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

Tolerability and Effectiveness of Glucagon-Like Peptide-1 Receptor Agonists in Lung Transplant Recipients: A Single Center Report

INTRODUCTION

Diabetes and obesity increase risk of death after lung transplantation. Optimal treatment of diabetes and obesity may improve post-transplant outcomes. Glucagon-like peptide-1 receptor agonists (GLP-1RA) are FDA-approved to treat diabetes and obesity and demonstrate improvement in renal and cardiovascular outcomes in the general population. However, side effects may limit tolerability in lung transplant recipients. We hypothesized that GLP-1RA would be stopped due to side effects in a higher proportion of lung transplant recipients compared to the general population but result in weight loss for those who were able to tolerate them.

METHODS

We performed a single-center case series of lung transplant recipients initiated on a GLP-1RA post-transplant between April 1, 2005 and December 31, 2023. We assessed side effects and complications during GLP-1RA use. Weight was assessed at time of GLP-1RA initiation and 3-, 6-, and 12-months postinitiation.

RESULTS

Fifty-nine lung transplant recipients initiated a GLP-1RA during the study period with a median (IQR) total time of use of 590 (280-891) days. Thirty-seven percent (22/59) stopped the medication due to side effects, with nausea and vomiting being most common. The median (IQR) percent change in weight at 12-months post-GLP-1RA initiation was -2.5% (-8.7% to 1.5%).

DISCUSSION

We report the largest study evaluating GLP-1RA use in lung transplant recipients. Discontinuation rates are higher and weight loss is lower than in the general population. However, most lung transplant recipients tolerated long-term use of GLP-1RA. Further work is required to identify which recipients are most likely to benefit and how to optimize tolerability.

The Year in Cardiothoracic Transplant Anesthesia: Selected Highlights From 2022 Part I: Lung Transplantation

These highlights focus on the research in lung transplantation (LTX) that was published in 2022 and includes the assessment and optimization of candidates for LTX, donor optimization, the use of organs from donation after circulatory death, and outcomes when using marginal or novel donors; recipient factors affecting LTX, including age, disease, the use of extracorporeal life support; and special situations, such as coronavirus disease2019, pediatric LTX, and retransplantation. The remainder of the article focuses on the perioperative management of LTX, including the perioperative risk factors for acute renal failure (acute kidney injury); the incidence and management of phrenic nerve injury, delirium, and pain; and the postoperative management of hyperammonemia, early postoperative infections, and the use of donor-derived cell-free DNA to detect rejection.

The Association Between Patient-Level Factors and Physical Function in Lung Transplant Recipients

Purpose

Despite the dramatic improvement in pulmonary function after lung transplantation, lung transplant recipients often have reduced physical function. The purpose of this study was to investigate the associations between physical function and a wide range of patient-level factors among lung transplant recipients to allow researchers and healthcare providers to identify and better understand contributors to poor physical function.

Methods

A cross-sectional study of lung transplant recipients enrolled in Lung Transplant Go (LTGO), a randomized, controlled trial evaluating the efficacy of a telerehabilitation behavioral exercise intervention on physical function. Data were collected at the time of study enrollment for physical function using 30-second sit-to-stand test (STS-30), and patient-level factors: discharge destination, time since transplant, hospital length of stay, participation in exercise program outside the study, comorbidities, psychological distress, and symptoms. Regression analysis was performed to identify the association between physical function and patient-level factors.

Results

A total of 72 lung transplant recipients with a mean age of 56 (13), 58% male, and 88% white, completed the STS-30. The bivariate analysis identified factors associated with STS-30, which are age, marital status, time since transplant, Questionnaire for Lung Transplant Patients' activity intolerance subscale, and psychological distress. Factors significantly predicted STS-30 using the regression analysis were age, time since transplant, and psychological distress (p< 0.05).

Conclusion

Age, time since lung transplantation, and psychological distress significantly predicted poor physical function. Interventions to prevent poor physical function post-lung transplantation should consider these factors. Research is needed to better understand patient-level factors on other physical function measures.

Effectiveness of pulmonary rehabilitation on exercise capacity in adult patients with lung transplantation: a systematic review and single-arm meta-analysis

Background

Lung transplantation (LTx) is a well-established option for patients in the end-stage of lung disease that is not responsive to other treatments. Although the survival rate after LTx has seen a significant increase, exercise tolerance is still limited and poses a big obstacle to recovery after LTx. Pulmonary rehabilitation (PR) is a comprehensive intervention that has many benefits for patients with chronic respiratory disease. However, the effectiveness of PR on adult patients with LTx is inconclusive. We performed this meta-analysis to assess the efficacy of PR in adult LTx recipients.

Methods

Eligible randomized controlled trials (RCTs) and quasi-experimental studies published until March 25, 2024 were searched in MEDLINE, Embase, Web of Science and CINAHL. Additionally, reference lists and published systematic reviews were scanned by manual searching. Studies selection, data extraction, and risk of bias assessment were conducted independently. Stata software (version 17.0) was utilized.

Results

There were 21 studies (9 RCTs and 12 quasi-experimental studies) were identified. Pooled analysis showed that PR positive effect in improving 6-minute walking distance (6MWD) [standard mean difference (SMD) =1.28, 95% confidence interval (CI): 1.05-1.50, P<0.001], maximum oxygen consumption (VO2max) (SMD =0.42, 95% CI: 0.15-0.68, P=0.002), handgrip force (HGF) (SMD =0.49, 95% CI: 0.26-0.73, P<0.001), and quadriceps force (QF) (SMD =0.63, 95% CI: 0.45-0.82, P<0.001). There was no significant publication bias in those outcomes mentioned above.

Conclusions

PR shows evidence for being an effective adjunctive strategy for improving exercise capacity after LTx, but multi-center trials on larger populations are required to confirm its clinical benefits in the real-world setting.

Exercise training in solid organ transplant candidates and recipients

PURPOSE OF REVIEW

Exercise training programs are an integral part of the management of solid organ transplantation (SOT) candidates and recipients. Despite this, they are not widely available and specific guidelines on exercise parameters for each type of organ are not currently provided. A review of this topic could help clinicians to prescribe appropriate exercise regimens for their patients.

RECENT FINDINGS

In this narrative review, we discuss the physical impairments of SOT candidates and recipients and how these affect their physical function and transplant outcomes. We examine recent systematic reviews, statements, and randomized controlled trials on exercise training in SOT candidates and recipients and present the current available evidence while providing some practical recommendations for clinicians based on the frequency, intensity, time, and type principle.

SUMMARY

While randomized controlled trials of better methodology quality are needed to strengthen the evidence for the effects of exercise training and for the optimal training characteristics, the available evidence points to beneficial effects of many different types of exercise. The current evidence can provide some guidance for clinicians on the prescription of exercise training for transplant candidates and recipients.

[Relationship between frailty and functional status in lung transplant candidates]

INTRODUCTION

Lung transplant (LT) is one of the therapeutic options for patients with terminal respiratory diseases. It is highly important to incorporate the functional status and frailty assessment into the selection process of candidates for LT.

OBJECTIVES

Identify the prevalence of frailty in the LT waiting list. Study the relationship between frailty, functional status, Lung Allocation Score (LAS) and muscular dysfunction.

METHODOLOGY

Descriptive transversal study of patients on the waiting list for LT.

POPULATION

74 patients with chronic respiratory diseases assessed by the lung transplant committee and accepted to be transplanted in a university hospital in Barcelona. The outcome variables were frailty status was evaluate for SPPB test, functional capacity was evaluate for the six-minute walking test (6MWT) and muscular dysfunction. The results were analyzed with the statistical package STATA 12.

RESULTS

Sample of 48 men and 26 women, with a median age of 56.55 years (SD 10.87. The prevalence of frailty assessed with the SPPB was 33.8% (8.1% are in frailty and 25.7% are in a state of pre-frailty). There is a relationship between the SPPB, 6MWT and maximal inspiratory pressure, but not with others force values. There is a relationship between the risk of frailty (scores below 9 in SPPB) and the meters walked in 6 but not with the LAS.

CONCLUSIONS

The risk of frailty in patients with terminal chronic respiratory diseases is high. Frailty is related with functional capacity, but not with LAS.

The Rationale, Evidence, and Adaptations to Pulmonary Rehabilitation for Chronic Respiratory Diseases Other Than COPD

Over the last 3 decades, pulmonary rehabilitation (PR) has become an integral part of the management of COPD. Many other chronic respiratory diseases have similar systemic manifestations including skeletal muscle impairment, commonly through deconditioning, and may benefit from PR. However, whereas many programs may accept patients with other respiratory diseases, the program may need several adaptations to optimally manage patients. This article uses the examples of interstitial lung disease including idiopathic pulmonary fibrosis, bronchiectasis, pulmonary hypertension, post lung transplantation, and post-COVID condition to highlight exemplar clinical problems. In addition, the rationale and latest evidence for PR are described alongside the adaptations to the program, including education needs of the delivery team and close integrated care with the wider clinical team. Finally, future directions for clinical care and research are discussed.

Virtual Physical Prehabilitation in Lung Transplant Candidates: A Proof-of-Concept Study

This study aimed to preliminary test the effectiveness of 12-week virtual physical prehabilitation program followed by a maintenance phase. The main objective was to estimate the extent to which it affects exercise capacity, frailty, lower limb strength and health-related quality of life (HRQOL) in lung transplant candidates. The program offered supervised strengthening exercises, independent aerobic exercises and weekly phone calls (maintenance phase). Primary outcome was the six-minute walk distance (6MWD). Secondary outcomes: the Short Physical Performance Battery (SPPB), five-times sit-to-stand test (5STS), the St George's Respiratory Questionnaire (SGRQ) for HRQOL. Twenty patients were included (mean age 57.9; 6 women/14 men); fourteen completed the prehabilitation program and 5 completed the maintenance phase. There was no statistically significant improvement in 6MWD, SPPB or SGRQ after the 12-week program. Most patients either maintained or improved the 6MWT and SPPB scores. There was a significant improvement in the 5STS. After the maintenance phase, most patients either improved or maintained their scores in all outcomes except for the sub-score of symptoms in the SGRQ. A 12-week virtual physical prehabilitation program with a 12-week maintenance phase can help lung transplant candidates improve or maintain their physical function while waiting for transplantation.

Prehabilitation in Adult Solid Organ Transplant Candidates

Purpose of Review

To highlight the importance of biological age in the context of prehabilitation and to present relevant research regarding prehabilitation prior to solid organ transplantation.

Recent Findings

Studies on the effect of prehabilitation have been performed in kidney-, lung-, liver-, and heart transplant patient populations. Prior to kidney transplantation, exercise interventions have been shown to improve cardiopulmonary- and physical fitness and result in a decreased length of hospital stay postoperatively. Among lung transplant candidates, various methods of prehabilitation have been studied including home-based, outpatient and in-patient programs, consisting of physical training, psychological support, education, and nutritional interventions. Overall, prehabilitation seems to improve or maintain quality of life and exercise capacity in this patient population. Patients undergoing liver transplantation seem to benefit from prehabilitation as well. Not only does it seem safe and feasible, but significant improvements in aerobic and functional capacity have also been found. Regarding heart transplant candidates, both inpatient and outpatient, supervised prehabilitation programs show promising results with improvements in exercise capacities and quality of life.

Summary

Prehabilitation is an effective and safe intervention for improving functional outcomes of solid organ transplant patients. Future studies should evaluate whether prehabilitation translates into improved pre- and post-transplant clinical outcomes.