Association of Frailty With Health-Related Quality of Life in Liver Transplant Recipients

Abstract

ImportanceFrailty has been recognized as a risk factor for mortality after liver transplant (LT) but little is known of its association with functional status and health-related quality of life (HRQL), termed global functional health, in LT recipients.ObjectiveTo evaluate the association between pre-LT and post-LT frailty with post-LT global functional health.Design, Setting, and ParticipantsThis prospective cohort study was conducted at 8 US LT centers and included adults who underwent LT from October 2016 to February 2020.ExposuresFrail was defined by a pre-LT Liver Frailty Index (LFI) score of 4.5 or greater.Main Outcomes and MeasuresGlobal functional health at 1 year after LT, assessed using surveys (Short Form-36 [SF-36; summarized by physical component scores (PFC) and mental component summary scores (MCS)], Instrumental Activities of Daily Living scale) and performance-based tests (LFI, Fried Frailty Phenotype, and Short Physical Performance Battery).ResultsOf 358 LT recipients (median [IQR] age, 60 [53-65] years; 115 women [32%]; 25 [7%] Asian/Pacific Islander, 21 [6%] Black, 54 [15%] Hispanic White, and 243 [68%] non-Hispanic White individuals), 68 (19%) had frailty pre-LT. At 1 year post-LT, the median (IQR) PCS was lower in recipients who had frailty vs those without frailty pre-LT (42 [31-53] vs 50 [38-56]; P = .002), but the median MCS was similar. In multivariable regression, pre-LT frailty was associated with a −5.3-unit lower post-LT PCS (P < .001), but not MCS. The proportion who had difficulty with 1 or more Instrumental Activities of Daily Living (21% vs 10%) or who were unemployed/receiving disability (38% vs 29%) was higher in recipients with vs without frailty. In a subgroup of 210 recipients with LFI assessments 1 year post-LT, 13% had frailty at 1 year post-LT. Recipients who had frailty post-LT reported lower adjusted SF-36–PCS scores (coefficient, −11.4; P < .001) but not SF-36–MCS scores. Recipients of LT who had frailty vs those without frailty 1 year post-LT also had worse median (IQR) Fried Frailty Phenotype scores (1 [1-2] vs 1 [0-1]) and higher rates of functional impairment by a Short Physical Performance Battery of 9 or less (42% vs 20%; P = .01).Conclusions and RelevanceIn this cohort study, pre-LT frailty was associated with worse global functional health 1 year after LT. The presence of frailty after LT was also associated with worse HRQL in physical, but not mental, subdomains. These data suggest that interventions and therapeutics that target frailty that are administered before and/or early post-LT may help to improve the health and well-being of LT recipients.

A randomized, controlled, prehabilitation intervention to maximize early recovery (PRIMER) in liver transplantation

“…A recent report from the multicenter Functional Assessment in Liver Transplantation (FrAILT) consortium showed that LT recipients with pretransplant frailty were more likely to exhibit physical frailty after LT, had lower odds of employment and had lower self-reported physical functioning. Only 5% of frail pretransplant recipients were robust at 1-year post-transplant, highlighting the need to developed tailored pretransplant interventions 25 …”

“…Only 5% of frail pretransplant recipients were robust at 1-year post-transplant, highlighting the need to developed tailored pretransplant interventions. [25] Behavior change is difficult and notoriously so in the setting of decompensated liver disease, whereby patients suffer from weakness, fatigue, anhedonia, and impaired mobility in addition to symptoms of cramping and volume overload. A growing body of evidence supports the use of small financial incentives to promote physical activity among healthy adults as well as those with chronic conditions such as solid organ transplant recipients and patients with ischemic heart disease.…”

Frailty as an Outcome Measurement Before and After Liver Transplant

“…Frailty has been shown to have a considerable negative economic impact on the hospital system and on patients' families. 4 If more emphasis were placed on prehabilitation or on early postoperative rehabilitation, as suggested in this study 3 as means to improve compliance, there could be a considerable positive economic impact on hospital systems. This includes postdischarge rehabilitation care, physical therapy, home nursing visits, and skilled nursing facilities, which are underused by many transplant centers.…”

“…The difficulty in liver disease, though, is that sarcopenia and frailty are a result of end-stage liver disease and commonly the only option for survival is liver transplant, especially when a patient is severely decompensated and with inpatient treatment status. The model presented by Lai et al 3 works well for outpatients, but in the current allocation scheme, patients are commonly inpatient when undergoing transplant and this population is not addressed in this series.…”

“…Despite this knowledge, the Liver Frailty Index and frailty do not currently factor into a person’s position on the wait list. Based on the findings of the study by Lai et al, we now know that frailty not only helps predict wait list mortality, but can also help predict quality of life after liver transplant. When considering the morbidity associated with an invasive procedure such as a liver transplant as well as the associated cost to the patient, family, and the health care system, should posttransplant quality of life not be a consideration in patient selection, timing, and assessment of outcome after transplant?…”