The primary goals of solid organ transplantation (SOT) are to prolong survival, enhance quality of life and return patients to a normal state of well-being. Significant improvements in short-term outcomes after SOT have been achieved, thanks to more effective immunosuppression and better perioperative management. However, due to prolonged waiting times and stagnant organ availability, patients are increasingly transplanted in a state of profound illness, increasing the likelihood of posttransplant frailty and healthcare utilization.1 , 2 In order to overcome such hurdles, transplant physicians must not only provide high-quality, evidence-based medical care but also empower recipients with the self-care tools for long-term posttransplant success.
In their paper, Berben et al3 perform a comprehensive assessment of the available literature on low physical activity after SOT. The value of this work lies in the authors’ focus on routine physical activity, rather than exercise interventions of limited applicability to the day-to-day management of SOT recipients. Their most salient finding is a clear need for more sophisticated research in this field. While the observation of significant study heterogeneity is somewhat expected, it is surprising that many of the publications included failed to use validated self-report measures or even define low physical activity altogether. Furthermore, none evaluated low physical activity in the context of established guidance recommendations for the general adult population, or as a predictor of patient and graft survival. Thus, the overall prevalence of low physical activity after SOT, and its impact on arguably the most important posttransplant outcomes remain unknown. Despite these limitations, Berben et al3 do demonstrate a significant association of low physical activity and quality of life after SOT, an increasingly relevant secondary endpoint.
Taken as a whole, the findings of this study are unlikely to change usual posttransplant care today. However, the authors will hopefully inspire innovative and practice-altering research in this area. More objective measurements of physical activity should be strongly encouraged in future studies of SOT recipients, particularly given the wide availability of wearable technologies. The inadequate validity and reliability of self-report questionnaires may have contributed to the lack of identification of significant correlates of low physical activity in this paper.4 The small number of available studies also precluded any organ-specific analyses. Though physical activity likely benefits all SOT recipients, its association with posttransplant outcomes could differ in magnitude across organ types, as might its relationship to other posttransplant factors. Moreover, the selected publications did not permit any further evaluation of the sources of heterogeneity related to the examined correlates and outcomes.
In their discussion, Bergen et al4 identify a clear need for standardized physical activity recommendations after SOT. This would not only help physicians to better inform their patients but also allow investigators to use a common benchmark. Current posttransplant management guidelines use generic, nonspecific language when discussing physical activity, and those for liver transplant recipients only address exercise in the context of osteopenia and diabetes.5 , 6 In contrast, a wealth of guidance on physical activity expectations exists in the cancer survivorship literature.7 Such recommendations could potentially serve as a basis for the development of SOT-specific guidelines: similar to SOT recipients, many cancer survivors also face significant challenges with returning to a state of physical well-being after a sustained period of illness.
Ultimately, the fundamental question is how can transplant physicians help recipients to increase physical activity after SOT in a manner that is time-saving, cost-effective, and long lasting. Leveraging the unique facilitators of physical activity in transplant recipients is critical.8 Moreover, identifying novel behavioral interventions, such as financial incentives, may also be of value.9 The findings presented by Bergen et al3 provide an important first step to enhance available physical activity recommendations and promote new investigation in this aspect of posttransplant care.
1. McAdams-DeMarco MA, Law A, King E, et al. Frailty and mortality in kidney transplant recipients. Am J Transplant. 2015;15:149–154.
2. Bittermann T, Hubbard RA, Serper M, et al. Healthcare utilization after liver transplantation is highly variable both among centers and recipients. Am J Transplant. 2017;18:1197–1205.
3. Berben L, Engberg SJ, Rossmeissl A, et al. Correlates and outcomes of low physical activity post-transplant: a systematic review and meta-analysis. Transplantation. In press.
4. Dowd KP, Szeklicki R, Minetta MA, et al. A systematic literature review of reviews on techniques for physical activity measurement in adults: a DEDIPAC study. Int J Behav Nutr Phys Act. 2018;15(1):15.
5. Kidney Disease: Improving Global Outcomes (KDIGO) Transplant Work Group. KDIGO clinical practice guideline for the care of kidney transplant recipients. Am J Transplant. 2009;2009(Suppl 3):S1–S155.
6. Lucey MR, Terrault N, Ojo L, et al. Long-term management of the successful adult liver transplant: 2012 practice guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation. Liver Transpl. 2013;19:3–26.
7. Doyle C, Kushi LH, Byers T, et al. Nutrition and physical activity during and after cancer treatment: an American Cancer Society guide for informed choices. CA Cancer J Clin. 2006;56:323–353.
8. van Adriachem EJ, van de Zande SC, Dekker R, et al. Perceived barriers to and facilitators of physical activity in recipients of solid organ transplantation, a qualitative study. PLoS One. 2016;11(9):e0162725.