, Italy
| | - Savino Spadaro
- Department of Translational Medicine, University of Ferrara, Italy; Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria of Ferrara, Italy
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Singer JP, Gao Y, Huang CY, Kordahl RC, Sriram A, Hays SR, Kukreja J, Venado A, Calabrese DR, Greenland JR. The Association Between Frailty and Chronic Lung Allograft Dysfunction After Lung Transplantation. Transplantation 2023; 107:2255-2261. [PMID: 37287095 PMCID: PMC10524113 DOI: 10.1097/tp.0000000000004672] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND After lung transplantation, both frailty and chronic lung allograft dysfunction (CLAD) commonly develop, and when they do, are associated with poorer outcomes. Given their potential shared mechanisms, we sought to explore the temporal relationship between frailty and CLAD onset. METHODS In a single center, we prospectively measured frailty by the short physical performance battery (SPPB) repeatedly after transplant. Because of the nature of the relationship between frailty and CLAD is unknown, we tested the association between frailty, modeled as a time-dependent predictor, and CLAD development as well as CLAD development, modeled as a time-dependent predictor, and frailty development. To do so, we used Cox proportional cause-specific hazards and conditional logistic regression models adjusted for age, sex, race, diagnosis, cytomegalovirus serostatus, posttransplant body mass index, and acute cellular rejection episodes as time-dependent covariates. We tested SPPB frailty as a binary (≤9 points) and continuous predictor (12-point scale); as an outcome, we defined frailty as SPPB ≤9. RESULTS The 231 participants were a mean age of 55.7 y (SD 12.1). After adjusting for covariates, the development of frailty within 3 y after lung transplant was associated with cause-specific CLAD risk (adjusted cause-specific hazard ratio: 1.76; 95% confidence interval [CI], 1.05-2.92 when defining frailty as SPPB ≤9 and adjusted cause-specific hazard ratio: 1.10, 95% CI, 1.03-1.18 per 1-point worsening in SPPB). CLAD onset did not appear to be a risk factor for subsequent frailty (odds ratio, 4.0; 95% CI, 0.4-197.0). CONCLUSIONS Studying the mechanisms underlying frailty and CLAD could provide new insights into the pathobiology of both and potential targets for intervention.
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Affiliation(s)
- Jonthan P Singer
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Ying Gao
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Chiung-Yu Huang
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA
| | - Rose C Kordahl
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Anya Sriram
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Steven R Hays
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Jasleen Kukreja
- San Francisco Veterans Affairs Health Care System, San Francisco, CA
| | - Aida Venado
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Daniel R Calabrese
- Department of Medicine, University of California San Francisco, San Francisco, CA
- San Francisco Veterans Affairs Health Care System, San Francisco, CA
| | - John R Greenland
- Department of Medicine, University of California San Francisco, San Francisco, CA
- San Francisco Veterans Affairs Health Care System, San Francisco, CA
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4
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Osadnik CR, Brighton LJ, Burtin C, Cesari M, Lahousse L, Man WDC, Marengoni A, Sajnic A, Singer JP, Ter Beek L, Tsiligianni I, Varga JT, Pavanello S, Maddocks M. European Respiratory Society statement on frailty in adults with chronic lung disease. Eur Respir J 2023; 62:2300442. [PMID: 37414420 DOI: 10.1183/13993003.00442-2023] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 06/11/2023] [Indexed: 07/08/2023]
Abstract
Frailty is a complex, multidimensional syndrome characterised by a loss of physiological reserves that increases a person's susceptibility to adverse health outcomes. Most knowledge regarding frailty originates from geriatric medicine; however, awareness of its importance as a treatable trait for people with chronic respiratory disease (including asthma, COPD and interstitial lung disease) is emerging. A clearer understanding of frailty and its impact in chronic respiratory disease is a prerequisite to optimise clinical management in the future. This unmet need underpins the rationale for undertaking the present work. This European Respiratory Society statement synthesises current evidence and clinical insights from international experts and people affected by chronic respiratory conditions regarding frailty in adults with chronic respiratory disease. The scope includes coverage of frailty within international respiratory guidelines, prevalence and risk factors, review of clinical management options (including comprehensive geriatric care, rehabilitation, nutrition, pharmacological and psychological therapies) and identification of evidence gaps to inform future priority areas of research. Frailty is underrepresented in international respiratory guidelines, despite being common and related to increased hospitalisation and mortality. Validated screening instruments can detect frailty to prompt comprehensive assessment and personalised clinical management. Clinical trials targeting people with chronic respiratory disease and frailty are needed.
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Affiliation(s)
- Christian R Osadnik
- Monash University, Department of Physiotherapy, Frankston, Australia
- Monash Health, Monash Lung, Sleep, Allergy and Immunology, Frankston, Australia
| | - Lisa J Brighton
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK
- King's College London, Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Chris Burtin
- REVAL Rehabilitation Research Center, BIOMED Biomedical Research Institute, Hasselt University, Hasselt, Belgium
| | - Matteo Cesari
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Lies Lahousse
- Department of Bioanalysis, Ghent University, Ghent, Belgium
| | - Will D C Man
- Heart Lung and Critical Care Group, Guy's and St Thomas' NHS Foundation Trust, London, UK
- National Heart and Lung Institute, Imperial College, London, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Alessandra Marengoni
- Department of Clinical and Experimental Science, University of Brescia, Brescia, Italy
- Aging Research Center, Karolinska Institutet, Stockholm, Sweden
| | - Andreja Sajnic
- Department for Respiratory Diseases Jordanovac, University Hospital Center, Zagreb, Croatia
| | - Jonathan P Singer
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Lies Ter Beek
- Vrije Universiteit Amsterdam, University Medical Center Groningen, Amsterdam, The Netherlands
| | - Ioanna Tsiligianni
- Department of Social Medicine, Faculty of Medicine, University of Crete, Heraklion, Greece
| | - Janos T Varga
- Semmelweis University, Department of Pulmonology, Budapest, Hungary
- National Koranyi Institute of Pulmonology, Department of Pulmonary Rehabilitation, Budapest, Hungary
| | | | - Matthew Maddocks
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK
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Wang L, Zhang X, Liu X. Prevalence and clinical impact of frailty in COPD: a systematic review and meta-analysis. BMC Pulm Med 2023; 23:164. [PMID: 37173728 PMCID: PMC10182679 DOI: 10.1186/s12890-023-02454-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 04/26/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Frailty has been increasingly identified as a risk factor of adverse outcomes in chronic obstructive pulmonary disease (COPD). The prevalence and impact of frailty on health outcomes in people with COPD require clarification. METHODS PubMed, Embase, The Cochrane Library and Web of Science (January 1, 2002, to July 1, 2022) were comprehensively searched to identify studies related to frailty and COPD. Comparisons were made between people who did and did not have frailty for pulmonary function, dyspnea severity, 6-minute walking distance, activities of daily life, and mortality. RESULTS Twenty studies (9 cross-sectional, 10 cohort studies,1 clinical trial) from Europe (9), Asia (6), and North and South America (4), Oceania (1) involving 11, 620 participants were included. The prevalence of frailty was 32.07% (95% confidence interval (CI) 26.64-37.49) with a range of 6.43-71.70% based on the frailty tool used. People with frailty had lower predicted forced expiratory volume in the first second (mean difference - 5.06%; 95%CI -6.70 to -3.42%), shorter 6-minute walking distance (mean difference - 90.23 m; 95%CI -124.70 to -55.76), poorer activities of daily life (standardized mean difference - 0.99; 95%CI -1.35 to -0.62), higher CAT(COPD Assessment Test) score(mean difference 6.2; 95%CI 4.43 to 7.96) and mMRC (modified Medical Research Council) grade (mean difference 0.93; 95%CI 0.85 to 1.02) compared with those who did not (P < 0.001 for all). Meta-analysis showed that frailty was associated with an increased risk of long-term all-cause mortality (HR 1.68; 95% CI 1.37-2.05; I2 = 0%, P < 0.001). CONCLUSION Frailty is prevalent in people with COPD and linked with negative clinical outcomes including pulmonary function, dyspnea severity, exercise capacity, quality of life and mortality.
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Affiliation(s)
- Lina Wang
- Geriatric Department, Peking University First Hospital, Xicheng District, Xishiku Avenue No 8, Beijing, 100034, China
| | - Xiaolin Zhang
- Geriatric Department, Peking University First Hospital, Xicheng District, Xishiku Avenue No 8, Beijing, 100034, China
| | - Xinmin Liu
- Geriatric Department, Peking University First Hospital, Xicheng District, Xishiku Avenue No 8, Beijing, 100034, China.
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Singer JP, Calfee CS, Delucchi K, Diamond JM, Anderson MA, Benvenuto LA, Gao Y, Wang P, Arcasoy SM, Lederer DJ, Hays SR, Kukreja J, Venado A, Kolaitis NA, Leard LE, Shah RJ, Kleinhenz ME, Golden J, Betancourt L, Oyster M, Brown M, Zaleski D, Medikonda N, Kalman L, Balar P, Patel S, Calabrese DR, Greenland JR, Christie JD. Subphenotypes of frailty in lung transplant candidates. Am J Transplant 2023; 23:531-539. [PMID: 36740192 PMCID: PMC11005295 DOI: 10.1016/j.ajt.2023.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 12/16/2022] [Accepted: 12/30/2022] [Indexed: 02/05/2023]
Abstract
Heterogeneous frailty pathobiology might explain the inconsistent associations observed between frailty and lung transplant outcomes. A Subphenotype analysis could refine frailty measurement. In a 3-center pilot cohort study, we measured frailty by the Short Physical Performance Battery, body composition, and serum biomarkers reflecting causes of frailty. We applied latent class modeling for these baseline data. Next, we tested class construct validity with disability, waitlist delisting/death, and early postoperative complications. Among 422 lung transplant candidates, 2 class model fit the best (P = .01). Compared with Subphenotype 1 (n = 333), Subphenotype 2 (n = 89) was characterized by systemic and innate inflammation (higher IL-6, CRP, PTX3, TNF-R1, and IL-1RA); mitochondrial stress (higher GDF-15 and FGF-21); sarcopenia; malnutrition; and lower hemoglobin and walk distance. Subphenotype 2 had a worse disability and higher risk of waitlist delisting or death (hazards ratio: 4.0; 95% confidence interval: 1.8-9.1). Of the total cohort, 257 underwent transplant (Subphenotype 1: 196; Subphenotype 2: 61). Subphenotype 2 had a higher need for take back to the operating room (48% vs 28%; P = .005) and longer posttransplant hospital length of stay (21 days [interquartile range: 14-33] vs 18 days [14-28]; P = .04). Subphenotype 2 trended toward fewer ventilator-free days, needing more postoperative extracorporeal membrane oxygenation and dialysis, and higher need for discharge to rehabilitation facilities (P ≤ .20). In this early phase study, we identified biological frailty Subphenotypes in lung transplant candidates. A hyperinflammatory, sarcopenic Subphenotype seems to be associated with worse clinical outcomes.
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Affiliation(s)
- Jonathan P Singer
- Division of Pulmonary and Critical Care, Department of Medicine, University of California, San Francisco, California, USA.
| | - Carolyn S Calfee
- Division of Pulmonary and Critical Care, Department of Medicine, University of California, San Francisco, California, USA
| | - Kevin Delucchi
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, California, USA
| | - Joshua M Diamond
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michaela A Anderson
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Luke A Benvenuto
- Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University Medical Center, New York City, New York, USA
| | - Ying Gao
- Division of Pulmonary and Critical Care, Department of Medicine, University of California, San Francisco, California, USA
| | - Ping Wang
- Division of Pulmonary and Critical Care, Department of Medicine, University of California, San Francisco, California, USA; San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - Selim M Arcasoy
- Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University Medical Center, New York City, New York, USA
| | | | - Steven R Hays
- Division of Pulmonary and Critical Care, Department of Medicine, University of California, San Francisco, California, USA
| | - Jasleen Kukreja
- Division of Cardiothoracic Surgery, University of California, San Francisco, California, USA
| | - Aida Venado
- Division of Pulmonary and Critical Care, Department of Medicine, University of California, San Francisco, California, USA
| | - Nicholas A Kolaitis
- Division of Pulmonary and Critical Care, Department of Medicine, University of California, San Francisco, California, USA
| | - Lorianna E Leard
- Division of Pulmonary and Critical Care, Department of Medicine, University of California, San Francisco, California, USA
| | - Rupal J Shah
- Division of Pulmonary and Critical Care, Department of Medicine, University of California, San Francisco, California, USA
| | - Mary Ellen Kleinhenz
- Division of Pulmonary and Critical Care, Department of Medicine, University of California, San Francisco, California, USA
| | - Jeffrey Golden
- Division of Pulmonary and Critical Care, Department of Medicine, University of California, San Francisco, California, USA
| | - Legna Betancourt
- Division of Pulmonary and Critical Care, Department of Medicine, University of California, San Francisco, California, USA
| | - Michelle Oyster
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Melanie Brown
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Derek Zaleski
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nikhila Medikonda
- Division of Pulmonary and Critical Care, Department of Medicine, University of California, San Francisco, California, USA
| | - Laurel Kalman
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Priya Balar
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Shreena Patel
- Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University Medical Center, New York City, New York, USA
| | - Daniel R Calabrese
- Division of Pulmonary and Critical Care, Department of Medicine, University of California, San Francisco, California, USA; San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - John R Greenland
- Division of Pulmonary and Critical Care, Department of Medicine, University of California, San Francisco, California, USA; San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - Jason D Christie
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Rudym D, Natalini JG, Trindade AJ. Listing Dilemmas: Age, Frailty, Weight, Preexisting Cancers, and Systemic Diseases. Clin Chest Med 2023; 44:35-46. [PMID: 36774166 DOI: 10.1016/j.ccm.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Selection of lung transplant candidates is an evolving field that pushes the boundaries of what is considered the norm. Given the continually changing demographics of the typical lung transplant recipient as well as the growing list of risk factors that predispose patients to poor posttransplant outcomes, we explore the dilemmas in lung transplant candidate selections pertaining to older age, frailty, low and high body mass index, preexisting cancers, and systemic autoimmune rheumatic diseases.
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Affiliation(s)
- Darya Rudym
- Division of Pulmonary and Critical Care Medicine, New York University, Langone Health, 530 First Avenue, HCC-4A, New York, NY 10016, USA.
| | - Jake G Natalini
- Division of Pulmonary and Critical Care Medicine, New York University, Langone Health, 530 First Avenue, HCC-4A, New York, NY 10016, USA
| | - Anil J Trindade
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Oxford House, Room 539, 1313 21st Avenue South, Nashville, TN 37232, USA
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8
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Kristobak BM, Bezinover D, Geyer N, Cios TJ. Decline in Functional Status While on the Waiting List Predicts Worse Survival After Lung Transplantation. J Cardiothorac Vasc Anesth 2022; 36:4370-4377. [PMID: 36163154 DOI: 10.1053/j.jvca.2022.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 08/17/2022] [Accepted: 08/22/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To determine if decreases in the Karnofsky Performance Score (KPS) while on the waitlist predict decreased survival after lung transplantation (LTx). DESIGN A retrospective evaluation of the United Network for Organ Sharing database. The KPS was evaluated at the time of listing for transplant and at the time of transplantation. Group I consisted of patients having a decrease in KPS during the time on the waiting list (from the time of listing to the time of transplant), and Group II consisted of patients whose KPS stayed the same or increased during the same period. The authors used propensity-score weighting for comparisons of these groups. SETTING Retrospective observational database review. PARTICIPANTS Adult patients undergoing lung transplantation. INTERVENTIONS None. Patients were stratified according to a change in their KPS. MEASUREMENTS AND MAIN RESULTS Patient and graft survival of patients with decreasing or not decreasing KPS were compared. Of the 27,558 subjects included in the analysis, 17,986 (65%) had worsening KPS, which was associated with worse graft (p = 0.0003) and patient (p = 0.0019) survival after LTx. Using multivariate regression, a decrease in KPS of ≥40 was associated with decreased survival, and an increase of ≥40 was associated with improved survival (HR = 1.245, 95% CI [1.181-1.312], p < 0.0001 and HR = 0.866, 95% CI [0.785, 0.955], respectively). Among patients with a KPS <40 at the time of transplant, those with a decrease in KPS of ≥40 had decreased graft and patient survival compared with those with a smaller decrease (p = 0.0002 and p = 0.0021, respectively). CONCLUSIONS Deterioration of KPS on the waiting list for LTx is associated with significantly greater postoperative mortality in patients after LTx. These results should be taken into consideration when allocating organs. Strategies to increase or to prevent a decrease in KPS before LTx should be evaluated.
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Affiliation(s)
- Benjamin M Kristobak
- Department of Anesthesiology and Perioperative Medicine, Penn State Hershey Medical Center, Hershey, PA
| | - Dmitri Bezinover
- Department of Anesthesiology and Perioperative Medicine, Penn State Hershey Medical Center, Hershey, PA
| | - Nathaniel Geyer
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
| | - Theodore J Cios
- Department of Anesthesiology and Perioperative Medicine, Penn State Hershey Medical Center, Hershey, PA.
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9
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Kao J, Reid N, Hubbard RE, Homes R, Hanjani LS, Pearson E, Logan B, King S, Fox S, Gordon EH. Frailty and solid-organ transplant candidates: a scoping review. BMC Geriatr 2022; 22:864. [PMID: 36384461 PMCID: PMC9667636 DOI: 10.1186/s12877-022-03485-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 09/14/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND There is currently no consensus as to a standardized tool for frailty measurement in any patient population. In the solid-organ transplantation population, routinely identifying and quantifying frailty in potential transplant candidates would support patients and the multidisciplinary team to make well-informed, individualized, management decisions. The aim of this scoping review was to synthesise the literature regarding frailty measurement in solid-organ transplant (SOT) candidates. METHODS A search of four databases (Cochrane, Pubmed, EMBASE and CINAHL) yielded 3124 studies. 101 studies (including heart, kidney, liver, and lung transplant candidate populations) met the inclusion criteria. RESULTS We found that studies used a wide range of frailty tools (N = 22), including four 'established' frailty tools. The most commonly used tools were the Fried Frailty Phenotype and the Liver Frailty Index. Frailty prevalence estimates for this middle-aged, predominantly male, population varied between 2.7% and 100%. In the SOT candidate population, frailty was found to be associated with a range of adverse outcomes, with most evidence for increased mortality (including post-transplant and wait-list mortality), post-operative complications and prolonged hospitalisation. There is currently insufficient data to compare the predictive validity of frailty tools in the SOT population. CONCLUSION Overall, there is great variability in the approach to frailty measurement in this population. Preferably, a validated frailty measurement tool would be incorporated into SOT eligibility assessments internationally with a view to facilitating comparisons between patient sub-groups and national and international transplant services with the ultimate goal of improved patient care.
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Affiliation(s)
- Jonathan Kao
- Princess Alexandra Hospital, Metro South Hospital and Health Service, Queensland, Australia.
- Geriatrics and Rehabilitation Unit, Building 7 Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, QLD, 4102, Australia.
| | - Natasha Reid
- Centre for Health Services Research, The University of Queensland, Queensland, Australia
| | - Ruth E Hubbard
- Princess Alexandra Hospital, Metro South Hospital and Health Service, Queensland, Australia
- Centre for Health Services Research, The University of Queensland, Queensland, Australia
| | - Ryan Homes
- School of Biomedical Science, The University of Queensland, Queensland, Australia
| | - Leila Shafiee Hanjani
- Centre for Health Services Research, The University of Queensland, Queensland, Australia
| | - Ella Pearson
- School of Biomedical Science, The University of Queensland, Queensland, Australia
| | - Benignus Logan
- Centre for Health Services Research, The University of Queensland, Queensland, Australia
| | - Shannon King
- North Metropolitan Health Service, WA Health, Western Australia, Australia
| | - Sarah Fox
- Centre for Health Services Research, The University of Queensland, Queensland, Australia
- The Prince Charles Hospital, Metro North Hospital and Health Service, Queensland, Australia
| | - Emily H Gordon
- Princess Alexandra Hospital, Metro South Hospital and Health Service, Queensland, Australia
- Centre for Health Services Research, The University of Queensland, Queensland, Australia
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10
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Koons B, Anderson MR, Smith PJ, Greenland JR, Singer JP. The Intersection of Aging and Lung Transplantation: its Impact on Transplant Evaluation, Outcomes, and Clinical Care. CURRENT TRANSPLANTATION REPORTS 2022; 9:149-159. [PMID: 36341000 PMCID: PMC9632682 DOI: 10.1007/s40472-022-00365-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2022] [Indexed: 10/18/2022]
Abstract
Purpose Older adults (age ≥ 65 years) are the fastest growing age group undergoing lung transplantation. Further, international consensus document for the selection of lung transplant candidates no longer suggest a fixed upper age limit. Although carefully selected older adults can derive great benefit, understanding which older adults will do well after transplant with improved survival and health-related qualiy of life is key to informed decision-making. Herein, we review the epidemiology of aging in lung transplantation and its impact on outcomes, highlight selected physiological measures that may be informative when evaluating and managing older lung transplant patients, and identify directions for future research. Recent Findings In general, listing and transplanting older, sicker patients has contributed to worse clinical outcomes and greater healthcare use. Emerging evidence suggest that measures of physiological age, such as frailty, body composition, and neurocognitive and psychosocial function, may better identify risk for poor transplant outcomes than chronlogical age. Summary The evidence base to inform transplant decision-making and improvements in care for older adults is small but growing. Multipronged efforts at the intersection of aging and lung transplantation are needed to improve the clinical and patient centered outcomes for this large and growing cohort of patients. Future research should focus on identifying novel and ideally modifiable risk factors for poor outcomes specific to older adults, better approaches to measuring physiological aging (e.g., frailty, body composition, neurocognitive and psychosocial function), and the underlying mechanisms of physiological aging. Finally, interventions that can improve clinical and patient centered outcomes for older adults are needed.
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Affiliation(s)
- Brittany Koons
- M. Louise Fitzpatrick College of Nursing, Villanova University, 800 Lancaster Avenue, Driscoll Hall Room 350, Villanova, PA 19085, USA
| | - Michaela R. Anderson
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Patrick J. Smith
- Department of Psychiatry and Behavioral Sciences, Division of Behavioral Medicine and Neurosciences, Duke University Medical Center, Durham, NC, USA
| | - John R. Greenland
- Department of Medicine, University of California, San Francisco, CA, USA
- Medical Service, Veterans Affairs Health Care System, San Francisco, CA, USA
| | - Jonathan P. Singer
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, UC San Francisco, San Francisco, CA, USA
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11
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Leard LE, Holm AM, Valapour M, Glanville AR, Attawar S, Aversa M, Campos SV, Christon LM, Cypel M, Dellgren G, Hartwig MG, Kapnadak SG, Kolaitis NA, Kotloff RM, Patterson CM, Shlobin OA, Smith PJ, Solé A, Solomon M, Weill D, Wijsenbeek MS, Willemse BWM, Arcasoy SM, Ramos KJ. Consensus document for the selection of lung transplant candidates: An update from the International Society for Heart and Lung Transplantation. J Heart Lung Transplant 2021; 40:1349-1379. [PMID: 34419372 PMCID: PMC8979471 DOI: 10.1016/j.healun.2021.07.005] [Citation(s) in RCA: 330] [Impact Index Per Article: 110.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 07/14/2021] [Indexed: 02/06/2023] Open
Abstract
Tens of thousands of patients with advanced lung diseases may be eligible to be considered as potential candidates for lung transplant around the world each year. The timing of referral, evaluation, determination of candidacy, and listing of candidates continues to pose challenges and even ethical dilemmas. To address these challenges, the International Society for Heart and Lung Transplantation appointed an international group of members to review the literature, to consider recent advances in the management of advanced lung diseases, and to update prior consensus documents on the selection of lung transplant candidates. The purpose of this updated consensus document is to assist providers throughout the world who are caring for patients with pulmonary disease to identify potential candidates for lung transplant, to optimize the timing of the referral of these patients to lung transplant centers, and to provide transplant centers with a framework for evaluating and selecting candidates. In addition to addressing general considerations and providing disease specific recommendations for referral and listing, this updated consensus document includes an ethical framework, a recognition of the variability in acceptance of risk between transplant centers, and establishes a system to account for how a combination of risk factors may be taken into consideration in candidate selection for lung transplantation.
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Affiliation(s)
| | | | | | | | - Sandeep Attawar
- Krishna Institute of Medical Sciences Institute for Heart and Lung Transplantation, Hyderabad, India
| | | | - Silvia V Campos
- Heart Institute (InCor) University of Sao Paulo Medical School, Sao Paulo, Brazil
| | | | | | - Göran Dellgren
- Sahlgrenska University Hospital and University of Gothenburg, Sweden
| | | | | | | | | | | | | | | | | | - Melinda Solomon
- Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - David Weill
- Weill Consulting Group, New Orleans, Louisiana
| | | | - Brigitte W M Willemse
- Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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12
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Abstract
Rationale: Sarcopenia is associated with disability and death. The optimal definition and clinical relevance of sarcopenia in lung transplantation remain unknown. Objectives: To assess the construct and predictive validity of sarcopenia definitions in lung transplant candidates. Methods: In a multicenter prospective cohort of 424 lung transplant candidates, we evaluated limited (muscle mass only) and expanded (muscle mass and quality) sarcopenia definitions from the European Working Group on Sarcopenia in Older People 2 (EWGSOP2), the Foundation for the National Institutes of Health (FNIH), and a cohort-specific distribution-based lowest quartile definition. We assessed construct validity using associations with conceptually related factors. We evaluated the relationship between sarcopenia and frailty using generalized additive models. We also evaluated associations between sarcopenia definitions and key pretransplant outcomes, including disability (quantified by the Lung Transplant Valued Life Activities scale [range, 0-3; higher scores = worse disability; minimally important difference, 0.3]) and waitlist delisting/death, by multivariate linear and Cox regression, respectively. Results: Sarcopenia prevalence ranged from 6% to13% by definition used. The limited EWGSOP2 definition demonstrated the highest construct validity, followed by the expanded EWGSOP2 definition and both limited and expanded FNIH and lowest quartile definitions. Sarcopenia exhibited a linear association with the risk of frailty. The EWGSOP2 and expanded lowest quartile definitions were associated with disability, ranging from 0.20 to 0.25 higher Lung Transplant Valued Life Activities scores. Sarcopenia was associated with increased risk of waitlist delisting or death by the limited and expanded lowest quartile definitions (hazard ratio [HR], 3.8; 95% confidence interval [CI], 1.4-9.9 and HR, 3.5; 95% CI, 1.1-11.0, respectively) and the EWGSOP2 limited definition (HR, 2.8; 95% CI, 0.9-8.6) but not with the three other candidate definitions. Conclusions: The prevalence and validity of sarcopenia vary by definition; the EWGSOP2 limited definition exhibited the broadest validity in lung transplant candidates. The linear relationship between low muscle mass and frailty highlights sarcopenia's contribution to frailty and also questions the clinical utility of a sarcopenia cut-point in advanced lung disease. The associations between sarcopenia and important pretransplant outcomes support further investigation into using body composition for candidate risk stratification.
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13
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Lomonaco I, Araújo AS, de Figueiredo MRF, Holanda MA, Pereira EDB. Assessment of functional status by the Duke Activity Status Index in stable bronchiectasis. Expert Rev Respir Med 2021; 15:1239-1244. [PMID: 34251944 DOI: 10.1080/17476348.2021.1951238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Bronchiectasis is a growing global health problem. OBJECTIVE AND METHODS To evaluate the functional status of stable bronchiectasis patients recruited from a terciary hospital in Fortaleza, Brazil.The patients were submitted to spirometry, six minute walking test (6MWT), step test (6MST), measurement of fibrinogen,E-FACED scores(incorporates FEV1 ,age,colonisation by Pseudomonas,radiological extension, dyspnoea and exarcebation) and Duke Activity Status Index(DASI) test.Each item of DASI scored proportionally to the metabolic equivalentes(METs). The sum of DASI scores was applied for an estimation of oxygen consumption(VO2). RESULTS The sample comprised 101 patients.Patients with post-tuberculosis bronchiectsis had the lowest level of functional parameters than those with others etiologies[DASI(19.9 ±10.9 vs 31.2±14.4 p<0.001); VO2 (18.1 ± 4.7 vs 23.1 ± 6.1 p< 0.001 respectively)]. DASI scores and estimated VO2 correlated with E-FACED(r= -0.44 p=0.001; and r= -0.44 p=0.001 respectively) and 6MST r= 0.37 p<0.001 and r=0.40 p<0.001 respectively). CONCLUSION After multivariate analysis , bronchiectasis post-TB , E-FACED and 6MWT explained the impact on performance in bronchiectasis patients.
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Affiliation(s)
- Isabella Lomonaco
- Department of Medicine, Federal University of Ceará, Fortaleza, Brazil
| | - Amanda Souza Araújo
- Department of Surgery, Federal University of Ceará, Fortaleza, Brazil.,Department of Rehabilitation, Hospital de Messejana dr. Carlos Alberto Studart, Fortaleza, Brazil
| | - Mara Rúbia F de Figueiredo
- Department of Surgery, Federal University of Ceará, Fortaleza, Brazil.,Department of Rehabilitation, Hospital de Messejana dr. Carlos Alberto Studart, Fortaleza, Brazil
| | - Marcelo A Holanda
- Department of Medicine, Federal University of Ceará, Fortaleza, Brazil
| | - Eanes D B Pereira
- Department of Medicine, Federal University of Ceará, Fortaleza, Brazil
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14
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Schaenman JM, Diamond JM, Greenland JR, Gries C, Kennedy CC, Parulekar AD, Rozenberg D, Singer JP, Singer LG, Snyder LD, Bhorade S. Frailty and aging-associated syndromes in lung transplant candidates and recipients. Am J Transplant 2021; 21:2018-2024. [PMID: 33296550 PMCID: PMC8178173 DOI: 10.1111/ajt.16439] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 11/17/2020] [Accepted: 11/18/2020] [Indexed: 01/25/2023]
Abstract
Many lung transplant candidates and recipients are older and frailer compared to previous eras. Older patients are at increased risk for pre- and posttransplant mortality, but this risk is not explained by numerical age alone. This manuscript represents the product of the American Society of Transplantation (AST) conference on frailty. Experts in the field reviewed the latest published research on assessment of elderly and frail lung transplant candidates. Physical frailty, often defined as slowness, weakness, low physical activity, shrinking, and exhaustion, and frailty evaluation is an important tool for evaluation of age-associated dysfunction. Another approach is assessment by cumulative deficits, and both types of frailty are common in lung transplant candidates. Frailty is associated with death or delisting before transplant, and may be associated with posttransplant mortality. Sarcopenia, cognitive dysfunction, depression, and nutrition are other important components for patient evaluation. Aging-associated inflammation, telomere dysfunction, and adaptive immune system senescence may also contribute to frailty. Developing tools for frailty assessment and interventions holds promise for improving patient outcomes before and after lung transplantation.
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Affiliation(s)
- Joanna M. Schaenman
- Department of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Joshua M. Diamond
- Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John R. Greenland
- Department of Medicine, San Francisco VA Health Care System, San Francisco, CA and University of California, San Francisco CA
| | - Cynthia Gries
- Department of Medicine, AdventHealth Transplant Institute, Orlando FL
| | | | | | - Dmitry Rozenberg
- Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Jonathan P. Singer
- Department of Medicine, San Francisco VA Health Care System, San Francisco, CA and University of California, San Francisco CA
| | - Lianne G. Singer
- Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | - Sangeeta Bhorade
- Medical Affairs-Pulmonary, Veracyte Inc, South San Francisco, CA
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15
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Diamond JM, Courtwright AM, Balar P, Oyster M, Zaleski D, Adler J, Brown M, Hays SR, Sutter N, Garvey C, Kukreja J, Gao Y, Bruun A, Smith PJ, Singer JP. Mobile health technology to improve emergent frailty after lung transplantation. Clin Transplant 2021; 35:e14236. [PMID: 33527520 DOI: 10.1111/ctr.14236] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/22/2021] [Accepted: 01/25/2021] [Indexed: 12/18/2022]
Abstract
We evaluated the feasibility, safety, and efficacy of a mHealth-supported physical rehabilitation intervention to treat frailty in a pilot study of 18 lung transplant recipients. Frail recipients were defined by a short physical performance battery (SPPB score ≤7). The primary intervention modality was Aidcube, a customizable rehabilitation mHealth platform. Our primary aims included tolerability, feasibility, and acceptability of use of the platform, and secondary outcomes were changes in SPPB and in scores of physical activity, and disability measured using the Duke Activity Status Index (DASI) and Lung Transplant-Value Life Activities (LT-VLA). Notably, no adverse events were reported. Subjects reported the app was easy to use, usability improved over time, and the app enhanced motivation to engage in rehabilitation. Comments highlighted the complexities of immediate post-transplant rehabilitation, including functional decline, pain, tremor, and fatigue. At the end of the intervention, SPPB scores improved a median of 5 points from a baseline of 4. Physical activity and patient-reported disability also improved. The DASI improved from 4.5 to 19.8 and LT-VLA score improved from 2 to 0.59 at closeout. Overall, utilization of a mHealth rehabilitation platform was safe and well received. Remote rehabilitation was associated with improvements in frailty, physical activity and disability. Future studies should evaluate mHealth treatment modalities in larger-scale randomized trials of lung transplant recipients.
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Affiliation(s)
- Joshua M Diamond
- Pulmonary Allergy, and Critical Care Division, University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew M Courtwright
- Pulmonary Allergy, and Critical Care Division, University of Pennsylvania, Philadelphia, PA, USA
| | - Priya Balar
- Pulmonary Allergy, and Critical Care Division, University of Pennsylvania, Philadelphia, PA, USA
| | - Michelle Oyster
- Pulmonary Allergy, and Critical Care Division, University of Pennsylvania, Philadelphia, PA, USA
| | - Derek Zaleski
- Good Shepherd Penn Partners at the University of Pennsylvania, Philadelphia, USA
| | - Joe Adler
- Good Shepherd Penn Partners at the University of Pennsylvania, Philadelphia, USA
| | - Melanie Brown
- Pulmonary Allergy, and Critical Care Division, University of Pennsylvania, Philadelphia, PA, USA
| | - Steven R Hays
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Nicole Sutter
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Chris Garvey
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Jasleen Kukreja
- Division of Adult Cardiothoracic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Ying Gao
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California San Francisco, San Francisco, CA, USA
| | | | - Patrick J Smith
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
| | - Jonathan P Singer
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California San Francisco, San Francisco, CA, USA
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16
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Frailty in Lung Transplantation - Candidate Assessment and Optimization. Transplantation 2021; 105:2201-2212. [PMID: 33982913 DOI: 10.1097/tp.0000000000003671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The concept of frailty has gained considerable interest in clinical solid organ transplantation over the past decade. Frailty as a phenotypic construct to describe a patient's risk from biologic stresses, has an impact on posttransplant survival. There is keen interest in characterizing frailty in lung transplantation, both to determine which patients are suitable candidates for listing and also to prepare for their care in the aftermath of lung transplantation. Here we review the current status of research on frailty in lung transplant candidates and recipients. This review will highlight areas of uncertainty for frailty in clinical lung transplantation which are likely to impact the state-of-the-art in the field for the next decade.
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17
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Baldwin MR, Pollack LR, Friedman RA, Norris SP, Javaid A, O'Donnell MR, Cummings MJ, Needham DM, Colantuoni E, Maurer MS, Lederer DJ. Frailty subtypes and recovery in older survivors of acute respiratory failure: a pilot study. Thorax 2020; 76:350-359. [PMID: 33298583 DOI: 10.1136/thoraxjnl-2020-214998] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 10/30/2020] [Accepted: 11/05/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND Identifying subtypes of acute respiratory failure survivors may facilitate patient selection for post-intensive care unit (ICU) follow-up clinics and trials. METHODS We conducted a single-centre prospective cohort study of 185 acute respiratory failure survivors, aged ≥ 65 years. We applied latent class modelling to identify frailty subtypes using frailty phenotype and cognitive impairment measurements made during the week before hospital discharge. We used Fine-Gray competing risks survival regression to test associations between frailty subtypes and recovery, defined as returning to a basic Activities of Daily Living disability count less than or equal to the pre-hospitalisation count within 6 months. We characterised subtypes by pre-ICU frailty (Clinical Frailty Scale score ≥ 5), the post-ICU frailty phenotype, and serum inflammatory cytokines, hormones and exosome proteomics during the week before hospital discharge. RESULTS We identified five frailty subtypes. The recovery rate decreased 49% across each subtype independent of age, sex, pre-existing disability, comorbidity and Acute Physiology and Chronic Health Evaluation II score (recovery rate ratio: 0.51, 95% CI 0.41 to 0.63). Post-ICU frailty phenotype prevalence increased across subtypes, but pre-ICU frailty prevalence did not. In the subtype with the slowest recovery, all had cognitive impairment. The three subtypes with the slowest recovery had higher interleukin-6 levels (p=0.03) and a higher prevalence of ≥ 2 deficiencies in insulin growth factor-1, dehydroepiandrostersone-sulfate, or free-testosterone (p=0.02). Exosome proteomics revealed impaired innate immunity in subtypes with slower recovery. CONCLUSIONS Frailty subtypes varied by prehospitalisation frailty and cognitive impairment at hospital discharge. Subtypes with the slowest recovery were similarly characterised by greater systemic inflammation and more anabolic hormone deficiencies at hospital discharge.
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Affiliation(s)
- Matthew R Baldwin
- Pulmonary, Allergy, and Critical Care, Columbia University Irving Medical Center, New York, New York, USA
| | - Lauren R Pollack
- Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Richard A Friedman
- Bioinformatics, Columbia University Irving Medical Center, New York, New York, USA
| | - Simone P Norris
- Pulmonary, Allergy, and Critical Care, Columbia University Irving Medical Center, New York, New York, USA
| | - Azka Javaid
- Pulmonary, Allergy, and Critical Care, Columbia University Irving Medical Center, New York, New York, USA
| | - Max R O'Donnell
- Pulmonary, Allergy, and Critical Care, Columbia University Irving Medical Center, New York, New York, USA
| | - Matthew J Cummings
- Pulmonary, Allergy, and Critical Care, Columbia University Irving Medical Center, New York, New York, USA
| | - Dale M Needham
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, Maryland, USA.,Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth Colantuoni
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, Maryland, USA.,Department of Biostatistics, Johns Hopkins University-Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Mathew S Maurer
- Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - David J Lederer
- Pulmonary, Allergy, and Critical Care, Columbia University Irving Medical Center, New York, New York, USA.,Regeneron Pharmaceuticals, Tarrytown, New York, USA
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18
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Anderson MR, Geleris J, Anderson DR, Zucker J, Nobel YR, Freedberg D, Small-Saunders J, Rajagopalan KN, Greendyk R, Chae SR, Natarajan K, Roh D, Edwin E, Gallagher D, Podolanczuk A, Barr RG, Ferrante AW, Baldwin MR. Body Mass Index and Risk for Intubation or Death in SARS-CoV-2 Infection : A Retrospective Cohort Study. Ann Intern Med 2020; 173:782-790. [PMID: 32726151 PMCID: PMC7397550 DOI: 10.7326/m20-3214] [Citation(s) in RCA: 153] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Obesity is a risk factor for pneumonia and acute respiratory distress syndrome. OBJECTIVE To determine whether obesity is associated with intubation or death, inflammation, cardiac injury, or fibrinolysis in coronavirus disease 2019 (COVID-19). DESIGN Retrospective cohort study. SETTING A quaternary academic medical center and community hospital in New York City. PARTICIPANTS 2466 adults hospitalized with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 infection over a 45-day period with at least 47 days of in-hospital observation. MEASUREMENTS Body mass index (BMI), admission biomarkers of inflammation (C-reactive protein [CRP] level and erythrocyte sedimentation rate [ESR]), cardiac injury (troponin level), and fibrinolysis (D-dimer level). The primary end point was a composite of intubation or death in time-to-event analysis. RESULTS Over a median hospital length of stay of 7 days (interquartile range, 3 to 14 days), 533 patients (22%) were intubated, 627 (25%) died, and 59 (2%) remained hospitalized. Compared with overweight patients, patients with obesity had higher risk for intubation or death, with the highest risk among those with class 3 obesity (hazard ratio, 1.6 [95% CI, 1.1 to 2.1]). This association was primarily observed among patients younger than 65 years and not in older patients (P for interaction by age = 0.042). Body mass index was not associated with admission levels of biomarkers of inflammation, cardiac injury, or fibrinolysis. LIMITATIONS Body mass index was missing for 28% of patients. The primary analyses were conducted with multiple imputation for missing BMI. Upper bounding factor analysis suggested that the results are robust to possible selection bias. CONCLUSION Obesity is associated with increased risk for intubation or death from COVID-19 in adults younger than 65 years, but not in adults aged 65 years or older. PRIMARY FUNDING SOURCE National Institutes of Health.
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Affiliation(s)
- Michaela R Anderson
- Columbia University Irving Medical Center, New York, New York (M.R.A., J.G., J.Z., Y.R.N., D.F., J.S., K.N.R., S.C., K.N., D.R., E.E., A.P., A.W.F., M.R.B.)
| | - Joshua Geleris
- Columbia University Irving Medical Center, New York, New York (M.R.A., J.G., J.Z., Y.R.N., D.F., J.S., K.N.R., S.C., K.N., D.R., E.E., A.P., A.W.F., M.R.B.)
| | - David R Anderson
- Villanova School of Business, Villanova University, Villanova, Pennsylvania (D.R.A.)
| | - Jason Zucker
- Columbia University Irving Medical Center, New York, New York (M.R.A., J.G., J.Z., Y.R.N., D.F., J.S., K.N.R., S.C., K.N., D.R., E.E., A.P., A.W.F., M.R.B.)
| | - Yael R Nobel
- Columbia University Irving Medical Center, New York, New York (M.R.A., J.G., J.Z., Y.R.N., D.F., J.S., K.N.R., S.C., K.N., D.R., E.E., A.P., A.W.F., M.R.B.)
| | - Daniel Freedberg
- Columbia University Irving Medical Center, New York, New York (M.R.A., J.G., J.Z., Y.R.N., D.F., J.S., K.N.R., S.C., K.N., D.R., E.E., A.P., A.W.F., M.R.B.)
| | - Jennifer Small-Saunders
- Columbia University Irving Medical Center, New York, New York (M.R.A., J.G., J.Z., Y.R.N., D.F., J.S., K.N.R., S.C., K.N., D.R., E.E., A.P., A.W.F., M.R.B.)
| | - Kartik N Rajagopalan
- Columbia University Irving Medical Center, New York, New York (M.R.A., J.G., J.Z., Y.R.N., D.F., J.S., K.N.R., S.C., K.N., D.R., E.E., A.P., A.W.F., M.R.B.)
| | - Richard Greendyk
- NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York (R.G.)
| | - Sae-Rom Chae
- Columbia University Irving Medical Center, New York, New York (M.R.A., J.G., J.Z., Y.R.N., D.F., J.S., K.N.R., S.C., K.N., D.R., E.E., A.P., A.W.F., M.R.B.)
| | - Karthik Natarajan
- Columbia University Irving Medical Center, New York, New York (M.R.A., J.G., J.Z., Y.R.N., D.F., J.S., K.N.R., S.C., K.N., D.R., E.E., A.P., A.W.F., M.R.B.)
| | - David Roh
- Columbia University Irving Medical Center, New York, New York (M.R.A., J.G., J.Z., Y.R.N., D.F., J.S., K.N.R., S.C., K.N., D.R., E.E., A.P., A.W.F., M.R.B.)
| | - Ethan Edwin
- Columbia University Irving Medical Center, New York, New York (M.R.A., J.G., J.Z., Y.R.N., D.F., J.S., K.N.R., S.C., K.N., D.R., E.E., A.P., A.W.F., M.R.B.)
| | - Dympna Gallagher
- Institute of Human Nutrition, Columbia University Irving Medical Center, New York, New York (D.G.)
| | - Anna Podolanczuk
- Columbia University Irving Medical Center, New York, New York (M.R.A., J.G., J.Z., Y.R.N., D.F., J.S., K.N.R., S.C., K.N., D.R., E.E., A.P., A.W.F., M.R.B.)
| | - R Graham Barr
- Mailman School of Public Health, Columbia University Irving Medical Center, New York, New York (R.G.B.)
| | - Anthony W Ferrante
- Columbia University Irving Medical Center, New York, New York (M.R.A., J.G., J.Z., Y.R.N., D.F., J.S., K.N.R., S.C., K.N., D.R., E.E., A.P., A.W.F., M.R.B.)
| | - Matthew R Baldwin
- Columbia University Irving Medical Center, New York, New York (M.R.A., J.G., J.Z., Y.R.N., D.F., J.S., K.N.R., S.C., K.N., D.R., E.E., A.P., A.W.F., M.R.B.)
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Montgomery E, Macdonald PS, Newton PJ, Chang S, Wilhelm K, Jha SR, Malouf M. Reversibility of Frailty after Lung Transplantation. J Transplant 2020; 2020:3239495. [PMID: 32850137 PMCID: PMC7439792 DOI: 10.1155/2020/3239495] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/26/2020] [Accepted: 07/24/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Frailty contributes to increased morbidity and mortality in patients referred for and undergoing lung transplantation (LTX). The study aim was to determine if frailty is reversible after LTX in those classified as frail at LTX evaluation. METHODS Consecutive LTX recipients were included. All patients underwent modified physical frailty assessment during LTX evaluation. For patients assessed as frail, frailty was reassessed on completion of the post-LTX rehabilitation program. Frailty was defined by the presence of ≥ 3 domains of the modified Fried Frailty Phenotype (mFFP). RESULTS We performed 166 lung transplants (frail patients, n = 27, 16%). Eighteen of the 27 frail patients have undergone frailty reassessment. Eight frail patients died, and one interstate recipient did not return for reassessment. In the 18 (66%) patients reassessed, there was an overall reduction in their frailty score post-LTX ((3.4 ± 0.6 to 1.0 ± 0.7), p < 0.001) with 17/18 (94%) no longer classified as frail. Improvements were seen in the following frailty domains: exhaustion, mobility, appetite, and activity. Handgrip strength did not improve posttransplant. CONCLUSIONS Physical frailty was largely reversible following LTX, underscoring the importance of considering frailty a dynamic, not a fixed, entity. Further work is needed to identify those patients whose frailty is modifiable and establish specific interventions to improve frailty.
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Affiliation(s)
- Elyn Montgomery
- Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Peter S. Macdonald
- Heart & Lung Transplant Program, St Vincent's Hospital, Sydney, NSW, Australia
| | - Phillip J. Newton
- Western Sydney University, School of Nursing and Midwifery, Sydney, NSW, Australia
| | - Sungwon Chang
- Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Kay Wilhelm
- Heart & Lung Transplant Program, St Vincent's Hospital, Sydney, NSW, Australia
| | - Sunita R. Jha
- Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Monique Malouf
- Heart & Lung Transplant Program, St Vincent's Hospital, Sydney, NSW, Australia
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Abstract
Frailty is a clinical state of vulnerability to stressors resulting from cumulative alterations in multiple physiological and molecular systems. Frailty assessment in patients with chronic disease is useful for identifying those who are at increased risk for poor clinical and patient reported outcomes. Due to biobehavioral changes purported to cause both frailty and certain chronic lung diseases, patients with lung disease appear susceptible to frailty and prone to developing it decades earlier than community dwelling healthy populations. Herein, we review the literature and potential pathobiological mechanisms underpinning associations between frailty in lung disease and age, sex, comorbidity and symptom burden, severity of lung disease, inflammatory biomarkers, various clinical parameters, body composition measures, and physical activity levels. We also propose a multipronged program of future research focused on improving the accuracy and precision of frailty measurement in lung disease, identifying blood-based biomarkers and measures of body composition for frailty, determining whether subphenotypes of frailty with distinct pathobiology exist, and developing personalized interventions that target the specific underlying mechanisms causing frailty.
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Paul JA, Whittington RA, Baldwin MR. Critical Illness and the Frailty Syndrome: Mechanisms and Potential Therapeutic Targets. Anesth Analg 2020; 130:1545-1555. [PMID: 32384344 DOI: 10.1213/ane.0000000000004792] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Frailty is a syndrome characterized by decreased reserves across multiple physiologic systems resulting in functional limitations and vulnerability to new stressors. Physical frailty develops over years in community-dwelling older adults but presents or worsens within days in the intensive care unit (ICU) because common mechanisms governing age-related physical frailty are often exacerbated by critical illness. The hallmark of physical frailty is a combined loss of muscle mass, force, and endurance. About one-third of ICU patients have frailty before hospitalization, which increases their risk for both short- and long-term disability and mortality. While there are several valid ways to measure clinical frailty in patients before or after an ICU admission, the mechanistic underpinnings of frailty in critically ill patients and ICU survivors have not been thoroughly investigated. Furthermore, therapeutic interventions to treat frailty during and after time in the ICU are lacking. In this narrative review, we examine studies that identify potential biological mechanisms underlying the development and propagation of physical frailty in both aging and critical illness (eg, inflammation, mitochondrial myopathy, and neuroendocrinopathy). We discuss specific aspects of these frailty mechanisms in older adults, critically ill patients, and ICU survivors that may represent therapeutic targets. Consistent with complexity underlying frailty, this syndrome is unlikely to result from an excess of a single harmful mediator or deficit of a single protective mediator. Rather, frailty occurs in the presence of an incompletely understood state of multisystem dysregulation. We further describe knowledge gaps that warrant clinical and translational research in frailty and critical care with an overall goal of developing effective frailty treatments in critically ill patients and ICU survivors.
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Affiliation(s)
- Jonathan A Paul
- From the Department of Anesthesiology, Columbia University Irving Medical Center, New York, New York
| | - Robert A Whittington
- From the Department of Anesthesiology, Columbia University Irving Medical Center, New York, New York
| | - Matthew R Baldwin
- Division of Pulmonary, Allergy, and Critical Care, Department of Internal Medicine, Columbia University Irving Medical Center, New York, New York
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22
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Abstract
RATIONALE Frailty represents an increased vulnerability to adverse health outcomes. The frailty phenotype conceptual model (three or more patient attributes of wasting, exhaustion, low activity, slowness, and weakness) is associated with increased morbidity and mortality in geriatric populations. OBJECTIVES Our objective was to describe the risks associated with frailty in patients with chronic obstructive pulmonary disease. METHODS Data from the National Emphysema Treatment Trial (NETT) were retrospectively analyzed. The frailty phenotype conceptual model was operationalized as three or more frailty parameters (a body mass index decrease of ≥5% over 12 months, self-reported exhaustion, low 6-minute walk distance, or physical activity or respiratory muscle strength in the lowest quartile). Frail participants were compared with participants with two or fewer frailty parameters. Participants were followed starting 12 months after NETT randomization (to minimize surgical effect) for 24 months. Univariate, multivariate, Kaplan-Meier, and Cox proportional hazard analyses were performed, adjusting for treatment arm, age, modified Medical Research Council dyspnea scale, sex, and baseline forced expiratory volume in 1 second (FEV1). Multiple imputation was used for missing values. RESULTS The participants (N = 902) were predominantly white (94.5%) males (59.5%), with a median age of 67 years (interquartile range, 63-70 yr) and a median FEV1% predicted of 26 (interquartile range, 20-33). Six percent of the participants (95% confidence interval [CI], 4.5 to 7.6) were frail. The incidence rate of frailty was 6.4 per 100 person-years. Frail participants reported significantly worse disease-specific and overall quality of life by St. George's Respiratory Questionnaire total score (mean difference of 11.6; 95% CI, 7.6 to 15.6; P < 0.001), mental composite on Medical Outcomes Survey Short Form-36 (mean difference -6.8; 95% CI, -10.0 to -3.6; P < 0.001), and physical composite scores on Medical Outcomes Survey Short Form-36 (mean difference -16.7; 95% CI, -21.3 to -12.1; P = 0.001). Frail participants had an increased rate of hospitalization (adjusted hazard ratio, 1.6; 95% CI, 1.1 to 2.5; P = 0.02) and an adjusted increase in hospital use of 8.0 days (95% CI, 4.4 to 11.6; P < 0.001) compared with nonfrail participants. Frail participants had a higher mortality rate (adjusted hazard ratio, 1.4; 95% CI, 0.97 to 2.0; P = 0.07). CONCLUSIONS Among adults with chronic obstructive pulmonary disease, our measure of frailty (modified from the Fried frailty phenotype) was associated with incident and longer-duration hospitalization, and with poor quality of life.
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Montgomery E, Macdonald PS, Newton PJ, Jha SR, Malouf M. Frailty in lung transplantation: a systematic review. Expert Rev Respir Med 2019; 14:219-227. [DOI: 10.1080/17476348.2020.1702527] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Elyn Montgomery
- Heart & Lung Transplant Program, St Vincent’s Hospital, Sydney, Australia
- Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Peter S. Macdonald
- Heart & Lung Transplant Program, St Vincent’s Hospital, Sydney, Australia
| | - Phillip J. Newton
- School of Nursing and Midwifery, Western Sydney University, Sydney, Australia
| | - Sunita R. Jha
- Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Monique Malouf
- Heart & Lung Transplant Program, St Vincent’s Hospital, Sydney, Australia
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Rosenberg BJ, Hirano M, Quinzii CM, Colantuoni E, Needham DM, Lederer DJ, Baldwin MR. Growth differentiation factor-15 as a biomarker of strength and recovery in survivors of acute respiratory failure. Thorax 2019; 74:1099-1101. [PMID: 31534031 DOI: 10.1136/thoraxjnl-2019-213621] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 08/08/2019] [Accepted: 08/31/2019] [Indexed: 01/31/2023]
Abstract
Muscle mitochondrial dysfunction is implicated in intensive care unit-acquired weakness, but there is no serum biomarker of muscle mitochondrial function for critical illness survivors. Higher serum growth differentiation factor-15 (GDF-15) is a biomarker of inherited mitochondrial myopathy disease and is associated with mortality in several age-related diseases. Among 142 older (age ≥ 65 years) survivors of acute respiratory failure, we found that higher serum GDF-15 measured during the week prior to hospital discharge was cross-sectionally associated with weaker diaphragm, limb and hand-grip strength, and longitudinally associated with lower rates of functional recovery over 6 months, independent of age, sex, pre-existing disability, comorbidity, frailty, Acute Physiology and Chronic Health Evaluation II scores and concurrent interleukin-6 levels.
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Affiliation(s)
- Brian J Rosenberg
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care, Columbia University, New York, New York, USA
| | - Michio Hirano
- Department of Neurology, Division of Neuromuscular Disorders, Columbia University, New York, NY, United States
| | - Catarina M Quinzii
- Department of Neurology, Division of Neuromuscular Disorders, Columbia University, New York, NY, United States
| | - Elizabeth Colantuoni
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Biostatistics, Johns Hopkins University - Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Dale M Needham
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David J Lederer
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care, Columbia University, New York, New York, USA
| | - Matthew R Baldwin
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care, Columbia University, New York, New York, USA
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26
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Guan C, Niu H. Frailty assessment in older adults with chronic obstructive respiratory diseases. Clin Interv Aging 2018; 13:1513-1524. [PMID: 30214171 PMCID: PMC6120513 DOI: 10.2147/cia.s173239] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The number of patients with chronic obstructive pulmonary disease (COPD) has been rising with continued exposure to environmental risk factors and aging of populations around the world. Frailty is a geriatric syndrome with a decline in physiological reserve and often coexists with chronic diseases such as COPD. Frailty is an independent risk factor for the development and progression of COPD, and COPD can lead to frailty; treating one might improve the other. Thus, there is an increasing interest in the assessment of frailty in patients with COPD. Furthermore, early identification and assessment of frailty in patients with COPD may affect the choice of intervention and improve its effectiveness. Based on the current literature, the intent of this review was to summarize and discuss frailty assessment tools used for COPD patients and the relevant clinical practices for predicting outcomes. We ascertain that using suitable frailty assessment tools could facilitate physicians to screen and stratify physically frail patients with COPD. Screening appropriately targeted population can achieve better intervention outcomes and pulmonary rehabilitation among frail COPD patients.
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Affiliation(s)
- Chunyan Guan
- Department of Geriatrics, Sheng Jing Hospital, China Medical University, Shenyang, People's Republic of China,
| | - Huiyan Niu
- Department of Geriatrics, Sheng Jing Hospital, China Medical University, Shenyang, People's Republic of China,
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27
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Singer JP, Diamond JM, Anderson MR, Katz PP, Covinsky K, Oyster M, Blue T, Soong A, Kalman L, Shrestha P, Arcasoy SM, Greenland JR, Shah L, Kukreja J, Blumenthal NP, Easthausen I, Golden JA, McBurnie A, Cantu E, Sonett J, Hays S, Robbins H, Raza K, Bacchetta M, Shah RJ, D’Ovidio F, Venado A, Christie JD, Lederer DJ. Frailty phenotypes and mortality after lung transplantation: A prospective cohort study. Am J Transplant 2018; 18:1995-2004. [PMID: 29667786 PMCID: PMC6105397 DOI: 10.1111/ajt.14873] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 03/26/2018] [Accepted: 03/31/2018] [Indexed: 01/25/2023]
Abstract
Frailty is associated with increased mortality among lung transplant candidates. We sought to determine the association between frailty, as measured by the Short Physical Performance Battery (SPPB), and mortality after lung transplantation. In a multicenter prospective cohort study of adults who underwent lung transplantation, preoperative frailty was assessed with the SPPB (n = 318) and, in a secondary analysis, the Fried Frailty Phenotype (FFP; n = 299). We tested the association between preoperative frailty and mortality following lung transplantation with propensity score-adjusted Cox models. We calculated postestimation marginalized standardized risks for 1-year mortality by frailty status using multivariate logistic regression. SPPB frailty was associated with an increased risk of both 1- and 4-year mortality (adjusted hazard ratio [aHR]: 7.5; 95% confidence interval [CI]: 1.6-36.0 and aHR 3.8; 95%CI: 1.8-8.0, respectively). Each 1-point worsening in SPPB was associated with a 20% increased risk of death (aHR: 1.20; 95%CI: 1.08-1.33). Frail subjects had an absolute increased risk of death within the first year after transplantation of 12.2% (95%CI: 3.1%-21%). In secondary analyses, FFP frailty was associated with increased risk of death within the first postoperative year (aHR: 3.8; 95%CI: 1.1-13.2) but not over longer follow-up. Preoperative frailty is associated with an increased risk of death after lung transplantation.
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Affiliation(s)
| | - Joshua M. Diamond
- Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Michaela R. Anderson
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Patricia P. Katz
- Department of Medicine, University of California, San Francisco, CA
| | - Ken Covinsky
- Department of Medicine, University of California, San Francisco, CA
| | - Michelle Oyster
- Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Tatiana Blue
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Allison Soong
- Department of Medicine, University of California, San Francisco, CA
| | - Laurel Kalman
- Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Pavan Shrestha
- Department of Medicine, University of California, San Francisco, CA
| | - Selim M. Arcasoy
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY
| | | | - Lori Shah
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Jasleen Kukreja
- Department of Surgery, University of California, San Francisco, CA
| | | | - Imaani Easthausen
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY
| | | | - Amika McBurnie
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Ed Cantu
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Joshua Sonett
- Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Steven Hays
- Department of Medicine, University of California, San Francisco, CA
| | - Hilary Robbins
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Kashif Raza
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Matthew Bacchetta
- Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Rupal J. Shah
- Department of Medicine, University of California, San Francisco, CA
| | - Frank D’Ovidio
- Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Aida Venado
- Department of Medicine, University of California, San Francisco, CA
| | - Jason D. Christie
- Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - David J. Lederer
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
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Rozenberg D, Mathur S, Wickerson L, Chowdhury NA, Singer LG. Frailty and clinical benefits with lung transplantation. J Heart Lung Transplant 2018; 37:1245-1253. [PMID: 30293618 DOI: 10.1016/j.healun.2018.06.005] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 05/18/2018] [Accepted: 06/11/2018] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND The Fried frailty phenotype is associated with morbidity and mortality in lung transplant (LTx) candidates, but its clinical application and association with post-transplant outcomes are not well defined. We assessed 2 alternate frailty indices in LTx candidates and evaluated associations of frailty with early post-transplant outcomes and 1-year mortality. METHODS Frailty was prospectively evaluated in 50 LTx candidates using the Fried and 2 alternate phenotypic indices, one using variables readily available to clinicians and one using variables from an existing data set. Agreement between indices and associations with related measures were assessed to establish validity. The data set index was then applied retrospectively to 221 LTx patients. Post-transplant outcomes were compared between frail and non-frail patients using t-tests and multivariable regression analysis. RESULTS Frailty prevalence among the 3 indices was 26% to 30%, and the κ agreement was 0.38 to 0.41. All indices had moderate correlations with London Chest Activity of Daily Living (r = 0.48-0.62) and Short-Physical Performance Battery (r = -0.43 to -0.52). In the retrospective cohort, frail LTx candidates had a worse St. George's Respiratory Questionnaire total score (73 ± 12vs 62 ± 12, p < 0.001). Frail candidates had a larger improvement with transplant in the St. George's Respiratory Questionnaire (-52 ± 19vs -43 ± 18, p = 0.002) and 6-minute walk distance (191 ± 119vs 129 ± 94m, p = 0.001). Frailty was not associated with hospital length of stay or 1-year mortality. CONCLUSIONS There was good construct validity and acceptable agreement among the frailty indices. Despite significant disability pre-transplant, frail LTx candidates derived significant benefit with transplantation.
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Affiliation(s)
- Dmitry Rozenberg
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada; Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Sunita Mathur
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Lisa Wickerson
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Noori A Chowdhury
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Lianne G Singer
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada; Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada.
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29
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Singer JP, Soong A, Bruun A, Bracha A, Chin G, Hays SR, Kukreja J, Rigler J, Golden JA, Greenland JR, Garvey C. A mobile health technology enabled home-based intervention to treat frailty in adult lung transplant candidates: A pilot study. Clin Transplant 2018; 32:e13274. [PMID: 29742287 DOI: 10.1111/ctr.13274] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2018] [Indexed: 01/06/2023]
Abstract
BACKGROUND Frailty is prevalent in lung transplant candidates (LTC) and is associated with waitlist delisting or death. We performed a pilot study to assess the safety and feasibility of a home-based, mobile health technology-facilitated intervention to treat frailty in LTC. METHODS We performed an 8-week, nonrandomized, home-based exercise and nutrition intervention in LTC with Short Physical Performance Battery (SPPB) frailty scores of ≤11. The intervention utilized a customized, mobile device application ("app") enabling monitoring and progression of the intervention in real time. We aimed to evaluate key process measures. Secondarily, we tested whether the intervention could improve frailty scores quantified by the SPPB and Fried Frailty Phenotype (FFP). RESULTS A total of 15 subjects enrolled were 63 ± 5.7 years old; oxygen requirements ranged from 3 to 15LPM. Thirteen subjects completed the intervention. Over 108 subject-weeks, there were no adverse events. Subjects found the app engaging and easy to work with. SPPB frailty improved in 7 (54%) and FFP improved in 8 (62%). There was a strong trend toward improved frailty scores (SPPB change 1.0 ± 1.9; P = .08; FFP change -0.6 ± 1.0; P = .07). CONCLUSION In this pilot study, we found that a home-based prehabilitation program that leverages mobile health technology to target frailty in LTC is well received, safe, and capable of improving physical frailty scores.
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Affiliation(s)
- Jonathan P Singer
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Allison Soong
- Department of Medicine, University of California, San Francisco, CA, USA
| | | | - Ayana Bracha
- Department of Nutrition and Food Services, University of California, San Francisco, CA, USA
| | - Greg Chin
- Department of Nutrition and Food Services, University of California, San Francisco, CA, USA
| | - Steven R Hays
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Jasleen Kukreja
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Julia Rigler
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Jeff A Golden
- Department of Medicine, University of California, San Francisco, CA, USA
| | - John R Greenland
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Chris Garvey
- Department of Medicine, University of California, San Francisco, CA, USA
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30
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Assessing frailty in the intensive care unit: A reliability and validity study. J Crit Care 2018; 45:197-203. [DOI: 10.1016/j.jcrc.2018.02.004] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 02/03/2018] [Accepted: 02/05/2018] [Indexed: 12/13/2022]
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31
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Del Rio JM, Maerz D, Subramaniam K. Noteworthy Literature Published in 2017 for Thoracic Transplantation Anesthesiologists. Semin Cardiothorac Vasc Anesth 2018; 22:49-66. [DOI: 10.1177/1089253217749893] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Thoracic organ transplantation constitutes a significant proportion of all transplant procedures. Thoracic solid organ transplantation continues to be a burgeoning field of research. This article presents a review of remarkable literature published in 2017 regarding perioperative issues pertinent to the thoracic transplant anesthesiologists.
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Affiliation(s)
- J. Mauricio Del Rio
- Duke University, Durham, NC, USA
- Duke University Medical Center, Durham, NC, USA
| | - David Maerz
- University of Pittsburgh, Pittsburgh, PA, USA
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kathirvel Subramaniam
- University of Pittsburgh, Pittsburgh, PA, USA
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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