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EXMD4743 > WK2 - Exercise for Transplant Patients > Flashcards

WK2 - Exercise for Transplant Patients Flashcards

1
Q

What is an organ transplant?

A

Organ removed from one body and placed in body of recipient, to replace damaged or missing organ

Solid organ vs bone, muscle and tendons

Types of solid transplants
* kidney
* liver
* lung
* heart
* pancreas

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2
Q

What are the statistics for organ transplant procedures?

A

in 2021,
* 1850 waiting
* 421 donors
* 1174 transplant recipients
* 203 living organ donors

2021 Transplant procedures:
* 657 kidney
* 253 liver
* 171 lung
* 112 heart
* 38 pancreas
* 2 SI

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3
Q

What are some considerations for the transplant journey?

A
  • not everyone is a suitable candidate for transplant
  • to be eligible, need to be reasonably healthy
  • surgery and med to prevent rejection places strain on body
  • numerous med tests used to Ax health prior to being placed on transplantation list

–> CPETs prior to surgery - anaethesiology department

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4
Q

What happens prior to surgery with end stage organ failure?

A
  • prolonged bed rest and inactivity = loss of fitness/function and muscle mass
  • poorer preoperative physical condition = poorer response to detrimental effects of hospitalisation and surgery (e.g. anaethesia)
  • hampers postoperativerecovery, increasing hospitalisation times and operative mortality
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5
Q

What is pre-habilitation before surgery?

A
  • improve pre-operative conditioning of patients to improve pre- and post-operative outcomes
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6
Q

Is Ex recommended for pre-transplant?

A
  • generally well tolerated and effective
  • prescription needs to consider medical and physical patient condition
    –> depends on type of organ transplant, quality of recovery and complications
  • patients are waiting for organ and in unusal mental state
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7
Q

What to consider post-transplant?

A
  • massive improvements in graft survival over past 2-3decades
  • metabolic syndrome highly prevalent after transplant
  • CVD main health concern post-op
    –> mortality rate 5-10 fold greater than general pop.
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8
Q

What immunosuppressive therapies are available?

A

One or a combination…
* Prednisone
* Tacrolimus
* Cyclosporine
* Mycophenolate Mofetil
* Imuran
* Rapamune

Contribute to CVD burden
1. corticosteroids (prednisone) promote metabolic syndrome
2. cyclosporine associates with hypertension nad hyperlipidaemia
3. tacrolimus related with insulin resistance post-transplant diabetes

Little known about Ex and immunosuppressants

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9
Q

What are some considerations for Ex post-transplant?

A
  • Substantial variation in the length of time between surgery and starting Ex
  • Depends on type of organ transplant, quality of recovery and complications
  • Most patients encouraged to start walking while in hospital
  • Post discharge - aerobic and RT should begin asap
  • be careful of stress on wound site
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10
Q

What to consider for kidney transplant?

A
  • most common transplant
  • most desired renal replacement therapy for patients with ESKD
  • most go on dialysis first while waiting for kidney
  • if transplant fails, many are able to have second and subsequent transplants
  • metabolic syndrome highly prevalent after KTx
  • KTx have higher CRF than ESKD patients
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11
Q

What is the relationship between Ex and Kidney transplant?

A

A SR with MA found 24 studies on Ex in KTx patients
* most programs 3-6M
* significant improvement VO2peak, QoL and arterial stiffness
* no evidence for improved BP, lipid profile, BGL, kidney function, weight, BMI

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12
Q

What is a liver transplant?

A
  • removes liver that no long functions and replaces with healthy liver, from dead or portion of healthy liver from live donor
  • increase incidence of metabolic syndrome from 5.1% to 50%
  • increase CV morbidity by at least 3 fold
  • 22% of previously normal-weight becoming obese within 2y
  • independent predictors of obesity include episode of acute rejection and higher dose of prednisolone
  • increae BMI at 1y accurately predicts development of metabolic syndrome
  • 1/3 will have CVD at 8y
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13
Q

What are some end stage liver disease safety issues?

A
  • ascites - abnormal build-up of fluid in abdomen
  • variceal bleeding (in stomach)
  • hepatic encephalopathy (failure to metabolise Ammonia)
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14
Q

What is the relationship between Ex and liver transplant?

A

21 of 38 eligible agreed to be included
* safe - no episodes of variceal bleeding of hepatic encephalopathy
* feasible - excellent adherence
- supervised = 100%
- unsupervised = 88%
* efficacious - improved grip strength, and VT, VO2peak, 6MWD

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15
Q

What is lung transplant?

A
  • highly complex with perioperative and postoperative risks

Reasons for lung transplant:
- congenital disease
- COPD
- diffuse interstitial lung disease
- cystic fibrosis

3 types of Lung transplant - depending on underlying pathology
- single
-double
- simulataneous heart/lung transplant

1-5y survival rates for single/double are 77% and 59%

Main contributers to postoperative morbidity/mortality
- infection 38%
- rejection 29%
-malgnancy 15%
-CVD 10.9%

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16
Q

What is the relationship between exercise and lung transplant?

A
  • Ex capacity range of 40-60% of normal postoperatively
  • observational studies show not all Ex are equally effective

1 RCT (n=40) show structured Ex program improved:
- maximal Ex capacity
* physical function
* muscle strength
* BMD

17
Q

What is a heart transplant?

A

When med therapy unabel to halt progression of underlying pathology
* heart is surgically denervated - post-ganglionic neurons dissected
= chronotropic insufficiency
= reliance on circulating catecholamines to control HR
= slower increase in HR
= lower peak HR in response to Ex
= elevated RHR

  • in postoperative months, some show signs of partial cardiac reinnervation, which may normalise response to Ex
  • diastolic dysfunction = multifactorial cuases: hypertension and vasculopathy of allograft = influences Ex resposne
  • Ex capacity in 40-60% range of normal postoperatively
18
Q

What is the relationship between Ex and heart transplant?

A
  • failure to Ex is highest in heart recipients
  • 10 RCTs, n=300
  • Ex training started 1y after heart transplant
  • safe - one adverse event
  • improved VO2peak by 10.2%
  • no impact on health-related QoL in short-term
  • avoid Ex that require use of upper extremities until sternum completely healed
  • aerobic and combined training improved VO2peak and strength. HIIT = better choice for CRF improvements
19
Q

What is the relatinoship between HIIT and transplant?

A
  • generally superior or similar with other exercise training on VO2peak, HR, lVEF, cardiac biomarkers, vascular function, BP, body composition, adverse events and QoL
20
Q

What are the general Ex guidelines for transplant patients?

A
  • during discharge, home endurance Ex program should be established
  • eventually meet PA guidelines
  • longer WU and CD
  • walking program set ASAP postoperatively
  • distance based on patients tolerance
  • initially monitor HR, BP and RPE - prior to PA, in regular intervals (e.g. 5mins), regular intervals follow activity cessation
  • program progressed on FITT principles based on patients tolerance
  • avoid Ex that require upper extremities until sternum healed
  • interval training may be appropriate to advance program
21
Q

Discuss points of mental health in relation to transplants.

A
  • physical trauma vs emotional stress
  • impact surrounding people
  • monitor mental wellbeing important
  • establish social connections and health relationships
  • normal to feel elated with sense of hope post transplant
  • meds effect mood behaviours and sleep
  • after time, replaced iwht feelings of fear and worry
  • shame and guilt
  • concerns of organ rejection - burden responsibility
  • living with uncertainty
22
Q

What would be the main message in presentation regarding “pre-habilitation for transplant surgery”?

A
  • aims to improve pre-operative conditioning of patients to improve outcomes during and after operation
  • position statement recommends that Ex offered to all pre-transplant patients (adults and children)
  • it IS safe
  • poor condition of patients with end-stage organ failure means that care must be taken when prescribing and delivering Ex
  • opportunities to provide service for transplant departments at local hospital - suggest contacting Director of Transplant Program and discuss how service might work
23
Q

Is high intensity aerobic Ex beneficial for heart transplant patients?

A

Based on evidence HIIT should be part of aerobic Ex esp. for those who are:
- younger
- previous experience with higher intensities
- want to try it
- systematic review found that HIIT generally superior or similar with other Ex training on VO2peak, body comp, adverse events and QoL among transplant recipients

24
Q

Is Ex good for liver transplant patients?

A
  • no adverse events
  • feasible - excellent attendance/adherence
  • there were limited statistically significant improvements but it was shown in aerobic fitness, Ex capacity and strength
25
Q

Provide a summary of this topic. Ex and transplants.

A
  • Ex training offered pre- and post-transplant phase
  • safe feasible and effective
  • improve CRF, muscle mass, function and QoL
  • HIIT safe, feasible, efficient in heart transplant recipients
  • caution and monitoring always necessary and progression should be slow
  • mental health issues very common

EXMD4743 (9 decks)

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