Transplant patients can improve quality of life
Walking back to better health and productivity
More and more, exercise seems to be the answer to almost all health issues. Now it is being seen as an important answer even in an area where there was a body of thought that exercise might be detrimental: transplantation.
It appears that exercise is good for the organs, even if those organs once belonged to someone else. And as managed care increasingly is returning care of transplant patients to primary care physicians, transplant surgeons are eager for the word to get out. "Encourage your patients to exercise. At the very least, it will help keep their weight under control, raise HDL cholesterol, and improve quality of life," says Jon Kobashigawa, MD, medical director of the University of California-Los Angeles (UCLA) heart transplant program.
Immunosuppressant drugs, upon which virtually all transplant patients are dependent, have some very distressing side effects, including hypertension and hyperlipidemia and may cause myopathy, making it difficult for patients to exercise. In addition, cyclosporin, a steroid, causes weight gain, sometimes as much as 50 pounds in the aftermath of surgery. In addition immobility leads to increased morbidity due to infections and inability to mobilize air in the lungs.
"Many of these patients have diabetes, and often they were obese before a heart or kidney transplant. Add on postoperative weight gain, hypertension, and hyperlipidemia, and people with diabetes have got three strikes against them," Kobashigawa says. He is clinical professor of medicine/cardiology at UCLA and co-chief of the division of clinical faculty medicine. "In fact, 25% of the deaths of kidney transplant patients are due to cardiovascular causes."
Kobashigawa, lead author of the first study to show the benefits of exercise for heart transplant patients, says he and his UCLA colleagues designed their study as a response to the government’s denial of coverage of rehabilitation for heart transplant patients. He notes that Medicare will pay for rehabilitation for heart bypass and congestive heart failure patients, but not for heart transplant patients.1
In some medical circles, it is believed that denervated transplanted hearts respond abnormally to exercise and exercise tolerance is reduced, wrote Kobashigawa.
Transplanted hearts don’t respond to exercise in exactly the same manner as normal hearts because they don’t respond immediately to stress by beating faster. Instead, the heart responds initially by contracting harder to pump blood and then starts to beat faster after a few minutes in response to higher adrenaline levels.
"This is an extremely important result because we have shown that transplanted hearts can be trained and that moderate exercise is effective, even early after transplantation," he says.
Kobashigawa’s team assigned 14 heart transplant patients to a cardiac-rehabilitation exercise group just two weeks after their transplant surgery. A control group of 13 patients at the same stage of recovery underwent unstructured therapy at home and were given no specific exercise instructions. Each patient in the exercise group was given an individualized program of muscular strength and aerobic training under the guidance of a physical therapist.
The group assigned to exercise had been on transplant lists longer and therefore might be presumed to be in weaker physical condition at the time of transplant, Kobashigawa says.
Patients in the exercise group visited the cardiac rehab clinic three times a week and received specific instructions for exercising at home. The frequency of visits to the rehab clinic was reduced as patients became more independently involved in their home exercise programs. In addition to stretching exercises and calisthenics, patients were asked to follow this walking regimen:
• First week after discharge (usually about two weeks after surgery) — Walk five to 10 minutes three times a day at a comfortable pace without stopping.
• Week 2 — Walk 10 to 15 minutes three times a day.
• Week 3 — Walk 15 to 20 minutes twice a day.
• Week 4 — Walk 20 to 30 minutes once a day.
• Week 5 — Walk 30 to 40 minutes once a day.
• Week 6 — Continue walking 30 to 40 minutes a day while increasing the pace.
Cardiopulmonary exercise stress tests were performed at one month after surgery and six months.
Six months after surgery, the exercise group had a 49% increase in peak oxygen consumption vs. 18% for the control group. More significantly, the exercise group had a 59% improvement in workload capacity compared to 18% for the control and a greater reduction in ventilatory equivalent for carbon dioxide (20% for exercisers vs. 11% for controls).
The mean dose of prednisone, the number of patients taking antihypertensive medications, and the average number of episodes of rejections and of infection did not differ during the study period for both groups. Weight gain did not differ significantly between the groups.
"This study shows that moderate exercise can increase transplant patients’ capacity for physical work, but I would recommend against high intensity exercise, which may contribute to sudden death," says Kobashigawa.
Standard care for transplant patients?
He says a key element of the study was the early initiation of exercise therapy within a very short time after transplant surgery. "Exercise should be considered standard postoperative care for heart transplant patients."
Similar exercise recommendations have been made for patients with virtually all other types of organ transplants: kidney, liver, pancreas, lung, and bone marrow. Among them, a study from UCSF concluded that athletes at the 1996 U.S. Transplant Games, while not representative of the general population, had achieved near-normal levels of physical functioning and quality of life. It also suggested that transplant patients who participate in regular physical activity can achieve above-normal levels of physical function.2
While heart transplant patients may have performance limitations, other transplant recipients should be able to achieve peak fitness, says Lew Teperman, MD, transplantation director at New York University in New York City.
Yet there are some caveats or precautions that should be taken for transplant recipients engaging in exercise programs, says Teperman. "After most kinds of transplants, immunosuppressants may cause bone brittleness, so any kind of contact sport should be avoided.
"People feel better after exercise, so in addition to improving their physical condition, they are likely to be in a better mental state."
Teperman also warns that patients should not begin to exercise until they are sufficiently healed and they should work up to an exercise regimen gradually. "Many patients are quite debilitated when they finally get a transplant, so it is important to recognize their state of general health in implementing an exercise program."
A proper exercise program, physicians say, can bring heart transplant patients to a level of fitness that is approximately 80% of what might be expected of a person with his own heart, and the difference might not be noticeable except to elite athletes.
The issue of athletic performance by transplant patients was underscored in the past year. NBA All-Star forward Sean Elliott of the San Antonio Spurs developed kidney disease and received a kidney donated by his brother, Noel, in August 1999. Elliott said he felt great a month after surgery and began exercising. Despite a bout with pneumonia in December, Elliot persevered. By Feb. 2, he was back to full-contact workouts with his team. Saluted by standing ovations from fans, he returned to professional basketball on March 14, just seven months after his transplant, and became the first professional athlete to return to a sport after receiving an organ transplant.
"Seven months doesn’t seem like a long time," Elliott told ESPN News the night of his return to basketball. "I’m just pleased that I’ve made it this far, to be honest with you, especially with the several speed bumps I went through to get here."
References
1. Kobashigawa JA, Leaf DA, Lee N, et al. A controlled trial of exercise rehabilitation after heart transplantation. N Engl J Med 1999; 340:272-277.
2. Painter PL, Luetkemeier MJ, Moore GE, et al. Health-related fitness and quality of life in organ transplant recipients. Transplantation 1997; 64:1,795-1,800.
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