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Knobbe TJ, Kremer D, Bültmann U, Annema C, Navis G, Berger SP, Bakker SJ, Meuleman Y. Insights Into Health-Related Quality of Life of Kidney Transplant Recipients: A Narrative Review of Associated Factors. Kidney Med 2025; 7:100986. [PMID: 40182980 PMCID: PMC11964492 DOI: 10.1016/j.xkme.2025.100986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2025] Open
Abstract
Life expectancy and graft survival continue to improve after transplantation. However, improved posttransplant clinical outcomes do not necessarily translate into improved health-related quality of life (HRQoL). Therefore, there is an increased focus on HRQoL in kidney transplant recipients (KTRs). The HRQoL of KTRs is worse than that of the general population, but interventions that improve HRQoL in KTRs are scarce, and health care professionals in nephrology care do not routinely address HRQoL. To improve HRQoL, it is essential to understand which factors play a role in HRQoL and to pinpoint areas for intervention. This narrative review maps the concept of HRQoL within the KTR population and provides a comprehensive overview of factors associated with posttransplant HRQoL. The results are structured using an easy-to-understand conceptual model of HRQoL, which is instrumental for understanding how HRQoL is constituted of many clinical and nonclinical factors. We conclude that symptom burden among KTRs is high, which is likely a key driver of the limited HRQoL in this population. Moreover, myriad other clinical and nonclinical factors are associated with HRQoL, but the majority of the evidence is observational.
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Affiliation(s)
- Tim J. Knobbe
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Daan Kremer
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ute Bültmann
- Community and Occupational Medicine, Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Coby Annema
- Section of Nursing Science, Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Gerjan Navis
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Stefan P. Berger
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Stephan J.L. Bakker
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Yvette Meuleman
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
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Kirkman DL. Frailty in kidney transplant candidates: new therapeutic strategies to intervene. Curr Opin Organ Transplant 2025; 30:74-80. [PMID: 39868460 DOI: 10.1097/mot.0000000000001205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2025]
Abstract
PURPOSE OF REVIEW Patients that present with a physical frail phenotype have a higher risk of poor kidney transplant outcomes and are therefore less likely to be wait listed for a transplant. The physical frailty phonotype is more prevalent in older adults >65years with chronic and end stage kidney disease, thus partly contributing to inequitable access to transplant. Frailty can potentially be reversed by prehabilitation. RECENT FINDINGS Small studies of prehabilitation in kidney transplant candidates have demonstrated feasibility and safety. These pilot studies have shown efficacy for improving functional surrogates of frailty. Encouraging findings from one small pilot study reported a 50% reduction in postoperative length of hospital stay in patients that participated in prehabilitation. Exercise intervention should be supported with nutrition intervention aimed at increasing energy intake. Lifestyle behavior change coaching and case-by-case clinical psychology support are a key for successful uptake of prehabilitation and sustainable lifestyle change. SUMMARY There is consensus from the American Society of Transplantation, the European Society of Transplantation, and healthcare providers that prehabilitation is a valuable peri-operative intervention. Robust, multicenter randomized controlled trials will facilitate the establishment of evidence-based guidelines and widespread implementation of prehabilitation into clinical care.
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Affiliation(s)
- Danielle L Kirkman
- Department of Kinesiology and Health Sciences
- Kidney Disease and Transplant Epidemiology Consortium, Department of Internal Medicine, Division of Nephrology, Virginia Commonwealth University, Richmond, Virginia, USA
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Bartlett ST, Santi I, Hachaj G, Wilund KR, Tzvetanov I, Spaggiari M, Almario J, Di Cocco P, Bianco F, Hajjiri Z, Gallon L, Rana A, Kumar S, Benedetti E, Motl RW. Resistance-Based Muscle Therapy, Frailty, and Muscle Biopsy Findings in Kidney Transplant Candidates: A Clinical Trial. Kidney Med 2025; 7:100978. [PMID: 40201398 PMCID: PMC11978330 DOI: 10.1016/j.xkme.2025.100978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2025] Open
Abstract
Rationale & Objective Frailty is associated with increased morbidity and mortality in kidney transplant recipients. We hypothesized that frailty may be attributable to diminished muscle function associated with muscle morphologic changes. This trial in kidney transplant candidates tested the reversibility of frailty by specifically targeting the affected major muscle groups. Study Design Randomized clinical trial. Setting & Participants Kidney transplant candidates. Exposure Supervised, resistance-based muscle therapy program delivered for 1 hour, 2 times per week for 1 year. Outcomes Baseline, 6-month, and 12-month Short Physical Performance Battery, gait speed, grip strength, sit-to-stand in 30 s, 36-item Short Form Survey, Patient-Reported Outcomes Measurement Information System-29, and muscle biopsy light and electron microscopy and immunohistochemistry. Analytic Approach Paired 2-tailed t test, 1-way repeated measures analysis of variance. Results Twenty-nine participants (mean age, 55 years; female, 55%; African American, 65%) were analyzed: 23 intervention and 6 control. Exercise intervention participants had significant improvements in Short Physical Performance Battery, baseline 5.2 (95% CI, 3.6-6.7) versus 6 months, 6.9 (95% CI, 5.2-8.5; P < 0.001) and 12 months, 7.2 (95% CI, 5.6-8.8; P < 0.001); baseline hand grip, 14.3 kg (95% CI, 10.3-18.4) versus 6 months, 16.9 kg (95% CI, 13.1-20.8; P < 0.05) and 12 months, 17.4 kg (95% CI, 13.9-21.0; P < 0.05); and baseline sit-to-stand in 30 s, 8.0 (95% CI, 3.8-12.2) versus 6 months, 12.7 (95% CI, 8.2-17.1; P < 0.001) and 12 months, 16.2 (95% CI, 10.7-21.7; P < 0.001). The exercise group 12-month muscle fiber diameter increased by 18.6 μm (95% CI, 8.4-28.5; P = 0.003). Expression of immunohistology markers of muscle atrophy decreased significantly. The mean difference in immunohistology score of mitochondrial oxidative function improved for cytochrome c oxidase complex IV, 1.00 (95% CI, 0.71-1.29; P < 0.001) and ATP5I increased by 0.74 (95% CI, 0.49-0.99; P < 0.001). Increased mitochondrial count did not achieve statistical significance (P = 0.096). Controls showed no improvement in either physical performance or histology. Limitations Significant under-enrollment in the control group required a paired t test analysis of experimental participants. Conclusions One year of muscle rehabilitation therapy resulted in significant improvements in physical performance metrics accompanied by significant improvements in muscle morphology.
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Affiliation(s)
| | | | | | - Kenneth R. Wilund
- School of Nutritional Sciences and Wellness, University of Arizona, Tucson, Arizona
| | | | | | | | | | | | | | | | - Ajay Rana
- Department of Surgery, College of Medicine
| | | | | | - Robert W. Motl
- Department of Kinesiology and Nutrition, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, Illinois
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4
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Yoo J. Effect of Physical Function on Access to Repeat Kidney Transplantation. Biol Res Nurs 2025; 27:193-204. [PMID: 39451028 DOI: 10.1177/10998004241271380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2024]
Abstract
Background: The long-term success rate of kidney transplantation is disappointing, with repeat transplantation necessary for more than half of recipients. When a repeat kidney transplantation is needed, patients are often elderly and suffer from underlying advanced kidney disease, comorbidities, and adverse effects of immunosuppressants, leading to physical function limitations. Limited physical function is known to hinder access to an initial kidney transplantation, but there is no information about its impact on repeat transplantations. Objective: This study aimed to determine the effect of physical function on access to wait-listing for repeat transplantation. Methods: Data from the national registry was utilized to analyze 28,884 kidney transplant recipients. Physical function was assessed with Karnofsky scores, and patients were categorized into three strata: total assistance, some assistance, and no assistance. Logistic regression and multivariate Cox proportional hazard models were used to assess the impact of physical function on waiting list access and duration until wait-listing, respectively. Results: Patients with greater physical independence were more likely to be wait-listed for repeat kidney transplantation. Highly sensitized patients, those with diabetes, Black patients, and elderly individuals had a lower likelihood of access to wait-listing after kidney failure. Interestingly, those with limited physical function, provided they remained in the work-up process, experienced a relatively shorter duration to wait-listing after graft failure.Conclusions: These findings highlight the need to promote and support physical function throughout the kidney transplant journey to improve access to repeat transplantation and subsequent patient outcomes.
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Affiliation(s)
- Jongwon Yoo
- College of Nursing, Rush University, Chicago, IL, USA
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5
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Uchida J, Iwai T, Machida Y. Frailty in kidney transplant recipients. Int J Urol 2025; 32:229-238. [PMID: 39582365 DOI: 10.1111/iju.15639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2024] [Accepted: 11/13/2024] [Indexed: 11/26/2024]
Abstract
Kidney transplantation is the treatment of choice even for the elderly, as it improves quality of life and life expectancy, lowering the financial burden to the health care system compared to dialysis therapy. In Japan, kidney transplant recipients have become older due to the shift in demographics. Compared to community-dwelling elderly adults, elderly kidney transplant recipients undergoing immunosuppressive therapy have a higher risk of age-related outcomes including hospital readmissions, infections, dementia, malignancies, and fractures. In frailty, patients become vulnerable to adverse events after stressors due to a lack of physiologic reserve. Although it is often associated with aging, frailty can also occur in younger individuals with certain chronic illnesses or conditions including chronic kidney disease. Limited compensatory mechanisms result in functional impairment and adverse health outcomes, such as disability, falls, decreased mobility, hospitalization, and death. Although kidney transplant recipients can restore their kidney function after transplantation, most of them still have chronic kidney disease, as well as a gradual decline in graft function as a result of chronic allograft nephropathy. Wait-listed candidates for kidney transplantation with frailty are more likely to experience wait-list removal or death. Frailty at the time of transplantation is associated with complications after kidney transplantation such as delayed graft function, longer hospital stays, rehospitalizations, immunosuppression intolerance, surgical complications, and death. Nevertheless, kidney transplantation can be a viable intervention for frailty in dialysis patients.
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Affiliation(s)
- Junji Uchida
- Department of Urology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Osaka Prefecture, Japan
| | - Tomoaki Iwai
- Department of Urology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Osaka Prefecture, Japan
| | - Yuichi Machida
- Department of Urology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Osaka Prefecture, Japan
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Yatim K, Ribas GT, Elton DC, Rockenbach MABC, Al Jurdi A, Pickhardt PJ, Garrett JW, Dreyer KJ, Bizzo BC, Riella LV. Applying Artificial Intelligence to Quantify Body Composition on Abdominal CTs and Better Predict Kidney Transplantation Wait-List Mortality. J Am Coll Radiol 2025; 22:332-341. [PMID: 40044312 DOI: 10.1016/j.jacr.2025.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2024] [Revised: 01/06/2025] [Accepted: 01/06/2025] [Indexed: 05/13/2025]
Abstract
BACKGROUND Prekidney transplant evaluation routinely includes abdominal CT for presurgical vascular assessment. A wealth of body composition data are available from these CT examinations, but they remain an underused source of data, often missing from prognostication models, as these measurements require organ segmentation not routinely performed clinically by radiologists. We hypothesize that artificial intelligence facilitates accurate extraction of abdominal CT body composition data, allowing better prediction of outcomes. METHODS We conducted a retrospective, single-center observational study of kidney transplant candidates wait-listed between January 1, 2007, and December 31, 2017, with available CT data. Validated deep learning models quantified body composition including fat, aortic calcification, bone density, and muscle mass. Logistic regression was used to compare body composition data to Expected Post-Transplant Survival Score (EPTS) as a predictor of 5-year wait-list mortality. RESULTS In all, 899 patients were followed for a median 943 days (interquartile range 320-1,697). Of 899, 589 (65.5%) were men and 680 of 899 (75.6%) were White, non-Hispanic. Of 899, 167 patients (18.6%) died while on the waiting list. Myosteatosis (defined as the lowest tertile of muscle attenuation) and increased total aortic and abdominal calcification were associated with increased 5-year wait-list mortality. Logistic regression showed that imaging parameters performed similarly to EPTS at predicting 5-year wait-list mortality (area under receiver operating characteristic curve 0.70 [0.64-0.75] versus 0.67 [0.62-0.72], respectively), and combining body composition parameters with EPTS led to a slight improved survival prediction (area under receiver operating characteristic curve = 0.72, 95% confidence interval 0.66-0.76). CONCLUSIONS Fully automated quantification of body composition in kidney transplant candidates is feasible. Myosteatosis and atherosclerosis are associated with 5-year wait-list mortality.
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Affiliation(s)
- Karim Yatim
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts
| | - Guilherme T Ribas
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel C Elton
- Mass General Brigham AI, Mass General Brigham, Boston, Massachusetts
| | - Marcio A B C Rockenbach
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Mass General Brigham AI, Mass General Brigham, Boston, Massachusetts
| | - Ayman Al Jurdi
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts; Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Perry J Pickhardt
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - John W Garrett
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; Department of Medical Physics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Keith J Dreyer
- Mass General Brigham AI, Mass General Brigham, Boston, Massachusetts
| | - Bernardo C Bizzo
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Mass General Brigham AI, Mass General Brigham, Boston, Massachusetts
| | - Leonardo V Riella
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts; Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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Pérez-Sáez MJ, Pascual J. Unmet Questions About Frailty in Kidney Transplant Candidates. Transplantation 2025; 109:273-284. [PMID: 38886883 DOI: 10.1097/tp.0000000000005093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Abstract
Frailty occurs frequently among patients with advanced chronic kidney disease, especially among women. Assessing frailty in kidney transplant (KT) candidates is crucial for informing them about associated risks. However, there is poor agreement between frailty scales and research on their correlation with transplant outcomes. Being prefrail significantly impacts both graft and patient survival, often beginning with just 1 Fried criterion. Rather than viewing frailty as a categorical state, it should be regarded as a spectrum ranging from 1 to 5 criteria, with the risk of adverse outcomes escalating as frailty worsens. Frailty status fluctuates during the waiting period for KT; hence, a 1-time frailty evaluation is insufficient to determine risks and implement strategies for improving functional status. Further research should investigate the components of frailty that most frequently change during this waiting period and establish strategies to prevent or reverse frailty. Although careful evaluation of frail KT candidates is necessary to prevent early complications and mortality, exclusion based solely on a frailty score is unwarranted. Instead, efforts should focus on timely interventions to enhance their condition before transplantation. Although evidence is limited, exercise programs appear feasible and yield positive results. A pretransplant clinical framework encompassing multimodal prehabilitation-comprising physical therapy, nutritional measures, and psychological support-during the waiting list period may help alleviate the effects of frailty and poor fitness after KT, ultimately improving key outcomes. Despite logistical challenges, there is a pressing need for interventional trials in this area.
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Affiliation(s)
- María José Pérez-Sáez
- Nephrology Department, Hospital del Mar, Barcelona, Spain
- Nephropathies Research Group, Hospital del Mar Research Institute, Barcelona, Spain
| | - Julio Pascual
- Nephropathies Research Group, Hospital del Mar Research Institute, Barcelona, Spain
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
- Institute for Research i+12, Madrid, Spain
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Agarwal M, Alexiuk J, Bohm C, Sikora L, Zimmerman D. Factors Influencing Recruitment, Retention, and Adherence Rates in Exercise Interventions in ESKD: A Scoping Review. Kidney Med 2025; 7:100933. [PMID: 39810814 PMCID: PMC11732533 DOI: 10.1016/j.xkme.2024.100933] [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: 01/16/2025] Open
Abstract
Rational & Objective Majority of people with end-stage kidney disease (ESKD) are sedentary, which increases risk for decreased quality and quantity of life. Development of exercise programs with characteristics that address individual preferences may increase interest in participating and completing exercise programs. We evaluated which exercise intervention characteristics affect exercise program recruitment, adherence, and completion in people with ESKD receiving dialysis. Study Design Scoping review of randomized controlled trials (RCTs) with searching of Medline, Embase, Cochrane, and CINAHL databases through May 12, 2023. Setting & Study Populations Adults with ESKD receiving dialysis. Selection Criteria RCTs with exercise interventions of ≥12 weeks that included more than 10 people with ESKD receiving dialysis in each study arm. Data Extraction One individual extracted data and the second author checked for accuracy. Analytical Approach Data were synthesized qualitatively. Associations between intervention characteristics and recruitment, retention and adherence rates were assessed through one-way analysis of variance tests. Risk of bias was assessed using the Cochrane Risk of Bias 1.0 tool. Results Of 7,396 studies identified, 55 studies with 3,269 trial participants were included. The majority of participants were male (63.2%) and treated with hemodialysis (89.1%). Mean age was 56 ± 11.5 years. Average recruitment, retention and adherence rates were 77.4%, 81.2%, and 76.0%, respectively. Only 27% of studies reported adherence rates. No significant associations were found between intervention characteristics (ie, exercise type, duration, frequency, setting, and supervision) and recruitment, adherence, and retention rates. Limitations Data were limited by small sample size, suboptimal risk of bias, selective recruiting methods, and variability in definitions of adherence rates. Conclusion Average recruitment, retention, and adherence rates in exercise interventions for patients receiving dialysis were high although less than 1 in 4 studies reported adherence rates. These results call for standardized reporting of recruitment, retention, and adherence rates in exercise interventions.
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Affiliation(s)
| | - Jamie Alexiuk
- Faculty of Kinesiology, University of Manitoba, Manitoba, Canada
| | - Clara Bohm
- Section of Nephrology, Department of Internal Medicine, University of Manitoba, Manitoba, Canada
| | - Lindsey Sikora
- Faculty of Medicine, University of Ottawa, Ontario, Canada
| | - Deborah Zimmerman
- Kidney Research Centre, The Ottawa Hospital, Ontario, Canada
- Department of Nephrology, The Ottawa Hospital, Ontario, Canada
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Karnabi P, Massicotte-Azarniouch D, Marshall S, Knoll GA. Physical Frailty and Functional Status in Kidney Transplantation: A Systematic Review. Can J Kidney Health Dis 2024; 11:20543581241300777. [PMID: 39691414 PMCID: PMC11650569 DOI: 10.1177/20543581241300777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2024] [Accepted: 10/09/2024] [Indexed: 12/19/2024] Open
Abstract
Background Frailty and functional decline are being recognized as important conditions in kidney transplant candidates. However, the ideal measures of functional status and frailty remain unknown as there is not a complete understanding of the relationship between these conditions and important post-transplant outcomes. Objective The objective was to examine the association between different measures of frailty and functional status evaluated before or at the time of transplant with adverse clinical outcomes post-transplantation. Design This study is a systematic review. Setting Observational studies including cohort, case-control, or cross-sectional studies examining the effect of frailty and functional status on clinical outcomes. There were no restrictions on type of setting or country of origin. Patients Adults who were waitlisted for kidney transplant or had received a kidney transplant. Measurements Data including demographic information (eg, sample size, age, country), assessments of frailty or functional status and their domains, and outcomes including mortality, transplantation, graft loss, delayed graft function and hospital readmission were extracted. Methods A search was performed in Medline, Embase, and Cochrane Central Register for Controlled Trials. Studies were included from inception to February 7, 2023. The eligibility of studies was screened by 2 independent reviewers. Data were presented by frailty/functional status instrument and clinical outcome. Point estimates and 95% confidence intervals from fully adjusted statistical models were reported or calculated from the raw data. Results A total of 50 studies were identified, among which 36 unique instruments were found. Measurements of these instruments occurred mostly at time of kidney transplant, transplant evaluation, and waitlisting. The median sample size of studies was 457 patients (interquartile range = 183-1760). Frailty and lower functional status were associated with an increased risk for mortality. Similar trends were observed among other clinical outcomes such as graft loss and rehospitalization. Limitations The heterogeneity in measurement instruments, study designs, and outcome definitions prevents pooling of the data. Selection bias and the validity of data collection could not be ascertained for some studies. Conclusion Frailty and functional status measures are important predictors of post-kidney transplant outcomes. Further studies are needed to evaluate the best instruments to assess frailty and functional status, and importantly, interventional studies are needed to determine whether prehabilitation strategies can improve post-transplant outcomes. Registration PROSPERO CRD42016045251.
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Affiliation(s)
- Priscilla Karnabi
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, ON, Canada
| | - David Massicotte-Azarniouch
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, ON, Canada
- Department of Medicine, University of Ottawa, ON, Canada
- Division of Nephrology, Kidney Research Centre, The Ottawa Hospital Research Institute, ON, Canada
| | - Shawn Marshall
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, ON, Canada
- Department of Medicine, University of Ottawa, ON, Canada
| | - Greg A. Knoll
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, ON, Canada
- Department of Medicine, University of Ottawa, ON, Canada
- Division of Nephrology, Kidney Research Centre, The Ottawa Hospital Research Institute, ON, Canada
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Király E, Szőllősi GJ, Jenei Z, Balla J, Kárpáti I. Effects of a combined aerobic and core stabilization exercise training program on functional capacity, pain, and health-related quality of life in hemodialysis and kidney transplant patients. Ren Fail 2024; 46:2370439. [PMID: 38938194 PMCID: PMC11216259 DOI: 10.1080/0886022x.2024.2370439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Accepted: 06/14/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) poses a significant public health challenge globally while impacting patients' physical function and quality of life. Addressing the issues of physical inactivity and pain management is essential during treatment to improve health-related quality of life. The present study investigated the effect of an aerobic training program with core stabilization exercises for hemodialysis (HD) patients on a transplant waiting list and renal transplant (RTx) patients. METHODS A total of 45 patients with CKD were included in the 12-week study: 25 patients receiving HD (12 HD treatment group, 13 HD control group) and 20 patients with RTx (9 RTx treatment group, 11 RTx control group). Functional capacity was measured using the 6-min walk test, pain was measured using the visual analog scale, and health-related quality of life was measured using the Kidney Disease Quality of Life-Short Form 12 questionnaire. Nonparametric statistical tests were performed at a significance level of 0.05. RESULTS Both the HD and RTx treatment groups showed significantly reduced times for the 6-min walking test (p = 0.002 and p = 0.008, respectively), significantly reduced pain severity (p = 0.002 and p = 0.008, respectively), and significantly improved quality of life scores (p = 0.006 and p = 0.041, respectively) by the end of the study compared with control groups. CONCLUSION Based on the results, structured exercise programs could be effective therapies in CKD management. Therefore, health providers should promote their integration into routine care practices to enhance patient outcomes and well-being.
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Affiliation(s)
- Enikő Király
- Department of Medical Rehabilitation and Physical Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Doctoral School of Health Sciences, University of Debrecen, Debrecen, Hungary
| | - Gergő József Szőllősi
- Coordination Center for Research in Social Sciences, Faculty of Economics and Business, University of Debrecen, Debrecen, Hungary
| | - Zoltán Jenei
- Department of Medical Rehabilitation and Physical Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - József Balla
- Department of Nephrology, Institute of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - István Kárpáti
- Department of Nephrology, Institute of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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11
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Chanan EL, Wagener G, Whitlock EL, Berger JC, McAdams-DeMarco MA, Yeh JS, Nunnally ME. Perioperative Considerations in Older Kidney and Liver Transplant Recipients: A Review. Transplantation 2024; 108:e346-e356. [PMID: 38557579 PMCID: PMC11442682 DOI: 10.1097/tp.0000000000005000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
With the growth of the older adult population, the number of older adults waitlisted for and undergoing kidney and liver transplantation has increased. Transplantation is an important and definitive treatment for this population. We present a contemporary review of the unique preoperative, intraoperative, and postoperative issues that patients older than 65 y face when they undergo kidney or liver transplantation. We focus on geriatric syndromes that are common in older patients listed for kidney or liver transplantation including frailty, sarcopenia, and cognitive dysfunction; discuss important considerations for older transplant recipients, which may impact preoperative risk stratification; and describe unique challenges in intraoperative and postoperative management for older patients. Intraoperative challenges in the older adult include using evidence-based best anesthetic practices, maintaining adequate perfusion pressure, and using minimally invasive surgical techniques. Postoperative concerns include controlling acute postoperative pain; preventing cardiovascular complications and delirium; optimizing immunosuppression; preventing perioperative kidney injury; and avoiding nephrotoxicity and rehabilitation. Future studies are needed throughout the perioperative period to identify interventions that will improve patients' preoperative physiologic status, prevent postoperative medical complications, and improve medical and patient-centered outcomes in this vulnerable patient population.
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Affiliation(s)
- Emily L Chanan
- Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Grossman School of Medicine, New York, NY
| | - Gebhard Wagener
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY
| | - Elizabeth L Whitlock
- Department of Anesthesia & Perioperative Care, University of California, San Francisco, San Francisco, CA
| | - Jonathan C Berger
- Department of Surgery, NYU Grossman School of Medicine, New York, NY
| | - Mara A McAdams-DeMarco
- Department of Surgery, NYU Grossman School of Medicine, New York, NY
- Department of Population Health, NYU Grossman School of Medicine, New York, NY
| | - Joseph S Yeh
- Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Grossman School of Medicine, New York, NY
| | - Mark E Nunnally
- Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Grossman School of Medicine, New York, NY
- Department of Surgery, NYU Grossman School of Medicine, New York, NY
- Department of Neurology, NYU Grossman School of Medicine, New York, NY
- Department of Medicine, NYU Grossman School of Medicine, New York, NY
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Kirkman DL, Kidd JM, Carbone S, Pontinha VM, Tanriover B, Kumar D, Gupta G. Frailty and Prehabilitation: Navigating the Road to a Successful Transplant. J Am Soc Nephrol 2024; 35:1607-1609. [PMID: 39137041 PMCID: PMC11543015 DOI: 10.1681/asn.0000000000000485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Accepted: 08/06/2024] [Indexed: 08/15/2024] Open
Affiliation(s)
- Danielle L. Kirkman
- Department of Kinesiology and Health Sciences, Virginia Commonwealth University, Richmond, Virginia
| | - Jason M. Kidd
- Division of Nephrology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Salvatore Carbone
- Department of Kinesiology and Health Sciences, Virginia Commonwealth University, Richmond, Virginia
| | - Vasco M. Pontinha
- Department of Pharmacotherapy and Outcomes Sciences, Virginia Commonwealth University, Richmond, Virginia
| | - Bekir Tanriover
- Division of Nephrology, Department of Internal Medicine, University of Arizona at Tucson, Tucson, Arizona
| | - Dhiren Kumar
- Division of Nephrology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Gaurav Gupta
- Division of Nephrology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
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13
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Sim JAP, Perinpanayagam MA, Bahry V, Wytsma-Fisher K, Burak KW, Isaac DL, Mustata S, Culos-Reed SN. An Exercise and Wellness Behavior Change Program for Solid Organ Transplant: A Clinical Research Protocol for the Transplant Wellness Program. Can J Kidney Health Dis 2024; 11:20543581241289196. [PMID: 39449962 PMCID: PMC11500225 DOI: 10.1177/20543581241289196] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 08/02/2024] [Indexed: 10/26/2024] Open
Abstract
Background Exercise prehabilitation is an evidence-based, safe, and effective method to increase quality of life, physical fitness and function, and post-surgical outcomes in solid organ transplant (SOT) patients. However, few prehabilitation programs for SOT patients exist in practice. Furthermore, there is a lack of multimodal prehabilitation programs that include behavior change support. To address this need, the Transplant Wellness Program (TWP) was designed. Objectives The objective of the TWP is to assess both the effectiveness and implementation of a comprehensive and multimodal exercise and wellness behavior change intervention for patients undergoing kidney or liver transplant. Design The TWP is a hybrid effectiveness-implementation trial consisting of exercise and wellness behavior change support. Patients Individuals who are in evaluation or listed for kidney or liver transplant in Southern Alberta, Canada. Measurements The primary outcomes of self-reported exercise and quality of life are assessed at intake, post-exercise intervention, 6 months post-intake, 12 weeks post-transplant, and annually for 5 years after program completion. Functional fitness measures will be assessed at intake, post-exercise intervention, 12 weeks post-transplant, 6 months post-intake, and 1-year post-intake. The reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework is used to determine the impact of TWP at the individual and health care system level. Methods Recruitment began in November 2023 and will continue until November 2028. Participants take part in a 12-week exercise intervention and are offered individualized and group behavior change support. Continued exercise support is offered through maintenance classes after the completion of the 12-week intervention. Limitations The design of the hybrid effectiveness-implementation trial with a single experimental group will not allow for comparisons to a control or usual care group, potentially impacting internal validity. Differences in number of participants between organ groups (kidney vs liver) and cohorts (pre-transplant vs post-transplant) will likely be uneven, requiring consideration when running and interpreting analyses. Conclusions The TWP aims to support patients throughout the transplant journey through a multimodal and comprehensive exercise and wellness behavior change program. Results from this study will determine the effectiveness of the program and inform future scale-up and sustainability. Trial registry number NCT06367244.
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Affiliation(s)
| | | | - Vanessa Bahry
- Department of Medicine, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Kathryn Wytsma-Fisher
- Department of Medicine, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Kelly W. Burak
- Department of Medicine, Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Oncology, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Debra L. Isaac
- Department of Medicine, Cumming School of Medicine, University of Calgary, AB, Canada
- Southern Alberta Transplant Program, Alberta Health Services, Calgary, Canada
| | - Stefan Mustata
- Department of Medicine, Cumming School of Medicine, University of Calgary, AB, Canada
| | - S. Nicole Culos-Reed
- Faculty of Kinesiology, University of Calgary, AB, Canada
- Department of Oncology, Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Psychosocial Resources, Tom Baker Cancer Centre, Alberta Health Services, Calgary, Canada
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14
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de Sandes-Freitas TV, Domingues-da-Silva RDO, Sanders-Pinheiro H. Frailty in the context of kidney transplantation. J Bras Nefrol 2024; 46:e20240048. [PMID: 39332013 PMCID: PMC11435774 DOI: 10.1590/2175-8239-jbn-2024-0048en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Accepted: 07/07/2024] [Indexed: 09/29/2024] Open
Abstract
Frailty, defined as an inappropriate response to stressful situations due to the loss of physiological reserve, was initially described in the elderly population, but is currently being identified in younger populations with chronic diseases, such as chronic kidney disease. It is estimated that about 20% of patients are frail at the time of kidney transplantation (KT), and there is great interest in its potential predictive value for unfavorable outcomes. A significant body of evidence has been generated; however, several areas still remain to be further explored. The pathogenesis is poorly understood and limited to the extrapolation of findings from other populations. Most studies are observational, involving patients on the waiting list or post-KT, and there is a scarcity of data on long-term evolution and possible interventions. We reviewed studies, including those with Brazilian populations, assessing frailty in the pre- and post-KT phases, exploring pathophysiology, associated factors, diagnostic challenges, and associated outcomes, in an attempt to provide a basis for future interventions.
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Affiliation(s)
- Tainá Veras de Sandes-Freitas
- Universidade Federal do Ceará, Faculdade de Medicina, Fortaleza, CE,
Brazil
- Hospital Geral de Fortaleza, Fortaleza, CE, Brazil
| | | | - Helady Sanders-Pinheiro
- Universidade Federal de Juiz de Fora, Faculdade de Medicina, Núcleo
Interdisciplinar de Estudos e Pesquisas em Nefrologia (NIEPEN), Juiz de Fora, MG,
Brazil
- Universidade Federal de Juiz de Fora, Hospital Universitário,
Serviço de Transplante Renal, Juiz de Fora, MG, Brazil
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15
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Briggs J, Chilcot J, Greenwood SA. The use of digital health interventions to deliver prehabilitation in solid organ transplant recipients: are we there yet? Curr Opin Organ Transplant 2024; 29:357-362. [PMID: 39150352 DOI: 10.1097/mot.0000000000001164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2024]
Abstract
PURPOSE OF REVIEW Prehabilitation, defined as preparing the body physically and psychologically for upcoming surgery is of increasing prominence in presurgical care. The aim of this review is to discuss the evidence base around prehabilitation in solid organ transplantation, the use of digital health as a tool to deliver these interventions, and consider future directions. RECENT FINDINGS Prehabilitation is of increasing interest as an adjunct to pretransplant care for individuals working up for solid organ transplantation. To date, research has shown that prehabilitation is acceptable and feasible; however, the literature base remains small. The majority of research has been delivered using in-person rehabilitation programmes, and the evidence base utilizing digital health as a means to deliver prehabilitation is limited. SUMMARY To date, the research evidence base in prehabilitation for solid organ transplantation is limited. Evidence in other surgical populations has demonstrated promising results, particularly in aerobic capacity, physical function and postoperative complications. Further high-quality randomized controlled clinical trials are required to strengthen the evidence base, understand how digital health can be harnessed and utilized to deliver multimodal prehabilitation with an aim to see how this may form part of routine care in the solid organ transplantation pathway.
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Affiliation(s)
- Juliet Briggs
- Department of Renal Medicine, King's College Hospital NHS Trust
| | - Joseph Chilcot
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London UK
| | - Sharlene A Greenwood
- Department of Renal Medicine, King's College Hospital NHS Trust
- Renal Sciences, Faculty of Life Sciences and Medicine
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16
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Benes B, Langewisch ED, Westphal SG. Kidney Transplant Candidacy: Addressing Common Medical and Psychosocial Barriers to Transplant. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:387-399. [PMID: 39232609 DOI: 10.1053/j.akdh.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 03/04/2024] [Accepted: 03/05/2024] [Indexed: 09/06/2024]
Abstract
Improving access to kidney transplants remains a priority for the transplant community. However, many medical, psychosocial, geographic, and socioeconomic barriers exist that prevent or delay transplantation for candidates with certain conditions. There is a lack of consensus regarding how to best approach many of these issues and barriers, leading to heterogeneity in transplant centers' management and acceptance practices for a variety of pretransplant candidate issues. In this review, we address several of the more common contemporary patient medical and psychosocial barriers frequently encountered by transplant programs. The barriers discussed here include kidney transplant candidates with obesity, older age, prior malignancy, cardiovascular disease, history of nonadherence, and cannabis use. Improving understanding of how to best address these specific issues can empower referring providers, transplant programs, and patients to address these issues as necessary to progress toward eventual successful transplantation.
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Affiliation(s)
- Brian Benes
- Nephrology Division, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Eric D Langewisch
- Nephrology Division, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Scott G Westphal
- Nephrology Division, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE.
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17
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Nalatwad A, Quint EE, Fazal M, Thompson V, Chen X, Shrestha P, Van Pilsum Rasmussen SE, Li Y, Segev DL, Humbyrd CJ, McAdams-DeMarco M. Patient Perspectives on the Use of Aging Metrics for Kidney Transplant Decision-Making. Prog Transplant 2024; 34:81-88. [PMID: 39105243 PMCID: PMC11449634 DOI: 10.1177/15269248241268686] [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] [Indexed: 08/07/2024]
Abstract
INTRODUCTION Frailty and cognitive function are often measured during kidney transplant evaluation. However, patient perspectives on the ethical considerations of this practice are unclear. RESEARCH QUESTION What are patient perspectives on the use of aging metrics in kidney transplant decision-making? DESIGN One hundred participants who were evaluated for kidney transplantation and were enrolled in an ongoing prospective cohort study (response rate = 61.3%) were surveyed. Participants were informed of the definitions of frailty and cognitive impairment and then asked survey questions regarding the use of these measures of aging to determine kidney transplant candidacy. RESULTS Participants (75.6%) thought it was unfair to prevent older adults from receiving a kidney transplant based on age, but there was less agreement on whether it was fair to deny frail (46.5%) and cognitively impaired (45.9%) patients from accessing kidney transplantation. Compared to older participants, younger participants had 5.36-times (95%CI:1.94-14.81) the odds of choosing a hypothetical younger, frail patient to list for kidney transplantation than an older, non-frail patient; they also had 3.56-times (95%CI:1.33-9.56) the odds of choosing the hypothetical frail patient with social support rather than a non-frail patient without social support. Participants disagreed on the use of patient age as a listing criterion; 19.5% ranked it as the fairest and 28.7% as the least fair. CONCLUSION The patient views highlighted in this study are an important step toward developing ethical guidelines to ensure fair use of frailty, cognitive function, and chronological age for kidney transplant decision-making.
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Affiliation(s)
- Akanksha Nalatwad
- Department of Surgery, New York University Grossman School of Medicine and Langone Health, New York, New York, USA
| | - Evelien E Quint
- Division of Transplant Surgery, Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Maria Fazal
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Valerie Thompson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Xiaomeng Chen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Prakriti Shrestha
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sarah E Van Pilsum Rasmussen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Yiting Li
- Department of Surgery, New York University Grossman School of Medicine and Langone Health, New York, New York, USA
| | - Dorry L Segev
- Department of Surgery, New York University Grossman School of Medicine and Langone Health, New York, New York, USA
- Department of Population Health, New York University, New York, New York, USA
| | - Casey Jo Humbyrd
- Department of Orthopedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mara McAdams-DeMarco
- Department of Surgery, New York University Grossman School of Medicine and Langone Health, New York, New York, USA
- Department of Population Health, New York University, New York, New York, USA
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18
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Garnier-Crussard A, Collette-Robert S, Montredon C, Francq E, Guerville F. Should intrinsic capacity be assessed in addition to frailty in older kidney transplantation candidates? Clin Kidney J 2024; 17:sfae226. [PMID: 39421233 PMCID: PMC11483741 DOI: 10.1093/ckj/sfae226] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2024] [Indexed: 10/19/2024] Open
Affiliation(s)
- Antoine Garnier-Crussard
- Clinical and Research Memory Center of Lyon, Charpennes Hospital, Department of Geriatric Medicine, Lyon Institute For Aging, Hospices Civils de Lyon, Lyon 1 University, Villeurbanne, France
- Normandie Univ, UNICAEN, INSERM, U1237, PhIND “Physiopathology and Imaging of Neurological Disorders”, NeuroPresage Team, Institut Blood and Brain @ Caen-Normandie, Cyceron, Caen, France
| | - Sarah Collette-Robert
- Clinical and Research Memory Center of Lyon, Charpennes Hospital, Department of Geriatric Medicine, Lyon Institute For Aging, Hospices Civils de Lyon, Lyon 1 University, Villeurbanne, France
| | - Candice Montredon
- Department of Geriatric Medicine, Lyon Institute For Aging, Hospices Civils de Lyon, Lyon 1 University, Villeurbanne, France
| | - Eloïse Francq
- Clinical Gerontology Department, Bordeaux University Hospital, Bordeaux, France
- Immunoconcept Lab, CNRS UMR 5164, Inserm ERL 1303, Bordeaux University, Bordeaux, France
| | - Florent Guerville
- Clinical Gerontology Department, Bordeaux University Hospital, Bordeaux, France
- Immunoconcept Lab, CNRS UMR 5164, Inserm ERL 1303, Bordeaux University, Bordeaux, France
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19
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Fergie R, Maxwell AP, Cunningham EL. Latest advances in frailty in kidney transplantation: A narrative review. Transplant Rev (Orlando) 2024; 38:100833. [PMID: 38309184 DOI: 10.1016/j.trre.2024.100833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 01/19/2024] [Accepted: 01/20/2024] [Indexed: 02/05/2024]
Abstract
Frailty is a clinical syndrome that is characterised by decline in multiple systems with associated decreased physiological reserve and ability to respond to stressor events. It is associated with greater healthcare burden. It is common in patients with end-stage renal disease (ESRD). Kidney transplantation is considered the optimal form of renal replacement therapy for suitable patients with ESRD. However, surgery and immunosuppression are physiological stresses that can disproportionately affect frail individuals. Frailty is emerging as a potentially important risk factor in patients waitlisted for kidney transplantation. Most of the published research to date in this area comes from a single transplant centre in the USA. Frailty, as measured using the Physical Frailty Phenotype (FP), is prevalent in waitlisted patients and has been associated with early hospital re-admission, prolonged length of stay, delayed graft function and increased mortality after kidney transplantation. However, although kidney transplantation is a substantial physiological stress to a patient's reserve, by restoring kidney function, kidney transplantation has also been shown to improve a patient's frailty status. The FP is the most studied tool in patients waitlisted for transplantation, but it has not been able to distinguish those whose frailty is improved by kidney transplantation. In summary, there remain significant gaps in knowledge and uncertainties as to how to effectively use existing frailty measures to inform decision-making around kidney transplantation. Further research is needed to address these important gaps in the literature.
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Affiliation(s)
- Ruth Fergie
- Centre for Public Health, Queen's University of Belfast, Belfast BT12 6AB, UK; Regional Nephrology Unit, Belfast City Hospital, Lisburn Road, BT9 7BA Belfast, UK.
| | - Alexander P Maxwell
- Centre for Public Health, Queen's University of Belfast, Belfast BT12 6AB, UK.
| | - Emma L Cunningham
- Centre for Public Health, Queen's University of Belfast, Belfast BT12 6AB, UK.
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Quint EE, Liu Y, Shafaat O, Ghildayal N, Crosby H, Kamireddy A, Pol RA, Orandi BJ, Segev DL, Weiss CR, McAdams-DeMarco MA. Abdominal computed tomography measurements of body composition and waitlist mortality in kidney transplant candidates. Am J Transplant 2024; 24:591-605. [PMID: 37949413 PMCID: PMC10982050 DOI: 10.1016/j.ajt.2023.11.002] [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: 05/09/2023] [Revised: 10/10/2023] [Accepted: 11/02/2023] [Indexed: 11/12/2023]
Abstract
Body mass index is often used to determine kidney transplant (KT) candidacy. However, this measure of body composition (BC) has several limitations, including the inability to accurately capture dry weight. Objective computed tomography (CT)-based measures may improve pre-KT risk stratification and capture physiological aging more accurately. We quantified the association between CT-based BC measurements and waitlist mortality in a retrospective study of 828 KT candidates (2010-2022) with clinically obtained CT scans using adjusted competing risk regression. In total, 42.5% of candidates had myopenia, 11.4% had myopenic obesity (MO), 68.8% had myosteatosis, 24.8% had sarcopenia (probable = 11.2%, confirmed = 10.5%, and severe = 3.1%), and 8.6% had sarcopenic obesity. Myopenia, MO, and sarcopenic obesity were not associated with mortality. Patients with myosteatosis (adjusted subhazard ratio [aSHR] = 1.62, 95% confidence interval [CI]: 1.07-2.45; after confounder adjustment) or sarcopenia (probable: aSHR = 1.78, 95% CI: 1.10-2.88; confirmed: aSHR = 1.68, 95% CI: 1.01-2.82; and severe: aSHR = 2.51, 95% CI: 1.12-5.66; after full adjustment) were at increased risk of mortality. When stratified by age, MO (aSHR = 2.21, 95% CI: 1.28-3.83; P interaction = .005) and myosteatosis (aSHR = 1.95, 95% CI: 1.18-3.21; P interaction = .038) were associated with elevated risk only among candidates <65 years. MO was only associated with waitlist mortality among frail candidates (adjusted hazard ratio = 2.54, 95% CI: 1.28-5.05; P interaction = .021). Transplant centers should consider using BC metrics in addition to body mass index when a CT scan is available to improve pre-KT risk stratification at KT evaluation.
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Affiliation(s)
- Evelien E Quint
- Division of Transplant Surgery, Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Yi Liu
- Department of Surgery, New York University Grossman School of Medicine, New York, NY, USA
| | - Omid Shafaat
- Division of Vascular and Interventional Radiology, The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nidhi Ghildayal
- Department of Surgery, New York University Grossman School of Medicine, New York, NY, USA
| | - Helen Crosby
- Department of Surgery, New York University Grossman School of Medicine, New York, NY, USA
| | - Arun Kamireddy
- Division of Vascular and Interventional Radiology, The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Robert A Pol
- Division of Transplant Surgery, Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Babak J Orandi
- Division of Endocrinology, Joan & Sanford Weill Medical College of Cornell University, New York, NY, USA
| | - Dorry L Segev
- Department of Surgery, New York University Grossman School of Medicine, New York, NY, USA; Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Clifford R Weiss
- Division of Vascular and Interventional Radiology, The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mara A McAdams-DeMarco
- Department of Surgery, New York University Grossman School of Medicine, New York, NY, USA; Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA.
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21
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Hladek MD, Wilson D, Krasnansky K, McDaniel K, Shanbhag M, McAdams-DeMarco M, Crews DC, Brennan DC, Taylor J, Segev D, Walston J, Xue QL, Szanton SL. Using Photovoice to Explore the Lived Environment and Experience of Older Adults with Frailty on their Kidney Transplant Journey. KIDNEY360 2024; 5:589-598. [PMID: 38379153 PMCID: PMC11093540 DOI: 10.34067/kid.0000000000000380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 01/29/2024] [Indexed: 02/22/2024]
Abstract
Key Points Photovoice, a qualitative method, visually depicted the daily lives of participants with frailty, providing insights into independence and symptom management to guide clinicians and researchers. This photovoice study uncovered subthemes of home safety and organization, revealing potential safety hazards like dialysis fluid storage, and suggests its potential use in geriatric nephrology. The findings emphasize the importance of integrating participant values and goals into care decisions and interventional design in the context of kidney transplant journeys for frail adults. Background Older adults with frailty and kidney failure face higher waitlist mortality and are more likely to be listed as inactive on the kidney transplant (KT) waitlist. Photovoice is a qualitative participatory research method where participants use photographs to represent their environment, needs, and experiences. It offers unique insight into the lived environment and experience of patients and may offer direction in how to improve functional independence, symptom burden, and KT outcomes in adults with frailty. Methods This photovoice study was embedded within a larger intervention adaptation project. Participants with prefrailty or frailty awaiting a KT or recently post-transplant took photographs with Polaroid cameras and wrote short descriptions for 11 prompts. Each participant completed a semistructured interview wherein their photographs were discussed. The team coded and discussed photographs and interviews to determine overarching themes and implications. Focus groups were used to triangulate visual data findings. Results Sixteen participants completed both the photovoice and the interview. Participants were a mean age of 60.5 years, 31.2% female, 43.4% self-identifying as Black, and 69% were frail. Outcomes were categorized into seven themes: functional space, home safety, medication management, adaptive coping, life-changing nature of dialysis, support, and communication. Visual data clarified and sometimes changed the interpretations of the text alone. Especially within the themes of home safety and functional space, safety hazards not previously recognized in the literature, like dialysis fluid storage, were identified. Conclusions Photovoice contextualizes the living conditions and experiences of adults with frailty on the KT journey and could be a useful tool in geriatric nephrology and transplant. Addressing issues of home storage, organization, and accessibility should be explored as potential intervention targets. Incorporating participant values and goals into care decisions and interventional design should be further explored.
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Affiliation(s)
| | - Deborah Wilson
- Johns Hopkins School of Nursing, Baltimore, Maryland
- Auckland University of Technology School of Clinical Sciences, Auckland, New Zealand
| | | | | | - Meera Shanbhag
- University of Central Florida College of Medicine, Orlando, Florida
| | - Mara McAdams-DeMarco
- New York University Grossman School of Medicine Lagoune Health, New York, New York
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Deidra C. Crews
- Johns Hopkins School of Nursing, Baltimore, Maryland
- Johns Hopkins University School of Medicine, Baltimore, Maryland
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | | | | | - Dorry Segev
- New York University Grossman School of Medicine Lagoune Health, New York, New York
| | - Jeremy Walston
- Johns Hopkins School of Nursing, Baltimore, Maryland
- Johns Hopkins University School of Medicine, Baltimore, Maryland
- Johns Hopkins Center for Geriatric Medicine and Gerontology, Baltimore, Maryland
| | - Qian-Li Xue
- Johns Hopkins University School of Medicine, Baltimore, Maryland
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Sarah L. Szanton
- Johns Hopkins School of Nursing, Baltimore, Maryland
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
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22
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Krusemark H, Schiffer M. [Comprehensive care for kidney transplantation-optimization of interdisciplinary support before and after kidney transplantation]. UROLOGIE (HEIDELBERG, GERMANY) 2024; 63:333-340. [PMID: 38381167 DOI: 10.1007/s00120-024-02290-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/19/2024] [Indexed: 02/22/2024]
Abstract
Due to the divergence between the number of potential organ recipients and organ availability, transplant survival is of particular importance. In order to create the best possible conditions, it is not only important to address the risk factors for loss of organ functionality after transplantation, but also to focus on the time before transplantation. During this period, which lasts several years on average, the patient can create the conditions for risk reduction before and after transplantation with support. The optimization of physical health plays an important role here in order to maintain transplantability, on the one hand, and to counteract the general loss of physical performance due to dialysis, on the other. Therefore, the focus must be placed on "exercise" and "nutrition", which represent an increased risk of declining physical health in dialysis patients. After transplantation, the focus should again be on physical health. Through support, patients learn how to improve their cardiovascular risk profile and increase their physical performance. Psychosocial support is also important to combat psychological comorbidities and prevent risks such as nonadherence. In addition to improved physical and mental health, the focus here is also on the long-term survival of the patient and the transplant.
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Affiliation(s)
- Helge Krusemark
- Medizinische Klinik 4, Nephrologie/Hypertensiologie, Universitätsklinikum Erlangen, Ulmenweg 18, 91054, Erlangen, Deutschland.
| | - Mario Schiffer
- Medizinische Klinik 4, Nephrologie/Hypertensiologie, Universitätsklinikum Erlangen, Ulmenweg 18, 91054, Erlangen, Deutschland.
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23
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Sontag AF, Kiselev J, Schaller SJ, Spies C, Rombey T. Facilitators and barriers to the implementation of prehabilitation for frail patients into routine health care: a realist review. BMC Health Serv Res 2024; 24:192. [PMID: 38350947 PMCID: PMC10863196 DOI: 10.1186/s12913-024-10665-1] [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: 08/22/2023] [Accepted: 01/31/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Despite evidence supporting the effectiveness of prehabilitation as a new preoperative care pathway to optimise perioperative outcomes, its implementation into routine health care is widely pending. Frail patients might particularly benefit from prehabilitation interventions, but facilitating and hindering factors need to be considered in the implementation process. Thus, our aim was to derive a programme theory on what prehabilitation programmes work for frail patients in what circumstances and why. METHODS Following Pawson's realist review approach, preliminary programme theories on facilitators and barriers were established. General and topic-specific databases were searched systematically for facilitators and barriers to the implementation of prehabilitation for frail patients. Articles were included if they dealt with multimodal prehabilitation programmes prior to surgery in a frail population and if they contained information on facilitators and barriers during the implementation process in the full text. Based on these articles, refined programme theories were generated. RESULTS From 2,609 unique titles, 34 were retained for the realist synthesis. Facilitating factors included the individualisation of prehabilitation programmes to meet the patients' needs and abilities, multimodality, adaption to the local setting and health care system, endorsement by an ambassador and sharing of responsibilities among a multidisciplinary team. Central barriers for frail patients were transportation, lack of social support, and inadequate, overwhelming information provision. CONCLUSIONS Implementing prehabilitation as a new care pathway for frail patients requires organisational readiness and adaptability to the local setting. On an individual level, a clear understanding of responsibilities and of the intervention's goal among patients and providers are necessary. Added attention must be paid to the individualisation to fit the needs and restrictions of frail patients. This makes prehabilitation a resource-intense, but promising intervention for frail surgery patients. TRIAL REGISTRATION PROSPERO (CRD42022335282).
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Affiliation(s)
- Anna Frederike Sontag
- Berlin School of Public Health, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Jörn Kiselev
- Department for Anesthesiology and Intensive Care Medicine Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Stefan J Schaller
- Department for Anesthesiology and Intensive Care Medicine Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
- Department of Anesthesiology and Intensive Care, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Ismaninger Str.22, 81675, München, Germany
| | - Claudia Spies
- Department for Anesthesiology and Intensive Care Medicine Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Tanja Rombey
- Department of Health Care Management, Technische Universität Berlin, Straße des 17. Juni 135, 10623, Berlin, Germany.
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Hannan M, Chen J, Hsu J, Zhang X, Saunders MR, Brown J, McAdams-DeMarco M, Mohanty MJ, Vyas R, Hajjiri Z, Carmona-Powell E, Meza N, Porter AC, Ricardo AC, Lash JP. Frailty and Cardiovascular Outcomes in Adults With CKD: Findings From the Chronic Renal Insufficiency Cohort (CRIC) Study. Am J Kidney Dis 2024; 83:208-215. [PMID: 37741609 PMCID: PMC10810341 DOI: 10.1053/j.ajkd.2023.06.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 06/13/2023] [Accepted: 06/23/2023] [Indexed: 09/25/2023]
Abstract
RATIONALE & OBJECTIVE Frailty is common in individuals with chronic kidney disease (CKD) and increases the risk of adverse outcomes in adults with kidney failure requiring dialysis. However, this relationship has not been thoroughly evaluated among those with non-dialysis-dependent CKD. STUDY DESIGN Prospective cohort study. SETTING & PARTICIPANTS 2,539 adults in the Chronic Renal Insufficiency Cohort Study. EXPOSURE Frailty status assessed using 5 criteria: slow gait speed, muscle weakness, low physical activity, exhaustion, and unintentional weight loss. OUTCOME Atherosclerotic events, incident heart failure, all-cause death, and cardiovascular death. ANALYTICAL APPROACH Cause-specific hazards models. RESULTS At study entry, the participants' mean age was 62 years, 46% were female, the mean estimated glomerular filtration rate was 45.4mL/min/1.73m2, and the median urine protein was 0.2mg/day. Frailty status was as follows: 12% frail, 51% prefrail, and 37% nonfrail. Over a median follow-up of 11.4 years, there were 393 atherosclerotic events, 413 heart failure events, 497 deaths, and 132 cardiovascular deaths. In multivariable regression analyses, compared with nonfrailty, both frailty and prefrailty status were each associated with higher risk of an atherosclerotic event (HR, 2.03 [95% CI, 1.41-2.91] and 1.77 [95% CI, 1.35-2.31], respectively) and incident heart failure (HR, 2.22 [95% CI, 1.59-3.10] and 1.39 [95% CI, 1.07-1.82], respectively), as well as higher risk of all-cause death (HR, 2.52 [95% CI, 1.84-3.45] and 1.76 [95% CI, 1.37-2.24], respectively) and cardiovascular death (HR, 3.01 [95% CI, 1.62-5.62] and 1.78 [95% 1.06-2.99], respectively). LIMITATIONS Self-report of aspects of the frailty assessment and comorbidities, which may have led to bias in some estimates. CONCLUSIONS In adults with CKD, frailty status was associated with higher risk of cardiovascular events and mortality. Future studies are needed to evaluate the impact of interventions to reduce frailty on cardiovascular outcomes in this population. PLAIN-LANGUAGE SUMMARY Frailty is common in individuals with chronic kidney disease (CKD) and increases the risk of adverse outcomes. We sought to evaluate the association of frailty status with cardiovascular events and death in adults with CKD. Frailty was assessed according to the 5 phenotypic criteria detailed by Fried and colleagues. Among 2,539 participants in the CRIC Study, we found that 12% were frail, 51% were prefrail, and 37% were nonfrail. Frailty status was associated with an increased risk of atherosclerotic events, incident heart failure, and death.
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Affiliation(s)
- Mary Hannan
- Department of Biobehavioral Nursing Science, College of Nursing, University of Illinois Chicago, Chicago, Illinois.
| | - Jinsong Chen
- Department of Medicine, College of Medicine, University of Illinois Chicago, Chicago, Illinois; School of Public Health, University of Nevada, Reno, Reno, Nevada
| | - Jesse Hsu
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Xiaoming Zhang
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Milda R Saunders
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Julia Brown
- Department of Medicine, College of Medicine, University of Illinois Chicago, Chicago, Illinois
| | - Mara McAdams-DeMarco
- Department of Surgery, New York University Grossman School of Medicine, New York, New York
| | - Madhumita Jena Mohanty
- Department of Internal Medicine, School of Medicine, Wayne State University, Detroit, Michigan
| | - Rahul Vyas
- Department of Internal Medicine, School of Medicine, Wayne State University, Detroit, Michigan
| | - Zahraa Hajjiri
- Department of Medicine, College of Medicine, University of Illinois Chicago, Chicago, Illinois
| | - Eunice Carmona-Powell
- Department of Medicine, College of Medicine, University of Illinois Chicago, Chicago, Illinois
| | - Natalie Meza
- Department of Medicine, College of Medicine, University of Illinois Chicago, Chicago, Illinois
| | - Anna C Porter
- Department of Medicine, College of Medicine, University of Illinois Chicago, Chicago, Illinois; Jesse Brown VA Hospital, Chicago, Illinois
| | - Ana C Ricardo
- Department of Medicine, College of Medicine, University of Illinois Chicago, Chicago, Illinois
| | - James P Lash
- Department of Medicine, College of Medicine, University of Illinois Chicago, Chicago, Illinois
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25
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Kanbay M, Copur S, Yildiz AB, Tanriover C, Mallamaci F, Zoccali C. Physical exercise in kidney disease: A commonly undervalued treatment modality. Eur J Clin Invest 2024; 54:e14105. [PMID: 37814427 DOI: 10.1111/eci.14105] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/25/2023] [Accepted: 09/29/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND Physical inactivity has been identified as a risk factor for multiple disorders and a strong association exists between chronic kidney disease (CKD) and a sedentary lifestyle. Even though physical activity is crucial in the development and progression of disease, the general focus of the current medical practice is the pharmacological perspective of diseases with inadequate emphasis on lifestyle intervention. METHODS In this narrative review we explain the pathophysiological mechanisms underlying the beneficial effects of physical exercise on CKD in addition to discussing the clinical studies and trials centred on physical exercise in patients with CKD. RESULTS Physical activity influences several pathophysiological mechanisms including inflammation, oxidative stress, vascular function, immune response and macromolecular metabolism. While exercise can initially induce stress responses like inflammation and oxidative stress, long-term physical activity leads to protective countermeasures and overall improved health. Trials in pre-dialysis CKD patients show that exercise can lead to reductions in body weight, inflammation markers and fasting plasma glucose. Furthermore, it improves patients' functional capacity, cardiorespiratory fitness and quality of life. The effects of exercise on kidney function have been inconsistent in these trials. In haemodialysis, peritoneal dialysis and kidney transplant patients exercise interventions improve cardiorespiratory fitness, walking capacity and quality of life. Combined training shows the best performance to increase peak oxygen uptake in haemodialysis patients. In kidney transplant recipients, exercise improves walking performance, quality of life and potentially arterial stiffness. However, exercise does not affect glucose metabolism, serum cholesterol and inflammation biomarkers. Long-term, adequately powered trials are needed to determine the long-term feasibility, and effects on quality of life and major clinical outcomes, including mortality and cardiovascular risk, in all CKD stages and particularly in kidney transplant patients, a scarcely investigated population. CONCLUSION Physical exercise plays a crucial role in ameliorating inflammation, oxidative stress, vascular function, immune response and macromolecular metabolism, and contributes significantly to the quality of life for patients with CKD, irrespective of the treatment and stage. Its direct impact on kidney function remains uncertain. Further extensive, long-term trials to conclusively determine the effect of exercise on major clinical outcomes such as mortality and cardiovascular risk remain a research priority.
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Affiliation(s)
- Mehmet Kanbay
- Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Sidar Copur
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Abdullah B Yildiz
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Cem Tanriover
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Francesca Mallamaci
- Nephrology, Dialysis and Transplantation Unit Azienda Ospedaliera "Bianchi-Melacrino-Morelli" & CNR-IFC, Institute of Clinical Physiology, Research Unit of Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension of Reggio Calabria, Reggio Calabria, Italy
| | - Carmine Zoccali
- Renal Research Institute, New York, New York, USA
- Institute of Molecular Biology and Genetics (Biogem), Ariano Irpino, Italy
- Associazione Ipertensione Nefrologia Trapianto Renal (IPNET), c/o Nefrologia, Grande Ospedale Metropolitano, Reggio Calabria, Italy
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26
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Xu EJ, Kyriazis P, Pawar A, Pavlakis M, Aala A. Frailty and Kidney Transplant Waitlisting: A Single-Center Experience. Transplant Proc 2024; 56:37-43. [PMID: 38195285 DOI: 10.1016/j.transproceed.2023.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 09/28/2023] [Accepted: 10/22/2023] [Indexed: 01/11/2024]
Abstract
BACKGROUND Frailty is widely prevalent among kidney transplant (KT) candidates and is associated with poor peri and post-transplant outcomes. Whether frailty is a modifiable risk factor in KT candidates is unknown. Efforts to intervene in frailty have been hindered by a lack of a standardized approach to testing and treating frailty in clinical practice. METHODS Patients undergoing evaluation for kidney transplantation underwent frailty testing during their clinical visits using a combination of the Short Physical Performance Battery (SPPB) and Groningen Frailty Indicator (GFI) instruments. Scores from the SPPB and GFI were combined to stratify patients into 4 risk groups. Patients in the highest-risk groups were referred to physical therapy (PT) and returned for repeat frailty testing. Pre- and post-PT scores were compared with assessment for improvement. RESULTS Forty patients met the criteria for PT, of which 16 (40%) completed PT and returned for repeat frailty testing. The mean SPPB score improved from 5.88 to 8.94 after PT (P < .01). The mean GFI score improved from 5.25 to 4.06 after PT but was not statistically significant (P = .081). CONCLUSIONS Our unique approach of using 2 validated scores, SPPB and GFI, together addressed many components of frailty evaluation, including physical, cognitive, and psychosocial components. We used PT as a targeted intervention for addressing both the physical and non-physical impairments among frail KT candidates. Physical therapy was noted to have a positive impact on each of these components.
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Affiliation(s)
- Eric J Xu
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Periklis Kyriazis
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Aditya Pawar
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Martha Pavlakis
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Amtul Aala
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
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27
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Wadhwa A, Balbale SN, Palleti SK, Samra M, Lopez-Soler RI, Stroupe KT, Markossian TW, Huisingh-Scheetz M. Prevalence and feasibility of assessing the frailty phenotype among hemodialysis patients in a dialysis unit. BMC Nephrol 2023; 24:371. [PMID: 38093284 PMCID: PMC10720194 DOI: 10.1186/s12882-023-03413-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 11/28/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Frailty increases risk of morbidity and mortality in hemodialysis patients. Frailty assessments could trigger risk reduction interventions if broadly adopted in clinical practice. We aimed to assess the clinical feasibility of frailty assessment among Veteran hemodialysis patients. METHODS Hemodialysis patients' ≥50 years were recruited from a single dialysis unit between 9/1/2021 and 3/31/2022.Patients who consented underwent a frailty phenotype assessment by clinical staff. Five criteria were assessed: unintentional weight loss, low grip strength, self-reported exhaustion, slow gait speed, and low physical activity. Participants were classified as frail (3-5 points), pre-frail (1-2 points) or non-frail (0 points). Feasibility was determined by the number of eligible participants completing the assessment. RESULTS Among 82 unique dialysis patients, 45 (52%) completed the assessment, 13 (16%) refused, 18 (23%) were not offered the assessment due to death, transfers, or switch to transplant or peritoneal dialysis, and 6 patients were excluded because they did not meet mobility criteria. Among assessed patients, 40(88%) patients were identified as pre-frail (46.6%) or frail (42.2%). Low grip strength was most common (90%). Those who refused were more likely to have peripheral vascular disease (p = 0.001), low albumin (p = 0.0187), low sodium (p = 0.0422), and ineligible for kidney transplant (p = 0.005). CONCLUSIONS Just over half of eligible hemodialysis patients completed the frailty assessment suggesting difficulty with broad clinical adoption expectations. Among those assessed, frailty and pre-frailty prevalence was high. Given patients who were not tested were clinically high risk, our reported prevalence likely underestimates true frailty prevalence. Providing frailty reduction interventions to all hemodialysis patients could have high impact for this group.
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Affiliation(s)
- Anuradha Wadhwa
- Department of Medicine/ Nephrology, Edward Hines Jr. Veterans Administration Hospital, Hines, IL, USA.
- Department of Medicine/ Nephrology, Loyola University Chicago, Maywood, IL, USA.
| | - Salva N Balbale
- Division of Gastroenterology and Hepatology, Department of Medicine, Center for Health Services and Outcomes Research, Institute of Public Health and Medicine, Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines, Jr. VA Hospital, Hines, IL, USA
| | - Sujith K Palleti
- Department of Medicine/ Nephrology, Edward Hines Jr. Veterans Administration Hospital, Hines, IL, USA
- Department of Medicine/ Nephrology, Loyola University Chicago, Maywood, IL, USA
| | - Manpreet Samra
- Department of Medicine/ Nephrology, Edward Hines Jr. Veterans Administration Hospital, Hines, IL, USA
- Department of Medicine/ Nephrology, Loyola University Chicago, Maywood, IL, USA
| | - Reynold I Lopez-Soler
- Department of Surgery and Renal Transplant, Edward Hines Jr. Veterans Administration Hospital, Hines, IL, USA
- Department of Surgery and Renal Transplant, Loyola University Chicago, Maywood, IL, USA
| | - Kevin T Stroupe
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines, Jr. VA Hospital, Hines, IL, USA
- Department of Public Health Sciences, Parkinson School of Health Science and Public Health, Loyola University Chicago, Maywood, IL, USA
| | - Talar W Markossian
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines, Jr. VA Hospital, Hines, IL, USA
- Department of Public Health Sciences, Parkinson School of Health Science and Public Health, Loyola University Chicago, Maywood, IL, USA
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Swaab TDA, Quint EE, Westenberg LB, Zorgdrager M, Segev DL, McAdams‐DeMarco MA, Bakker SJL, Viddeleer AR, Pol RA. Validity of computed tomography defined body composition as a prognostic factor for functional outcome after kidney transplantation. J Cachexia Sarcopenia Muscle 2023; 14:2532-2539. [PMID: 37731200 PMCID: PMC10751408 DOI: 10.1002/jcsm.13316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 06/08/2023] [Accepted: 07/31/2023] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND The prevalence of sarcopenia is markedly higher in kidney transplant candidates than in the general population. It is a syndrome characterized by progressive and generalized loss of skeletal muscle mass and strength, which increases the risk of adverse postoperative outcomes. METHODS We studied the impact of computed tomography defined preoperative sarcopenia, defined as a skeletal muscle index below age and gender specific cut-off values, on postoperative physical functional outcomes (grip strength, 4-m walking test, timed up and go, and sit to stand) at 6 months follow up. RESULTS A total of 107 patients transplanted between 2015 and 2019 were included in this single-centre study. Mean age was 60.3 (±13.1), and 68.2% of patients were male. Ten patients (9.4%) were identified as sarcopenic. Sarcopenic patients were younger (55.6 (±15.1) vs. 60.8 (±12.9) years), more likely to be female (60.0% vs. 28.9%), and had an increased dialysis vintage (19 [2.5-32.8] vs. 9 [0.0-21.0] months) in comparison with their non-sarcopenic counterparts. In univariate analysis, they had a significantly lower body mass index and skeletal muscle area (P ≤ 0.001). In multivariate regression analysis, skeletal muscle index was significantly associated with grip strength (β = 0.690, R2 = 0.232) and timed up and go performance (β = -0.070, R2 = 0.154). CONCLUSIONS We identified a significant association between sarcopenia existing pre-transplantation and poorer 6 months post-transplantation physical functioning with respect to hand grip strength and timed up and go tests in kidney transplant recipients. These results could be used to preoperatively identify patients with an increased risk of poor postoperative physical functional outcome, allowing for preoperative interventions to mitigate these risks.
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Affiliation(s)
- Tim D. A. Swaab
- Department of Surgery, Division of Transplantation Surgery, University Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Evelien E. Quint
- Department of Surgery, Division of Transplantation Surgery, University Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Lisa B. Westenberg
- Department of Surgery, Division of Transplantation Surgery, University Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Marcel Zorgdrager
- Department of Radiology, Medical Imaging CenterUniversity Medical Center GroningenGroningenThe Netherlands
| | - Dorry L. Segev
- Department of SurgeryNYU Grossman School of MedicineNew YorkNew YorkUSA
| | | | - Stephan J. L. Bakker
- Department of Internal Medicine, Division of Nephrology, University Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Alain R. Viddeleer
- Department of Radiology, Medical Imaging CenterUniversity Medical Center GroningenGroningenThe Netherlands
| | - Robert A. Pol
- Department of Surgery, Division of Transplantation Surgery, University Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
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Castle EM, Billany RE, Lightfoot CJ, Annema C, De Smet S, Graham-Brown MP, Greenwood SA. Exercise as a therapeutic intervention in chronic kidney disease: are we nearly there yet? Curr Opin Nephrol Hypertens 2023; 32:502-508. [PMID: 37622530 PMCID: PMC10552838 DOI: 10.1097/mnh.0000000000000923] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
PURPOSE OF REVIEW The opportunity to review the more recent evidence for prescribing exercise-based physical rehabilitation for people living with chronic kidney disease (CKD) is timely. There has been a recent global focus evaluating how physical activity interventions might improve health-related quality of life and outcomes for people living with chronic health conditions in a post-COVID era. There is finally a long overdue commitment from the kidney research and clinical community to deliver pragmatic interventions to help people living with CKD to be able to live well with their condition. RECENT FINDINGS This article reviews recent research, and discusses the challenges and potential solutions, for providing exercise-based therapeutic options for people living with CKD; including predialysis self-management interventions, options for both prehabilitation and posttransplant rehabilitation, pragmatic considerations for delivery of exercise therapy for people receiving haemodialysis treatment and the role of virtual kidney-specific rehabilitation. SUMMARY Whilst there remains a need for further research in this area of patient care, there is now a body of evidence and kidney-specific guidelines that firmly support a rollout of pragmatic and scalable exercise-based interventions for people living with CKD. We are indeed nearly there now.
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Affiliation(s)
- Ellen M. Castle
- Physiotherapy, Department of Health Sciences, College of Health, Medicine, and life Sciences, Brunel University, London, UK
| | - Roseanne E. Billany
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Courtney J. Lightfoot
- Leicester Kidney Lifestyle Team, Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - Coby Annema
- Section of Nursing Science, Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Stefan De Smet
- Group Rehabilitation for Internal Disorders, Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
- Nephrology and Renal Transplantation, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Laboratory of Abdominal Transplantation, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | | | - Sharlene A. Greenwood
- Renal Therapies, King's College Hospital NHS Trust, London, UK
- Faculty of Life Sciences & Medicine, King's College London, London, UK
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Weerasekera S, Reid N, Young A, Homes R, Sia A, Giddens F, Francis RS, Hubbard RE, Gordon EH. Putting Guidelines Into Practice: Is Frailty Measurement at the Time of Kidney Transplant Eligibility Assessment Valid, Feasible, and Acceptable to Patients? Transplant Direct 2023; 9:e1548. [PMID: 37854024 PMCID: PMC10581598 DOI: 10.1097/txd.0000000000001548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 08/22/2023] [Accepted: 09/08/2023] [Indexed: 10/20/2023] Open
Abstract
Background Clinical Practice Guidelines suggest that frailty be measured during kidney transplant eligibility assessments. Yet it is not known how frailty is best assessed in this setting or whether its assessment is acceptable to patients. We aimed to examine the construct validity and feasibility of Frailty Index (FI) assessment among patients attending a kidney transplant assessment clinic and to explore patients' perspectives on frailty and the acceptability of its routine assessment. Methods A 58-item FI was calculated for 147 clinic patients. Semistructured interviews were conducted with a subgroup of 29 patients. The FI was validated against normative FI characteristics (mean, distribution, limit), age, and the Estimated Post-Transplant Survival Score. Feasibility was assessed using descriptive statistics. Qualitative data were analyzed using reflexive thematic analysis. Results The mean FI was 0.23 (±0.10, normal distribution, limit 0.53). FI increased with age and Estimated Post-Transplant Survival score. The FI was completed for 62.8% of eligible patients (147/234). The median completion time was 10 min, and completion rate (with no missing data) was 100%. Four themes were identified: perceptions of frailty, acceptability, perceived benefits, and risks of frailty measurement. Patients linked frailty with age and adverse outcomes, and most did not consider themselves frail. Patients reported that the FI was quick, simple, and efficient. They felt that frailty assessment is relevant to transplant eligibility and should be used to address potentially reversible factors. Conclusions The FI demonstrated construct validity and was feasible and acceptable in this clinic setting. The challenge is ensuring that routine assessments lead to better care.
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Affiliation(s)
- Shavini Weerasekera
- Geriatrics and Rehabilitation Unit, Princess Alexandra Hospital, Metro South Hospital & Health Service, Brisbane, Australia
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
- School of Medicine and Dentistry, Griffith University, Gold Coast, Australia
| | - Natasha Reid
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
| | - Adrienne Young
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
| | - Ryan Homes
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Aaron Sia
- Geriatrics and Rehabilitation Unit, Princess Alexandra Hospital, Metro South Hospital & Health Service, Brisbane, Australia
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
| | - Fiona Giddens
- Department of Nephrology, Princess Alexandra Hospital, Metro South Hospital & Health Service, Brisbane, Australia
| | - Ross S. Francis
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
- Department of Nephrology, Princess Alexandra Hospital, Metro South Hospital & Health Service, Brisbane, Australia
| | - Ruth E. Hubbard
- Geriatrics and Rehabilitation Unit, Princess Alexandra Hospital, Metro South Hospital & Health Service, Brisbane, Australia
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
| | - Emily H. Gordon
- Geriatrics and Rehabilitation Unit, Princess Alexandra Hospital, Metro South Hospital & Health Service, Brisbane, Australia
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
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31
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Battaglia Y, Amicone M, Mantovani A, Combe C, Mitra S, Basile C. Home-based exercise in patients on maintenance dialysis: a systematic review and meta-analysis of randomized clinical trials. Nephrol Dial Transplant 2023; 38:2550-2561. [PMID: 37202219 DOI: 10.1093/ndt/gfad102] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Indexed: 05/20/2023] Open
Abstract
BACKGROUND The impact of home-based exercise on physical performance and quality of life (QoL) in patients on maintenance dialysis has not yet been fully established. METHODS We searched four large electronic databases to identify randomized controlled trials (RCTs) reporting the impact of home-based exercise interventions vs. usual care or intradialytic exercise interventions, on physical performance and QoL in patients on dialysis. The meta-analysis was performed using fixed effects modeling. RESULTS We included 12 unique RCTs involving 791 patients of various ages on maintenance dialysis. Home-based exercise interventions were associated with an improvement of walking speed at the 6 Minutes Walking Test [6MWT; nine RCTs; pooled weighted mean differences (WMD): 33.7 m, 95% confidence interval (CI) 22.8-44.5; P < 0.001; I2 = 0%) and in aerobic capacity as assessed by the peak oxygen consumption (VO2 peak; 3 RCTs; pooled WMD: 2.04 ml/kg/min, 95% CI 0.25-3.83; P = 0.03; I2 = 0%). They were also associated with improved QoL, as assessed by the Short Form (36) Health (SF-36) score. Stratifying the RCTs by control groups, no significant difference was found between home-based exercise and intradialytic exercise interventions. Funnel plots did not reveal any significant publication bias. CONCLUSIONS Our systematic review and meta-analysis showed that home-based exercise interventions for 3-6 months were associated with significant improvements in physical performance in patients on maintenance dialysis. However, further RCTs with a longer follow-up should be conducted to assess the safety, adherence, feasibility, and effects on QoL of home-based exercise programs in dialysis patients.
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Affiliation(s)
- Yuri Battaglia
- University of Verona, Department of Medicine, Verona, Italy
- Pederzoli Hospital, Nephrology and Dialysis Unit, Peschiera del Garda, Italy
| | - Maria Amicone
- Department of Public Health, Chair of Nephrology, University of Naples Federico II, Italy
| | - Alessandro Mantovani
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Christian Combe
- Department of Nephrology, CHU de Bordeaux and INSERM U1026, University of Bordeaux, Bordeaux, France
| | - Sandip Mitra
- Manchester Academy of Health Sciences Centre (MAHSC), University Hospitals, Oxford Road, Manchester, UK
| | - Carlo Basile
- Associazione Nefrologica Gabriella Sebastio, Martina Franca, Italy
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Karumuri K, Desai KB, Hippalgaonkar K, Vecham R, Gurava Reddy AV. Is it worth the risk? Frailty transition and complications following robotic total knee arthroplasty: A retrospective observational study. Knee 2023; 44:72-78. [PMID: 37536072 DOI: 10.1016/j.knee.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 07/08/2023] [Accepted: 07/20/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND Frailty is an underutilized prognostic parameter in the geriatric population. Our study aimed to analyse the frailty incidence, its transition over 1 year and its influence on complication rate in patients undergoing elective robotic-assisted total knee arthroplasty (TKA). METHODS This was a retrospective study wherein an accumulation of deficits model was used to evaluate frailty of 435 consecutive patients undergoing primary unilateral Mako-assisted cemented TKA between January 2020 and July 2021. Based upon the preoperative values, participants were divided into three groups; non-frail (FI < 0.11), vulnerable (0.11-0.20) and frail (FI > 0.20) states and were followed up for 1 year for change in frailty class, complications, re-admissions and mortality. RESULTS A total of 435 patients were divided into three groups, non-frail (178), vulnerable (208) and frail (49). Improvement in mean frailty scores was seen in all three groups (P < 0.0001); 21.63% of the vulnerable and 48.97% of the frail participants improved by one frailty class. Multivariate analysis showed the co-relation of change in frailty index (ΔFI) with preoperative FI (r = 0.083) and Knee Society Score (KSS) (r = 0.742). The frail group had a significantly higher re-admission rate over 1 year. When compared with the vulnerable group, the frail group had a higher hazard ratio for readmission (3.12 vs. 0.96) and complications (1.62 vs. 1.26). CONCLUSION Although frail individuals are at a higher risk for readmissions and perioperative complications, TKA significantly improves the mobility and frailty status of elderly individuals. With explained higher risk of complications, surgeons should not refrain from offering TKA to elderly frail individuals disabled with knee pain.
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Affiliation(s)
- Kishore Karumuri
- Sunshine Bone and Joint Institute, Sunshine Hospitals, Hyderabad, India
| | - Keyur B Desai
- Sunshine Bone and Joint Institute, Sunshine Hospitals, Hyderabad, India.
| | | | - Ratnakar Vecham
- Sunshine Bone and Joint Institute, Sunshine Hospitals, Hyderabad, India
| | - A V Gurava Reddy
- Sunshine Bone and Joint Institute, Sunshine Hospitals, Hyderabad, India
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Quint EE, Haanstra AJ, van der Veen Y, Maring H, Berger SP, Ranchor A, Bakker SJL, Finnema E, Pol RA, Annema C. PREhabilitation of CAndidates for REnal Transplantation (PreCareTx) study: protocol for a hybrid type I, mixed method, randomised controlled trial. BMJ Open 2023; 13:e072805. [PMID: 37500274 PMCID: PMC10387712 DOI: 10.1136/bmjopen-2023-072805] [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] [Indexed: 07/29/2023] Open
Abstract
INTRODUCTION Kidney transplant candidates (KTCs) need to be in optimal physical and psychological condition prior to surgery. However, KTCs often experience compromised functional capacity which can be characterised as frailty. Prehabilitation, the enhancement of a person's functional capacity, may be an effective intervention to improve the health status of KTCs. The PREhabilitation of CAndidates for REnal Transplantation (PreCareTx) study aims to examine the effectiveness of a multimodal prehabilitation programme on the health status of KTCs, and to explore the potential of implementation of prehabilitation in daily clinical practice. METHODS AND ANALYSIS This study uses a single centre, effectiveness-implementation hybrid type I study design, comprised of a randomised controlled trial and a mixed-methods study. Adult patients who are currently on the transplant waiting list or are waitlisted during the study period, at a university medical centre in The Netherlands, will be randomly assigned to either prehabilitation (n=64) or care as usual (n=64) groups. The prehabilitation group will undergo a 12-week home-based, tailored prehabilitation programme consisting of physical and/or nutritional and/or psychosocial interventions depending on the participant's deficits. This programme will be followed by a 12-week maintenance programme in order to enhance the incorporation of the interventions into daily life. The primary endpoint of this study is a change in frailty status as a proxy for health status. Secondary endpoints include changes in physical fitness, nutritional status, psychological well-being, quality of life and clinical outcomes. Tertiary endpoints include the safety, feasibility and acceptability of the prehabilitation programme, and the barriers and facilitators for further implementation. ETHICS AND DISSEMINATION Medical ethical approval was granted by the Medical Ethics Committee Groningen, Netherlands (M22.421). Written informed consent will be obtained from all participants. The results will be disseminated at international conferences and in peer-reviewed journals. TRIAL REGISTRATION NUMBER ClinicalTrials.gov, NCT05489432.
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Affiliation(s)
- Evelien E Quint
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Avril J Haanstra
- Department of Health Sciences, Section of Nursing Science, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Yvonne van der Veen
- Department of Health Sciences, Section of Nursing Science, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Internal Medicine, Department of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Heleen Maring
- Department of Health Sciences, Section of Nursing Science, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Physical Therapy, University Medical Center Groningen, Groningen, The Netherlands
| | - Stefan P Berger
- Internal Medicine, Department of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Adelita Ranchor
- Department of Health Sciences, Section of Health Psychology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Stephan J L Bakker
- Internal Medicine, Department of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Evelyn Finnema
- Department of Health Sciences, Section of Nursing Science, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Robert A Pol
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Coby Annema
- Department of Health Sciences, Section of Nursing Science, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Annema C, De Smet S, Castle EM, Overloop Y, Klaase JM, Janaudis-Ferreira T, Mathur S, Kouidi E, Perez Saez MJ, Matthys C, Dobbels F, Ferrari P, Gołębiewska J, Mrzljak A, Girman P, Perch M, Lopez-Lopez V, White C, Koval D, Greenwood S, Monbaliu D. European Society of Organ Transplantation (ESOT) Consensus Statement on Prehabilitation for Solid Organ Transplantation Candidates. Transpl Int 2023; 36:11564. [PMID: 37547750 PMCID: PMC10401602 DOI: 10.3389/ti.2023.11564] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 06/15/2023] [Indexed: 08/08/2023]
Abstract
There is increasingly growing evidence and awareness that prehabilitation in waitlisted solid organ transplant candidates may benefit clinical transplant outcomes and improve the patient's overall health and quality of life. Lifestyle changes, consisting of physical training, dietary management, and psychosocial interventions, aim to optimize the patient's physical and mental health before undergoing surgery, so as to enhance their ability to overcome procedure-associated stress, reduce complications, and accelerate post-operative recovery. Clinical data are promising but few, and evidence-based recommendations are scarce. To address the need for clinical guidelines, The European Society of Organ Transplantation (ESOT) convened a dedicated Working Group "Prehabilitation in Solid Organ Transplant Candidates," comprising experts in physical exercise, nutrition and psychosocial interventions, to review the literature on prehabilitation in this population, and develop recommendations. These were discussed and voted upon during the Consensus Conference in Prague, 13-15 November 2022. A high degree of consensus existed amongst all stakeholders including transplant recipients and their representatives. Ten recommendations were formulated that are a balanced representation of current published evidence and real-world practice. The findings and recommendations of the Working Group on Prehabilitation for solid organ transplant candidates are presented in this article.
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Affiliation(s)
- Coby Annema
- Section of Nursing Science, Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Stefan De Smet
- Group Rehabilitation for Internal Disorders, Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
- Nephrology and Renal Transplantation, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Laboratory of Abdominal Transplantation, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Ellen M. Castle
- Physiotherapy, Department of Health Sciences, College of Health, Medicine and Life Sciences, Brunel University London, London, United Kingdom
| | - Yasna Overloop
- Department of Endocrinology, University Hospitals Leuven, Leuven, Belgium
| | - Joost M. Klaase
- Section of Hepatobiliary Surgery & Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Tania Janaudis-Ferreira
- Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, Research Institute of McGill University Health Centre, Montreal, QC, Canada
- School of Physical and Occupational Therapy, McGill University, Montreal, QC, Canada
| | - Sunita Mathur
- School of Rehabilitation Therapy, Queen’s University, Kingston, ON, Canada
| | - Evangelia Kouidi
- Laboratory of Sports Medicine, Department of Physical Education and Sports Science, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Christophe Matthys
- Department of Endocrinology, University Hospitals Leuven, Leuven, Belgium
- Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Fabienne Dobbels
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium
| | - Pisana Ferrari
- Associazione Italiana Ipertensione Polmonare (AIPI), Bologna, Italy
| | - Justyna Gołębiewska
- Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Anna Mrzljak
- Liver Transplant Center, University Hospital Center Zagreb, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Peter Girman
- Diabetes Center, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Michael Perch
- Section of Lung Transplantation, Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Victor Lopez-Lopez
- Department of General, Visceral and Transplant Surgery, Hospital Clínico y Universitario Virgen de La Arrixaca, Murcia, Spain
| | - Colin White
- Representative of the European Kidney Patients’ Federation, Dublin, Ireland
| | - Dmytro Koval
- Ukrainian Transplant Coordination Center, Specialized State Institution, Kiev, Ukraine
| | - Sharlene Greenwood
- Renal Medicine and Therapies, King’s College Hospital NHS Trust, London, United Kingdom
- Centre for Nephrology, Urology and Transplantation, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Diethard Monbaliu
- Laboratory of Abdominal Transplantation, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Transplantoux Foundation, Leuven, Belgium
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Weimann A, Ahlert M, Seehofer D, Zieschang T, Schweda M. Old Age and Frailty in Deceased Organ Transplantation and Allocation-A Plea for Geriatric Assessment and Prehabilitation. Transpl Int 2023; 36:11296. [PMID: 37476294 PMCID: PMC10354295 DOI: 10.3389/ti.2023.11296] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 06/21/2023] [Indexed: 07/22/2023]
Abstract
Due to demographic ageing and medical progress, the number and proportion of older organ donors and recipients is increasing. At the same time, the medical and ethical significance of ageing and old age for organ transplantation needs clarification. Advanced age is associated with the frailty syndrome that has a negative impact on the success of organ transplantation. However, there is emerging evidence that frailty can be modified by suitable prehabilitation measures. Against this backdrop, we argue that decision making about access to the transplant waiting list and the allocation of donor organs should integrate geriatric expertise in order to assess and manage frailty and impairments in functional capacity. Prehabilitation should be implemented as a new strategy for pre-operative conditioning of older risk patients' functional capacity. From an ethical point of view, advanced chronological age per se should not preclude the indication for organ transplantation and the allocation of donor organs.
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Affiliation(s)
- Arved Weimann
- Department of General, Visceral and Oncological Surgery, St. George Hospital, Leipzig, Germany
| | - Marlies Ahlert
- Department of Economics, Martin-Luther-University of Halle, Halle, Germany
| | - Daniel Seehofer
- Department of Visceral, Transplantation, Thoracic and Vascular Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Tania Zieschang
- Division of Geriatric Medicine, Department of Health Services Research, School of Medicine and Health Sciences, University of Oldenburg, Oldenburg, Germany
| | - Mark Schweda
- Division of Medical Ethics, Department of Health Services Research, School of Medicine and Health Sciences, University of Oldenburg, Oldenburg, Germany
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Karnabi P, Massicotte-Azarniouch D, Ritchie LJ, Marshall S, Knoll GA. Physical Frailty and Functional Status in Patients With Advanced Chronic Kidney Disease: A Systematic Review. Can J Kidney Health Dis 2023; 10:20543581231181026. [PMID: 37377480 PMCID: PMC10291542 DOI: 10.1177/20543581231181026] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 05/04/2023] [Indexed: 06/29/2023] Open
Abstract
Background With an aging population and growing number of patients with chronic kidney disease (CKD), integrating the latest risk factors when deciding on a treatment plan can result in better patient care. Frailty remains a prevalent syndrome in CKD resulting in adverse health outcomes. However, measures of frailty and functional status remain excluded from clinical decision making. Objective To examine the degree to which different measures of frailty and functional status are associated with mortality, hospitalization, and other clinical outcomes in patients with advanced CKD. Design Systematic review. Setting Observation studies including cohort study, case-control study, or cross-sectional study examining frailty and functional status on clinical outcomes. There were no restrictions on type of setting or country of origin. Patients Adults with advanced CKD, including both types of dialysis patients. Measurements Data including demographic information (e.g., sample size, follow-up time, age, country), assessments of frailty or functional status and their domains, and outcomes including mortality, hospitalization, cardiovascular events, kidney function, and composite outcomes were extracted. Methods A search was conducted using databases Medline, Embase, and Cochrane Central Register for Controlled Trials. Studies were included from inception to March 17, 2021. The eligibility of studies was screened by 2 independent reviewers. Data were presented by instrument and clinical outcome. Point estimates and 95% confidence intervals from the fully adjusted statistical model were reported or calculated from the raw data. Results A total of 117 unique instruments were found among 140 studies. The median sample size of studies was 319 (interquartile range, 161-893). Most studies focused on incident and chronic dialysis patient populations, with only 15% of studies examining non-dialysis CKD patients. Frailty and lower functional status were associated with an increased risk for adverse clinical outcomes such as mortality and hospitalization. The 5 individual domains of frailty were also found to be associated with poor health outcomes. Limitations Meta-analysis could not be performed due to significant heterogeneity between studies and methods used to measure frailty and functional status. Many studies had issues with methodological rigor. Selection bias and the validity of data collection could not be ascertained for some studies. Conclusion Frailty and functional status measures should be integrated to help guide clinical care decision making for a comprehensive assessment of risk for adverse outcomes among patients with advanced CKD. Registration PROSPERO CRD42016045251.
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Affiliation(s)
- Priscilla Karnabi
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, ON, Canada
| | - David Massicotte-Azarniouch
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, ON, Canada
- Department of Medicine, University of Ottawa, ON, Canada
- Division of Nephrology, Kidney Research Centre, The Ottawa Hospital Research Institute, ON, Canada
| | - Lindsay J. Ritchie
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, ON, Canada
| | - Shawn Marshall
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, ON, Canada
- Department of Medicine, University of Ottawa, ON, Canada
| | - Greg A. Knoll
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, ON, Canada
- Department of Medicine, University of Ottawa, ON, Canada
- Division of Nephrology, Kidney Research Centre, The Ottawa Hospital Research Institute, ON, Canada
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Lorenz EC, Hickson LJ, Khairallah P, Najafi B, Kennedy CC. Cellular Senescence and Frailty in Transplantation. CURRENT TRANSPLANTATION REPORTS 2023; 10:51-59. [PMID: 37576589 PMCID: PMC10414789 DOI: 10.1007/s40472-023-00393-6] [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: 02/16/2023] [Indexed: 03/28/2023]
Abstract
Purpose of review To summarizes the literature on cellular senescence and frailty in solid-organ transplantation and highlight the emerging role of senotherapeutics as a treatment for cellular senescence. Recent findings Solid-organ transplant patients are aging. Many factors contribute to aging acceleration in this population, including cellular senescence. Senescent cells accumulate in tissues and secrete proinflammatory and profibrotic proteins which result in tissue damage. Cellular senescence contributes to age-related diseases and frailty. Our understanding of the role cellular senescence plays in transplant-specific complications such as allograft immunogenicity and infections is expanding. Promising treatments, including senolytics, senomorphics, cell-based regenerative therapies, and behavioral interventions, may reduce cellular senescence abundance and frailty in patients with solid-organ transplants. Summary Cellular senescence and frailty contribute to adverse outcomes in solid-organ transplantation. Continued pursuit of understanding the role cellular senescence plays in transplantation may lead to improved senotherapeutic approaches and better graft and patient outcomes.
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Affiliation(s)
| | - LaTonya J. Hickson
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, Florida
| | | | - Bijan Najafi
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, Texas
| | - Cassie C. Kennedy
- Division of Pulmonary, Critical Care, and Sleep Medicine, Mayo Clinic, Rochester, Minnesota
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López-Baamonde M, Arguis MJ, Navarro-Ripoll R, Gimeno-Santos E, Romano-Andrioni B, Sisó M, Terès-Bellès S, López-Hernández A, Burniol-García A, Farrero M, Sebio-García R, Sandoval E, Sanz-de la Garza M, Librero J, García-Álvarez A, Castel MÁ, Martínez-Pallí G. Multimodal Prehabilitation in Heart Transplant Recipients Improves Short-Term Post-Transplant Outcomes without Increasing Costs. J Clin Med 2023; 12:jcm12113724. [PMID: 37297919 DOI: 10.3390/jcm12113724] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 05/21/2023] [Accepted: 05/26/2023] [Indexed: 06/12/2023] Open
Abstract
(1) Background and aim: This study aimed to investigate the impact of prehabilitation on the postoperative outcomes of heart transplantation and its cost-effectiveness. (2) Methods: This single-center, ambispective cohort study included forty-six candidates for elective heart transplantation from 2017 to 2021 attending a multimodal prehabilitation program consisting of supervised exercise training, physical activity promotion, nutritional optimization, and psychological support. The postoperative course was compared to a control cohort consisting of patients transplanted from 2014 to 2017 and those contemporaneously not involved in prehabilitation. (3) Results: A significant improvement was observed in preoperative functional capacity (endurance time 281 vs. 728 s, p < 0.001) and quality-of-life (Minnesota score 58 vs. 47, p = 0.046) after the program. No exercise-related events were registered. The prehabilitation cohort showed a lower rate and severity of postoperative complications (comprehensive complication index 37 vs. 31, p = 0.033), lower mechanical ventilation time (37 vs. 20 h, p = 0.032), ICU stay (7 vs. 5 days, p = 0.01), total hospitalization stay (23 vs. 18 days, p = 0.008) and less need for transfer to nursing/rehabilitation facilities after hospital discharge (31% vs. 3%, p = 0.009). A cost-consequence analysis showed that prehabilitation did not increase the total surgical process costs. (4) Conclusions: Multimodal prehabilitation before heart transplantation has benefits on short-term postoperative outcomes potentially attributable to enhancement of physical status, without cost-increasing.
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Affiliation(s)
- Manuel López-Baamonde
- Anesthesiology and Intensive Care Department, Hospital Clínic, 08036 Barcelona, Spain
- Prehabilitation Group (Surgifit), Hospital Clínic, 08036 Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB), 08193 Barcelona, Spain
| | - María José Arguis
- Anesthesiology and Intensive Care Department, Hospital Clínic, 08036 Barcelona, Spain
- Prehabilitation Group (Surgifit), Hospital Clínic, 08036 Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB), 08193 Barcelona, Spain
| | - Ricard Navarro-Ripoll
- Anesthesiology and Intensive Care Department, Hospital Clínic, 08036 Barcelona, Spain
- Prehabilitation Group (Surgifit), Hospital Clínic, 08036 Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB), 08193 Barcelona, Spain
| | - Elena Gimeno-Santos
- Prehabilitation Group (Surgifit), Hospital Clínic, 08036 Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB), 08193 Barcelona, Spain
- Barcelona Institute for Global Health (ISGlobal), 08036 Barcelona, Spain
| | - Bárbara Romano-Andrioni
- Prehabilitation Group (Surgifit), Hospital Clínic, 08036 Barcelona, Spain
- Endocrinology and Nutrition Department, Hospital Clínic, 08036 Barcelona, Spain
- Institut Clínic de Malalties Digestives i Metabòliques, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Marina Sisó
- Prehabilitation Group (Surgifit), Hospital Clínic, 08036 Barcelona, Spain
- Endocrinology and Nutrition Department, Hospital Clínic, 08036 Barcelona, Spain
- Institut Clínic de Malalties Digestives i Metabòliques, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Silvia Terès-Bellès
- Prehabilitation Group (Surgifit), Hospital Clínic, 08036 Barcelona, Spain
- Institut Clínic de Malalties Digestives i Metabòliques, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Antonio López-Hernández
- Anesthesiology and Intensive Care Department, Hospital Clínic, 08036 Barcelona, Spain
- Prehabilitation Group (Surgifit), Hospital Clínic, 08036 Barcelona, Spain
| | | | - Marta Farrero
- Heart Failure and Heart Transplantation Unit, Cardiology Department, Hospital Clínic Barcelona, 08036 Barcelona, Spain
- Cardiology Department, Cardiovascular Institute, Hospital Clínic de Barcelona-IDIBAPS, 08036 Barcelona, Spain
| | - Raquel Sebio-García
- Prehabilitation Group (Surgifit), Hospital Clínic, 08036 Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB), 08193 Barcelona, Spain
- Physical Medicine and Rehabilitation Department, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Elena Sandoval
- Cardiovascular Surgery Department, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - María Sanz-de la Garza
- Cardiology Department, Cardiovascular Institute, Hospital Clínic de Barcelona-IDIBAPS, 08036 Barcelona, Spain
| | - Julián Librero
- Navarra Institute for Health Research (IdiSNA), 31008 Pamplona, Spain
- Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), 31008 Pamplona, Spain
- Red de Investigación en Servicios Sanitarios y Enfermedades Crónicas (REDISSEC), 28029 Madrid, Spain
| | - Ana García-Álvarez
- Cardiology Department, Cardiovascular Institute, Hospital Clínic de Barcelona-IDIBAPS, 08036 Barcelona, Spain
- CIBER-CV, Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - María Ángeles Castel
- Heart Failure and Heart Transplantation Unit, Cardiology Department, Hospital Clínic Barcelona, 08036 Barcelona, Spain
- Cardiology Department, Cardiovascular Institute, Hospital Clínic de Barcelona-IDIBAPS, 08036 Barcelona, Spain
- CIBER-CV, Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Graciela Martínez-Pallí
- Anesthesiology and Intensive Care Department, Hospital Clínic, 08036 Barcelona, Spain
- Prehabilitation Group (Surgifit), Hospital Clínic, 08036 Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB), 08193 Barcelona, Spain
- Biomedical Research Networking Center on Respiratory Diseases (CIBERES), 28029 Madrid, Spain
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McAdams-DeMarco MA, Thind AK, Nixon AC, Woywodt A. Frailty assessment as part of transplant listing: yes, no or maybe? Clin Kidney J 2023; 16:809-816. [PMID: 37151416 PMCID: PMC10157764 DOI: 10.1093/ckj/sfac277] [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] [Received: 10/04/2022] [Indexed: 12/31/2022] Open
Abstract
Frailty, characterized by a decreased physiological reserve and an increased vulnerability to stressors, is common among kidney transplant (KT) candidates and recipients. In this review, we present and summarize the key arguments for and against the assessment of frailty as part of KT evaluation. The key arguments for including frailty were: (i) sheer prevalence and far-reaching consequences of frailty on KT, and (ii) the ability to conduct a more holistic and objective evaluation of candidates, removing the inaccuracy associated with 'eye-ball' assessments of transplant fitness. The key argument against were: (i) lack of agreement on the definition of frailty and which tools should be used in renal populations, (ii) a lack of clarity on how, by whom and how often frailty assessments should be performed, and (iii) a poor understanding of how acute stressors affect frailty. However, it is the overwhelming opinion that the time has come for frailty assessments to be incorporated into KT listing. Although ongoing areas of uncertainty exist and further evidence development is needed, the well-established impact of frailty on clinical and experiential outcomes, the invaluable information obtained from frailty assessments, and the potential for intervention outweigh these limitations. Proactive and early identification of frailty allows for individualized and improved risk assessment, communication and optimization of candidates.
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Affiliation(s)
- Mara A McAdams-DeMarco
- Department of Surgery, NYU Grossman School of Medicine and NYU Langone Health, New York, USA
- Department of Population Health, NYU Grossman School of Medicine, New York, USA
| | - Amarpreet K Thind
- Division of Immunology and Inflammation, Department of Medicine, Centre for Inflammatory Disease, Imperial College London, London, UK
- Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, Manchester, UK
| | - Andrew C Nixon
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
- Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
| | - Alexander Woywodt
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
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Mark E, Goldsman D, Gurbaxani B, Keskinocak P, Sokol J. Predicting a kidney transplant patient's pre-transplant functional status based on information from waitlist registration. Sci Rep 2023; 13:6164. [PMID: 37061525 PMCID: PMC10105757 DOI: 10.1038/s41598-023-33117-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 04/07/2023] [Indexed: 04/17/2023] Open
Abstract
With over 100,000 patients on the kidney transplant waitlist in 2019, it is important to understand if and how the functional status of a patient may change while on the waitlist. Recorded both at registration and just prior to transplantation, the Karnofsky Performance Score measures a patient's functional status and takes on values ranging from 0 to 100 in increments of 10. Using machine learning techniques, we built a gradient boosting regression model to predict a patient's pre-transplant functional status based on information known at the time of waitlist registration. The model's predictions result in an average root mean squared error of 12.99 based on 5 rolling origin cross validations and 12.94 in a separate out-of-time test. In comparison, predicting that the pre-transplant functional status remains the same as the status at registration, results in average root mean squared errors of 14.50 and 14.11 respectively. The analysis is based on 118,401 transplant records from 2007 to 2019. To the best of our knowledge, there has been no previously published research on building a model to predict kidney pre-transplant functional status. We also find that functional status at registration and total serum albumin, have the most impact in predicting the pre-transplant functional status.
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Affiliation(s)
- Ethan Mark
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - David Goldsman
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Brian Gurbaxani
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Pinar Keskinocak
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA, USA.
| | - Joel Sokol
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA, USA
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Fulinara CP, Huynh A, Goldwater D, Abdalla B, Schaenman J. Frailty and Age-Associated Assessments Associated with Chronic Kidney Disease and Transplantation Outcomes. J Transplant 2023; 2023:1510259. [PMID: 37038595 PMCID: PMC10082678 DOI: 10.1155/2023/1510259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 01/03/2023] [Accepted: 02/06/2023] [Indexed: 04/04/2023] Open
Abstract
Background. Frailty is often defined as a decrease in physiological reserve and has been shown to be correlated with adverse health outcomes and mortality in the general population. This condition is highly prevalent in the chronic kidney disease (CKD) patient population as well as in kidney transplant (KT) recipients. Other age-associated changes include sarcopenia, nutrition, cognition, and depression. In assessing the contributions of these components to patient outcomes and their prevalence in the CKD and KT patient population, it can be determined how such variables may be associated with frailty and the extent to which they may impact the adverse outcomes an individual may experience. Objectives. We sought to perform a systematic literature review to review published data on frailty and associated age-associated syndromes in CKD and KT patients. Results. Over 80 references pertinent to frailty, sarcopenia, nutrition, cognition, or depression in patients with CKD or KT were identified. Systematic review was performed to evaluate the data supporting the use of the following approaches: Fried Frailty, Short Physical Performance Battery, Frailty Index, Sarcopenia Index, CT scan quantification of muscle mass, health-related quality of life, and assessment tools for nutrition, cognition, and depression. Conclusion. This report represents a comprehensive review of previously published research articles on this topic. The intersectionality between all these components in contributing to the patient’s clinical status suggests a need for a multifaceted approach to developing comprehensive care and treatment for the CKD and KT population to improve outcomes before and after transplantation.
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Affiliation(s)
- Christian P. Fulinara
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Alina Huynh
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Deena Goldwater
- Divisions of Geriatrics and Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Basmah Abdalla
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Joanna Schaenman
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
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Chan GCK, Fung WWS, Szeto CC, Ng JKC. From MIA to FIFA: The vicious matrix of frailty, inflammation, fluid overload and atherosclerosis in peritoneal dialysis. Nephrology (Carlton) 2023; 28:215-226. [PMID: 36807408 DOI: 10.1111/nep.14150] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 01/25/2023] [Accepted: 02/14/2023] [Indexed: 02/20/2023]
Abstract
Cardiovascular disease (CVD) is a major cause of mortality and morbidity in peritoneal dialysis (PD) patients. Two decades ago, the common co-existence of malnutrition and systemic inflammation PD patients with atherosclerosis and CVD led to the proposed terminology of 'malnutrition-inflammation-atherosclerosis (MIA) syndrome'. Although the importance of malnutrition is well accepted, frailty represents a more comprehensive assessment of the physical and functional capability of the patient and encompasses the contributions of sarcopenia (a key component of malnutrition), obesity, cardiopulmonary as well as neuropsychiatric impairment. In recent years, it is also increasingly recognized that fluid overload is not only the consequence but also play an important role in the pathogenesis of CVD. Moreover, fluid overload is closely linked with the systemic inflammatory status, presumably by gut oedema, gastrointestinal epithelial barrier dysfunction and leakage of bacterial fragments to the systemic circulation. There are now a wealth of published evidence to show intricate relations between frailty, inflammation, fluid overload and atherosclerotic disease in patients with chronic kidney disease (CKD) and those on PD, a phenomenon that we propose the term 'FIFA complex'. In this system, frailty and atherosclerotic disease may be regarded as two patient-oriented outcomes, while inflammation and fluid overload are two inter-connected pathogenic processes. However, there remain limited data on how the treatment of one component affect the others. It is also important to define how treatment of fluid overload affect the systemic inflammatory status and to develop effective anti-inflammatory strategies that could alleviate atherosclerotic disease and frailty.
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Affiliation(s)
- Gordon Chun-Kau Chan
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Winston Wing-Shing Fung
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Cheuk-Chun Szeto
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
- Li Ka Shing Institute of Health Sciences (LiHS), Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Jack Kit-Chung Ng
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
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Integrating Frailty into Clinical Care. Am J Transplant 2023; 23:453-454. [PMID: 36878432 DOI: 10.1016/j.ajt.2023.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
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Fleetwood VA, Caliskan Y, Rub FAA, Axelrod D, Lentine KL. Maximizing opportunities for kidney transplantation in older adults. Curr Opin Nephrol Hypertens 2023; 32:204-211. [PMID: 36633323 DOI: 10.1097/mnh.0000000000000871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE OF REVIEW To summarize the current state of evidence related to the outcomes of older adults who need and receive kidney transplants, and strategies to facilitate appropriate transplant access in this at-risk group. RECENT FINDINGS Older adults are a rapidly growing subgroup of the kidney transplant waitlist. Compared to younger adults, older kidney transplant recipients have increased mortality after kidney transplant and lower death-censored graft survival. In determining suitability for transplantation in older patients, clinicians must balance procedural and immunosuppression-related risk with incremental survival when compared with dialysis. To appropriately increase access to transplantation in this population, clinicians and policy makers consider candidates' chronological age and frailty, as well as the quality of and waiting time for a donated allograft. Given risk of deterioration prior to transplant, candidates should be rapidly evaluated, listed, and transplanted using living donor and or less than ideal deceased donor organs when available. SUMMARY Access to transplantation for older adults can be increased through targeted interventions to address frailty and reduce waiting times through optimized organ use. Focused study and educational interventions for patients and providers are needed to improve the outcomes of this vulnerable group.
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Affiliation(s)
- Vidya A Fleetwood
- Saint Louis University Center for Abdominal Transplantation, SSM-Saint Louis University Hospital
| | - Yasar Caliskan
- Saint Louis University Center for Abdominal Transplantation, SSM-Saint Louis University Hospital
| | - Fadee Abu Al Rub
- Saint Louis University Center for Abdominal Transplantation, SSM-Saint Louis University Hospital
| | | | - Krista L Lentine
- Saint Louis University Center for Abdominal Transplantation, SSM-Saint Louis University Hospital
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45
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Parsons RF, Tantisattamo E, Cheungpasitporn W, Basu A, Lu Y, Lentine KL, Woodside KJ, Singh N, Scalea J, Alhamad T, Dunn TB, Rivera FHC, Parajuli S, Pavlakis M, Cooper M. Comprehensive review: Frailty in pancreas transplant candidates and recipients. Clin Transplant 2023; 37:e14899. [PMID: 36591953 DOI: 10.1111/ctr.14899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 12/22/2022] [Accepted: 12/29/2022] [Indexed: 01/03/2023]
Abstract
Well-selected patients with kidney disease and diabetes mellitus who undergo simultaneous kidney-pancreas transplantation often experience dramatic improvements in quality of life and long-term survival compared to those who remain on medical therapy. Over the past several years the importance of frailty in the pancreas transplant candidate and recipient populations has grown. More patients with advanced age have entered the waitlist, and complications from prolonged diabetes, even in younger patients, have created increased evidence of risk for frailty. Given these concerns, and the broad challenges facing pancreas transplantation volumes overall, we generated this review to help establish the impact and implications. We summarize the interplay of immunological factors, aging, environmental factors, diabetes mellitus, and chronic kidney disease that put these patients at risk for frailty. We discuss its measurement and recommend a combination of two instruments (both well-validated and one entirely objective). We describe the outcomes for patients before and after pancreas transplantation who may have frailty, and what interventions can be taken to mitigate its effects. Broader investigation into frailty in the pancreas transplant population is needed to better understand how to select patients for pancreas transplantation and to how manage its consequences thereafter.
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Affiliation(s)
| | | | | | | | - Yee Lu
- University of Michigan, Ann Arbor, Michigan, USA
| | | | | | - Neeraj Singh
- John C. McDonald Regional Transplant Center, Shreveport, Los Angeles, USA
| | - Joseph Scalea
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Tarek Alhamad
- Washington University School of Medicine, St. Louis, Missouri, USA
| | - Ty B Dunn
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | - Martha Pavlakis
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Matthew Cooper
- Medstar Georgetown Transplant Institute, Washington DC, USA
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Quint EE, Ferreira M, van Munster BC, Nieuwenhuijs-Moeke G, te Velde-Keyzer C, Bakker SJL, Annema C, Mathur S, Pol RA. Prehabilitation in Adult Solid Organ Transplant Candidates. CURRENT TRANSPLANTATION REPORTS 2023; 10:70-82. [PMID: 37124070 PMCID: PMC10039771 DOI: 10.1007/s40472-023-00395-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2023] [Indexed: 05/02/2023]
Abstract
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.
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Affiliation(s)
- Evelien E. Quint
- Division of Transplantation Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, P.O. Box 30 001, 9700 RB Groningen, The Netherlands
| | - Manoela Ferreira
- Department of Physical Therapy, University of Toronto, Toronto, ON Canada
| | - Barbara C. van Munster
- Division of Geriatric Medicine, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Gertrude Nieuwenhuijs-Moeke
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Charlotte te Velde-Keyzer
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Stephan J. L. Bakker
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Coby Annema
- Division of Nursing Science, Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Sunita Mathur
- School of Rehabilitation Therapy, Queen’s University, Kingston Ontario, Canada
| | - Robert A. Pol
- Division of Transplantation Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, P.O. Box 30 001, 9700 RB Groningen, The Netherlands
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Tan JHS, Bhatia K, Sharma V, Swamy M, van Dellen D, Dhanda R, Khambalia H. Enhanced recovery after surgery recommendations for renal transplantation: guidelines. Br J Surg 2022; 110:57-59. [PMID: 36168725 DOI: 10.1093/bjs/znac325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 08/01/2022] [Accepted: 08/22/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) protocols are now widely practiced in major surgery, improving postsurgical outcomes. Uptake of these programmes have been slow in kidney transplantation due to challenges in evaluating their safety and efficacy in this high-risk cohort. To date, there are no unified guidance and protocols specific to ERAS in kidney transplantation surgery. This paper aims to summarise current evidence in the literature and develop ERAS protocol recommendations for kidney transplantation recipients. METHODS PubMed, Cochrane, Embase and Medline databases were screened for studies relevant to ERAS protocols in kidney transplantation, up to August 2021. A secondary search was repeated for each ERAS recommendation to explore the specific evidence base available for each section of the protocol. Randomised controlled trials, case-control and cohort studies were included. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework was used to evaluate the quality of evidence available and recommendations. RESULTS We identified six eligible studies with a total of 1225 participants. All studies found a reduction in length of hospital stay without affecting readmission rates. The evidence behind specific pre-operative, intra-operative and post-operative interventions included in current ERAS protocols are reviewed and discussed. CONCLUSION Compared to other surgical specialties, the evidence base for ERAS in kidney transplantation remains lacking, with further room for research and development. However, significant improvements to patient outcomes are already possible with application of the currently available evidence. This has shown that ERAS in kidney transplantation surgery is safe and feasible, with improved postoperative outcomes.
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Affiliation(s)
- Jaimee H S Tan
- Department of Renal and Pancreas Transplantation, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Kailash Bhatia
- Department of Renal and Pancreas Transplantation, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Videha Sharma
- Department of Renal and Pancreas Transplantation, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Mruthunjaya Swamy
- Department of Renal and Pancreas Transplantation, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - David van Dellen
- Department of Renal and Pancreas Transplantation, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Raman Dhanda
- Department of Renal and Pancreas Transplantation, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Hussein Khambalia
- Department of Renal and Pancreas Transplantation, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
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Alfieri C, Malvica S, Cesari M, Vettoretti S, Benedetti M, Cicero E, Miglio R, Caldiroli L, Perna A, Cervesato A, Castellano G. Frailty in kidney transplantation: a review on its evaluation, variation and long-term impact. Clin Kidney J 2022; 15:2020-2026. [PMID: 36325001 PMCID: PMC9613431 DOI: 10.1093/ckj/sfac149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Indexed: 10/15/2023] Open
Abstract
The problem of frailty in kidney transplantation is an increasingly discussed topic in the transplant field, partially also generated by the multiple comorbidities by which these patients are affected. The criteria currently used to establish the presence and degree of frailty can be rapidly assessed in clinical practice, even in patients with chronic kidney disease (CKD). The main objectives of this work are: (i) to describe the method of evaluation and the impact that frailty has in patients affected by CKD, (ii) to explore how frailty should be studied in the pre-transplant evaluation, (iii) how frailty changes after a transplant and (iv) the impact frailty has over the long term on the survival of renal transplant patients.
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Affiliation(s)
- Carlo Alfieri
- Department of Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Policlinico Milan, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Silvia Malvica
- Department of Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Policlinico Milan, Milan, Italy
| | - Matteo Cesari
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Simone Vettoretti
- Department of Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Policlinico Milan, Milan, Italy
| | - Matteo Benedetti
- Department of Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Policlinico Milan, Milan, Italy
| | - Elisa Cicero
- Department of Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Policlinico Milan, Milan, Italy
| | - Roberta Miglio
- Department of Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Policlinico Milan, Milan, Italy
| | - Lara Caldiroli
- Department of Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Policlinico Milan, Milan, Italy
| | - Alessandro Perna
- Department of Translational Medical Sciences, University of Campania ‘L. Vanvitelli’, Naples, Italy
| | - Angela Cervesato
- Department of Translational Medical Sciences, University of Campania ‘L. Vanvitelli’, Naples, Italy
| | - Giuseppe Castellano
- Department of Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Policlinico Milan, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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Shrestha P, Van Pilsum Rasmussen SE, Fazal M, Chu NM, Garonzik-Wang JM, Gordon EJ, McAdams-DeMarco M, Humbyrd CJ. Patient Perspectives on the Use of Frailty, Cognitive Function, and Age in Kidney Transplant Evaluation. AJOB Empir Bioeth 2022; 13:263-274. [PMID: 35802563 PMCID: PMC11288332 DOI: 10.1080/23294515.2022.2090460] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND The allocation of scarce deceased donor kidneys is a complex process. Transplant providers are increasingly relying on constructs such as frailty and cognitive function to guide kidney transplant (KT) candidate selection. Patient views of the ethical issues surrounding the use of such constructs are unclear. We sought to assess KT candidates' attitudes and beliefs about the use of frailty and cognitive function to guide waitlist selection. METHODS KT candidates were randomly recruited from an ongoing single-center cohort study of frailty and cognitive function. Semi-structured interviews were conducted, and thematic analysis was performed. Inductively derived themes were mapped onto bioethics principles. RESULTS Twenty interviews were conducted (65% contact rate, 100% participation rate) (60% male; 70% White). With respect to the use of frailty and cognitive function in waitlisting decisions, four themes emerged in which participants: (1) valued maximizing a scarce resource (utility); (2) prioritized equal access to all patients (equity); (3) appreciated a proportional approach to the use of equity and utility (precautionary utility); and (4) sought to weigh utility- and equity-based concerns regarding social support. While some participants believed frailty and cognitive function were useful constructs to maximize utility, others believed their use would jeopardize equity. Patients were uncomfortable with using single factors such as frailty or cognitive impairment to deny someone access to transplantation; participants instead encouraged using the constructs to identify opportunities for intervention to improve frailty and cognitive function prior to KT. CONCLUSIONS KT candidates' values mirrored the current allocation strategy, seeking to balance equity and utility in a just manner, albeit with conflicting viewpoints on the appropriate use of frailty and cognitive impairment in waitlisting decisions.
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Affiliation(s)
- Prakriti Shrestha
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Maria Fazal
- Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nadia M. Chu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | - Elisa J. Gordon
- Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine
- Department of Surgery, Northwestern University Feinberg School of Medicine
| | | | - Casey Jo Humbyrd
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA
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50
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Brotherton A, Evison F, Gallier S, Sharif A. Pre-operative Waterlow score and outcomes after kidney transplantation. BMC Nephrol 2022; 23:273. [PMID: 35927670 PMCID: PMC9351155 DOI: 10.1186/s12882-022-02902-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 07/28/2022] [Indexed: 11/24/2022] Open
Abstract
Background Waterlow scoring was introduced in the 1980s as a nursing tool to risk stratify for development of decubitus ulcers (pressure sores) and is commonly used in UK hospitals. Recent interest has focussed on its value as a pre-op surrogate marker for adverse surgical outcomes, but utility after kidney transplantation has never been explored. Methods In this single-centre observational study, data was extracted from hospital informatics systems for all kidney allograft recipients transplanted between 1st January 2007 and 30th June 2020. Waterlow scores were categorised as per national standards; 0–9 (low risk), 10–14 (at risk), 15–19 (high risk) and ≥ 20 (very high risk). Multiple imputation was used to replace missing data with substituted values. Primary outcomes of interest were post-operative length of stay, emergency re-admission within 90-days and mortality analysed by linear, logistic or Cox regression models respectively. Results Data was available for 2,041 kidney transplant patients, with baseline demographics significantly different across Waterlow categories. As a continuous variable, the median Waterlow score across the study cohort was 10 (interquartile range 8–13). As a categorical variable, Waterlow scores pre-operatively were classified as low risk (n = 557), at risk (n = 543), high risk (n = 120), very high risk (n = 27) and a large proportion of missing data (n = 794). Median length of stay in days varied significantly with pre-op Waterlow category scores, progressively getting longer with increasing severity of Waterlow category. However, no difference was observed in risk for emergency readmission within 90-days of surgery with severity of Waterlow category. Patients with ‘very high risk’ Waterlow scores had increased risk for mortality at 41.9% versus high risk (23.7%), at risk (17.4%) and low risk (13.4%). In adjusted analyses, ‘very high risk’ Waterlow group (as a categorical variable) or Waterlow score (as a continuous variable) had an independent association with increase length of stay after transplant surgery only. No association was observed between any Waterlow risk group/score with emergency 90-day readmission rates or post-transplant mortality after adjustment. Conclusions Pre-operative Waterlow scoring is a poor surrogate marker to identify kidney transplant patients at risk of emergency readmission or death and should not be utilised outside its intended use. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-022-02902-8.
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Affiliation(s)
- Anna Brotherton
- Department of Nephrology and Transplantation, University Hospitals Birmingham, Queen Elizabeth Hospital, Edgbaston, Birmingham, B15 2WB, UK
| | - Felicity Evison
- Research Informatics, Research Development and Innovation, University Hospitals Birmingham, Queen Elizabeth Hospital, Birmingham, UK
| | - Suzy Gallier
- Research Informatics, Research Development and Innovation, University Hospitals Birmingham, Queen Elizabeth Hospital, Birmingham, UK.,PIONEER - HDR-UK Health Data Hub in Acute Care, University of Birmingham, Birmingham, UK
| | - Adnan Sharif
- Department of Nephrology and Transplantation, University Hospitals Birmingham, Queen Elizabeth Hospital, Edgbaston, Birmingham, B15 2WB, UK. .,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.
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