Frailty as a Predictor of Outcomes in Heart Transplant-Eligible Patients With Advanced Heart Failure

Discharge frailty following lung transplantation

INTRODUCTION

Frailty at listing for lung transplant has been associated with waitlist and post-transplant mortality. Frailty trajectories following transplant, however, have been less well characterized, including whether recipient frailty improves. The objective of this study was to identify prevalence and risk factors for frailty at discharge and to evaluate changes in frail recipients enrolled in an outpatient physical therapy program.

METHODS

This was a single-center prospective cohort study of lung transplant recipients. Enrollees completed a short physical performance battery (SPPB) to assess frailty at listing and at initial hospital discharge.

RESULTS

Of the 111 enrolled recipients, none were frail at listing and 18 (16.2%) were prefrail. At discharge, however, 60 (54.1%) patients were frail. Discharge frailty was associated with prefrailty at listing, acute kidney injury post-transplant, and longer intensive care unit stay. Among the 35 patients who were frail at discharge and who were enrolled in an outpatient PT program, the median improvement in SPPB was 6 points (IQR = 5-7 points), and 85.7% became not frail over a median of 6 weeks.

CONCLUSION

Discharge frailty is common following lung transplantation. In most frail patients, an intensive outpatient physical therapy program is associated with improvement in frailty, as assessed by the SPPB.

Risk of early, intermediate, and late rejection following heart transplantation: Trends over the past 25 years and relation to changes in medical management. Tertiary center experience: The Sheba Heart Transplantation Registry

AIM

To explore the trends in the risk for rejection following heart transplantation (HT) over the past 25 years, and their relation to changes in medical management.

METHODS

The study population comprised 216 HT patients. Rejection periods were defined as follows: 0-3 months (early), 3-12 months (intermediate), and 12+ months (late). HT era was dichotomized as follows: 1991-1999 (remote era) and 2000-2016 (recent era). Medication combination was categorized as newer (TAC, MMF, and everolimus) vs older therapies (AZA, CSA).

RESULTS

Multivariate analysis showed that patients who underwent HT during the recent era experienced a significant reduction in the risk for major rejection. These findings were consistent for early (OR = 0.44 [95% CI 0.22-0.88]), intermediate (OR = 0.02 [95% CI 0.003-0.11]), and late rejections (OR = 0.18 [95% CI 0.05-0.52]). Using the year of HT as a continuous measure showed that each 1-year increment was independently associated with a significant reduction in the risk for early, intermediate, and late rejections (5%, 21%, 18%, respectively). In contrast, the risk reduction associated with newer types of immunosuppressive therapies was not statistically significant after adjustment for the treatment period.

CONCLUSIONS

Major rejection rates following HT have significantly declined over the past 2 decades even after adjustment for changes in immunosuppressive therapies, suggesting that other factors may also play a role in the improved outcomes of HT recipients.

Latest developments in heart transplantation: a review

PURPOSE

Heart transplantation (HT) remains the treatment of choice for advanced heart failure despite improvements in medical therapy and mechanical circulatory support. Significant developments have occurred in the field of HT over the past year, in particular the successful transplantation of donor hearts after circulatory determination of death. The purpose of this article was to review developments in HT published in 2014 and 2015.

METHODS

Selected articles found using a MEDLINE search of the key term heart transplant were reviewed.

FINDINGS

The year has seen improvements in the attenuation of ischemia and reperfusion injury, patient selection, immunosuppression, imaging of the transplanted heart, and donor organ preservation that hold promise for increasing the number of transplantations and improving outcomes in HT recipients. Advances in the detection and attenuation of cardiac rejection and allograft vasculopathy are highlighted.

IMPLICATIONS

A number of significant advances over the past year hold promise for tangible improvements in outcomes in the field of HT.