Personalized Prehabilitation: A Pathway to Improved Frailty Metrics and Survival in Liver Transplant Candidates

Outpatient prehabilitation can potentially improve frailty in liver transplant (LT) candidates. Our aim was to determine the impact of prehabilitation on physical fitness and mortality, and to identify the minimum clinically important change needed to improve survival.

In this ambispective cohort study, LT candidates underwent baseline evaluation with a dedicated physical therapist (PT) and were prescribed a personalized prehabilitation program based on their functional status. Liver frailty index (LFI), 6-min walk test (6MWT), and gait speed test (GST) were assessed. Multilevel linear mixed-effects models and multivariable survival analyses were fitted, including competing risks models against LT.

A total of 1275 patients (59% male, age 57±11, MELD 14±6) attended 1973 LT-PT visits. Of these, 355 attended two or more follow-up visits, participating in the prehabilitation program. At baseline, median LFI was 3.8 (3.2-4.4), 6MWT 336 m (243-403), and GST 1 (0.8-1.2); 23%, 26%, and 29% of the cohort were frail by each tool, respectively. Among subjects who improved LFI (n=226/352), the absolute change was -0.39 (-0.32 to -0.46), and for 6MWT (n=212/334) it was 54 m (43-64); fewer than half improved GST. A total of 667 (55%) patients were waitlisted, 462 (37%) transplanted, and 335 (26%) died. LFI improvement by at least 0.4 was associated with a ∼50% reduction in mortality (HR=0.56, p=0.037). Improvement in 6MWT was not associated with a survival advantage.

Individualized prehabilitation in LT candidates was associated with significant improvement in LFI and 6MWT. A minimum LFI improvement of 0.4 was associated with improved survival and could be considered a minimal clinically important difference for frailty interventions in LT candidates.