The impact of supervised aerobic and resistance exercise prehabilitation on frailty and recovery after living donor liver transplantation: Open-label randomized trial

Background: Frailty adversely affects post-transplant outcomes in chronic liver disease (CLD). This study evaluated the feasibility and the impact of preoperative supervised aerobic and resistance exercises (SARE) on frailty and outcomes after living donor liver transplantation (LDLT). Methods: This single-centre randomized controlled trial assigned the LDLT recipients to standard medical therapy (SMT) or SARE+SMT for 4 weeks pre-LDLT. Liver Frailty Index (LFI), Short Physical Performance Battery (SPPB), pulmonary function tests (PFTs) and postoperative outcomes were compared. Results: Sixty patients, [54 (90%) males, 26 (43.33%) alcoholic liver disease, 18 (30%) NASH, median MELDNa of 22 (19-27) and CTP A 5 (8.33%), B 22 (36.67%), C 33 (55%) were randomised (30/group)]. Baseline parameters, LFI and SPPB were comparable. At enrolment, 46(76.67%) were pre-frail, 7(11.67%) frail and 53(88.33%) were sarcopenic. Seven(11.66%) patients died during workup, four lost to follow-up and 49 underwent LDLT. In SARE arm, 40% patients attended ≥5 exercise sessions. No adverse events occurred; recurrent admissions were hinderance to study adherence. Adjusted analysis showed similar LFI ( p =0.92), SPPB ( p =0.71) and PFT between groups. A borderline improvement in NIV discontinuation ( p =0.05) and earlier chair and bipedal ambulation ( p =0.10 and p =0.09, respectively) was observed with SARE. Significant correlations were observed for POD30 LFI [MV duration- r =0.56 ( p =0.00) , NIV duration- r =0.509 ( p =0.00) , hospital stay- r =0.547 ( p =0.00) and ICU stay- r =0.563 ( p =0.00) ], with similar statistically significant correlations for POD14 and POD30 LFI, SPPB and PFTs. Conclusions: Preoperative SARE is safe and feasible in high MELD/ Child patients. LFI, SPPB, PFT, and postoperative outcomes were comparable between groups. SARE showed borderline improvement in ambulation and NIV discontinuation. Better LFI, SPPB, PFTs predicted improved clinical outcomes.