WK2 - Exercise for Transplant Patients Flashcards
What is an organ transplant?
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
What are the statistics for organ transplant procedures?
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
What are some considerations for the transplant journey?
- 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
What happens prior to surgery with end stage organ failure?
- 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
What is pre-habilitation before surgery?
- improve pre-operative conditioning of patients to improve pre- and post-operative outcomes
Is Ex recommended for pre-transplant?
- 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
What to consider post-transplant?
- 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.
What immunosuppressive therapies are available?
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
What are some considerations for Ex post-transplant?
- 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
What to consider for kidney transplant?
- 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
What is the relationship between Ex and Kidney transplant?
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
What is a liver transplant?
- 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
What are some end stage liver disease safety issues?
- ascites - abnormal build-up of fluid in abdomen
- variceal bleeding (in stomach)
- hepatic encephalopathy (failure to metabolise Ammonia)
What is the relationship between Ex and liver transplant?
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
What is lung transplant?
- 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%
What is the relationship between exercise and lung transplant?
- 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
What is a heart transplant?
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
What is the relationship between Ex and heart transplant?
- 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
What is the relatinoship between HIIT and transplant?
- generally superior or similar with other exercise training on VO2peak, HR, lVEF, cardiac biomarkers, vascular function, BP, body composition, adverse events and QoL
What are the general Ex guidelines for transplant patients?
- 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
Discuss points of mental health in relation to transplants.
- 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
What would be the main message in presentation regarding “pre-habilitation for transplant surgery”?
- 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
Is high intensity aerobic Ex beneficial for heart transplant patients?
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
Is Ex good for liver transplant patients?
- no adverse events
- feasible - excellent attendance/adherence
- there were limited statistically significant improvements but it was shown in aerobic fitness, Ex capacity and strength
