Liver disease, the third commonest cause of death in the UK, predominantly kills between the ages of 18 and 65. This leads to the loss of 62,000 years of working life each year in the UK. Liver transplantation (LT) remains the only curative treatment for patients with liver failure and the number of transplantations in the UK has risen in recent years. LT is a highly resourced intensive procedure requiring a large investment of healthcare resources. The average cost per procedure is estimated at over £1.1m, which includes pre-LT work-up, surgery, perioperative care, and an estimated seven year postoperative follow-up (https://www.nsd.scot.nhs.uk/publications). Complications whilst on the waiting list and in the perioperative period contribute substantially to this cost, and their likelihood is increased markedly by the presence of physical frailty (Lai et al., 2014; Patel et al., 2016 & Son et al., 2018).
LT exerts a phenomenal physiological and psychological stress on recipients who are frail as a result of long-standing liver failure. Post LT readmission rates are around 50% (Patel et al., 2016) and perioperative complications can lead to reduced long-term quality of life (QoL) and delayed/reduced return to productive employment (Onghena et al., 2016; Saab et al., 2007). End-stage liver disease can lead to skeletal muscle sarcopenia which contributes to a high prevalence (70%) of physical frailty (Sinclair et al., 2016). Frailty both before and after LT is associated with poor psychological and physical health-related QoL (Painter etal., 2001; Tapper et al., 2018 & Derck et al, 2015) which is itself an independent predictor of mortality (Macdonald et al., 2019). Although the majority of patients are under 65 years old, fewer than 50% return to employment, which is largely attributed to prolonged disability/frailty.(Saab et al., 2007)
Trial Rationale
Exercise interventions have been shown to be effective in other fields of medicine including prior to elective major surgery. However, due to the life-threatening, multi-systemic effects of end-stage liver disease, patients awaiting LT are often perceived as ‘too sick’ to exercise by healthcare professionals and the patient/carers themselves (PPI/Expert observations); with virtually no published data to support the benefits and safety of exercise in this cohort. Effective exercise interventions that reduce frailty pre- and post-LT have the potential to improve clinical outcomes and long-term QoL for this patient group, leading to cost savings for the NHS. Furthermore, a better understanding of how exercise works (i.e. on the muscular and cardiopulmonary systems) and how it can be effectively delivered (i.e. motivational approach adopted) in this unique cohort, will guide future exercise prescriptions (‘type’, ‘dose’, ‘duration’, ‘motivational strategies’) that are required to maximise the efficiency and longevity of this life-changing surgery. In an environment of substantial NHS resource limitation, identifying simple, cost-effective and remotely monitored home-based interventions should be a priority in those patients who may benefit the most.