Development of the Lung Transplant Frailty Scale (LT-FS)

Frailty in lung transplant recipients is associated with anemia and telomere dysfunction but independent of epigenetic age

Frailty is a syndrome of vulnerability to stressors linked to worse outcomes before and after lung transplantation. However, the biological basis of this association is unknown. Biological correlates of aging include epigenetic reprograming, chronic inflammation, telomere dysfunction, and anemia. We hypothesized that these aging-associated biological processes would be associated with frailty in lung transplant recipients. In a nested case-control study, we compared 43 lung transplant recipients who were frail pretransplant and posttransplant with 43 nonfrail matched controls. We quantified peripheral blood leukocyte epigenetic aging (Horvath) and longevity (GrimAge) clocks, telomere length, cytokine profiles, and hemoglobin before transplant. Epigenetic clocks were correlated with age but not frailty. However, we observed hypermethylation of multiple gene pathways, including hedgehog signaling and angiogenesis, and associated decreased levels of plasma cytokines in frail recipients. Frailty was also associated with telomere dysfunction and anemia. Overall, telomere dysfunction and anemia of chronic disease were most linked to frailty in this cohort, whereas epigenetic aging and chronic inflammation were not. Understanding the heterogeneity of aging syndromes may help target interventions in frail lung transplant recipients.

The Path Forward: A Review on Enhanced Recovery After Cardiothoracic Transplantation

Enhanced Recovery After Surgery (ERAS) protocols represent a contemporary, evidence-based strategy for optimizing perioperative care to enhance patient outcomes through a standardized approach. While ERAS protocols have demonstrated significant benefits across a range of surgical specialties, specific guidelines tailored for cardiothoracic transplantation have yet to be developed. Given the unique complexity and heightened vulnerability of transplant patients, the implementation of ERAS principles in this context could potentially mitigate postoperative complications, reduce the length of hospital stays, and facilitate improved recovery trajectories. This review highlights the critical importance of adapting and applying ERAS methodologies in cardiothoracic transplantation to achieve improved surgical outcomes and elevate patient quality of life.

The Liver Frailty Index: a model for establishing organ-specific frailty metrics across all solid organ transplantation

PURPOSE OF REVIEW

In this review, we discuss the development of the Liver Frailty Index (LFI) and how it may serve as a model for developing other organ-specific frailty indices.

RECENT FINDINGS

As the demand for solid organ transplants continues to increase, the transplantation community is enhancing its strategies for organ allocation to gain deeper insights into patient risk profiles and anticipated outcomes. Frailty has emerged as a critical concept in transplant care, offering valuable insights into adverse health outcomes. Standardizing frailty assessment across transplant programs could enhance prognostic accuracy and inform pretransplant interventions.The LFI comprises of three performance-based tests that each represents essential components of the multidimensional frailty construct. This composite metric provides insights beyond liver function and considers nonhepatic comorbid factors. Identifying common frailty principles among all transplant candidates and adopting the LFI methodology, which assesses fundamental frailty principles using liver-specific tools, could establish a foundational pool of shared core frailty principles. From this pool, organ-specific frailty indices could be derived, each equipped with the clinically relevant organ-specific tools to evaluate common core principles.

SUMMARY

Creating a standardized framework across all solid-organ transplants, with common principles and organ-specific measurements, would facilitate consistent frailty assessment, standardize the integration of the frailty construct into transplant decision-making, and enable center-level interventions to improve outcomes for patients with end-stage organ disease.

What Happens to Frailty in the First Year After Lung Transplantation?

BACKGROUND

Frailty is prevalent in lung transplant (LTx) candidates, but the impact and subsequent frailty trajectory is unclear. This study aimed to investigate frailty over the first year after LTx.

METHOD

Post-LTx recipients completed a thrice weekly 12-week directly supervised exercise rehabilitation program. Edmonton Frail Scale (EFS) was used to assess frailty. Primary outcome was 6-Minute Walk Distance (6MWD) measured at pre-LTx, prerehabilitation, postrehabilitation, and 1 year post-LTx.

RESULTS

106 of 139 recruited participants underwent LTx: mean age 58 years, 48% male, 52% with chronic obstructive pulmonary disease. Mean (± SD) frailty scores pre-LTx and 1 year post-LTx were 5.54 ± 2.4 and 3.28 ±1.5. Mean 6MWD improved significantly for all: prerehabilitation 326 m (SD 116), versus postrehabilitation 523 m (SD 101) (p < 0.001) versus 1 year 512 m (SD 120) (p < 0.001). There were significant differences between an EFS > 7 (frail) and EFS ≤ 7 (not frail) for 6MWD, grip strength (GS), anxiety, and depression. Postrehabilitation, there were no significant differences in 6MWD, GS, anxiety, or depression while comparing EFS > 7 versus ≤ 7. At 1 year, there was a significant difference in depression but not 6MWD, GS, or anxiety between those EFS ≤ 7 and > 7 (p = 0.017).

CONCLUSION

Participants in a structured post-LTx rehabilitation program improved in functional exercise capacity (6MWD), GS, depression, and anxiety. For frail participants exercise capacity, depression, anxiety, and GS were well managed in rehabilitation with no significant differences between those who were not frail. Pre-LTx frailty may be reversible post-LTx and should not be an absolute contraindication to LTx.

Comparison of the Effects of Multiple Frailty and Nutritional Indexes on Postoperative Outcomes in Critically Ill Patients Undergoing Lung Transplantation

Background and Objective: Lung transplantation is the only life-extending therapy for end-stage pulmonary disease patients, but its risks necessitate an understanding of outcome predictors, with the frailty index and nutritional status being key assessment tools. This study aims to evaluate the relationship between preoperative frailty and nutritional indexes and the postoperative mortality rate in patients receiving lung transplants, and to determine which measure is a more potent predictor of outcomes. Materials and Methods: This study reviewed 185 adults who received lung transplants at a single medical center between January 2013 and May 2023. We primarily focused on postoperative 7-year overall survival. Other outcomes measured were short-term mortalities, acute rejection, kidney complications, infections, and re-transplantation. We compared the predictive abilities of preoperative nutritional and frailty indicators for survival using receiver operating characteristic curve analysis and identified factors affecting survival through regression analyses. Results: There were no significant differences in preoperative nutritional indicators between survivors and non-survivors. However, preoperative frailty indicators did differ significantly between these groups. Multivariate analysis revealed that the American Society of Anesthesiologists Class V, clinical frailty scale, and Charlson Comorbidity Index (CCI) were key predictors of 7-year overall survival. Of these, the CCI had the strongest predictive ability with an area under the curve of 0.755, followed by the modified frailty index at 0.731. Conclusions: Our study indicates that for critically ill patients undergoing lung transplantation, frailty indexes derived from preoperative patient history and functional autonomy are more effective in forecasting postoperative outcomes, including survival, than indexes related to preoperative nutritional status.

Advances in lung transplantation: 60 years on

Lung transplantation is a well-established treatment for advanced lung disease, improving survival and quality of life. Over the last 60 years all aspects of lung transplantation have evolved significantly and exponential growth in transplant volume. This has been particularly evident over the last decade with a substantial increase in lung transplant numbers as a result of innovations in donor utilization procurement, including the use donation after circulatory death and ex-vivo lung perfusion organs. Donor lungs have proved to be surprisingly robust, and therefore the donor pool is actually larger than previously thought. Parallel to this, lung transplant outcomes have continued to improve with improved acute management as well as microbiological and immunological insights and innovations. The management of lung transplant recipients continues to be complex and heavily dependent on a tertiary care multidisciplinary paradigm. Whilst long term outcomes continue to be limited by chronic lung allograft dysfunction improvements in diagnostics, mechanistic understanding and evolutions in treatment paradigms have all contributed to a median survival that in some centres approaches 10 years. As ongoing studies build on developing novel approaches to diagnosis and treatment of transplant complications and improvements in donor utilization more individuals will have the opportunity to benefit from lung transplantation. As has always been the case, early referral for transplant consideration is important to achieve best results.

Rehabilitation interventions to modify physical frailty in adults before lung transplantation: a systematic review protocol

INTRODUCTION

Lung transplantation is the gold-standard treatment for end-stage lung disease for a small group of patients meeting strict acceptance criteria after optimal medical management has failed. Physical frailty is prevalent in lung transplant candidates and has been linked to worse outcomes both on the waiting list and postoperatively. Exercise has been proven to be beneficial in optimising exercise capacity and quality of life in lung transplant candidates, but its impact on physical frailty is unknown. This review aims to assess the effectiveness of exercise interventions in modifying physical frailty for adults awaiting lung transplantation.

METHODS AND ANALYSIS

This protocol was prospectively registered on the PROSPERO database. We will search four databases plus trial registries to identify primary studies of adult candidates for lung transplantation undertaking exercise interventions and assessing outcomes pertaining to physical frailty. Studies must include at least 10 participants. Article screening will be performed by two researchers independently at each stage. Extraction will be performed by one reviewer and checked by a second. The risk of bias in studies will be assessed by two independent reviewers using tools appropriate for the research design of each study; where appropriate, we will use Cochrane Risk of Bias 2 or ROBINS-I. At each stage of the review process, discrepancies will be resolved through a consensus or consultation with a third reviewer. Meta-analyses of frailty outcomes will be performed if possible and appropriate as will prespecified subgroup and sensitivity analyses. Where we are unable to perform meta-analysis, we will conduct narrative synthesis following Synthesis without Meta-analysis guidance. The review will be reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist.

ETHICS AND DISSEMINATION

No ethical issues are predicted due to the nature of this study. Dissemination will occur via conference abstracts, professional networks, peer-reviewed journals and patient support groups.

PROSPERO REGISTRATION NUMBER

CRD42022363730.

ERS International Congress 2023: highlights from the Thoracic Surgery and Lung Transplantation Assembly

Five sessions presented at the European Respiratory Society Congress 2023 were selected by Assembly 8, consisting of thoracic surgeons and lung transplant professionals. Highlights covering management of adult spontaneous pneumothorax, malignant pleural effusion, infectious and immune-mediated complications after lung transplantation, as well as the pro and con debate on age limit in lung transplantation and results of the ScanCLAD study were summarised by early career members, supervised by the assembly faculty.

Optimizing the prelung transplant candidate

PURPOSE OF REVIEW

Lung transplant outcomes are impacted by multiple modifiable risk factors. Candidate deterioration on the wait list remains problematic. Innovative technology and strategies to identify and impact pretransplant morbidity have improved short- and long-term outcomes. We focus our review on recent advances in pretransplant recipient assessment and optimization.

RECENT FINDINGS

Advancements in recipient management have focused on risk factor identification for adverse outcomes and the development of a lung transplant specific frailty assessment. Early surgical correction of gastroesophageal reflux disease (GERD), including the use of partial fundoplication in the setting of esophageal dysmotility, leads to improvements in graft function/longevity. New evidence supports expanding criteria for extracorporeal life support as a bridge to transplant.

SUMMARY

Candidate optimization requires early intervention to limit functional deterioration potentially contributing to adverse outcomes. Frailty can be identified with a transplant specific frailty assessment, and positively impacted with dedicated rehabilitation. Pretransplant frailty is reversible following transplant and should be considered in the context of overall fitness at the time of candidate selection. Invasive support modes including extracorporeal membrane oxygenation (ECMO) are appropriate to preserve strength and mobility, with awake, ambulatory ECMO preferred. The deleterious effect of GERD on graft function can be managed with early fundoplication over medical management alone.

The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights From 2023

This special article is the 16th in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, and the editorial board for the opportunity to continue this series, namely the research highlights of the past year in the specialty of cardiothoracic and vascular anesthesiology. The major themes selected for 2023 are outlined in this introduction, and each highlight is reviewed in detail in the main article. The literature highlights in the specialty for 2023 begin with an update on perioperative rehabilitation in cardiothoracic surgery, with a focus on novel methods to best assess patients in the preoperative and postoperative periods, and the impact of rehabilitation on outcomes. The second major theme is focused on cardiac surgery, with the authors discussing new insights into inhaled pulmonary vasodilators, coronary revascularization surgery, and discussion of causes of coronary graft failure after surgery. The third theme is focused on cardiothoracic transplantation, with discussions focusing on bridge-to-transplantation strategies. The fourth theme is focused on mechanical circulatory support, with discussions focusing on both temporary and durable support. The fifth and final theme is an update on medical cardiology, with a focus on outcomes of invasive approaches to heart disease. The themes selected for this article are only a few of the diverse advances in the specialty during 2023. These highlights will inform the reader of key updates on various topics, leading to improved perioperative outcomes for patients with cardiothoracic and vascular disease.