Frailty in the End-Stage Lung Disease or Heart Failure Patient: Implications for the Perioperative Transplant Clinician

Abstract

The syndrome of frailty for patients undergoing heart or lung transplantation has been a recent focus for perioperative clinicians because of its association with postoperative complications and poor outcomes. Patients with end-stage cardiac or pulmonary failure may be under consideration for heart or lung transplantation along with bridging therapies such as ventricular assist device implantation or venovenous extracorporeal membrane oxygenation, respectively. Early identification of frail patients in an attempt to modify the risk of postoperative morbidity and mortality has become an important area of study over the last decade. Many quantification tools and risk prediction models for frailty have been developed but have not been evaluated extensively or standardized in the cardiothoracic transplant candidate population. Heightened awareness of frailty, coupled with a better understanding of distinct cellular mechanisms and biomarkers apart from end-stage organ disease, may play an important role in potentially reversing frailty related to organ failure. Furthermore, the clinical management of these critically ill patients may be enhanced by waitlist and postoperative physical rehabilitation and nutritional optimization.

Development of frailty subtypes and their associated risk factors among the community-dwelling elderly population

“…With the rapid aging global population, frailty, a multidimensional syndrome associated with subclinical dysfunction and limited physiologic reserve that may affect one or more organs, has received increasing attention [1]. Frailty is common among older people, affecting 7%-12% of adults aged 65 years and older [2], and makes them vulnerable to stressful events and functional deterioration [3,4].…”

The impact of severe acute kidney injury requiring renal replacement therapy on survival and renal function of heart transplant recipients – a UK cohort study

“…The differences in the characteristics of the 3‐month survivors in the RRT and non‐RRT groups could not explain this phenomenon, which had never been discussed in the literature either. Other factors that were not considered in this study, such as frailty [27,28], might shed light on the difference in the long‐term attrition rate between the two groups. We hypothesized that these recipients in the RRT group, who survived through the haemodynamic instability and other major complications in the initial post‐transplant period, were perhaps a group of self‐selected patients with better physiological ‘reserve’.…”

Multimodal prehabilitation as a promising strategy for preventing physical deconditioning on the heart transplant waiting list

“…Patients awaiting heart transplantation exhibit poor quality of life (QoL) and the post-transplant morbi-mortality is high. 1,2 A recent study showed the protective effect of physical activity on mortality in elderly patients with advanced heart failure. 3 Frailty and physical deconditioning generate a vicious circle leading to avoidance of physical activity, which in turn worsens their functional capacity.…”

“…This situation progresses while waiting for heart transplantation and patients are commonly transplanted in a very poor functional, nutritional and emotional status. 1…”