Hello and welcome to the 2020 AAPMNR Virtual Annual Assembly. I'm Dr. Jonathan Biteson, one of the speakers today and also the session moderator. This session is a live session, Solid Organ Transplant Rehabilitation, the New Frontier of Rehabilitation Medicine. To post questions to the faculty, please type questions in the Q&A or chat field on the left side of your screen. To claim CME credit, you will need to complete an evaluation for each session you attend live or watch on demand during the assembly. All sessions will be recorded and made available on demand until January 31st, 2021. Visit the Member Resource Center if you have questions. Also note, your feedback on the evaluation does help the Program Planning Committee outline content for future annual assemblies, so please ensure to give suggestive content. And with that, I'm going to hand it over to the session director, Dr. Jeffrey Cohen. Thank you, Jonathan, and good morning. Welcome to our presentation entitled Solid Organ Transplant Rehabilitation Team, the New Frontier of Rehabilitation Medicine. We have a team of expert speakers today, including Dr. Niying Lam, Dr. Sophia Prillik, Dr. David Prince, and Dr. Jonathan Weixson. Next slide. 65 years ago was the first successful organ transplant, a kidney transplant. By the late 1960s, there was liver, heart, and pancreas transplants. By the 1980s, lung and intestinal organ transplants. There's been remarkable advances in surgical techniques, pre- and post-operative care, as well as the rehabilitative management of these patients. This has led to a markedly reduced morbidity and mortality in post-transplant patients. Now there are more than 22 transplantable organ systems, and this course will focus on the four most common solid transplants in rehabilitation medicine, cardiac, pulmonary, liver, and renal. Next slide. Pre-op and post-op rehabilitation management, post-op complications, and outcomes for each transplant organ will be discussed. And we'll focus on a team approach with the physiatrist as team leader, with close collaboration between the rehab and the transplant surgery team. This team approach has led to a decrease in complications, hospital length of stay, readmissions, and an improvement in the patient's overall well-being. We will show you specific case examples to illustrate potential challenges and solutions that the physiatrist may face. Next slide. These are our learning objectives. Number one, we want to understand the indications for, the selection process for, and contraindications to these four most common solid organ transplantations that we see in rehabilitation medicine. We want to become familiar with how key medical issues in this population affect your prescription of a rehabilitation program. We want you to learn how to design a pre-operative and post-operative rehabilitation program for these patients. Next slide. We want you to learn how to quickly recognize and manage post-organ transplantation complications. We want you to become familiar with the most frequently used immunosuppressive agents for this population and their potential side effects. And we want you to become familiar with the major functional outcome studies on patients undergoing solid organ transplantation. Our next speaker is Dr. Niying Lam who will speak on prehab and functional outcome studies. Thanks so much, Jeff. Good morning. I'm an assistant professor at the University of Washington, and I'm going to kick off this lecture discussing prehab for transplant candidates. It can be challenging deciding if these patients nearing end organ damage are safe to be transplanted. And if so, how can we determine if these patients nearing end organ damage are safe to exercise, as well as to determine how to utilize prehabilitation to set these patients up for success after transplant? Let's start with a theoretical case. A 55-year-old gentleman presents to the heart failure clinic with worsening heart failure exacerbations. They're considering listing him for transplant. He reports that he gets short of breath when he's just walking and has AHA class 3 symptoms. So how can he exercise or strengthen while preparing for surgery? Is it safe for him to work with therapies if he's then hospitalized at the next heart failure exacerbation and sort of on inotropes? Talking broadly and considering all transplant types, there are several contributing factors resulting in activity limitations. Most of these patients have become symptomatic due to their illness, whether that's shortness of breath due to conditions like heart failure or COPD, generalized fatigue, or excess fluid on board due to kidney, liver, or heart failure. Patients living with chronic illness have also been noted to develop muscle changes such as sarcopenia, characterized by low skeletal muscle mass and reduced muscle function. Specifically in the heart failure population, there appears to be a notable shift in muscle fiber types due to chronic hypoperfusion. Cachexia is also commonly seen, particularly in liver and lung candidates, and is defined as weight loss greater than 5% of body mass, as well as the presence of other markers such as anorexia, weight loss, low fat-free muscle index, and increased inflammatory markers. Malnutrition can also contribute to these muscle changes as well as to symptoms such as fatigue. Frailty is another particularly hot concept in the literature these days, but as of yet there is no consensus definition being used across populations, although a variety of scales have been developed to measure frailty, such as the Fried criteria. In general terms, frailty presents as a physiologic decline, including features such as weight loss, fatigue, muscle weakness, decreased physical activity, and reduced gait speed. Most notably, frailty is considered a modifiable risk factor, with potential interventions including exercise and nutritional supplementation. In the literature, there are a variety of measures being used to track functional outcomes in transplant patients. Traditional transplant literature tends to focus on the use of more subjective measures, such as the Karnofsky performance score, but there is a growing body of literature really looking at more objective measures of strength, gait speed, and exercise tolerance to better characterize the outcomes in these populations. In the next few slides, I want to highlight some of the research being done in transplant candidates. These studies are beginning to frame the importance of prehabilitation in these populations. However, few programs have truly embraced prehabilitation as a standard of care. The HF Action Study was a large study demonstrating the safety of exercise intervention in stable NYHA class 2 through 4 heart failure patients. Noted positive outcomes included improved gait speed and exercise tolerance, with improvements lasting 12 months after the intervention was completed. There are many qualifying diagnoses for cardiac rehabilitation programs, which incorporate a supervised exercise program along with health promotion education. Since increased exertional activity can sometimes induce cardiac ischemia or arrhythmias, it is wise to ensure that patients are appropriately risk stratified prior to starting a program. For those being considered for transplant listing, it's recommended to start cardiac rehab as soon as feasible after being placed on the list. Studies have demonstrated that lung transplant candidates who are identified as frail have a higher risk of death before and after lung transplant. Since frailty can be combated with exercise, these patients should be enrolled in pulmonary rehab programs, which serve as prehab for the lung transplant patients. Pulmonary rehab closely mirrors cardiac rehab programs with fewer contraindications than in the cardiac population. The 2013 American Thoracic Society consensus statement on pulmonary rehab highlighted several functional outcomes, including improved dyspnea, gait speed, and quality of life. Another interesting study by Lee et al. found that pre-transplant gait speed predicted shorter hospital length of stay post transplant, implying that interventions to improve gait speed could affect meaningful change in post-transplant outcomes. Frailty in kidney transplant recipients has been shown to increase risk for early readmission, prolonged hospital length of stay post-transplant, and portends a worse five-year mortality. There is one clinic based at Stanford that assesses kidney transplant candidates and has noted worsening gait speed and reduced strength as measured by sit-to-stand is associated with weightless removal or death. Some considerations when designing prehab programs for these patients include deciding if exercise should occur on dialysis or non-dialysis days. There is a cycle of affective and physical consequences for patients waiting on dialysis. Those coming to a center for dialysis might be a captive audience to participate in exercise programs, but they're also dealing with more fatigue and edema on those days and may be less able to participate. There's also a noted high attrition in exercise studies for end-stage renal patients, so another idea has been to incorporate exercise as a part of the standard pre-transplant guidelines for patients to follow, which may make them more motivated to participate. Finally, in end-stage liver disease, frailty predicted weightless mortality in those with higher MELD scores, but also predicted lower survival regardless of severity of liver disease in patients who are unable to be transplanted. There are few exercise studies in patients awaiting liver transplant, though one study in cirrhotic patients does show that exercise can be safe. Another study looking at a combined nutrition and exercise program for patients on the weight list did demonstrate improved gait speed after completion of the program. What about for those patients with acute decompensated end-organ failure admitted to the hospital or ICU? In addition to sarcopenia, malnutrition, and cachexia, these patients may develop critical illness or ICU-acquired weakness. The goals for these patients is to continue to mobilize them as able, promoting the highest level of activities that are deemed safe for the patient. In summary, exercise is a safe intervention for patients with end-stage organ failure. Early implementation of prehab programs are recommended to mitigate signs of frailty, sarcopenia, or cachexia. Objective physical function measures should be integrated as standard screening tools and pre-transplant evaluations to identify those that would benefit from exercise interventions. And most importantly, much more research needs to be done to demonstrate the effect of prehabilitation on post-transplant outcomes. I'll now hand it over to Dr. Sophia Prillik, who will be speaking on complications of cardiac and pulmonary transplant. Thank you. Hi, my name is Sophia Prillik, and I'm a clinical director of cardiac and pulmonary rehab at NYU Rusk. My topic is transplant complications, and I'm going to focus mostly on cardiac and pulmonary rehabilitation. I have nothing to disclose. So just to go over the recent trends in transplants, I'd like to, again, focus on heart and lung. It looks like we are dealing with more and more transplants every year. Specifically, there were 4.2% more heart transplants in 2019. The numbers are missing here for some reason, compared to 2018. The trends include increase in BMI in recipients, increase in the number of recipients with various comorbidities such as diabetes, hypertension, malignancy. And donors are also looked at that have high-risk conditions such as HIV and hepatitis. Specifically, for the heart transplant, survival after the cardiac transplant listed right here. So after one year, about 90% survive. At five years, 70%. And 20 years from the transplant surgery, about 20% or less. Post-op mortality is, of course, significant in the first 30 days. It's 5% to 10%. And some of the causes after the first month include graft failure, multi-system organ failure, and infection. At one year, we still have to deal with the graft failure, acute rejection, and infection. And after one year, the causes of mortality include cardiac allograft vasculopathy, which is a sort of coronary disease of the cardiac transplant patients, as well as malignancy. So we're Some of the physiology that we need to be aware of as physiatrists, and of course, for other specialties as well, in a transplanted heart, are the ones that I'm going to discuss right now. So most importantly, vagal tone is lost. So because of that, patients will have resting tachycardia, approximately 15 to 25 beats above normal. Their stroke volumes will be decreased, approximately 15 to 25 beats above normal. Their stroke volumes will be decreased. Vagal maneuvers usually don't work. And their heart rate adjustment is absent or very, very slow, with increase and decrease in heart rate. And it's dependent on circulating catecholamines. Cardiac output increases with activity through the Frank Starling mechanism, where preload is extremely important and affects the stroke volume. And these patients also have resting hypertension, whether from peripheral vascular resistance or chronic presence of catecholamines that are left over from the longstanding heart failure. So this slide describes much of what was just mentioned, but also I want to highlight that the ADO2 difference or concentration of oxygen in the arterial versus venous blood is 24% lower than in age-matched control. And most of the time, this is due to weak muscles and decreased muscle quality, decreased mitochondria and oxidative enzymes. Historically, we're used to thinking that these patients require slow warm-ups and slow cool-downs in order to accommodate for the heart rate. However, there's some literature out there and also clinical evidence that these patients don't really need to have slow warm-ups and cool-downs. As far as the lung transplant, so for survival, at one year, 80%, at three years, 65%, at five years, 53%. And that's a lower number than for heart transplant patients, probably because these patients require much more immunosuppression. At 10 years, 32% or less survive. On average, single lung transplant leads to additional 4.6 to 6.4 years of survival and double lung almost up to 10 years. Causes of mortality in adult primary lung transplant include graft failure, acute rejection, malignancy and lymphoma, infection, specifically CMV, I'd like to highlight because it causes most morbidity and mortality, as well as non-CMV infections, bronchiolitis and cardiovascular complications. Physiology of transplanted lung, much like the heart transplant, these patients have denervated lung, but what ends up happening is that they lose their core reflex and need aggressive chest physical therapy. Their mucociliary clearance also decreases and so it's harder for them to expel sputum. Pulmonary vascular resistance is also increased. As far as the blood supply, so the bronchial blood supply is really not honest the most in the transplanted lung. And so the lung depends on collaterals, which form over the first month after the surgery. And so as a result, some of the complications that can occur include bronchial stenosis, bronchial malatia and dehiscence at the anastomosis site. Moreover, the new graft is susceptible to pulmonary edema and so it's very important not to over fluid overload these patients. Their lymphatic clearance is compromised and so we have to be very aware. As far as the medications used for heart and lung transplants, as well as other transplant surgeries, of course we need to have three types of immunosuppressive medications. Those include antiproliferative agent. So in this case, it's Cellcept or mycophenolate. The side effect that is most prominent with this medication is a GI side effect. So these include diarrhea or constipation, could be bloating, nausea and vomiting. But this medication also suppresses bone marrow, so we have to monitor blood counts. It can also cause liver toxicity. Another class is called calcineurin inhibitor and two of the examples are tacrolimus, otherwise known as Prograf, and cyclosporine. So for tacrolimus, the most prominent side effects are nephrotoxicity as well as electrolyte abnormalities. In fact, this medication leaches out potassium and magnesium, so we have to be pretty aggressive supplementing those. But also, this medication is known for neurotoxicity as well as exacerbation of hyperglycemia and bone marrow suppression. As far as corticosteroids, we know prednisone, obviously, and we know the side effects that come with it, including AVN, low bone mass, steroid-induced diabetes, fluid retention and hypertension. Some of the precautions we need to be aware of in cardiac transplant patients include the fact that they have a sternal wound, which is vertical. They have drained sides in the upper abdomen and lower chest. They may have inguinal sites for prior angiograms. They also may have neck access site from cardiac biopsies. They get cardiac biopsies weekly for the first four weeks, and then once every two weeks for the following month, and then once a month after that, usually. They may also have orthostatic hypotension. We mentioned resting tachycardia previously. Immunosuppression, of course, steroid-induced hyperglycemia, electrolyte abnormalities, cognitive issues, of course, infections such as CMV, PCP or PJP, fungal reactivation, and these patients may also have signs of rejection. They usually present as acute CHF and arrhythmias and ischemia, but it doesn't present typically as chest pain because the heart is denervated rather it presents as acute onset heart failure. As far as the precautions for the lung, much of these precautions are the same as for the heart. I just highlighted here the ones that are different. So incisions are either bilateral as anterolateral theracotomies or clamshell incision and sternotomy as well as posterior thoracotomy or posterolateral thoracotomy for a single lung transplant. These patients will also have drain sites, access sites, they may have orthostatic hypotension, resting tachycardia, but what's different is that they may have, they're more prone to atelectasis development, again because their lungs are denervated and so they need to be very aggressive with chest PT and central spirometry, and they may also have pulmonary edema. Everything else is pretty similar with the exception of aspergillus, really liking that anastomotic site with the transplanted lung, and so we have to be careful. Most of these patients are on antifungal nebulizer amphotericin. Patient and caregiver education is extremely important in the postoperative period, in the rehab period, and so patients and caregivers have to be aware of the immune system and the purpose of immunosuppression. They also have to know how to avoid potential infection exposures. They need to know about mouth care, dental health. They also need to know about sexual activity and birth control. A lot of the medications they're on can be teratogenic medications. They need to know the types of medications and what they're for. Signs and symptoms of rejection and infection. There's usually a way for them to home monitor their vital signs and transmit results to their providers. Daily weights are important to keep track of. Urine and stool appearance because that may be an early sign of infection. Dietary guidelines, effects of steroids on hyperglycemia. Cancer monitoring and prophylactic antibiotics prior to dental visits. And their transplant team is usually their primary care team. As physiatrists, we need to know that it is important to run all the changes in the medical medication regimen or other regimen with their transplant providers. Thank you for listening. And on to the next speaker. Hi, I guess that's me. I'm Dr. Jonathan Whiteson and a pleasure to be speaking to all of you. Thank you so much for attending this course. Remember, you can put your questions in the chat box and we'll answer them at the end of the talk. Just so you know, I'm an associate professor of rehabilitation medicine and medicine at NYU Grossman School of Medicine. I'm the vice chair for clinical operations and the medical director of cardiac and pulmonary rehabilitation at Rusk Rehabilitation. I have nothing to disclose. And just so we have a broad perspective, when we're talking about lung transplantation, there are three main reasons or three main categories of lung disease. Obstructive lung disorder, which typically with COPD, although bronchiectasis is also an obstructive lung disorder. COPD includes chronic bronchitis and emphysema, as well as some asthmatic overlays. And while close to 16 million people are diagnosed with COPD, that probably vastly underestimates the number of people who have it. Restricted lung disorders of which the fibrotic lung disorders are the most common. And we see idiopathic pulmonary fibrosis is the most common form of interstitial lung disease. And we see the United States as a region that actually has more interstitial lung disease than other areas around the globe. Once the diagnosis of idiopathic pulmonary fibrosis has been made, survival is quite poor. Pulmonary vascular disease as well with thromboembolism from deep vein thrombosis and PE, as well as pulmonary arterial hypertension, are other causes as well of chronic lung diseases. All chronic lung diseases typically lead on to a cycle of deconditioning. Avoidance of dyspnea is not uncommon. Progressive muscle atrophy through disuse, through steroids, through hypoxia, leading to sarcopenia frailty has been discussed already. But typically the avoidance of activity leads to a cycle from chronic lung disease to progressive deconditioning and disability. So what does end-stage lung disease look like? Well, obviously shortness of breath is very significant, can be prominent at rest as well. Many patients are on oxygen for hypoxia. Some will have hypercapnia. So caution with oxygen usage, especially at rest, especially at nighttime. But feel free to use oxygen with activity to maintain adequate O2 saturations. People will complain of increased work of breathing. They'll have decreased mobility and decreased independence with activities of daily living. And overall will have low quality of life with psychological impact as well. So what about lung transplantation for patients with chronic lung disease? Well, the two most common causes or reasons diagnosis for lung transplant include COPD and interstitial lung disease. And you see over the past 30 years, the trend continues to support both COPD in green and the interstitial lung disease in blue. And cystic fibrosis as well. And depending on what region and if you're in a medical center that has a pediatric slash adult cystic fibrosis program, you may be seeing more patients with cystic fibrosis coming through to your program. We know and we've been discussing or heard it mentioned that there are two different kinds of lung transplantation, bilateral versus single. Depending on organ availability and the patient status, bilateral is by far the surgery of preference, although it is a more significant surgery. Elderly patients, those with significant coronary disease or those who may have had previous thoracic surgery may not be amenable to bilateral lung transplant. But in many cases, bilateral is the transplant of preference. And you see, again, over the past 30 years, a significant increase in bilateral lung transplant versus single lung transplant. And that is in part related to outcomes. And I'll show that in a little bit. So when we think about patients going through lung transplantation, typically we think through a continuum of care. Many patients with lung disease have chronic lung disease. They don't necessarily present acutely, although with COVID, certainly we're seeing that. But for the majority of lung transplant stun, patients have a long course leading up to their transplant. And therefore, the pre-habilitation that was discussed by Dr. Lam is so essential. Again, patients are followed for a number of years and getting patients on a pre-transplant rehabilitation program. And again, patients may be on the list or maybe being considered for transplant for several years. So, you know, getting them on a program, getting them re-engaged again on a program is sometimes important. Again, many of these patients, for a number of reasons, have frailty and sarcopenia. Dr. Lam discussed this, but it is worth emphasizing this must be looked for. And a pre-habilitation program may not look like a pulmonary rehabilitation program per se. It may look very much like a typical physical therapy program working on strength and balance and gait and stair training before we can get people onto aerobic conditioning. So what about pulmonary rehabilitation post-lung transplant in the acute care setting? Well, many people have heard about early mobilization intensive care unit. Many programs have this. And there is significant benefit in terms of reduction in post-op compensations. The advance of function and functional independence is improved, reduced risk for complications, both physical and cognitive, and overall decreased length of stay. I'll show some evidence about that in a few moments. Patients must be evaluated very rigorously, delirium, confused cognitive states being very prevalent in the immediate post-operative state related to anesthesia and medications, as well as various lines, tubes, pumps, etc. that Dr. Prillik talked about must all be evaluated for. Early mobilization is key if the patient is medically stable. If they remain significantly sedated or significantly agitated, orthostatic, or there are surgical complications, including open chest, then they may not be amenable. But many patients are, and it should be the goal of the rehabilitation team to get the patient up as soon as the surgical team agree. Dr. Prillik mentioned about the denovated lung, and a very significant element of this is the risk for silent aspiration because of the impaired or decreased cough reflex. Patients cannot be fed lying in bed. They must be fed out of bed. And again, using the mouth and the gut rather than any other form of nutrition is essential in the recovery post-op. So the sooner we can get, as a rehabilitation team, patients out of bed, the better it is in terms of feeding them and getting their nutrition status back. Well, ICU early mobilization is key. Many programs have it, whether you do or do not have a transplant program. The rehabilitation team is ideal to lead that collaboration. We must address, as mentioned, sedation and delirium, sleep-wake cycles, and pain. We must develop a culture that goes beyond the ICU and help the ICU teams recognize that what happens day one, day two really does impact how things are week one, week two, and month one, month two. And we must have administrative buy-in as well, but it's all possible to do. The NYU team published back in 2016 the results of our early mobilization program. We had a significant length of ICU days as well as acute care post-op surgeon medical beds. We had a significant improvement in disposition to home and disposition without services, and there was a significant cost savings when we consider value-based care, value-based management. Early mobilization and the rehabilitation team have a significant amount to add to our healthcare practice. So post-op day one, Dr. Prillik mentioned as well, the denevated lung, and the need for secretion clearance and chest physical therapy, bed-level exercises, but already considering getting patients out of bed if they're hemodynamically stable. Post-op day two and three, those processes continue, and we're already thinking about getting patients up and ambulating them. The sooner patients can ambulate, the better it is. The sooner they can engage in self-care, the better it is for the patient. Again, post-op day four and five, we're starting to think about the disposition of the patient, if all is well with regards to their medical status, but they should be ambulating at this time, now working on balance training as well, and then considering high-level function, as well as energy conservation techniques. Post-op day six, we're really thinking about disposition, where should patients be going to. The ANPAC is a score that really helps us determine where patients should be sent. The majority of our patients, if not close to 100% of our lung transplant patients, do progress on to acute inpatient rehabilitation, which is the next step in our continuum of care. Again, when you're thinking of sending your transplant patient to inpatient rehabilitation, you really should consider a unit that is dedicated to the management of transplant patients, because this is complex, and you need a dedicated and educated rehabilitation team. It is good to have it on site as well with the transplant program, because never a day goes by when the transplant team aren't rounding on their patients, hopefully routinely, but many times there are complications that arise, and we need the transplant team there as well. The specialized education, as I mentioned, of the physicians and the therapists and the nurses, the psychologists and the social workers and case management, because this is not a typical rehabilitation situation and requires specialist help. When should you admit the patient to the inpatient rehabilitation program? When they are medically appropriate. Do not look for medical stability, because these patients continue to medically improve throughout the course of the rehabilitation stay and even beyond discharge to home, so appropriate is the correct term as opposed to medically stable. The rehabilitation team addresses all of those basic needs that we typically think of in an inpatient rehabilitation setting, as well as being responsible for medical stability in conjunction with the transplant team. We can consider ourselves the canary in the coal mine. We want to educate patients and families to the recovery process, as well as engage in medication education, and many of these patients are on medications that they've never been on before, and it's a huge part of their ongoing care, not just through rehab, but into the transition to home as well. And of course, we work on discharge planning. Readmission reduction is a very significant role of the rehabilitation team. The rate of readmission within the first 30 days following transplantation, lung transplantation is high, and the readmission team, the rehabilitation team have a significant role to play in reducing readmission. Typical length of stay, 10 to 14 days, but it can be longer if there are ongoing complications. And when patients leave the inpatient setting, we want to get them to home, so have partnerships with your home care agencies. They may not be familiar with transplant patients. The transplant team will for sure follow these patients very closely once the patient's gone home, but the home care team is essential as well. Transitional care management is a program supported by insurance that encourages follow-up with a discharging team, and the rehabilitation physician can do this, that really looks to make sure that all the home care services are right, all the medications are correct with the patient being at home, and make sure that outpatient follow-up is also established with not just the transplant team, but any consulting physicians as well. Transitional care management lasts for 30 days. There is an enhanced payment for the physician, which from the business side makes sense, but most significantly, there is a reduction in readmissions as well, which is really very important. Again, initially for the outpatient, they may need more general rehabilitation needs and physical therapy, and then progress on to an outpatient pulmonary rehabilitation program. What does the outpatient pulmonary rehab program look like? Well, just as Dr. Lam said, for the prehabilitation, it's really quite the same. We work on strength and posture, breathing and endurance, frequency, intensity, type, and time, as well as progression of exercise. We continue education, nutrition support, psychological support, and we look at outcomes through the cardiopulmonary exercise stress test, which is often done pre-surgery in a prehab program, and is done again post-op, and can be used to track patients in terms of their progression, lifelong follow-up. Objective measures, as I said, the CPET, the six-minute walk test, and quality of life measures, these are all looked at to gauge the success of your rehabilitation program, and when we're talking about successive programs, we think about survival, and you can see over the past three decades, the blue bottom line is the 1990s, the green is the early 2000s, and the red is 2010 and on. Transplant survival has improved over successive decades, and here is the reference to the success of bilateral lung transplantation. It is a greater success rate, close to 50% surviving 10 years, as opposed to single lung transplant, or in the idiopathic pulmonary fibrosis group, if we don't transplant them at all, they have the worst outcomes. So in summary, there are increasing numbers of patients with chronic lung disease. COVID may produce both acute and chronic lung disease as well that might require transplantation. There's increasing number of organs that the narcotic opioid epidemic has led to a number of organs being available. There's an increasing number of transplant programs. There is an increasing opportunity for pulmonary rehabilitation programs to manage chronic lung disease, both pre- and post-transplant status. You require a specialized rehabilitation team that's well integrated with the transplant team. Don't forget there remain general rehabilitation needs as well. There is a significant positive impact of pulmonary rehabilitation on lung transplant outcomes, including readmission and survival. And with that, those are my references, and it's my pleasure to hand on to Dr. David Prince, who's going to be talking about heart transplantation. Thank you. Okay. This is David Prince. I'm sorry the audio is not working, but I'm happy to be talking about cardiac transplant and cardiac rehab after cardiac transplant. So I'm just practicing advancing my slides. Okay, we're good to go. So one of the things that's unique about cardiac transplant patients compared to the rest of the other populations we've been talking about is that the cardiac transplant patient has probably been in the cardiac rehab system for a while prior to their transplant. They may have started with cardiac rehab after a heart attack or angina, continued following procedures including possibly an LVAD, and then they come right back to the program that they were in following the organ transplant. So there's an opportunity in this population to really actually be part of the care team all the way through their course of their potentially ischemic or heart failure disease. Of course, everyone has mentioned early mobilization and this population would benefit from it just as anyone following an illness in the intensive care setting or the SICU. One of the things to take into account in this population is that some of the immunosuppressives that are common can contribute to hypertension. So that would be something that would be, could have an impact in your conditioning program that you'd keep an eye on. As far as the way we condition them, it's the same as any other cardiac rehab patient. We're actually can be more liberal because we don't have to worry about chronic ischemic disease in this population. And so we've conditioned them at 60 to 70% of their peak effort for 30 to 60 minutes, three to five times a week, and a Borg intensity scale of 13 to 14, similar to everything else that we're gonna do with the cardiac rehab population in general. Now, how many people are we talking about? Well, not really a lot. Here's a UNIS numbers from 2019, and it's about 3,500 a year. That seems like a decent number, but just to put it in perspective, about 9,000 people get a LVAD a year in the country. And that is a 1% of a 1% for the number of people who are living with heart failure, which would be about 5 million a year. The indications are the same in terms of acute rehab, same as any other patient. The only thing that we wanna pay a little more attention to is the hemodynamic stability, and that would really be the only contraindication, but that would be obvious to anyone taking care of the patient. Just a nod to general rehab and the importance of addressing MSK issues. It's critical that I think that, although it's not critical in terms of hemodynamics, that these patients have a complete physiatric view of how they're functioning, because cardiac rehab is higher intensity and higher in frequency than general physical therapy and many of our other modalities that we're using, which means that we're gonna provoke the musculoskeletal system more frequently and with possibly more intensity. So they're really gonna do much better if we address all of their general rehab needs before we start conditioning them. This is a visualization of early mobilization that has a little bit of a nod towards the cardiac patient, although it will be pretty universal across the board. I like to tell people early mobilization is like if you take your getting out of bed and getting showered and getting done in the morning and you spread it out over an hour and a half, and add three therapists, that's pretty much early mobilization. And I think other people have talked about it in more detail in terms of some things to just bear in mind when you're writing a prescription for this population is not only the overall exercise tolerance, but if they might have a good tolerance but be limited by certain conditions that could be a result of this specific kind of surgery, including sternal precautions, there could be shoulder issues related to pacemakers. So a big overall view of the person from a rehab point of view will benefit them. They all are sarcopenic and they all are frail and they all need to be screened for neurologic deficits. It is unlikely in a large setting, but it is possible in the community setting that you could be the first person to pick up a neurologic deficit that you could also address. And so this is also a nice visualization of what the components of an exercise prescription, and you can see in the orange boxes at the bottom that there's an aerobic component that may or may not include interval training if they're up to it, or they may get up to it later in the program, strength training, and then they may have a respiratory component that's indicated probably more likely immediately post-op. And it's important to bear in mind that in cardiac rehab, we wanna map the discharge prescription and recommendations to the patient's preferences and their lifestyle and their likes and dislikes. So it's fine for them to be exercising on treadmills and bikes and discharge them to swimming and stairs at home. As long as they're moving, as long as they're exercising within the recommended range, they're going to be benefiting. In any talk at a conference like this, I always like to throw a nod to any of our trainees or residents who say, oh, that's interesting, maybe I wanna learn more about that, as well as keep in mind that most of our audience are general physiatrists. So I have some recommendations on where to learn more and how to think about if this is of interest to you. Of course, I'm available if anyone wants to contact me by email. And I just wanna emphasize that you don't have to be a cardiac rehab specialist to make a very significant contribution to the care of these patients. Just your initial evaluation, the ability to condition them before identification of barriers, physiatrists are the best communicators in the medical universe. And that certainly is well appreciated in the transplant setting when there's so many moving parts and people involved. So everyone can contribute to the care of these patients. And if this is something that's of interest, then here are some recommendations. The only thing I would emphasize for people who are starting their training or in the middle of their training is Excel skills. I wish I could tell my younger self to go back and have improved them because they help you gather data and present it in a way that makes a compelling story no matter what your career objectives are. And please bear in mind that when you're modeling things financially, it's not only what you're billing, especially in this population when you're dealing with any transplant patient. If you are able to help the patients leave sooner and stay out of the hospital longer, then you're adding very significantly to your institution's bottom line. And a great way to express that is in the quality improvement or performance improvement setting. And I have my references and I will be handing it back to Dr. Cohn. Thank you, Dr. Prince. I will be talking about liver transplant and renal transplant and rehabilitation. I have no disclosures. As we've seen, the past 25 years have led to considerable advances in the field of organ transplantation. And that's what we've been talking about today. For liver transplants, in the pre-transplantation era, liver failure was nearly universally fatal. In 1963 were the first attempts at a human liver transplant. In 1967, the first successful transplant. The rise of immunosuppressive drugs have been so critical in improving the survival rate for these patients. There's basically two types of liver failure. There's acute fulminant hepatic failure and chronic liver failure. Acute failure may occur, for example, in an acetaminophen overdose. There are many causes of chronic liver failure, ranging from primary biliary cirrhosis, the chronic hepatitis B and C, to alcoholic cirrhosis. In the pediatric population, biliary atresia and alpha-1 antitrypsin deficiency are the most common ideologies. Acute liver failure patients, it occurs suddenly and the patients often present with limited functional deficits, whereas in the chronic liver population, it's been a generalized decline and they're often severely deconditioned and fatigued. We talk about allograft, which is a replacement of a deceased or injured liver with a new one. And then we have deceased donor liver transplants and live donor liver transplants. When we're selecting a patient for a liver transplant, we need to know what is the stage of the disease? What is the patient's psychosocial status? Are there potential contraindications to surgery? These are the reasons why someone may need to undergo a liver transplant. And it ranges from fulminant hepatic failure to intractable ascites to refractory encephalopathy, as you can see. The MELD system model of end-stage liver disease is what we use to place patients on the waiting list. It utilizes three objective variables, INR, serum bilirubin and creatinine. Contraindications to liver transplant, as you can imagine, uncontrolled infection, metastatic disease, active substance or alcohol abuse, et cetera. Alcohol cirrhosis is the second most common indication for liver transplant. And what we have to know is that patients with alcohol dependence are at high risk for relapse even after the transplantation. So we request that there be a minimum of six months of alcohol abstinence required before the transplant. The goals of our therapy, we try to see the patient before the liver transplant. We wanna improve their physical and psychological status. And we wanna get this therapy going as soon as possible. In the preoperative period, we may introduce greater isometric exercises, range of motion exercises, a respiratory physiotherapy program consisting of diaphragmatic breathing exercises. We wanna make sure they're in good nutrition, nutrient dense foods, consume foods high in calcium and vitamin D, et cetera. Clearly psychological support is key throughout the whole process, both before the transplant and after. What about post liver transplant complications? Well, there are many, as you can see from this table. Most occur in the perioperative period. Risk of rejection is highest in the first three to six months and then decreases significantly after. We have an acute type of rejection and a chronic type of rejection. Acute rejection typically occurs seven to 14 days post transplant but can occur earlier or later. You wanna pick up on a fever, malaise, right upper quadrant pain or tenderness, a rise in the bilirubin or transaminase levels. Most are treated by augmentation of the immunosuppressive agents or high doses of steroids. Chronic rejection tends to occur months to years later and ultimately may require a retransplantation. Very important to monitor electrolytes in this population, particularly attention to the serum magnesium level because a low magnesium level tends to potentiate cyclosporine and tacrolimus neurotoxicity and may actually result in seizures. We try to keep the magnesium level at two or above. Of course, musculoskeletal complications. These patients are weak. They often have bone and joint discomfort. They have osteoporosis. They're very fatigued. Studies have shown that the cardiorespiratory fitness in these patients are on average 16 to 34% lower. Neurological complications can occur ranging from anything from disorientation to seizures to neuropathies. Long-term morbidity and mortality tends to be the result of the immunosuppressive agents that we've talked about. What about the post liver transplant rehab program? Again, you wanna institute this as soon as the patient is stable. Studies have shown that if you compare an exercise in a control group, the exercise group tends to do much better. They actually, one study showed a 19.4% increase in distance walk as well as an increase in their resting energy expenditure. There's a lot of literature showing that really looking at exercise control versus exercise groups, transplant patients, post liver transplant do very well with a good rehab program. Fatigue, as we mentioned, is very common in these patients and studies have shown that they do improve in their fatigue level. Employment remains an issue though. Even though we're getting better at survival rates, there are not that many patients that actually go back to work. Studies have shown as few as 50%. So although we wanna work on quality of life, we also wanna see if we can get them involved with vocational programs to help them get back to work. Clearly psychological importance throughout. Good psychological support, especially those who have had alcohol history so they don't relapse. Studies have shown the survival rate is very good. 86% one year, 78% three years, 72% five years. And even with those with alcohol related liver disease, survival has improved steadily to reach 80 to 85% at one year. And we need to make sure though that they can abstain from alcohol for six months before the transplant. This is the only definitive treatment, is liver transplant for end stage liver disease. And there needs to be, the problem is that there are not enough donors and we need to raise public awareness of the shortage of donors. Renal transplant. This is the treatment of choice for patients with end stage renal disease. Again, it can be a deceased donor or a living donor related transplant. End stage renal disease is the indication regardless of the primary cause. Diabetes is the leading cause of end stage renal disease, but you can see from this list, there are many other ideologies that can result in end stage renal disease. When you're working with these patients pre-op, you have to realize they have reduced joint flexibility, they have decreased exercise tolerance, they have decreased maximum VO2 uptake. They have weakness, they have atrophy, they have deficiencies of vitamin D and parathyroid hormone which make the tissues a little stiffer. Pre-op rehab has been shown to improve physical work capacity, improve depressed mood and actually increase the hematocrit level. Complications post renal transplant. Rejection is something to always keep an eye on. The patient may present with malaise and anorexia. They may have an elevated temperature, decreased urine output, edema, a sudden increase in weight. Make sure to monitor the BUN and creatinine levels. Infection is another risk of a complication. In the first month post-op, typically a wounded, the lungs, the urinary tract, is there a vascular catheter? Those could be ideologies. As we go from one to six months, the opportunistic infections become a real problem. Bleeding can be an issue. Most small perirenal hematomas are asymptomatic, and a small hematoma can produce flank pain and the patient may present with hypotension, tachycardia, and the laboratory results may show a decrease in hematocrit. Post renal transplant, when you're working with these patients, remember their capacity for exercise remains limited. They're anemic. They may have sodium and water retention. They have a decreased VO2 max, and they may have an abnormal BP response to exercise that when you exercise them, their blood pressure may shoot up very quickly. They also have reduced bone and mineral density. They're prone to fractures. They're prone to muscle and tendon injuries, so you wanna avoid overloading the tendons in order to prevent tendon rupture. Our goals, we wanna just, again, improve the physical and psychological status, stretching exercises, repetitive low-level resistance exercises, aerobic exercises. Again, in this group, there's been exercise and control group studies clearly showing that a good rehab program will help to improve the cardiopulmonary fitness, the strength of these patients who've undergone renal transplants. Studies have shown, literature studies have shown that you can improve the VO2 peak. You can improve the quality of life. So clearly, there's a lot of benefit to a good exercise program post renal transplant. Employment remains an issue, just like it was with the liver transplant population. The mean percentage of return to work is really 30 to 40%. So along with the improved survival rate, get vocational rehab in if the patient may be a candidate for return to work. Survival rates remain very good. Kidney transplant is clearly associated with a very good survival rate. In fact, in the United States, the one-year survival rate is over 90%. And again, those who do receive the transplants really often have very good incomes. Again, there's a shortage of donors. So just as with the liver transplant candidates, we wanna make sure, increase public awareness of the shortage of kidney donors because a renal transplant can certainly markedly improve the quality of life of these patients who've been on long-term hemodialysis. Thank you. Dr. Weitzen. Yes. So thank you, Dr. Cohen. Thank you, Dr. Lam, Dr. Prillick, Dr. Prince. We have just a few moments left. We have been answering questions in the chat box. And there was a question that came from Dr. Flanagan about, does prehabilitation reduce or improve outcomes following lung transplant? I, and I think David answered that to some degree, which is, we don't have that body of literature, although I suspect there, if we could look at claims data, we could certainly answer that question. There is literature though that suggests that in general thoracic surgery, a prehabilitation program does improve outcomes in terms of the hospitalized stage during that thoracic surgery with shorter times of a chest tube being placed, shorter lengths of stay, and an enhanced functional outcome. That literature has been published on a small group of patients, but it seems to make sense that those patients who are stronger going into a transplant surgery are gonna do better through it and after it as well. I wonder if anyone else on the panel has any thoughts on that in the 30 or 40 seconds we have left before we have to stop. Yeah, this is Nying Lam. Just reviewing some of that prehabilitation literature, there really wasn't great direct correlation between going through a prehabilitation program pre-transplant and seeing those outcomes. And so some of the inferences we could make though is that you're seeing decreased gait speed causing reduced or poor outcomes post-transplant. And so then theoretically, if we improve someone's gait speed, then could we improve their outcome? So definitely a lot more research needs to be done in this area. Well, I am very sensitive to the time and we have answered some questions in the chat box. We are supposed to stop at the hour mark and we have just a few seconds over that. So again, I wanna thank Dr. Cohen for putting this session together and being the session director. Dr. Nying Lam, Dr. Sophia Pullick, Dr. David Prince for doing such wonderful presentations. And hopefully you, our listeners have found this interesting and we'll look to develop a transplant rehabilitation program with that. We'll say thank you so much and enjoy the rest of the assembly.

solid organ transplant rehabilitation

advancements in surgical techniques

post-operative care

transplant patients

team approach

physiatrist

prehabilitation

post-operative complications

individualized exercise programs