The impact of frailty on outcomes for liver transplant recipients is gaining widespread attention in transplant programs around the world. In numerous studies, frailty has been associated with increased length of stay, increased hospitalizations, increased costs, and increased mortality. Frailty has even been shown to have as much of an impact on patient survival as a high MELD (Model for End Stage Liver Disease).
“Frailty and malnutrition adversely affect outcomes and are potentially modifiable factors,” says Jeanette Hasse, PhD, RD, LD, FADA, CNSC, transplant nutrition manager, Baylor Scott & White Annette C. and Harold C. Simmons Transplant Institute at Baylor University Medical Center (Baylor Dallas). “When someone has trauma or undergoes a transplant, there is a dip in their physiologic reserves. If that patient starts out robust, that dip is likely temporary. If the patient starts out on the frail side, they may not be able to recover as well. We are developing a program to assess and treat both malnutrition and frailty to improve patients’ pre- and post-transplant outcomes.”
Frailty is characterized by an increased vulnerability to stressors with a reduction in reserves and function. Patients may experience weight loss, exhaustion, reduced physical activity, slowness and weakness. Many patients have a combination of frailty, malnutrition and sarcopenia, a loss of skeletal mass and function associated with aging and increasingly chronic disease.
To measure the level of a patient’s frailty, Baylor Scott & White Annette C. and Harold C. Simmons Transplant Institute uses the Functional Assessment in Liver Transplantation (FrAILT) to arrive at a Liver Frailty Index (LFI), a measurement tool validated at the University of California San Francisco. The tool measures dominant hand grip strength, time to do five chair stands and a balance test with the feet in three separate positions. Clinic nurses will measure frailty during the liver transplant evaluation with the results reported through dietitian notes. The Liver Transplant Selection Committee will then be able to know the degree of the patient’s frailty. The goal is to make this a broader program over time with frailty measured at intervals before and after transplantation to assess progress.
“The LFI is an important objective measure of frailty because the correlation between the LFI and subjective clinician assessment scores is low1,” Dr. Hasse says. “A patient can look healthy, but often may not have the strength to hold up the grip dynamometer. They may have to push themselves out of the chair to stand up. The tandem balance test can be challenging for anyone, but certainly more difficult if a patient is weak or has a lot of ascites.”
Studies have shown that LFI predicts survival as accurately as MELD does. The best scenario for survival is a robust patient with a low MELD. The worst scenario is a frail patient with a higher MELD. But frailty has been shown to be just as bad for patient survival as having a higher MELD. In one study, frail patients with a MELD of only 14 had the same outcomes as those with a higher MELD.2 In patients who had variables such as ascites or hepatic encephalopathy, the mortality rate was higher when the patients were also frail.3
The goal of the Institute’s frailty treatment program is to help patients become stronger for transplant, as well as improve their quality of life after transplant. The program will have three components: exercise (aerobic, resistance and balance), nutrition and psychosocial support.
Baylor Dallas and Baylor Scott & White All Saints Medical Center – Fort Worth currently offer FitSteps for Life® to pre- and post-transplant patients who are approved by a hepatologist or surgeon to participate. FitSteps is an organized exercise program for patients with chronic medical illnesses to help them improve fitness and increase strength during their recovery. FitSteps focuses on strength training of the big muscle groups, core strength and passive range of motion stretching. For patients who do not live in Dallas or Fort Worth, exercise specialists are available by phone to coach them in a home-based exercise program.
“This program just makes so much sense,” says Johanna Bayer, MD, a transplant surgeon on the medical staff at Baylor Dallas and physician champion of the frailty treatment program. “Frailty is a big problem in our patient population. There is an abundance of literature available that shows how frailty adversely impacts outcomes after transplantation. So why not address this beforehand and ‘prehabilitate’ our patients in order to make them better candidates? If they are better candidates, then this should have a positive impact on their outcomes. To facilitate this change, the program will require all disciplines involved in the transplant process to assist. I believe that this multidisciplinary approach will ultimately allow them to achieve the most benefit from their transplant, and shouldn’t that always be the goal?”
Dr. Hasse adds, “If we can make patients better candidates for transplant, they will recover more quickly, handle complications better, have fewer readmissions and can return to work with a better quality of life. A lot will come down to patient adherence to an individualized plan, but I think there is great potential in the effort.”