Frailty in liver transplantation: An expert opinion statement from the American Society of Transplantation Liver and Intestinal Community of Practice

Jennifer C Lai, Christopher J Sonnenday, Elliot B Tapper, Andres Duarte-Rojo, Michael A Dunn, William Bernal, Elizabeth J Carey, Srinivasan Dasarathy, Binita M Kamath, Matthew R Kappus, Aldo J Montano-Loza, Shunji Nagai, Puneeta Tandon, Jennifer C Lai, Christopher J Sonnenday, Elliot B Tapper, Andres Duarte-Rojo, Michael A Dunn, William Bernal, Elizabeth J Carey, Srinivasan Dasarathy, Binita M Kamath, Matthew R Kappus, Aldo J Montano-Loza, Shunji Nagai, Puneeta Tandon

Abstract

Frailty has emerged as a powerful predictor of outcomes in patients with cirrhosis and has inevitably made its way into decision making within liver transplantation. In an effort to harmonize integration of the concept of frailty among transplant centers, the AST and ASTS supported the efforts of our working group to develop this statement from experts in the field. Frailty is a multidimensional construct that represents the end-manifestation of derangements of multiple physiologic systems leading to decreased physiologic reserve and increased vulnerability to health stressors. In hepatology/liver transplantation, investigation of frailty has largely focused on physical frailty, which subsumes the concepts of functional performance, functional capacity, and disability. There was consensus that every liver transplant candidate should be assessed at baseline and longitudinally using a standardized frailty tool, which should guide the intensity and type of nutritional and physical therapy in individual liver transplant candidates. The working group agreed that frailty should not be used as the sole criterion for delisting a patient for liver transplantation, but rather should be considered one of many criteria when evaluating transplant candidacy and suitability. A road map to advance frailty in the clinical and research settings of liver transplantation is presented here.

Keywords: clinical research/practice; guidelines; liver transplantation/hepatology; nutrition; recipient selection.

© 2019 The American Society of Transplantation and the American Society of Transplant Surgeons.

Figures

FIGURE 1
FIGURE 1
Liver-related and non-liver-related factors that contribute to the development of physical frailty in patients with cirrhosis
FIGURE 2
FIGURE 2
A conceptual model of some of the patient components that clinicians incorporate into their global assessment of a patient’s transplant candidacy and the tools that they use to inform this holistic assessment. An objective frailty tool kit should be used to inform clinicians’ assessments of muscle wasting, under-nutrition, and physical inactivity—which, together, form the major components of physical frailty—to improve objectivity and accuracy of the clinician’s global assessment of transplant candidacy for the purposes of transplant decision-making (adapted from Lai JC, AJG 2017)
FIGURE 3
FIGURE 3
Algorithm to tailor prehabilitation recommendations based on frailty assessment

References

    1. Lai JC. Advancing adoption of frailty to improve the care of patients with cirrhosis: time for a consensus on a frailty index. Am J Gastroenterol. 2016;111(12):1776–1777.
    1. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):146–156.
    1. American Thoracic Society: Quality Life Resource. Functional Status. Available at: Accessed February 23, 2018.
    1. Ney M, Tangri N, Dobbs B, et al. Predicting hepatic encephalopathy-related hospitalizations using a composite assessment of cognitive impairment and frailty in 355 patients with cirrhosis. Am J Gastroenterol. 2018;113(10):1–10.
    1. Tapper EB, Konerman M, Murphy S, Sonnenday CJ. Hepatic encephalopathy impacts the predictive value of the Fried Frailty Index. Am J Transplant. 2018;18(10):2566–2570.
    1. Lai JC, Feng S, Terrault NA, Lizaola B, Hayssen H, Covinsky K. Frailty predicts waitlist mortality in liver transplant candidates. Am J Transplant. 2014;14(8):1870–1879.
    1. Lai JC, Covinsky KE, Dodge JL, et al. Development of a novel frailty index to predict mortality in patients with end-stage liver disease. Hepatology. 2017;66(2):564–574.
    1. Lai JC, Covinsky KE, McCulloch CE, Feng S. The liver frailty index improves mortality prediction of the subjective clinician assessment in patients with cirrhosis. Am J Gastroenterol. 2017;10:1–8.
    1. Carey EJ, Steidley DE, Aqel BA, et al. Six-minute walk distance predicts mortality in liver transplant candidates. Liver Transpl. 2010;16(12):1373–1378.
    1. Ney M, Haykowsky MJ, Vandermeer B, Shah A, Ow M, Tandon P. Systematic review: pre-and post-operative prognostic value of cardiopulmonary exercise testing in liver transplant candidates. Aliment Pharmacol Ther. 2016;44(8):796–806.
    1. Orman ES, Ghabril M, Chalasani N. Poor performance status is associated with increased mortality in patients with cirrhosis. Clin Gastroenterol Hepatol. 2016;14(8):1189–1195.e1.
    1. Faustini Pereira JXL, Galant LH, Rossi D, et al. Functional capacity, respiratory muscle strength, and oxygen consumption predict mortality in patients with cirrhosis. Can J Gastroenterol Hepatol. 2016;2016(1):1–6.
    1. Sundaram V, Lim J, Tholey DM, et al. The Braden Scale, a standard tool for assessing pressure ulcer risk, predicts early outcomes after liver transplantation. Liver Transpl. 2017;23(9):1153–1160.
    1. Tapper EB, Finkelstein D, Mittleman MA, Piatkowski G, Lai M. Standard assessments of frailty are validated predictors of mortality in hospitalized patients with cirrhosis. Hepatology. 2015;62(2):584–590.
    1. Tandon P, Reddy KR, O’Leary JG, et al. A Karnofsky performance status-based score predicts death after hospital discharge in patients with cirrhosis. Hepatology. 2017;65(1):217–224.
    1. Tandon P, Tangri N, Thomas L, et al. A rapid bedside screen to predict unplanned hospitalization and death in outpatients with cirrhosis: a prospective evaluation of the clinical frailty scale. Am J Gastroenterol. 2016;111(12):1759–1767.
    1. Dunn MA, Josbeno DA, Tevar AD, et al. Frailty as tested by gait speed is an independent risk factor for cirrhosis complications that require hospitalization. Am J Gastroenterol. 2016;111(12):1768–1775.
    1. Sinclair M, Poltavskiy E, Dodge JL, Lai JC. Frailty is independently associated with increased hospitalisation days in patients on the liver transplant waitlist. World J Gastroenterol. 2017;23(5):899.
    1. Dasarathy S, Merli M. Sarcopenia from mechanism to diagnosis and treatment in liver disease. J Hepatol. 2016;65(6):1232–1244.
    1. Lai JC. A framework to determine when liver transplantation is futile. Clin Liver Dis. 2016;8(6):137–139.
    1. Rockwood K, Mitnitski A. Frailty in relation to the accumulation of deficits. J Gerontol A Biol Sci Med Sci. 2007;62(7):722–727.
    1. 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;63:574–580.
    1. Wang CW, Lebsack A, Chau S, Lai JC. The range and reproducibility of the Liver Frailty Index (published online ahead of print March 2019). Liver Transpl. 10.1002/lt.25449..
    1. Lurz E, Quammie C, Englesbe M, et al. Frailty in children with liver disease: a prospective multicenter study. J Pediatr. 2018;194:109–115.
    1. Duarte-Rojo A, Ruiz-Margáin A, Montano-Loza AJ, Macías-Rodríguez RU, Ferrando A, Kim WR. Exercise and physical activity for patients with end-stage liver disease: improving functional status and sarcopenia while on the transplant waiting list. Liver Transpl. 2017;24(1):122–139.
    1. Tandon P, Ismond KP, Riess K, et al. Exercise in cirrhosis: translating evidence and experience to practice. J Hepatol. 2018;69:1164–1177.
    1. Volk ML, Sonnenday C. Patient-centered liver transplantation. Clin Liver Dis. 2016;8(1):24–27.
    1. Samoylova ML, Covinsky KE, Haftek M, Kuo S, Roberts JP, Lai JC. Disability in patients with end-stage liver disease: results from the functional assessment in liver transplantation study. Liver Transpl. 2017;23(3):292–298.
    1. Malinis MF, Chen S, Allore HG, Quagliarello VJ. Outcomes among older adult liver transplantation recipients in the model of end stage liver disease (MELD) era. Ann Transplant. 2014;19:478–487.
    1. Yadav A, Chang Y-H, Carpenter S, et al. Relationship between sarcopenia, six-minute walk distance and health-related quality of life in liver transplant candidates. Clin Transpl. 2015;29(2):134–141.
    1. Rakoski MO, McCammon RJ, Piette JD, et al. Burden of cirrhosis on older Americans and their families: analysis of the health and retirement study. Hepatology. 2012;55(1):184–191.

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