|
1
|
Balogh J, Mubashir T, Li Y, Digbeu BD, Hegde N, Pour FM, Rezapour M, Lai HY, West K, Chaudhry RA, Williams GW, Maroufy V. Effect of frailty as measured by functional impairment on long-term outcomes in liver transplantation in the United States. World J Transplant 2025; 15:98228. [DOI: 10.5500/wjt.v15.i2.98228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Revised: 10/08/2024] [Accepted: 12/09/2024] [Indexed: 02/21/2025] Open
Abstract
BACKGROUND In patients with chronic liver disease or hepatic dysfunction with sarcopenia, there is an increased risk of frailty as measured by functional impairment, making frailty a vital predictor of post-transplant mortality.
AIM To investigate the effects of frailty on mortality after liver transplantation.
METHODS A retrospective review of post-transplant outcomes in liver transplant recipients assessed frailty using Karnofsky Performance Score. Data from the Scientific Registry of Transplant Recipients database for 37427 liver transplant recipients was used.
RESULTS Of 82.7% frail patients, 42.7% were severely frail and 40% were moderately frail (P < 0.001) at the time of transplantation. Compared with non-frail patients, post-transplant mortality in frail patients was significantly higher at 12 months [odds ratio (OR) = 1.94, P = 0.02)]. Secondary analysis of the data revealed that liver grafts from donation after circulatory death (DCD) were more likely to be associated with frail patients at transplant (OR = 1.86, P < 0.001). Furthermore, a donor history of hypertension was associated with a lower likelihood of frailty in the recipient at the time of transplant (OR = 0.65, P = 0.03).
CONCLUSION Recipient frailty is associated with increased mortality at 12 months following liver transplantation, and liver transplants from donors with DCD are associated with increased frailty of the liver transplant recipient.
Collapse
Affiliation(s)
- Julius Balogh
- Department of CV Anesthesia, CHI St. Vincent Infirmary, Little Rock, AR 72205, United States
| | - Talha Mubashir
- Department of CV Anesthesia, CHI St. Vincent Infirmary, Little Rock, AR 72205, United States
| | - Yuan Li
- Department of Biostatistics and Data Science, The University of Texas Health Center at Houston School of Public Health, Houston, TX 77030, United States
| | - Biai D Digbeu
- Department of Biostatistics and Data Science, The University of Texas Health Center at Houston School of Public Health, Houston, TX 77030, United States
| | - Nikita Hegde
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA 98195, United States
| | - Fatemeh Movaghari Pour
- Department of Comprehensive Dentistry, UT Health San Antonio School of Dentistry, San Antonio, TX 78229, United States
| | | | - Hong-Yin Lai
- Department of Biostatistics and Data Science, The University of Texas Health Center at Houston School of Public Health, Houston, TX 77030, United States
| | - Kelly West
- Department of Anesthesiology, Critical Care and Pain Medicine, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX 77030, United States
| | - Rabail A Chaudhry
- Department of Anesthesiology and Pain Medicine, University of Arizona College of Medicine-Tucson, Tucson, AZ 85724, United States
| | - George W Williams
- Department of Anesthesiology, Critical Care and Pain Medicine, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX 77030, United States
| | - Vahed Maroufy
- Department of Biostatistics and Data Science, The University of Texas Health Center at Houston School of Public Health, Houston, TX 77030, United States
| |
Collapse
|
|
2
|
Puchades L, Herreras J, Cebrià i Iranzo MÀ, Reyes É, Crespo G, Rodríguez-Perálvarez M, Cortés L, Serrano T, Fernández-Yunquera A, Montalvá E, Berenguer M. Frailty Changes After Liver Transplantation. Results From a Spanish Multicenter Prospective Cohort Study. Transplant Direct 2024; 10:e1599. [PMID: 38529356 PMCID: PMC10962876 DOI: 10.1097/txd.0000000000001599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 12/06/2023] [Indexed: 03/27/2024] Open
Abstract
INTRODUCTION Until now, there has been limited evidence, primarily from US cohorts, focusing on frailty as a patient-oriented outcome after liver transplantation (LT). Our study aimed to explore the relationship between pre- and post-LT frailty in a multicenter European cohort of outpatients with cirrhosis undergoing LT. METHODS We conducted a prospective analysis of data from 180 LT recipients recruited between 2018 and 2020 from 5 Spanish centers. Participants underwent objective and subjective frailty assessments using the Liver Frailty Index (LFI) and the Subjective Clinician Assessment (SCA) pretransplant and at 3- and/or 6-mo posttransplant. RESULTS The median pretransplant LFI was 3.9, showing minimal change at 3 mo (3.8; P = 0.331) and improvement at 6-mo post-LT (3.6; P = 0.001). Conversely, the SCA significantly improved early post-LT: at 3 mo, poor SCA decreased from 11% to 1%, and good SCA increased from 54% to 89% (P < 0.001), remaining stable between 3- and 6-mo post-LT. Multivariable analysis revealed that each 0.1 increase in pretransplant LFI correlated with a reduced probability of being robust at 3-mo (odds ratio [OR] = 0.75; P < 0.001) and 6-mo post-LT (OR = 0.74; P < 0.001). There was poor concordance between SCA and LFI, with SCA underestimating frailty both pre- and post-LT (Kappa < 0.20). CONCLUSION In our European cohort, incomplete improvement of physical frailty was observed, with <20% achieving robust physical condition within 6-mo post-LT. The pretransplant LFI strongly predicted posttransplant frailty. As the SCA tends to overestimate physical function, we recommend using both subjective and objective tools for frailty assessment in LT candidates and recipients.
Collapse
Affiliation(s)
- Lorena Puchades
- Hepatology and Liver Transplantation Group, Medical Research Institute Hospital La Fe, Valencia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Valencia, Spain
| | - Julia Herreras
- Hepatology and Liver Transplantation Group, Medical Research Institute Hospital La Fe, Valencia, Spain
| | - Maria Àngels Cebrià i Iranzo
- Medical Research Institute Hospital La Fe, Hepatology and Liver Transplantation Group, Valencia, Spain
- Department of Physical Medicine and Rehabilitation, La Fe University Hospital, University of Valencia, Valencia, Spain
- Physiotherapy Department, University of Valencia, Valencia, Spain
| | - Érick Reyes
- Liver Unit, Hospital Clínic, Institut d’Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Gonzalo Crespo
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Valencia, Spain
- Liver Unit, Hospital Clínic, Institut d’Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Manuel Rodríguez-Perálvarez
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Valencia, Spain
- Department of Hepatology and Liver Transplantation, University Hospital Reina Sofía, Córdoba University, IMIBIC, Córdoba, Spain
| | - Luis Cortés
- Liver Transplantation Unit, Department of Gastroenterology, University Hospital Lozano Blesa, Zaragoza, Spain
| | - Trinidad Serrano
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Valencia, Spain
- Liver Transplantation Unit, Department of Gastroenterology, University Hospital Lozano Blesa, Zaragoza, Spain
| | - Ainhoa Fernández-Yunquera
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Valencia, Spain
- Department of Gastroenterology, Gregorio Marañón University General Hospital, Madrid, Spain
| | - Eva Montalvá
- Hepatology and Liver Transplantation Group, Medical Research Institute Hospital La Fe, Valencia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Valencia, Spain
- Liver Transplantation Unit, Department of General Surgery, La Fe University Hospital, Valencia, Spain
| | - Marina Berenguer
- Hepatology and Liver Transplantation Group, Medical Research Institute Hospital La Fe, Valencia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Valencia, Spain
- Hepatology Unit, Department of Gastroenterology, La Fe University Hospital, University of Valencia, Medicine Department, Valencia, Spain
| |
Collapse
|
|
3
|
Thuluvath AJ, Verna EC. Deciphering an expanding array of clinical and research frailty measures. Clin Liver Dis (Hoboken) 2024; 23:e0180. [PMID: 38872786 PMCID: PMC11168841 DOI: 10.1097/cld.0000000000000180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 03/01/2024] [Indexed: 06/15/2024] Open
Affiliation(s)
- Avesh J. Thuluvath
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
- Department of Surgery, Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York, New York, USA
| | - Elizabeth C. Verna
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
- Department of Surgery, Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York, New York, USA
| |
Collapse
|
|
4
|
Puchades Renau L, Herreras López J, Cebrià I Iranzo MÀ, Cezón Serrano N, Berenguer Haym M. Physical frailty in liver transplantation. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2021; 113:533-540. [PMID: 33371691 DOI: 10.17235/reed.2020.7448/2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
In patients with cirrhosis, frailty represents a status of global physical dysfunction associated with a multiplicity of factors, including muscle wasting, undernutrition and malnutrition, and functional impairment. This condition is particularly prevalent among those with advanced cirrhosis, such as liver transplant (LT) candidates. Studies in this vulnerable population have demonstrated that its presence is independently predictive of adverse outcomes both pre- and post-transplantation, and thus that its incorporation into clinical practice could result in improved clinical decision-making, particularly regarding the identification of candidates for physical and nutritional interventions. There are, however, some limitations to its immediate incorporation into organ allocation prioritization models, including the wide heterogeneity of instruments used for measuring frailty, and particularly the lack of a single one suitable in all LT clinical scenarios (inpatient vs outpatient; pre- vs post-transplant). Finally, the data on the potential effects of frailty improvement on the diverse range of outcome measures are still preliminary.
Collapse
Affiliation(s)
- Lorena Puchades Renau
- Grupo de Hepatología y Trasplante Hepático, Instituto de Investigación Sanitaria La Fe, España
| | - Julia Herreras López
- Grupo de Hepatología y Trasplante Hepático, Instituto de Investigación Sanitaria La Fe, España
| | | | - Natalia Cezón Serrano
- Grupo de Hepatología y Trasplante Hepático, Instituto de Investigación Sanitaria La Fe, España
| | - Marina Berenguer Haym
- Grupo de Hepatología y Trasplante Hepático, Instituto de Investigación Sanitaria La Fe, España
| |
Collapse
|
|
5
|
Puchades Renau L, Herreras López J, Cebrià I Iranzo MÀ, Cezón Serrano N, Di Maira T, Berenguer M. Frailty and Sarcopenia in Acute-on-Chronic Liver Failure. Hepatol Commun 2021; 5:1333-1347. [PMID: 34430779 PMCID: PMC8369934 DOI: 10.1002/hep4.1722] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 02/03/2021] [Accepted: 03/08/2021] [Indexed: 02/04/2023] Open
Abstract
In patients with cirrhosis, sarcopenia is a critical reduction in skeletal muscle mass and frailty represents a status of global physical dysfunction caused by under nutrition, muscle wasting, and functional impairment. Both are prevalent conditions in liver transplant candidates and have shown to be independent predictors of adverse outcome. Evidence supports their incorporation into clinical practice both as a prognostic factor guiding clinical decision making and as a tool to identify candidates for physical and nutritional interventions. The wide heterogeneity of instruments used for sarcopenia and frailty measurement, the absence of a single suitable instrument for sarcopenia and frailty assessment in the outpatient versus inpatient acute-on-chronic clinical scenario, and the lack of strong evidence showing a beneficial effect of sarcopenia and frailty improvement on outcomes before and after transplantation are some of the questions that remain unanswered.
Collapse
Affiliation(s)
- Lorena Puchades Renau
- Hepatology and Liver Transplantation GroupMedical Research Institute Hospital La FeValenciaSpain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y DigestivasValenciaSpain.,Department of GastroenterologyHepatology UnitLa Fe University HospitalValenciaSpain
| | - Julia Herreras López
- Hepatology and Liver Transplantation GroupMedical Research Institute Hospital La FeValenciaSpain
| | - Maria Àngels Cebrià I Iranzo
- Hepatology and Liver Transplantation GroupMedical Research Institute Hospital La FeValenciaSpain.,Physiotherapy DepartmentUniversity of ValenciaValenciaSpain.,Rehabilitation and Physical Therapy DepartmentLa Fe University HospitalValenciaSpain
| | - Natalia Cezón Serrano
- Hepatology and Liver Transplantation GroupMedical Research Institute Hospital La FeValenciaSpain.,Physiotherapy DepartmentUniversity of ValenciaValenciaSpain
| | - Tommaso Di Maira
- Hepatology and Liver Transplantation GroupMedical Research Institute Hospital La FeValenciaSpain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y DigestivasValenciaSpain
| | - Marina Berenguer
- Hepatology and Liver Transplantation GroupMedical Research Institute Hospital La FeValenciaSpain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y DigestivasValenciaSpain.,Department of GastroenterologyHepatology UnitLa Fe University HospitalValenciaSpain.,Medicine DepartmentUniversity of ValenciaValenciaSpain
| |
Collapse
|
|
6
|
Neurocognitive and Muscular Capacities Are Associated with Frailty in Adults with Cirrhosis. Dig Dis Sci 2020; 65:3734-3743. [PMID: 31982996 PMCID: PMC7814530 DOI: 10.1007/s10620-020-06099-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 01/20/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Frailty is common in cirrhosis and associated with mortality, hospitalization, and reduced quality of life. Interventions aimed at forestalling frailty are limited by a lack of understanding of underlying physiologic deficits. AIMS This study's aim was to examine contributions of discrete sensorimotor and neurocognitive capacities to conventional frailty measures of unipedal stance time, chair stands, and grip strength. METHODS This cross-sectional study enrolled 119 outpatients with cirrhosis (50% female, aged 62.9 ± 7.3 years). Capacities included sensory (lower limb sensation and visual contrast), neurocognitive (Number Connection Tests A and B, simple and recognition reaction time), and muscular (hip/core strength determined by lateral plank time (LPT)). Bivariate analyses and linear regression models were performed to identify significant contributors to each frailty measure. RESULTS The average performance was 9.8 ± 3.9 chair stands, 12.7 s ±9.9 unipedal stance time, and 60.3 ± 25.6 lb grip strength. In multivariate models, factors explained 40% of variance in unipedal stance and 43% of variance in chair stands. The LPT was most strongly associated with unipedal stance and chair stands. Grip strength was associated with LPT, but did not have physiologic predictors. CONCLUSIONS Clinically useful measures of frailty in adults with cirrhosis can be explained by disease severity but also deficits in strength and neurocognitive function. Recognition reaction time, a novel measure in cirrhosis, had a significant contribution to frailty. These findings have implications for frailty assessment and suggest that the optimal rehabilitation approach to frailty targets neurocognitive function in addition to strengthening.
Collapse
|
|
7
|
Wiering L, Öllinger R, Kruppa J, Schoeneberg U, Dziodzio T, Jara M, Biebl M, Dargie R, Raschzok N, Schöning W, Eurich D, Schmelzle M, Sauer IM, Pratschke J, Ritschl PV. Hospitalization Before Liver Transplantation Predicts Posttransplant Patient Survival: A Propensity Score-Matched Analysis. Liver Transpl 2020; 26:628-639. [PMID: 32159923 DOI: 10.1002/lt.25748] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 01/22/2020] [Accepted: 02/11/2020] [Indexed: 01/13/2023]
Abstract
In contrast to donor factors predicting outcomes of liver transplantation (LT), few suitable recipient parameters have been identified. To this end, we performed an in-depth analysis of hospitalization status and duration prior to LT as a potential risk factor for posttransplant outcome. The pretransplant hospitalization status of all patients undergoing LT between 2005 and 2016 at the Charité-Universitätsmedizin Berlin was analyzed retrospectively using propensity score matching. At the time of organ acceptance, 226 of 1134 (19.9%) recipients were hospitalized in an intensive care unit (ICU), 146 (12.9%) in a regular ward (RW) and 762 patients (67.2%) were at home. Hospitalized patients (RW and ICU) compared with patients from home showed a dramatically shorter 3-month survival (78.7% versus 94.4%), 1-year survival (66.3% versus 87.3%), and 3-year survival (61.7% versus 81.7%; all P < 0.001), whereas no significant difference was detected for 3-year survival between ICU and RW patients (61.5% versus 62.3%; P = 0.60). These results remained significant after propensity score matching. Furthermore, in ICU patients, but not in RW patients, survival correlated with days spent in the ICU before LT (1-year survival: 1-6 versus 7-14 days: 73.7% versus 60.5%, P = 0.04; 7-14 days versus >14 days, 60.5% versus 51.0%, P = 0.006). In conclusion, hospitalization status before transplantation is a valuable predictor of patient survival following LT.
Collapse
Affiliation(s)
- Leke Wiering
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Robert Öllinger
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jochen Kruppa
- Institute of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Uwe Schoeneberg
- Institute of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Tomasz Dziodzio
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Maximillian Jara
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Biebl
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Richard Dargie
- Division of Emergency and Acute Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Nathanael Raschzok
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health Charité Clinician Scientist Program, Berlin Institute of Health, Berlin, Germany
| | - Wenzel Schöning
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Dennis Eurich
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Moritz Schmelzle
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Igor M Sauer
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Paul V Ritschl
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health Charité Clinician Scientist Program, Berlin Institute of Health, Berlin, Germany
| |
Collapse
|
|
8
|
Dolgin NH, Movahedi B, Anderson FA, Brüggenwirth IMA, Martins PN, Bozorgzadeh A. Impact of recipient functional status on 1-year liver transplant outcomes. World J Transplant 2019; 9:145-157. [PMID: 31850158 PMCID: PMC6914386 DOI: 10.5500/wjt.v9.i7.145] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 10/16/2019] [Accepted: 11/07/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The Karnofsky Performance Status (KPS) scale has been widely validated for clinical practice for over 60 years.
AIM To examine the extent to which poor pre-transplant functional status, assessed using the KPS scale, is associated with increased risk of mortality and/or graft failure at 1-year post-transplantation.
METHODS This study included 38278 United States adults who underwent first, non-urgent, liver-only transplantation from 2005 to 2014 (Scientific Registry of Transplant Recipients). Functional impairment/disability was categorized as severe, moderate, or none/normal. Analyses were conducted using multivariable-adjusted Cox survival regression models.
RESULTS The median age was 56 years, 31% were women, median pre-transplant Model for End-Stage for Liver Disease score was 18. Functional impairment was present in 70%; one-quarter of the sample was severely disabled. After controlling for key recipient and donor factors, moderately and severely disabled patients had a 1-year mortality rate of 1.32 [confidence interval (CI): 1.21-1.44] and 1.73 (95%CI: 1.56-1.91) compared to patients with no impairment, respectively. Subjects with moderate and severe disability also had a multivariable-adjusted 1-year graft failure rate of 1.13 (CI: 1.02-1.24) and 1.16 (CI: 1.02-1.31), respectively.
CONCLUSION Pre-transplant functional status is a useful prognostic indicator for 1-year post-transplant patient and graft survival.
Collapse
Affiliation(s)
- Natasha H Dolgin
- Department of Surgery, Division of Organ Transplantation, UMass Memorial Medical Center, University of Massachusetts Medical School, Worcester, MA 01605, United States
- Department of Quantitative Health Sciences, Clinical and Population Health Research Program, University of Massachusetts Medical School, Worcester, MA 01605, United States
- Department of Surgery, Center for Outcomes Research, University of Massachusetts Medical School, Worcester, MA 01655, United States
| | - Babak Movahedi
- Department of Surgery, Division of Organ Transplantation, UMass Memorial Medical Center, University of Massachusetts Medical School, Worcester, MA 01605, United States
| | - Frederick A Anderson
- Department of Surgery, Center for Outcomes Research, University of Massachusetts Medical School, Worcester, MA 01655, United States
| | - Isabel MA Brüggenwirth
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen 9713GZ, Netherlands
| | - Paulo N Martins
- Department of Surgery, Division of Organ Transplantation, UMass Memorial Medical Center, University of Massachusetts Medical School, Worcester, MA 01605, United States
| | - Adel Bozorgzadeh
- Department of Surgery, Division of Organ Transplantation, UMass Memorial Medical Center, University of Massachusetts Medical School, Worcester, MA 01605, United States
| |
Collapse
|
|
9
|
Cipolletta S, Entilli L, Nucci M, Feltrin A, Germani G, Cillo U, Volpe B. Psychosocial Support in Liver Transplantation: A Dyadic Study With Patients and Their Family Caregivers. Front Psychol 2019; 10:2304. [PMID: 31649602 PMCID: PMC6795706 DOI: 10.3389/fpsyg.2019.02304] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 09/27/2019] [Indexed: 12/17/2022] Open
Abstract
Background and aims: Liver transplantation provides an opportunity of survival for patients with liver failure; however, this procedure is known to be psychologically and physically fatiguing for patients and their informal caregivers. The aim of this study was to investigate how perceived social support and the distribution of dependency were associated with the psychological wellbeing of patients waiting for liver transplantation and their caregivers, as a dyad. Methods: The present was a cross-sectional study. Ninety-five participants were recruited at a hospital in Northern Italy, during the psychological evaluation for inclusion in the transplantation list: 51 patients (19 with alcohol-related illness) and 44 family caregivers. Both patients and caregivers filled in a Symptom Checklist and Kelly’s Dependency Grids. Patients also compiled the Medical Outcome Study Social-Support Survey, and caregivers compiled the Family Strain Questionnaire Short-Form. Results: Caregivers reported important levels of strain and strongly related to a worsening of their own and patients’ symptoms. Patients with alcohol-related pathologies had a narrower social network, which corresponded to an increase in family strain. On the sample as a whole, regression analyses showed that perceived social support and dependency measures did not predict patients’ and caregivers’ symptoms. Nevertheless, cluster analysis identified a group of caregivers who distributed their dependency more and experienced lower levels of depression, anxiety, and strain. Conclusions: These results suggest the usefulness of a dyadic approach in the research, prevention, and care of liver diseases. A deeper comprehension of the functioning of dyads will help practitioners in the identification of situations at risk.
Collapse
Affiliation(s)
| | - Lorenza Entilli
- Department of General Psychology, University of Padua, Padua, Italy
| | - Massimo Nucci
- Department of General Psychology, University of Padua, Padua, Italy
| | | | - Giacomo Germani
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Umberto Cillo
- Hepatobiliary Surgery and Liver Transplantation Unit, Department of General Surgery and Organ Transplantation, Padua University Hospital, Padua, Italy
| | | |
Collapse
|
|
10
|
Abstract
Purpose of review Frailty is an emerging concept in liver transplantation. We reviewed the literature for the tests of frailty which have been validated to predict outcomes in patients with cirrhosis evaluated for liver transplantation. Recent findings Several tools have been developed to further stratify risk of adverse events independent of liver disease severity. These include tests of disability such as activities of daily living and the Karnofsky Performance Score as well as tests of physical frailty such as the Liver Frailty Index (hand-grip, chair stands, and balance). Summary Increasingly, the frailty assessment is seen as a critical component of the liver transplant evaluation. Further research is needed to clarify the optimal timing of testing and the implications of longitudinal change.
Collapse
Affiliation(s)
- Elliot B Tapper
- Division of Gastroenterology and Hepatology, University of Michigan.,Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor
| |
Collapse
|
|
11
|
Tapper EB, Konerman M, Murphy S, Sonnenday CJ. Hepatic encephalopathy impacts the predictive value of the Fried Frailty Index. Am J Transplant 2018; 18:2566-2570. [PMID: 30019835 PMCID: PMC6166663 DOI: 10.1111/ajt.15020] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 06/10/2018] [Accepted: 06/28/2018] [Indexed: 01/25/2023]
Abstract
Frailty is increasingly recognized as a predictor of poor outcomes in solid organ transplantation. The most widely utilized frailty tool, the Fried Frailty Index (FFI), includes patient-reported exhaustion, weight loss, and physical activity as well as measured walk speed and handgrip. Although hepatic encephalopathy (HE) is common among liver transplant candidates, data are lacking regarding its impact on the interpretation of frailty. We prospectively enrolled 685 patients with cirrhosis during their transplant evaluation, following them until death or transplantation. Our cohort was aged 54.5 ± 10.3 years, 60% male, with an average MELD score of 14.7 ± 6.3. A history of HE was present in 39%. Frailty was present in 41%, associated with higher MELD, low albumin, ascites, and HE. HE was associated with frail performance on three components of the FFI-grip (odds ratio 1.41 95% CI, 1.03-1.92), walk speed (1.56 95% CI, 1.14-2.15), and decreased energy (1.44 95% CI, 1.05-1.99). These three components were associated with transplant free survival in the whole cohort: energy (hazard ratio 1.67 95% CI, 1.25-2.28), grip (1.63 95% CI, 1.24-2.16), and walk speed (1.56 95% CI, 1.19-2.04). However, among patients with HE, the FFI was not associated with survival. HE plays a critical role in the frailty phenotype and the implications of frailty among patients with cirrhosis evaluated for liver transplantation.
Collapse
Affiliation(s)
- Elliot B. Tapper
- Division of Gastroenterology and Hepatology, University of
Michigan
- Gastroenterology Section, VA Ann Arbor Healthcare System,
Ann Arbor
| | - Monica Konerman
- Division of Gastroenterology and Hepatology, University of
Michigan
| | - Susan Murphy
- Department of Physical Medicine and Rehabilitation,
University of Michigan
- VA Ann Arbor Healthcare System, GRECC
| | | |
Collapse
|
|
12
|
Abstract
PURPOSE OF REVIEW This review gives an overview of the evolving concept of physical frailty in patients with cirrhosis. As well as summarizing the available metrics that have been used to diagnose it, this review also examines the major recent trials that have investigated frailty in patients with cirrhosis. The complex relationship between sarcopenia and frailty is explored, and strategies to optimize frailty, such as including pharmacological and non-pharmacological therapies, are discussed. RECENT FINDINGS Though there is heterogeneity between studies on how physical frailty in cirrhosis has been assessed, it is nonetheless becoming increasingly apparent that frailty in cirrhosis contributes to poor outcomes. A growing body of evidence strongly supports that frailty, as an entity distinct from comorbidity or measurable by laboratory-based liver disease severity, contributes to pre-transplant mortality and unplanned hospital admissions. If taken into account, frailty may improve pre-transplant mortality risk prediction. Physical frailty in cirrhosis may be objectively assessed by a number of validated metrics though at present, we lack a uniform consensus on the most appropriate tool. Early identification of frailty may allow optimization of the patient with the potential to avoiding adverse outcomes. Further studies are awaited validating and exploring optimal approaches to diagnosing and reversing frailty.
Collapse
|
|
13
|
The Liver Frailty Index Improves Mortality Prediction of the Subjective Clinician Assessment in Patients With Cirrhosis. Am J Gastroenterol 2018; 113:235-242. [PMID: 29231189 PMCID: PMC5866923 DOI: 10.1038/ajg.2017.443] [Citation(s) in RCA: 118] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 10/15/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Frailty, a critical determinant of health outcomes, is most commonly assessed in patients with cirrhosis by general clinician assessment that is limited by its subjectivity. We aimed to compare the objective Liver Frailty Index (LFI), consisting of three performance-based tests (grip, chair stands, balance), with a subjective hepatologist assessment. METHODS Outpatients with cirrhosis awaiting liver transplantation (LT) underwent: (1) objective measurement using the LFI and (2) subjective clinician assessment. Spearman's correlation assessed associations between the LFI and clinician assessment; Cox regression with waitlist mortality (death/delisting for sickness); discriminative ability with Concordance(C) statistics. The net reclassification index evaluated the percentage of patients correctly reclassified by adding the LFI to the clinician assessment. RESULTS Of the 529 patients with cirrhosis, median LFI was 3.8 (range 1.0-7.0) and clinician assessment was 3 (range 0-5). Correlation between LFI and the clinician assessment was modest (ρ=0.38) with high variability by hepatologist (ρ=0.26-0.70). At a median of 11 months, 102 (19%) died/were delisted. Both the LFI (hazard ratio (HR) 2.2, 95% confidence interval (CI) 1.7-2.9) and clinician assessment (HR 1.6, 95% CI 1.3-1.9) were associated with adjusted waitlist mortality risk (P<0.01). The addition of the LFI to the clinician assessment significantly improved mortality prediction over the clinician assessment alone (0.74 vs. 0.68; P=0.02). Compared with the clinician assessment alone, the addition of the LFI correctly reclassified 34% (95% CI 8-53%) of patients to their correct survival status. CONCLUSION The subjective clinician assessment can predict waitlist mortality in patients with cirrhosis but is subjective and variable by hepatologist. The addition of the LFI to the subjective clinician assessment significantly improved mortality risk prediction, reclassifying 34% of patients. Our data strongly support the incorporation of the objective LFI to anchor our assessments of patients with cirrhosis to enhance our decision-making.
Collapse
|
|
14
|
Hansen L, Lyons KS, Dieckmann NF, Chang MF, Hiatt S, Solanki E, Lee CS. Background and design of the symptom burden in end-stage liver disease patient-caregiver dyad study. Res Nurs Health 2017; 40:398-413. [PMID: 28666053 PMCID: PMC5597485 DOI: 10.1002/nur.21807] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 06/05/2017] [Indexed: 12/25/2022]
Abstract
Over half a million Americans are affected by cirrhosis, the cause of end-stage liver disease (ESLD). Little is known about how symptom burden changes over time in adults with ESLD and their informal caregivers, which limits our ability to develop palliative care interventions that can optimize symptom management and quality of life in different patient-caregiver dyads. The purpose of this article is to describe the background and design of a prospective, longitudinal descriptive study, "Symptom Burden in End-Stage Liver Disease Patient-Caregiver Dyads," which is currently in progress. The study is designed to (i) identify trajectories of change in physical and psychological symptom burden in adults with ESLD; (ii) identify trajectories of change in physical and psychological symptom burden in caregivers of adults with ESLD; and (iii) determine predictors of types of patient-caregiver dyads that would benefit from tailored palliative care interventions. We aim for a final sample of 200 patients and 200 caregivers who will be followed over 12 months. Integrated multilevel and latent growth mixture modeling will be used to identify trajectories of change in symptom burden, linking those changes to clinical events, and quality of life outcomes and characterizing types of patient-caregiver dyads based on patient-, caregiver-, and dyad-level factors. Challenges we have encountered include unexpected attrition of study participants, participants not returning their baseline questionnaires, and hiring and training of research staff. The study will lay the foundation for future research and innovation in ESLD, end-of-life and palliative care, and caregiving.
Collapse
Affiliation(s)
- Lissi Hansen
- School of Nursing, Oregon Health and Science University, Portland, Oregon
| | - Karen S Lyons
- School of Nursing, Oregon Health and Science University, Portland, Oregon
| | - Nathan F Dieckmann
- School of Nursing, Oregon Health and Science University, Portland, Oregon
| | - Michael F Chang
- Gastroenterology and Hepatology, VA Portland Healthcare System, Portland, Oregon
| | - Shirin Hiatt
- School of Nursing, Oregon Health and Science University, Portland, Oregon
| | - Emma Solanki
- School of Nursing, Oregon Health and Science University, Portland, Oregon
| | - Christopher S Lee
- School of Nursing, Oregon Health and Science University, Portland, Oregon
| |
Collapse
|
|
15
|
Lai JC, Covinsky KE, Dodge JL, Boscardin WJ, Segev DL, Roberts JP, Feng S. Development of a novel frailty index to predict mortality in patients with end-stage liver disease. Hepatology 2017; 66:564-574. [PMID: 28422306 PMCID: PMC5519430 DOI: 10.1002/hep.29219] [Citation(s) in RCA: 364] [Impact Index Per Article: 45.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 03/17/2017] [Accepted: 04/03/2017] [Indexed: 12/13/2022]
Abstract
UNLABELLED Cirrhosis is characterized by muscle wasting, malnutrition, and functional decline that confer excess mortality not well quantified by the Model for End-Stage Liver Disease (MELD) Sodium (MELDNa) score. We aimed to develop a frailty index to capture these extrahepatic complications of cirrhosis and enhance mortality prediction in patients with cirrhosis. Consecutive outpatients listed for liver transplantation at a single transplant center without MELD exceptions were assessed with candidate frailty measures. Best subset selection analyses with Cox regression identified subsets of frailty measures that predicted waitlist mortality (=death or delisting because of sickness). We selected the frailty index by balancing statistical accuracy with clinical utility. The net reclassification index (NRI) evaluated the %patients correctly reclassified by adding the frailty index to MELDNa. Included were 536 patients with cirrhosis with median MELDNa of 18. One hundred seven (20%) died/were delisted. The final frailty index consisted of: grip strength, chair stands, and balance. The ability of MELDNa and the frailty index to correctly rank patients according to their 3-month waitlist mortality risk (i.e., concordance-statistic) was 0.80 and 0.76, respectively, but 0.82 for MELDNa+frailty index together. Compared with MELDNa alone, MELDNa+frailty index correctly reclassified 16% of deaths/delistings (P = 0.005) and 3% of nondeaths/delistings (P = 0.17) with a total NRI of 19% (P < 0.001). Compared to those with robust frailty index scores (<20th percentile), cirrhotics with poor frailty index scores (>80th percentile) were more impaired by gait speed, difficulty with Instrumental Activities of Daily Living, exhaustion, and low physical activity (P < 0.001 for each). CONCLUSION Our frailty index for patients with cirrhosis, comprised of three performance-based metrics, has construct validity for the concept of frailty and improves risk prediction of waitlist mortality over MELDNa alone. (Hepatology 2017;66:564-574).
Collapse
Affiliation(s)
- Jennifer C. Lai
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California-San Francisco, San Francisco, CA
| | - Kenneth E. Covinsky
- Department of Medicine, Division of Geriatrics, University of California-San Francisco, San Francisco, CA
| | - Jennifer L. Dodge
- Department of Surgery, Division of Transplant Surgery, University of California-San Francisco, San Francisco, CA
| | - W. John Boscardin
- Department of Medicine, Division of Geriatrics, University of California-San Francisco, San Francisco, CA,Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, CA
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - John P. Roberts
- Department of Surgery, Division of Transplant Surgery, University of California-San Francisco, San Francisco, CA
| | - Sandy Feng
- Department of Surgery, Division of Transplant Surgery, University of California-San Francisco, San Francisco, CA
| |
Collapse
|
|
16
|
Affiliation(s)
- Jennifer C. Lai
- Division of Gastroenterology and Hepatology, Department of MedicineUniversity of CaliforniaSan FranciscoCA
| |
Collapse
|
|
17
|
Tapper EB, Su GL. Does Karnofsky Performance Status of Patients With Cirrhosis on the Transplant Waitlist Meet the Eyeball Test? Clin Gastroenterol Hepatol 2016; 14:1196-8. [PMID: 27112107 DOI: 10.1016/j.cgh.2016.04.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Accepted: 04/19/2016] [Indexed: 02/07/2023]
Affiliation(s)
- Elliot B Tapper
- Division of Gastroenterology/Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, Massachusetts
| | - Grace L Su
- Division of Gastroenterology, Department of Medicine, University of Michigan Hospitals, Ann Arbor, Michigan
| |
Collapse
|
|
18
|
Kim CW, Kim HY. Clinical assessments of health status as a potential marker to identify patients who are too sick to undergo transplantation. Liver Int 2016; 36:610. [PMID: 26479733 DOI: 10.1111/liv.12983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Affiliation(s)
- Chang Wook Kim
- Division of Hepatology, Department of Internal Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 271, Cheonbo-Ro, Uijeongbu-si, Gyeonggi-do, 11765, Korea
| | - Hee Yeon Kim
- Division of Hepatology, Department of Internal Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 271, Cheonbo-Ro, Uijeongbu-si, Gyeonggi-do, 11765, Korea
| |
Collapse
|
|
19
|
Lai JC, Dodge JL, Sen S, Covinsky K, Feng S. Functional decline in patients with cirrhosis awaiting liver transplantation: Results from the functional assessment in liver transplantation (FrAILT) study. Hepatology 2016; 63:574-80. [PMID: 26517301 PMCID: PMC4718851 DOI: 10.1002/hep.28316] [Citation(s) in RCA: 153] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 10/21/2015] [Indexed: 12/15/2022]
Abstract
UNLABELLED Cirrhosis is characterized by sarcopenia and malnutrition, leading to progressive functional decline. We aimed to objectively measure functional decline in patients with cirrhosis awaiting liver transplantation and its association with waiting list mortality. Consecutive adults listed for liver transplantation with laboratory Model for End-Stage Liver Disease (MELD) ≥12 at a single center underwent functional status assessments at every outpatient visit using the Short Physical Performance Battery (0 = impaired to 12 = robust), consisting of gait, chair stands, and balance tests. Joint linear time-to-event analyses modeled the simultaneous impact of the longitudinal trajectory of physical function on waiting list mortality (=death or delisted for being too sick for liver transplantation). Included were 309 liver transplantation candidates. Median laboratory MELD was 15, serum albumin was 3.0 g/dL, 28% had ascites, 18% had hepatic encephalopathy, and 83% were Child class B or C. At a median follow-up of 14 months, 15% died or were delisted and 28% underwent liver transplantation. Average physical function worsened per 3 months on the waiting list: -0.38 kg in grip strength, -0.05 meters/second in gait, 0.03 seconds in chair stands, and -0.16 Short Physical Performance Battery points. In joint models of longitudinal trajectories of physical function and waiting list mortality adjusted for MELD-Na, albumin, hepatocellular carcinoma, and baseline physical function, the longitudinal trajectories of each physical function measure were significantly associated with waiting list mortality: grip (hazard ratio = 0.89, 95% confidence interval 0.83-0.95), gait (hazard ratio = 0.72, 95% confidence interval 0.62-0.84), chair stands (hazard ratio = 1.17, 95% confidence interval 1.09-1.25), and Short Physical Performance Battery <10 (hazard ratio = 1.45, 95% confidence interval 1.15-2.20). CONCLUSION Liver transplantation candidates experience significant functional decline on the waiting list, despite modest wait time and low baseline MELD; decline in physical function is associated with an increased risk of death or delisting, independent of liver disease severity.
Collapse
Affiliation(s)
- Jennifer C. Lai
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California-San Francisco, San Francisco, CA
| | - Jennifer L. Dodge
- Department of Surgery, Division of Transplant Surgery, University of California-San Francisco, San Francisco, CA
| | - Saunak Sen
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, CA
| | - Kenneth Covinsky
- Department of Medicine, Division of Geriatrics, University of California-San Francisco, San Francisco, CA
| | - Sandy Feng
- Department of Surgery, Division of Transplant Surgery, University of California-San Francisco, San Francisco, CA
| |
Collapse
|
|
20
|
WangBA CW, Covinsky KE, Feng S, Hayssen H, Segev DL, Lai JC. Functional impairment in older liver transplantation candidates: From the functional assessment in liver transplantation study. Liver Transpl 2015; 21:1465-70. [PMID: 26359787 PMCID: PMC4715618 DOI: 10.1002/lt.24334] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 08/10/2015] [Accepted: 08/23/2015] [Indexed: 12/13/2022]
Abstract
The emerging epidemic of older patients with cirrhosis has led to a sharp increase in the number of ≥65 year olds considering liver transplantation (LT). However, clinicians lack objective measures to risk stratify older patients. We aimed to determine whether the short physical performance battery (SPPB), a well-validated geriatric measure of physical function, has greater prognostic value in older versus younger LT candidates. Adult outpatients listed for LT with laboratory Model for End-Stage Liver Disease score ≥ 12 underwent physical function testing using the SPPB, consisting of gait speed, chair stands, and balance. Patients were categorized by age ("younger," < 65 years; "older," ≥ 65 years) and SPPB ("impaired," ≤ 9; "robust," > 9). Competing risks models associated age and SPPB with wait-list death/delisting. Of 463 LT candidates, 21% were ≥ 65 years and 18% died or were delisted. Older patients had slower gait (1.1 versus 1.3 m/seconds; P < 0.001), a trend of slower chair stands (12.8 versus 11.8 seconds; P = 0.06), and a smaller proportion able to complete all balance tests (65% versus 78%; P = 0.01); SPPB was lower in older versus younger patients (10 versus 11; P = 0.01). When compared to younger robust patients as a reference group, younger impaired patients (hazard ratio [HR], 1.77; P = 0.03) and older impaired patients (HR, 2.70; P = 0.003) had significantly higher risk of wait-list mortality, but there was no difference in risk for older robust patients (HR 1.38; P = 0.35) [test of equality, P = 0.01]. After adjustment for Model for End-Stage Liver Disease-sodium (MELD-Na) score, only older impaired patients had an increased risk of wait-list mortality compared to younger robust patients (HR, 2.36; P = 0.01; test of equality P = 0.05). In conclusion, functional impairment, as assessed by the SPPB, predicts death/delisting for LT candidates ≥65 years independent of MELD-Na. Further research into activity-based interventions to reduce adverse transplant outcomes in this population is warranted.
Collapse
Affiliation(s)
- Connie W. WangBA
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, CA
| | - Kenneth E. Covinsky
- Division of Geriatrics, Department of Medicine, University of California-San Francisco, San Francisco, CA
| | - Sandy Feng
- Division of Transplant Surgery, Department of Surgery, Division of Transplant Surgery, University of California-San Francisco, San Francisco, CA
| | - Hilary Hayssen
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, CA
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, CA
| |
Collapse
|