Systematic Reviews
Copyright ©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Oct 27, 2023; 15(10): 1153-1163
Published online Oct 27, 2023. doi: 10.4254/wjh.v15.i10.1153
Exercise training as an intervention for frailty in cirrhotic patients on the liver transplant waiting list: A systematic review
Thais Mellato Loschi, Melline D T A Baccan, Bianca Della Guardia, Paulo N Martins, Amanda P C S Boteon, Yuri L Boteon
Thais Mellato Loschi, Melline D T A Baccan, Bianca Della Guardia, Amanda P C S Boteon, Yuri L Boteon, Transplant Centre, Hospital Israelita Albert Einstein, São Paulo 05652-900, Brazil
Thais Mellato Loschi, Yuri L Boteon, Instituto Israelita de Ensino e Pesquisa Albert Einstein, Faculdade Israelita de Ciências da Saúde Albert Einstein, São Paulo 05652-900, Brazil
Paulo N Martins, Department of Surgery, Transplant Division, University of Massachusetts Medical School, Worcester, MA 01655, United States
Author contributions: Loschi TM and Boteon YL designed this study and drafted the manuscript; Loschi TM and Baccan MDTA performed the literature review and analysis; Loschi TM, Baccan MDTA, Della Guardia B, Martins PN, Boteon APCS, Boteon YL reviewed the manuscript critically; and all authors contributed to editing and approved the final manuscript version.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Yuri L Boteon, FACS, MD, PhD, Doctor, Professor, Surgeon, Transplant Centre, Hospital Israelita Albert Einstein, 2nd Floor, Building A1, Office 200B, 627/701 Albert Einstein Avenue, São Paulo 05652-900, Brazil. yuri.boteon@einstein.br
Received: August 25, 2023
Peer-review started: August 25, 2023
First decision: September 15, 2023
Revised: September 21, 2023
Accepted: October 8, 2023
Article in press: October 8, 2023
Published online: October 27, 2023
Processing time: 59 Days and 13.3 Hours
ARTICLE HIGHLIGHTS
Research background

In patients with end-stage liver disease candidates for liver transplant (LT), frailty is associated with worse clinical outcomes and a higher probability of death. Therefore, the identification of interventions which could modify or reverse this condition is of paramount importance. Although exercise training is widely recommended for individuals with other chronic diseases, evidence still lags well behind for this population.

Research motivation

Exercise programs for cirrhotic patients are still not so frequent, and there is still debate about the optimal method to deliver exercises to them (in-person supervised exercise or home-based programs).

Research objectives

To investigate the existing exercise programmes and prescriptions for cirrhotic patients on the waiting list for liver transplantation, their results concerning frailty pre- and post-intervention and their impact on clinical outcomes.

Research methods

We searched the PubMed, MEDLINE and Scopus databases using the keyword and free terms “liver transplant”, “frailty”, and “exercise”. The research findings, their contributions to the research in this field, and the problems that remain to be solved should be described in detail. The results were subsequently analysed for the instrument for physical frailty assessment, whether there were any pre-established criteria for inclusion in the transplant list related to frailty assessment, frequency, intensity, type and time of exercise performed, and primary and secondary outcomes evaluated after the physical exercise program.

Research results

We identified nine research articles that were included in this review. The instruments for frailty assessment varied amongst them, and five studies prescribed physical activity to patients, one in-person and four to be performed remotely and unsupervised. None reported adverse events related to exercise training. Three articles evaluated the impact of the exercise program on clinical outcomes, reporting a reduction in 90-d readmission rates post-transplant and improvement of frailty scores followed by improved survival of cirrhotic patients waiting for a transplant.

Research conclusions

We found that the routine assessment of frailty and practice of regular physical exercise, either in-person or remote, of low to moderate intensity is safe and capable of improving the patient’s functional capacity and favour positive pre- and post-LT outcomes.

Research perspectives

Although further studies are still required to guide exercise prescription and validate the practice of regular physical activity for cirrhotic patients on the waiting list for LT, it may improve their outcomes.