Frailty trajectories in adult lung transplantation: A cohort study

Abstract

Background: Frailty is common in adults with advanced lung disease and is associated with death before and after lung transplantation. We aimed to determine whether frailty changes from before to after the lung transplant.

Methods: In a single-center, prospective cohort study among adults undergoing lung transplantation from 2010 to 2017, we assessed frailty by the Short Physical Performance Battery (SPPB; higher scores reflect less frailty) and Fried Frailty Phenotype (FFP; higher scores reflect greater frailty) before and repeatedly up to 36 months after transplant. We tested for changes in frailty scores over time using segmented mixed effects models, adjusting for age, sex, and diagnosis. We quantified the proportion of subjects transitioning between frailty states (frail vs not frail) from before to after the transplant.

Results: In 246 subjects, changes in frailty occurred within the first 6 post-operative months and remained stable thereafter. The overall change in frailty was attributable to improvements among those subjects who were frail before transplant. They experienced a 5.1-point improvement in SPPB (95% confidence interval [CI] 4.6-5.7) and a 1.8-point improvement in FFP (95% CI -2.1 to -1.6) during the early period. Frailty by SPPB and FFP did not change in those who were not frail before transplant. Approximately 84% of survivors who were frail before transplant became not frail after transplant.

Conclusions: Pre-operative frailty resolves in many patients after lung transplantation. Because a large proportion of frailty may be attributable to advanced lung disease, frailty alone should not be an absolute contraindication to transplantation.

Keywords: Fried Frailty Phenotype; Short Physical Performance Battery; frailty; frailty trajectory; lung transplant; pre-operative frailty; transplant evaluation.

Figure 1.

Participants with frailty assessments before and six months after lung transplant. The Short Physical Performance Battery (SPPB) was collected from the start of the study in 2010. The Fried Frailty Phenotype (FFP) was added to the study protocol in 2012. * Some subjects had both frailty measures performed; the numbers are not mutually exclusive.

Figure 2.

Frailty Change After Lung Transplant. Cubic spline plots of the change in Short Physical Performance Battery (A) and Fried Frailty Phenotype (B) from before to after lung transplant. There is an inflection point at 6 months after transplant that defines an “early period” of frailty change followed by a “late period” of stability. The shaded bands represent the 95% confidence intervals. The SPPB ranges from 0 to 12, a score ≤ 7 is considered frail. The FFP ranges from 0–5, a score ≥ 3 is considered frail.

Figure 3.

Change After Lung Transplant by Pre-transplant Frailty State. Change in Short Physical Performance Battery (SPPB) (A) and Fried Frailty Phenotype (FFP) (B) in segmented regressions for the “early period” (before transplant to six months after transplant) and “late period” (six months to 36 months after transplant). The model is adjusted for pre-transplant frailty state (not frail vs frail), pre-transplant frailty state by time period (early vs late), diagnosis, age, and sex. The estimated scores with 95% confidence intervals are shown. The SPPB ranges from 0 to 12, a score ≤ 7 is considered frail. The FFP ranges from 0–5, a score ≥ 3 is considered frail.

Figure 4.

Transitions of Frailty State from Before to After Lung Transplant. Proportion of subjects who transitioned between frailty state from before to six months after lung transplant when assessed by Short Physical Performance Battery (SPPB) (A) and Fried Frailty Phenotype (FFP) (B). The SPPB ranges from 0 to 12, a score ≤ 7 is considered frail. The FFP ranges from 0–5, a score ≥ 3 is considered frail.