Discharge frailty following lung transplantation

Abstract

Introduction: Frailty at listing for lung transplant has been associated with waitlist and post-transplant mortality. Frailty trajectories following transplant, however, have been less well characterized, including whether recipient frailty improves. The objective of this study was to identify prevalence and risk factors for frailty at discharge and to evaluate changes in frail recipients enrolled in an outpatient physical therapy program. Methods:This was a single-center prospective cohort study of lung transplant recipients. Enrollees completed a short physical performance battery (SPPB) to assess frailty at listing and at initial hospital discharge. Results:Of the 111 enrolled recipients, none were frail at listing and 18 (16.2%) were prefrail. At discharge, however, 60 (54.1%) patients were frail. Discharge frailty was associated with prefrailty at listing, acute kidney injury post-transplant, and longer intensive care unit stay. Among the 35 patients who were frail at discharge and who were enrolled in an outpatient PT program, the median improvement in SPPB was 6 points (IQR = 5-7 points), and 85.7% became not frail over a median of 6 weeks.Conclusion: Discharge frailty is common following lung transplantation. In most frail patients, an intensive outpatient physical therapy program is associated with improvement in frailty, as assessed by the SPPB. K E Y W O R D Sfrailty, lung transplantation, physical therapy, rehabilitation, short performance physical battery 2 of 7 | COURTWRIGHT eT al.length of stay. 9-12 Among lung transplant candidates, listing frailty, as measured by the SPPB, has been associated with increased waitlist mortality and death following transplantation. 13,14 There are, however, limited data in lung transplant on frailty trajectories from listing to post-transplant hospitalization discharge, including what fraction of recipients leave the hospital frail. Because it is unclear whether and to what extent frailty is a reversible state once it develops, identifying nonfrail candidates who are at risk for leaving the hospital frail is essential for targeted "prehabilitation" and rehabilitation efforts to reverse or stabilize frailty trajectories.Similarly, although there is an emerging literature suggesting that frailty in patients with advanced lung disease may be reversible, there are few studies reporting on programs designed to improve frailty in transplant recipients. 15-17 Understanding the extent to which frail recipients can be rehabilitated is an important starting point in evaluating whether improving frailty ameliorates the associated adverse outcomes. The primary objective of this study was to identify prevalence and risk factors for frailty at transplant hospitalization discharge. The secondary objective was to report subsequent changes in frail recipients enrolled in an intensive outpatient physical therapy (PT) program. | ME THODS | Study design and patient populationThis was a prospective cohort study at the Hospital of the University of Pennsylvania (HUP) from March 1, 2016, ...

Pre‐transplant short physical performance battery: Response to pre‐habilitation and relationship to pre‐ and early post–lung‐transplant outcomes

“…The SPPB increased over five points in patients who were frail pre‐transplant with most of the improvement occurring in the first six months. Courtwright and colleagues reported that of 111 LTx recipients (all non‐frail pre‐transplant), 54% were frail at the time of hospital discharge following transplantation 13 . Of 35 patients who were frail at discharge and attended outpatient physiotherapy (average of 75 days), the SPPB score increased a median of six points and 86% were no longer considered frail upon program completion.…”

“…There is a paucity of data regarding the association between pre‐transplant frailty/pre‐frailty and early post‐transplant hospital and exercise capacity outcomes in the first three months. Physical frailty may be responsive to rehabilitation, 11 and improvements in SPPB have been demonstrated following LTx 12,13 . Frailty trajectories in the pre‐transplant period are not well characterized, and it is not known whether frailty/pre‐frailty is remediable in LTx candidates with end‐stage lung disease.…”

“…Physical frailty may be responsive to rehabilitation, 11 and improvements in SPPB have been demonstrated following LTx. 12,13 Frailty trajectories in the pre-transplant period are not well characterized, and it is not known whether frailty/pre-frailty is remediable in LTx candidates with end-stage lung disease. Therefore, the aims of this study were to examine whether i) pre-habilitation changes the SPPB in LTx candidates and ii) pre-transplant SPPB predicts pre-and early post-transplant outcomes.…”

Readmissions After Lung Transplantation

“…Patients with lower SPPB scores (indicative of more frailty) had considerably higher risk of readmission as compared to those with a higher score (indicative of less frailty). Later, Courtwright et al 11 proceeded to investigate changes in SPPB scores in frail recipients enrolled in an outpatient rehabilitation program with findings that 86% of patients were no longer frail over a median of 6 weeks. 11 Finally, a finding to be highlighted is that patients who underwent transplant between 2004 and 2010 were at a higher risk for readmissions than those after 2010, 6 which may account for advances in surgical and immunosuppression techniques of the present decade.…”

Frailty and the Potential Kidney Transplant Recipient: Time for a More Holistic Assessment?

“…An earlier study suggested increased risk of death and delisting in lung transplant candidates living with frailty (11). We also know that frailty is common at discharge after lung transplantation (12). Somewhat surprisingly, frailty does not seem to correlate with length of hospital stay nor with 1-year mortality (13).…”