Role of Exercise in Chronic Liver Disease Patients Undergoing Liver Transplantation

• Aim and Objective - Primary objective: To assess effects of pre-operative aerobic and resistance exercises in decompensated CLD patients planned for LDLT on the measures of frailty after 1 month of supervised exercise.

Secondary objectives: To assess effects of pre-operative aerobic and resistance exercises in decompensated CLD patients planned for LDLT on the post LDLT outcomes, myostatin levels (on POD 14) and skeletal muscle mass (on POD14).

• Methodology:

• Study population - Consecutive voluntary adults (>18 years) with chronic liver disease, planned for living donor liver transplantation fulfilling the conditions as per inclusion and exclusion criteria.
• Study design - Interventional study- Open label randomised controlled trial
• Study period - From time of ethical clearance till 31st December 2024
• Sample size - Assuming median LFI for CLD patients as 3.9 ± 0.3*, and assuming an improvement of 5% with introduction of exercise along with SMT after 1 follow up, and keeping alpha of 5%, and power of study as 90%, with 1:1 ratio of cases and controls, then by method of change we need to enroll a total of 54 patients with 27 in each arm. Assuming 10% non compliance, a total of 60 cases will be enrolled, with 30 cases in each arm.
• Intervention - Pre-operative supervised exercise-based regimen versus standard medical therapy alone for a minimum duration of 4 weeks.
• Monitoring and assessment - Clinical profile of the patient and symptoms will be serially followed during the patients OPD visits.
• Adverse effects - Exercise may aggravate encephalopathy, metabolic disorders, AKI/HRS. It may also lead to falls due to cardio-pulmonary intolerance or hepatic encephalopathy.
• Stopping rule - Inability to follow the exercise schedule, or development of any of the adverse effects due to exercise as mentioned above.
• Expected outcome of the project: Better values of measures of frailty and post LDLT outcomes in patients receiving pre-operative concurrent exerises as an intervention.

Inclusion criteria

• Voluntary adult patient (>18 years), decompensated chronic liver disease patients planned for LDLT, and Who pass the screening tests done in the OPD

• Able to follow the introductory level exercises as per the protocol in the OPD without any adverse event.
• No drop in the spO2 less than 93% on a 6 minute walk test.

Exclusion criteria

• Patients with a physical disability (upper or lower limb deformity/abnormality)
• Exercise intolerance or inability to follow exercise regime.
• Patients who fail the screening tests.
• Patients on the following drugs-

• Higher corticosteroid dose (>0.1mg/kg/day),
• BCAA (Branched chain amino acids)
• Growth hormone, testosterone, SARMs,
• Ghrelin agonists, myostatin antibodies,
• Activin IIR antagonists, angiotensin converting enzyme inhibitors,
• Espindolol (mixed beta agonist and antagonists), and
• Fast skeletal muscle troponin activators.