The influence of prehabilitation in patients with liver cirrhosis before liver transplantation: a randomized clinical trial.

BACKGROUND: The high prevalence of liver cirrhosis in Slovakia leads to a great need for transplant treatment. The outcome of liver transplantation is influenced by several factors. AIM: The main objective of this study is to test the effectiveness of prehabilitation compared to standard of care. DESIGN: Prospective, double-arm, randomized, open-registry study. SETTING: Patient in F. D. Roosevelt Teaching Hospital, Slovakia, Banská Bystrica. POPULATION: The participants consisted of patients with liver cirrhosis (55 men, 25 women). METHODS: The patients were randomized to the active prehabilitation group (N.=39) or the standard of care group (SOC) (N.=41). SOC represents the standard of care for patients prior to liver transplantation, consisting of a formal oral interview lasting 30 minutes. In addition to SOC, each patient with decompensated liver cirrhosis also underwent a prehabilitation intervention that included rehabilitation and nutrition support. Patients completed the exercises under the supervision of a physician during hospitalisation. RESULTS: After one month, the liver frailty index improved in the prehabilitation group (P=0.05). No improvement in MELD (Model of End Stage Liver Disease) was found in the group that underwent the prehabilitation program (P=0.28), and no improvement was found in the Child-Pugh score after one month (P=0.13). In the prehabilitation groups compared with the SOC group, differences were not found in the MELD score (P=0.11). Better clinical outcomes according to the Child-Pugh score was found for the prehabilitation group compared with the SOC group (P=0.02). According to LFI, there was no difference between the groups (P=0.26). Very low adherence was found after three months. Only three patients in the SOC group and six patients in the prehabilitation group came to the check-up. Due to low adherence after 3 months in patients with liver cirrhosis, it is not possible to make an adequate comparison between groups after three months. CONCLUSIONS: Despite the great effort to maintain adherence, it was not possible to draw a conclusion about the effectiveness of prehabilitation in patients before liver transplantation compared to standard of care because the main problem in Slovak patients with liver cirrhosis is low adherence. More studies are needed to identify the barriers that lead to low adherence in patients with liver cirrhosis. CLINICAL REHABILITATION IMPACT: A promising result was found due to improvement of the Liver Frailty Index and the Child-Pugh Score after one month in the prehabilitation group.

Frailty in Nonalcoholic Fatty Liver Cirrhosis: A Comparison with Alcoholic Cirrhosis, Risk Patterns, and Impact on Prognosis.

Background: Physical frailty increases susceptibility to stressors and predicts adverse outcomes of cirrhosis. Data on disease course in different etiologies are scarce, so we aimed to compare the prevalence and risk factors of frailty and its impact on prognosis in nonalcoholic fatty liver (NAFLD) and alcoholic (ALD) cirrhosis. Patients and Methods. Cirrhosis registry RH7 operates since 2014 and includes hospitalized patients with decompensated cirrhosis, pre-LT evaluation, or curable hepatocellular carcinoma (HCC). From the RH7, we identified 280 ALD and 105 NAFLD patients with at least 6 months of follow-up. Results: Patients with NAFLD compared with ALD were older and had a higher proportion of females, higher body mass index (BMI) and mid-arm circumference (MAC), lower MELD score, CRP, and lower proportion of refractory ascites. The liver frailty index did not differ, and the prevalence of HCC was higher (17.1 vs. 6.8%, p=0.002). Age, sex, serum albumin, and C-reactive protein (CRP) were independent predictors of frailty. In NAFLD, frailty was also associated with BMI and MAC and in ALD, with the MELD score. The Cox model adjusted for age, sex, MELD, CRP, HCC, and LFI showed that NAFLD patients had higher all-cause mortality (HR = 1.88 95% CI 1.32-2.67, p < 0.001) and were more sensitive to the increase in LFI (HR = 1.51, 95% CI 1.05-2.2). Conclusion: Patients with NAFLD cirrhosis had a comparable prevalence of frailty compared to ALD. Although prognostic indices showed less advanced disease, NAFLD patients were more sensitive to frailty, which reflected their higher overall disease burden and led to higher all-cause mortality.

Applicability and prognostic value of frailty assessment tools among hospitalized patients with advanced chronic liver disease.

AIM: To assess and compare the feasibility and prognostic value of various frailty assessment tools among decompensated cirrhosis inpatients. METHODS: Our prospective observational registry included consecutive patients admitted for cirrhosis between June 2017 and July 2018. Exclusion criteria were intensive-care unit admission, hepatocellular carcinoma outside of the Milan criteria, and other malignancies. Frailty at baseline was assessed with the Liver Frailty Index (LFI), Clinical Frailty Scale (CFS), Fried Frailty Score (FFS), and Short Physical Performance Battery test (SPPB). The follow-up lasted for at least 180 days. RESULTS: The study enrolled 168 patients (35.1% women, median age 57.9 years). The most frequent primary etiology was alcohol-related liver disease (78.6%). The Median Model for End-Stage Liver Disease (MELD) was 16. The 80th percentile of frailty scores was LFI>5.4, CFS>4, FFS>3, and SPPB<5, and it identified patients with higher mortality. LFI and CFS had the highest numerical prognostic value for in-hospital, and 90- and 180-day mortality. In a bivariate analysis of the risk of death or liver transplantation, the combination of MELD and LFI had the highest concordance (0.771±0.04). In a multivariate model, MELD score (HR 1.17, 95% CI 1.12-1.22), overt encephalopathy (2.39, 1.27-4.48), infection at baseline (2.32, 1.23-4.34), and numerical LFI (1.41, 1.02-1.95) were independent predictors of overall mortality. CONCLUSION: Frailty assessment using the evaluated tools is feasible among hospitalized cirrhotic patients, identifying those with worse prognosis. CFS had the highest applicability and accuracy for the initial assessment and LFI for the initial and follow-up assessments.