Remote telerehabilitation for frailty management in liver transplant candidates: A feasible yet underutilized strategy

Abstract

This letter reviews Loschi et al’s study evaluating structured telerehabilitation for frail cirrhotic liver transplant candidates, which fills a critical pre-transplant care gap. The video-based program, using low-cost tools and asynchronous sessions, improved liver frailty index reduction and function in adherent patients (29.8%) although a high attrition rate (70%) highlighted engagement challenges. Limitations include a small, non-randomized sample, mixed frailty subgroups, and unexplored long-term effects. Future directions emphasize hybrid models, patient-centered barrier analysis, and policy-driven frailty screening. This work advances digital health for cirrhosis; however, larger trials are needed to optimize outcomes.

Key Words: Telerehabilitation; Frailty; Cirrhotic patients; Liver transplantation; Adherence

Core Tip: This letter commends Loschi et al’s tele-rehabilitation study for frail cirrhotic transplant candidates (low-resource focus, low-tech cost-effectiveness, adherent patient improvements) while noting key challenges (high attrition, unaddressed frailty heterogeneity, lack of real-time biomarkers). It proposes artificial intelligence-driven personalization, wearable applications, and a three-tiered intervention, urging advancement of telehealth to precision care.

TO THE EDITOR

Loschi et al’s study[1] on telemedicine-delivered rehabilitation for frail cirrhotic liver transplant candidates addresses a critical unmet need in pre-transplant care. While we commend the authors for their innovative approach, we believe that the implications of their findings and broader field warrant deeper exploration. We contextualize their work, highlight underappreciated challenges, and propose a novel direction for future research.

NOVEL CONTRIBUTIONS AND CONTEXT

The study focuses on the telemedicine scalability in low-resource settings. With 27.6% of transplant candidates presenting as frail at baseline, the 12-week structured program improved liver frailty index (LFI) reduction (LFI reduction: 0.54 points) and improved functional capacity (4-minute step test, 4MST: Greater than 31%) in adherent patients (29.8%). This aligns with emerging evidence that telehealth can mitigate geographical barriers in chronic disease management[2]. However, the high attrition rate (70.18%) underscores a systemic issue: Frail patients often lack the physical or cognitive stamina for sustained engagement[3], a challenge exacerbated in cirrhotic populations with hepatic encephalopathy or fatigue[4].

A prominent finding is the cost-effectiveness of low-tech tools (e.g., elastic bands and water bottles). This mirrors innovations in stroke rehabilitation, where telehealth platforms using household items achieved comparable outcomes to in-person therapy[5]. Such approaches are particularly vital in regions like sub-Saharan Africa, where 70% of cirrhotic patients lack access to specialized rehabilitation.

UNDERAPPRECIATED LIMITATIONS AND A FORWARD-LOOKING GAP

While the authors acknowledge methodological constraints (e.g., small sample size, and non-randomized design), a critical oversight lies in heterogeneity of frailty phenotypes. Cirrhotic frailty is distinct from age-related frailty, driven by metabolic dysregulation and systemic inflammation. Subgroup analyses showed that non-adherent patients had higher baseline LFI scores (4.4 vs 3.49), suggesting that advanced frailty may require disease-specific protocols, a nuance absent in current telehealth frameworks.

A novel challenge lies in integrating real-time biomarkers. For instance, wearable devices tracking muscle atrophy (via inertial sensors) or inflammation (via interleukin-6 levels) could dynamically adjust rehabilitation intensity. Pilot studies in heart failure showed that artificial intelligence (AI)-driven platforms using such data improved adherence by 30%[6], yet this approach remains untested in cirrhotic populations.

POLICY IMPLICATIONS: STRATIFYING CARE THROUGH REMOTE FRAILTY ASSESSMENT

The call for frailty screening (e.g., LFI[7]) in transplant evaluation is timely but incomplete. We propose three tiers of intervention: (1) Pre-transplant: Remote LFI assessments during transplant listing could prioritize high-risk candidates for tailored rehabilitation; (2) Peri-transplant: Hybrid models combining telehealth (e.g., biweekly virtual sessions) with in-person nurse visits could address adherence barriers; and (3) Post-transplant: Embedding wearable sensors in rehabilitation protocols could monitor recovery and predict graft rejection, a critical unmet need, given that 20% of transplants fail within 5 years due to non-adherence. This tiered approach aligns with the World Health Organization’s framework for digital health in low-resource settings, where scalable solutions must balance accessibility and precision.

CONCLUSION

Loschi et al[1] have laid a foundation for telemedicine in cirrhotic rehabilitation, but their work raises unresolved questions: Can AI-driven platforms personalize care for heterogeneous frailty phenotypes? How can wearable biomarkers enhance adherence in cognitively impaired patients? Addressing these challenges will determine whether telehealth transcends its current role as a stopgap solution. We urge the authors and those engaged in this field to pursue these frontiers, ensuring that telemedicine evolves from a pragmatic tool to a precision intervention.

ACKNOWLEDGEMENTS

We are deeply grateful to Professor Chao-Ming Zhou and Professor Cai-Wen Duan for their guidance on this letter. As authoritative experts in oncology and metabolomics, their insightful suggestions have significantly enhanced the academic rigor and professional depth of this manuscript.