• June 2020

    Treatment of frailty can improve outcomes for transplant recipients

The impact of frailty on outcomes for organ 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 and malnutrition adversely affect outcomes and are potentially modifiable factors,” says Jeanette Hasse, PhD, RD, LD, FADA, CNSC, transplant nutrition manager, Baylor Annette C and Harold C Simmons Transplant Institute at Baylor University Medical Center.  “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 Annette C and Harold C Simmons Transplant Institute uses an objective measurement tool. 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 transplant evaluation with the results reported in the patient’s electronic health record. The 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.

“This tool is an important objective measure of frailty because subjective clinician assessment is often inaccurate,” 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.”

The goal of the Transplant 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 currently offers FitSteps for Life® to pre- and post-transplant patients who are approved by a hepatologist or surgeon to participate. Located in Baylor Sammons Cancer Center, 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, 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.”