Exercise training as an intervention for frailty in cirrhotic patients on the liver transplant waiting list: A systematic review

BACKGROUND

The existing literature suggests that exercise for cirrhotic patients is safe and favours significant improvement to their physical capacity. However, exercise training for this population and how to deliver activities, especially in severe stages of the disease and while waiting for a liver transplant (LT), remain undefined.

AIM

To review the existing exercise prescriptions for cirrhotic patients on the waiting list for LT, their results for frailty evolution and their effect on clinical outcomes.

METHODS

A systematic review was performed following the Preferred Reporting Review and Meta-Analysis guidelines and searching the PubMed, MEDLINE, and Scopus databases. The keyword "liver transplant" was used in combination with the free terms "frailty" and "exercise" for the literature review. Clinical studies that evaluated the effect of a regular training program, independent of supervision or the duration or intensity of physical exercise, in cirrhotic patients on the waiting list for LT were reviewed. The data on safe physical activity prescriptions following Frequency, Intensity, Time, and Type recommendations were extracted and summarised.

RESULTS

Nine articles met the inclusion criteria for this review. Various instruments for frailty assessment were used, frequently in combination. Five studies prescribed physical activity for patients, one in-person and four to be performed remotely and unsupervised. The remaining four studies only used a self-report instrument to assess the level of physical activity. None reported adverse events related to exercise training. The exercise frequency mainly varied from daily to a minimum of twice per week. The intensity depended on frailty and included increasing levels of activity. The type of exercise was predominantly a combination of aerobic and resistance training. The duration of exercise varied from 4 to 12 wk. Three articles evaluated the effect of the exercise program on clinical outcomes, reporting a reduction in 90-d readmission rates post-transplant and improved frailty scores, as well as improved survival of cirrhotic patients waiting for LT.

CONCLUSION

Routine frailty assessment is essential for this population. Although more robust evidence is required, the prescription of exercise is safe and can improve patients' functional capacity, improving pre- and post-LT outcomes.

Epidemiologic Profile of Transplant Patients Treated by the Physiotherapy

Transplant candidates have advanced chronic disease, which often leads to muscular and respiratory impairment contributing to reduced quality of life and daily life activities, and these patients are therefore referred to physiotherapy service. Because of this, it is necessary to know the epidemiologic and functional profile for a better physiotherapeutic approach. Inpatients of kidney, liver, heart, lung and multivisceral transplantation programs were followed up for 1 year. A comparative analysis between groups was performed, taking into account hospital stay time and functional independence measure (FIM). In all, 157 patients (88 post-transplant) were evaluated, with mean age of 54 years, and 99 were men. Prevalence of transplantation included liver: 87 (56%); kidney: 51 (32%); heart: 10 (6%); lung: 8 (5%); multivisceral: 1 (1%). The average length of hospital stay was 23 days for kidney patients, 19 days for lung patients, 18 days for heart patients, 15 days for liver patients, and the 15 days for multivisceral patients. The mean of FIM score was 94 for heart patients; 95 for liver patients, 96 for kidney patients, 99 for lung patients, and 120 for multivisceral patients. The highest incidence of hospitalization was of liver patients, although renal patients had a longer time of hospitalization. FIM score was higher at hospital discharge, if compared with the values at the moment of evaluation, but through the comparison of FIM previous with FIM final scores, the patients still presented functional limitation at the time of hospital discharge. Specific protocols for each transplant group, focused on the improvement of the functionality, are necessary.

Multivisceral Transplantation Rehabilitation Program-Case Report

Multivisceral transplantation is the treatment for multiple abdominal organ failure. The patient experiences reduced food intake and absorption of nutrients, contributing to weight loss and decreased muscle mass, reducing functional capacity. A physical and nutritional rehabilitation program based on adequate caloric intake associated with supervised physical exercise seems to support a gain of muscle mass, re-establishing its capacity and functional independence. A rehabilitation program was carried out, consisting of low-intensity aerobic exercise on treadmill, exercises of global strengthening (50% of 1 maximum repetition [1RM], with progressive increase), and nutritional monitoring (oral hypercaloric diet, hyperproteic supplementation daily and after exercise). Initial and final evaluation included weight, muscle mass index, brachial circumference (BC), tricipital cutaneous fold (TCF), hand grip strength (HGS), 6-minute walk test (6MWT), 1RM, vital capacity (VC), and respiratory muscle strength. After the program, functional capacity was evaluated through the 6MWT (92%), 1RM test, VC (55%), respiratory muscle strength, HGS at 5 kg, weight gain (4.75%), increase of BC in 2 cm, and TCF in 2 mm. The program contributed to functional independence, improved quality of life, and social reintegration, suggesting the importance of a supervised physical activity program associated with adequate nutritional intake after multivisceral transplantation.