Frailty and maximal exercise capacity in adult lung transplant candidates

Abstract

Background Frail lung transplant candidates are more likely to be delisted or die without receiving a transplant. Further knowledge of what frailty represents in this population will assist in developing interventions to prevent frailty from developing. We set out to determine whether frail lung transplant candidates have reduced exercise capacity independent of disease severity and diagnosis. Methods Sixty-eight adult lung transplant candidates underwent cardiopulmonary exercise testing (CPET) and a frailty assessment (Fried’s Frailty Phenotype (FFP)). Primary outcomes were peak workload and peak aerobic capacity ( trueV˙normalO2). We used linear regression to adjust for age, gender, diagnosis, and lung allocation score (LAS). Results The mean ± SD age was 57 ± 11 years, 51% were women, 57% had interstitial lung disease, 32% had chronic obstructive pulmonary disease, 11% had cystic fibrosis, and the mean LAS was 40.2 (range 19.2 to 94.5). In adjusted models, peak workload decreased by 10 watts (95% CI 4.7 to 14.6) and peak trueV˙normalO2 decreased by 1.8 ml/kg/min (95% CI 0.6 to 2.9) per 1 unit increment in FFP score. After adjustment, exercise tolerance was 38 watts lower (95% CI 18.4 to 58.1) and peak trueV˙normalO2 was 8.5 ml/kg/min lower (95% CI 3.3 to 13.7) among frail participants compared to non-frail participants. Frailty accounted for 16% of the variance (R2) of watts and 19% of the variance of trueV˙normalO2 in adjusted models. Conclusion Frailty contributes to reduced exercise capacity among lung transplant candidates independent of disease severity.

Long-Term Benefits of Tailored Exercise in Severe Sarcoidosis: A Case Report

“…A reduced maximum exercise capacity is related to frailty, conceptually defined as a physical vulnerability to stressors. Frailty is considered an important phenotype in lung transplant candidates independent of the severity of the disease [ 35 ]. On the other hand, 10% of patients with sarcoidosis progress to fibrotic lung disease and may be in need of lung transplant [ 18 ].…”

Selection Criteria for Lung Transplantation: Controversies and New Developments

“…Frailty is considered a potent predictor for poor outcomes after a range of surgical procedures, including lung transplantation. [9][10][11][12][13][14] Frailty consists of many components, and several surrogate markers have been established, including sarcopenia (relative loss of skeletal muscle mass, measured in variable ways), hypoalbuminemia, low BMI (<18.5 kg/m 2 ), and reduced exercise capacity (e.g., 6-minute walk distance). 9,10 Frailty is quite common in the lung transplant population, prevalence ranging from 33 to 45%.…”

“…9 This is probably a consequence of the catabolic process of chronic hypoxia, disuse atrophy, and chronic inflammation associated with end-stage pulmonary disease, making it difficult for lung transplant candidates to achieve physical "fitness." 10,13,15 Current frailty assessment tools (such as the Frailty Index, Fried's Frailty Phenotype, Clinical Frailty Scale, and Short Physical Performance Battery) do not distinguish between lung failure (or other organ failure) associated frailty and age-related frailty. This complicates selecting patients ill enough to need a lung transplant, but with sufficient fitness and acceptable frailty to undergo transplant surgery and thrive, despite possible postoperative complications.…”

“…9,10,12,14,[21][22][23] However, these are potentially modifiable factors, which could partially be mediated by goal-directed preoperative management, such as extensive training and nutritional improvement (called prehabilitation), as well as postoperative rehabilitation which have been shown to increase survival after lung transplantation. 10,13,14,23,24 The gold standard to reduce frailty in lung transplant candidates, however, is unknown, making it difficult to compare outcomes in studies using different frailty measures.…”

Telerehabilitation Using Fitness Application in Patients with Severe Cystic Fibrosis Awaiting Lung Transplant: A Pilot Study

“…Maintaining a level of physical vigor prior to lung transplantation is important in improving postoperative outcomes [1]. Patients with severe cystic fibrosis (CF) suffer from poor exercise tolerance and physical frailty that correlates with disease severity [2][3][4][5]. Traditional pulmonary rehabilitation (PR) improves exercise tolerance and physical frailty in severely ill CF patients, including those who may be eligible for lung transplant [6].…”