Management of end stage liver disease is often complicated by sarcopenia and frailty (1,2). New evidence-based guidelines recommend that pre-transplant nutrition assessment should incorporate measures of sarcopenia and frailty (3), however these had not traditionally been performed as part of dietetic practice in Australia, including the Queensland Liver Transplant Service. Using an implementation science approach, we needed to determine if these guidelines were feasible and acceptable and could be sustained in clinical practice. This project shows that we have successfully done this, and that the assessments are utilised to provide valuable data to support clinical decision-making regarding wait-listing for liver transplant. Protocols have been developed to assess for sarcopenia and frailty in the liver transplant population, which have the potential to be translated to other clinical conditions exposed to the same complications to enhance the assessment and care.
Nutrition assessment: Implementation of sarcopenia and frailty assessments of potential liver transplant recipients
Summary
Aim
To determine the feasibility and acceptability of implementing sarcopenia and frailty assessments as a component of the dietitian assessment of potential liver transplant recipients
Benefits
- Quality care requires health professionals to improve evidence uptake and identify barriers to change at a local level. This study demonstrated that dietetic assessment of muscle mass and physical function to diagnose sarcopenia and frailty is a reliable, feasible and acceptable component of the liver transplant assessment process, valued in clinical decision making.
- We have closed the evidence-practice gap through implementation of evidence-based guidelines (assessment of sarcopenia and frailty) into standard clinical care and demonstrated this is also sustainable in clinical practice.
- Analysis of pre-existing computed-tomography (CT) scans to diagnose sarcopenia by a dietitian produced similar results to health professionals who regularly view CT scans. This adds value to the role of the dietitian by advancing their scope of practice in the area of body composition analysis through analysing CT scans.
- Correctly diagnosing sarcopenia and frailty for these potential liver transplant recipients at the initial stage of the listing process provides an opportunity to refine risk assessment for organ allocation and may enable opportunities to intervene with "pre-habilitation" approaches.
- Where the assessment of physical status has historically been based on a clinician's subjective "end-of-bed" assessment, having the formal diagnosis of sarcopenia and frailty provides objective and meaningful data which can also be followed longitudinally along the transplant wait-list.
- Prevalence data is now be collected longitudinally to determine the impact of sarcopenia and frailty on the transplant journey, which will assist with addressing these issues pre-transplant moving forward, where there is limited evidence to date.
Background
Patients with end stage liver disease are often frail with severe muscle wasting and impaired muscle function (sarcopenia) (1,2). Whilst receiving a liver transplant saves lives, patients often wait for a transplant and the presence of sarcopenia and frailty whilst waitlisted is linked to poorer prognosis. Newly released evidence-based guidelines recommend assessment of sarcopenia in the pre-transplant nutrition assessment (3).
The Queensland Liver Transplant Service (QLTS) had not traditionally incorporated these measures into clinical practice and in 2018 the dietetic service was not performing these assessments as part of standard dietetic care. Measures of sarcopenia and frailty have the potential to refine risk assessment during the transplant evaluation process; and in determining relative priority of potential recipients during organ allocation. Sarcopenia diagnosis requires evidence of reduced muscle mass and impairment of strength or function (3). Sarcopenia and frailty in potential liver transplant recipients is associated with poorer outcomes (4,5).