The Impact of Exercise Training on Liver Transplanted Familial Amyloidotic Polyneuropathy (FAP) Patients:

Exercise interventions for adults after liver transplantation

BACKGROUND

The finding that exercise is inversely related to metabolic syndrome after transplantation is novel and suggests that exercise interventions might provide a means for reducing metabolic syndrome complications in liver transplantation recipients. The use of exercise for increasing the physical activity daily levels by more frequent, higher intensity, and longer duration of training sessions, or the sum of these components may be necessary to counteract the effects of the pretransplant reduced activity, metabolic disturbances, and post-transplant immunosuppression, as well as improve physical function and aerobic capacity following liver transplantation. Regular physical activity has a long-term positive impact on recovery following various surgical procedures including transplantation, giving people the opportunity to return to an active life with their families, in society, and in their professional life. Likewise, specific muscle strength training may attenuate the loss of strength after liver transplantation.

OBJECTIVES

To evaluate the benefits and harms of exercise-based interventions in adults after liver transplantation compared to no exercise, sham interventions, or another type of exercise.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 2 September 2022.

SELECTION CRITERIA

We included randomised clinical trials in liver transplantation recipients comparing any type of exercise with no exercise, sham interventions, or another type of exercise.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. all-cause mortality; 2. serious adverse events; and 3. health-related quality of life. Our secondary outcomes were 4. a composite of cardiovascular mortality and cardiac disease; 5. aerobic capacity; 6. muscle strength; 7. morbidity; 8. non-serious adverse events; and 9. cardiovascular disease post-transplantation. We assessed risk of bias of the individual trials using RoB 1, described the interventions using the TIDieR checklist, and used GRADE to assess certainty of evidence.

MAIN RESULTS

We included three randomised clinical trials. The trials randomised 241 adults with liver transplantation, of which 199 participants completed the trials. The trials were conducted in the USA, Spain, and Turkey. They compared exercise versus usual care. The duration of the interventions ranged from two to 10 months. One trial reported that 69% of participants who received the exercise intervention were adherent to the exercise prescription. A second trial reported a 94% adherence to the exercise programme, with participants attending 45/48 sessions. The remaining trial reported a 96.8% adherence to the exercise intervention during the hospitalisation period. Two trials received funding; one from the National Center for Research Resources (US) and the other from Instituto de Salud Carlos III (Spain). The remaining trial did not receive funding. All trials were at an overall high risk of bias, derived from high risk of selective reporting bias and attrition bias in two trials. The results on all-cause mortality showed a higher risk of death in the exercise group versus the control group, but these results are very uncertain (risk ratio (RR) 3.14, 95% confidence interval (CI) 0.74 to 13.37; 2 trials, 165 participants; I² = 0%; very low-certainty evidence). The trials did not report data on serious adverse events excluding mortality or non-serious adverse events. However, all trials reported that there were no adverse effects associated with exercise. We are very uncertain on whether exercise compared with usual care has a beneficial or harmful effect on health-related quality of life assessed using the 36-item Short Form Physical Functioning subscale at the end of the intervention (mean difference (MD) 10.56, 95% CI -0.12 to 21.24; 2 trials, 169 participants; I² = 71%; very low-certainty evidence). None of the trials reported data on composite of cardiovascular mortality and cardiovascular disease, and cardiovascular disease post-transplantation. We are very uncertain if there are differences in aerobic capacity in terms of VO2peak at the end of the intervention between groups (MD 0.80, 95% CI -0.80 to 2.39; 3 trials, 199 participants; I² = 0%; very low-certainty evidence). We are very uncertain if there are differences in muscle strength at end of the intervention between groups (MD 9.91, 95% CI -3.68 to 23.50; 3 trials, 199 participants; I² = 44%; very low-certainty evidence). One trial measured perceived fatigue using the Checklist Individual Strength (CIST). Participants in the exercise group showed a clinically important lower degree of fatigue perception than participants in the control group, with a mean reduction of 40 points in the CIST (95% CI 15.62 to 64.38; 1 trial, 30 participants).  We identified three ongoing studies.

AUTHORS' CONCLUSIONS

Based on very low-certainty evidence in our systematic review, we are very uncertain of the role of exercise training (aerobic, resistance-based exercises, or both) in affecting mortality, health-related quality of life, and physical function (i.e. aerobic capacity and muscle strength) in liver transplant recipients. There were few data on the composite of cardiovascular mortality and cardiovascular disease, cardiovascular disease post-transplantation, and adverse event outcomes. We lack larger trials with blinded outcome assessment, designed according to the SPIRIT statement and reported according to the CONSORT statement.

Does Exercise Training Improve Physical Fitness and Health in Adult Liver Transplant Recipients? A Systematic Review and Meta-analysis

BACKGROUND

The impaired physical fitness of end-stage liver disease patients often persists after liver transplantation (LT) and compromises posttransplant recovery. This systematic review and meta-analysis evaluated evidence supporting the potential of exercise training to improve physical fitness and health-related quality of life (HRQOL) after LT.

METHODS

Bibliographic searches identified all randomized controlled trials (RCTs) comparing aerobic and strength training versus usual care after LT. Risk of bias was assessed, and study outcomes measuring physical fitness and HRQOL were extracted. Meta-analysis was performed if at least 3 studies reported on an outcome.

RESULTS

Eight RCTs (n = 334) were identified. Methodological study quality varied and was poorly reported. Meta-analyses showed a trend for favorable effects of exercise on cardiorespiratory fitness (peak oxygen uptake or 6-min walking distance; 6 studies, n = 275; standardized mean difference: 0.23, 95% confidence interval [CI], -0.01 to 0.48) and of strength training either or not combined with aerobic training on muscular fitness (dynamometry-assessed muscle strength or 30-s sit-to-stand test; 3 studies, n = 114; standardized mean difference: 0.34, 95% CI, -0.03 to 0.72). A favorable effect was found for exercise on the Short-Form Health Survey-36 HRQOL physical function subcomponent (3 studies, n = 194; mean difference: 9.1, 95% CI, 0.3-17.8). No exercise-related adverse events were observed.

CONCLUSIONS

RCTs indicate that exercise training in LT recipients is safe, improves physical function aspects of HRQOL, and may benefit cardiorespiratory and muscular fitness. The strength of evidence is, however, limited by the low number of patients and study quality. More adequately powered, high-quality RCTs are warranted.

Expert consensus on liver transplantation perioperative evaluation and rehabilitation for acute-on-chronic liver failure

Acute-on-chronic liver failure (ACLF) can be cured by liver transplantation; however, perioperative complications still affect posttransplant outcomes. In recent years, early rehabilitation for critical illness, liver disease, and surgery have significantly improved organ reserve function, surgery tolerance, and postoperative quality of life. They could also be applied in the perioperative period of liver transplantation in patients with ACLF. Therefore, the Transplantation Immunology Committee of Branch of Organ Transplantation Physician of Chinese Medical Doctor Association, the Organ Transplant Committee of China Association Rehabilitation Medicine, and the Guangdong Medical Doctor Association of Organ Transplantation conducted a comprehensive review of rehabilitation in end-stage liver disease, critical illness and surgical patients by summarizing current evidence and best clinical practices and proposed a practice consensus on evaluation of cardiopulmonary and physical function, rehabilitation or physiotherapies, as well as the safety concerns in perioperative liver transplant recipients. It will be a valuable resource for hepatologists, transplant surgeons, and intensivists as they care for ACLF patients during transplantation.

Feasibility of a Home-Based Exercise Program for Managing Posttransplant Metabolic Syndrome in Lung and Liver Transplant Recipients: Protocol for a Pilot Randomized Controlled Trial

Background

Posttransplant metabolic syndrome (PTMS) is a common contributor to morbidity and mortality among solid organ transplant recipients in the late posttransplant period (≥1 year). Patients diagnosed with PTMS are at a higher risk of cardiovascular disease and frequently experience decreased physical function and health-related quality of life (HRQL). Studies in the early posttransplant period (<1 year) have shown the benefits of facility-based exercise training on physical function and HRQL, but have not evaluated the effects on metabolic risk factors. It remains unclear whether home-based exercise programs are feasible and can be delivered at a sufficient exercise dose to have effects on PTMS. This protocol outlines the methodology of a randomized controlled trial of a partly supervised home-based exercise program in lung transplant (LTx) and orthotopic liver transplant (OLT) recipients.

Objective

This study aims to evaluate the feasibility (ie, recruitment rate, program adherence, attrition, safety, and participant satisfaction) of a 12-week individualized, home-based aerobic and resistance training program in LTx and OLT recipients initiated 12 to 18 months after transplantation, and to assess estimates of intervention efficacy on metabolic risk factors, exercise self-efficacy, and HRQL.

Methods

In total, 20 LTx and 20 OLT recipients with ≥2 cardiometabolic risk factors at 12 to 18 months after transplantation will be randomized to an intervention (home-based exercise training) or control group. The intervention group will receive an individualized exercise prescription comprising aerobic and resistance training, 3 to 5 times a week for 12 weeks. Participants will meet on a weekly basis (via videoconference) with a qualified exercise professional who will supervise exercise progression, provide support, and support exercise self-efficacy. Participants in both study groups will receive a counseling session on healthy eating with a dietitian at the beginning of the intervention. For the primary aim, feasibility will be assessed through recruitment rate, program adherence, satisfaction, attrition, and safety parameters. Secondary outcomes will be measured at baseline and 12 weeks, including assessments of metabolic risk factors (ie, insulin resistance, abdominal obesity, blood pressure, and cholesterol), HRQL, and exercise self-efficacy. Descriptive statistics will be used to summarize program feasibility and effect estimates (means and 95% CIs) for sample size calculations in future trials.

Results

Enrollment started in July 2021. It is estimated that the study period will be 18 months, with data collection to be completed by December 2022.

Conclusions

A partly supervised home-based, individually tailored exercise program that promotes aerobic and resistance training and exercise self-efficacy may be an important intervention for improving the metabolic profile of LTx and OLT recipients with cardiometabolic risk factors. Thus, characterizing the feasibility and effect estimates of home-based exercise constitutes the first step in developing future clinical trials designed to reduce the high morbidity associated with PTMS.

Trial Registration

ClinicalTrials.gov NCT04965142; https://clinicaltrials.gov/ct2/show/NCT04965142

International Registered Report Identifier (IRRID)

DERR1-10.2196/35700

A 5-Year Follow-Up of The Benefits of an Exercise Training Program in Liver Recipients Transplanted Due to Familial Amyloidotic Polyneuropathy

BACKGROUND

Supervised (SE) and home-based exercise (HBE) training regimes are effective on reconditioning patients with familial amyloidotic polyneuropathy (FAP) after liver transplantation, but research of the long-term retention of the benefits attained in patients with FAP has not yet been conducted.

PURPOSE

In this 5-year follow-up study, we aimed to determine whether the exercise training gains in body composition, physical activity, and function promoted by a 24-week SE or HBE training regimes are retained in patients with FAP who resume normal activity.

METHODOLOGY

Sixteen liver-transplanted patients with FAP were reassessed for body composition (dual X-ray absorptiometry), physical activity (questionnaire), and function (handgrip strength and 6-minute walk test).

RESULTS

Total body fat increased with both exercise regimes during follow-up ( P < .05; η² = 0.432-0.625) as well as femoral neck bone density ( P = .048; η² = 0.119). However, gains in upper limbs muscle quality during follow-up ( P < .001; η² = 0.597) were only found in the SE group ( P = .042; η² = 0.245). Both exercise regimes showed retaining aptitudes in walking capacity ( P < .05; η² = 0.329-0.460) and muscle mass ( P = .05; η² = 0.245). Still, none could retain the physical activity levels.

CONCLUSION

Long-term resumption of normal activity following a 24-week SE or HBE regime in patients with FAP resulted in loss of exercise induced increases in physical activity but counterweighted postoperative losses in bone mineral density and substantially retained the benefits in walking capacity, muscle mass, and quality, in particular, in the SE group.

Combined resistance and endurance training at a moderate-to-high intensity improves physical condition and quality of life in liver transplant patients

Although currently moderate and high intensity concurrent physical exercise is prescribed in populations with special needs due to its greater effect on physical condition and health-related quality of life (HRQOL), there are no data in the liver transplantation (LT) setting. The aim of this study is to evaluate changes in maximal strength, aerobic capacity, body composition, liver function, and HRQOL in LT patients after a moderate-to-high intensity combined resistance-endurance training. Six months after LT, 54 patients were randomized into 2 groups: intervention group (IG) and control group (CG). A total of 50 patients completed the study with repeat testing at 6 and 12 months after LT. The IG completed a 6-month exercise training program, consisting of exercising 2 days for 24 weeks in the hospital facilities, whereas the CG followed usual care recommendations. Patients completed a 5-multijoint exercise circuit with elastic bands involving the major muscle groups. The effects of the concurrent training program on maximal oxygen consumption, overall and regional maximal strength, body composition, liver function, and HRQOL were analyzed. The IG showed a significant improvement (P < 0.05) in outcome measurements compared with the CG in aerobic capacity, hip extension, elbow flexion, overall maximal strength, physical functioning, and vitality of HRQOL, whereas no changes were observed in body composition and liver function tests. In conclusion, this is the first study that combines supervised resistance and aerobic training performed at moderate-to-high intensity in LT recipients. It results in significant improvements in aerobic capacity, maximal strength, and HRQOL. Liver Transplantation 23 1273-1281 2017 AASLD.

Effects of Exercise and Sport in Solid Organ Transplant Recipients: A Review

Solid organ transplantation is the criterion standard treatment for many with end-organ failure and can offer a new independence from the burden of disease. However solid organ transplant recipients (SOTRs) remain at high risk of cardiovascular (CV) disease, and poor quality of life and physical functioning. Increasing physical activity and exercise can improve the health of the general population; however, the effects on those with a transplant remain unclear. Intensive exercise and sporting activity has the potential to be beneficial, although there remain concerns particularly around the effects on immune function and the CV system. This review summarizes what is known about the effects of exercise on determinants of health in SOTRs and then collates the available literature investigating the consequences of intensive exercise and sport on the health of SOTR. There is a paucity of high-quality research, with most evidence being case studies or anecdotal; this is understandable given the relatively few numbers of SOTRs who are performing sport and exercise at a high level. However, if suitable evidence-based guidelines are to be formed and SOTRs are to be given reassurances that their activity levels are not detrimental to their transplanted organ and overall health, then more high-quality studies are required.

The Val30Met familial amyloid polyneuropathy specific Rasch-built overall disability scale (FAP-RODS(©) )

Familial amyloid polyneuropathy (FAP) is a chronic debilitating multi-organic disorder, mainly assessed using ordinal-based impairment measures. To date, no outcome measure at the activity and participation level has been constructed in FAP. The current study aimed to design an interval activity/participation scale for FAP through Rasch methodology. A preliminary FAP Rasch-built overall disability scale (pre-FAP-RODS) containing 146 activity/participation items was assessed twice (interval: 2-4 week; test-retest reliability) in 248 patients with Val30Met FAP examined in Porto, Portugal, of which 65.7% have received liver transplantation. An ordinal-based 24-item FAP-symptoms inventory questionnaire (FAP-SIQ) was also assessed (validity purposes). The pre-FAP-RODS and FAP-SIQ data were subjected to Rasch analyses. The pre-FAP-RODS did not meet model's expectations. On the basis of requirements such as misfit statistics, differential item functioning, and local dependency, items were systematically removed until a final 34-item FAP-RODS(©) was constructed fulfilling all Rasch requirements. Acceptable reliability/validity scores were demonstrated. In conclusion, the 34-item FAP-RODS(©) is a disease-specific interval measure suitable for detecting activity and participation restrictions in patients with FAP. The use of the FAP-RODS(©) is recommended for future international clinical trials in patients with Val30Met FAP determining its responsiveness and its cross-cultural validation. Its expansion to other forms of FAP should also be focus of future clinical studies.

Effect of a physical exercise program on the functional capacity of liver transplant patients

BACKGROUND

Recently there has been great concern about the quality of life and health of liver transplant patients (LTP). These patients often present with metabolic disorders, which can improve with regular physical exercise. The aim of this study was to investigate the effect of a physical exercise program on the functional capacity of LTP.

METHOD

The distance walked in the 6-minute walk test and the resting energy expenditure (REE) were evaluated in 15 subjects who regularly attend the outpatient Bias Fortes Clinic at Universidade Federal de Minas Gerais. The patients were divided into 2 groups, the Exercise Group (EG) (6 men and 3 women; 52 ± 15 years old, BMI 22.4 ± 4.0 kg/m²) performed 24 sessions of continuous 30 min treadmill exercise. Intensity of exercise was increased from 50%-70% of the maximum heart rate over the training period. A group of 3 men and 3 women (39 ± 15 years, BMI 24.5 ± 4.4 kg/m²) served as controls (CG).

RESULTS

After undergoing exercise training, patients in the EG showed a 19.4% increase in the distance walked (pre = 453.6 ± 128.0 m and post = 582.5 ± 90.1 m). Also, there was an increase in their REE (pre = 1,060.0 ± 194.2 kcal and post = 1,375.0 ± 258.6 kcal) (P < .05) indicating an increase in their exercise capacity and metabolic improvements. There were no differences in the distance walked (pre = 516.5 ± 62.0 m and post = 517.7 ± 71.9 m) and REE (pre = 1,393.0 ± 213.3 kcal to post = 1,465.0 ± 170.3 kcal) (P > .05) for CG. Our results are in agreement with previous studies.

CONCLUSIONS

We conclude that the exercise program promoted significant improvements in functional capacity. These findings have positive implications for the control of metabolic diseases, which are common in patients after liver transplantation.

Self-management and self-efficacy status in liver recipients

BACKGROUND

Liver transplantation (LT) is a viable treatment for patients with end-stage chronic liver diseases. The main aim of LT is to prolong life and improve life quality. However, although survival after LT continues to improve, some aspects of recipient's health-related quality of life such as self-management and self-efficacy have been largely ignored.

METHODS

A total of 124 LT recipients were included in this study. Questionnaires for general health status information and a "Self-Management Questionnaire for Liver Transplantation Recipients" modified from the Chinese version of "Chronic Disease Self-Management Program Questionnaire Code Book" were used in the survey. Data were collected by self-administered questionnaires.

RESULTS

The overall status of self-management in LT recipients was not optimistic. The major variables affecting the self-management of LT recipients were marital status, educational level and employment. The overall status of self-efficacy in LT recipients was around the medium-level. Postoperative time and self-assessment of overall health status were found as the factors impacting on self-efficacy.

CONCLUSIONS

The self-management behavior of LT recipients needs to be improved. The health care professionals need to offer targeted health education to individual patients, help them to establish healthy lifestyle, enhance physical activity and improve self-efficacy. The development of the multilevel and multifaceted social support system will greatly facilitate the self-management in LT patients.

Personalized adapted physical activity before liver transplantation: acceptability and results

BACKGROUND

Altered aerobic capacity and muscular strength among patients suffering from cirrhosis are poor prognosis factors of the overall survival after liver transplantation (LT). A program of adapted physical activity (APA) is recommended in patients awaiting solid organ transplantation. However, there is no standard program in LT, and therefore none is applied.

METHODS

Prospective pilot study to evaluate the acceptability of a 12-week personalized APA and its impact on aerobic capacity, muscle strength, and quality of life before LT.

RESULTS

Thirteen patients (six men, seven women) were included. Five patients interrupted the program: two for personal convenience, two were transplanted before the end of the program, and one for deterioration of the general condition. Eight patients (mean age, 51 ± 12 years; mean Child Pugh, 7 ± 3; and mean model for end-stage liver disease score, 13 ± 6) completed the program. The mean VO2 peak values increased from 21.5 ± 5.9 mL/kg per min at baseline to 23.2 ± 5.9 mL/kg per min after 12 weeks of training (P<0.008). The maximum power (P=0.02), the 6-min walk distance (P<0.02), the strength testing of knee extensor muscles (P=0.008), and the ventilatory threshold power (P=0.02) were also significantly increased. Quality of life scale showed a global trend to improvement. No adverse event was observed.

CONCLUSION

A personalized and standardized APA is acceptable, effective and safe in patients awaiting LT. It positively influences the index of fitness and quality of life. Its promising impact on the posttransplantation period, duration of hospitalization, and 6-month survival needs to be prospectively evaluated in a large randomized study.