Developing the Optimal Prehabilitation Program for Kidney Transplant Candidates on Hemodialysis - Resubmission - 1 - Project Summary For the more than 140,000 people waiting for a kidney transplant (KT), there is a profound loss of function due to aging, numerous comorbid conditions, and dialysis. Five years after addition to the KT waitlist, only 56% of candidates receive a KT and 15% die waiting. Given the adverse physiologic changes associated with dialysis, the long wait times for KT, and high waitlist mortality, interventions to enhance KT candidates' physiologic reserve are desperately needed. Prehabilitation refers to a myriad set of interventions seeking to enhance functional capacity to tolerate upcoming surgery's physiologic stresses. Prehabilitation's rationale—especially in KT candidates—is sound. In a single-arm pilot study of 24 patients, our group previously demonstrated a 64% increase in physical activity over 8 weeks with no adverse events; however, prehabilitation studies are plagued by significant heterogeneity, low enrollment, and poor adherence. Our pilot study was no exception. Major barriers to broad implementation are that these heterogeneous programs are often developed with a conjectural approach—based on individual investigators' conception of what such a program should be, rather than an empiric approach that incorporates key stakeholder input. Indeed, there is no consensus definition as to what defines “prehabilitation” or what components are needed. With potential for faster recovery, shorter length of stay, fewer readmissions, and earlier return to functionality, there may be a strong case for prehabilitation; however, a robust, empiric-based prehabilitation program must be developed before it can become a routine clinical practice. We first aim to elicit expert opinion to identify KT-specific prehabilitation constituent components and strategies to enhance enrollment and adherence through the conduct of 2 scoping reviews and a Delphi study of experts in nephrology, transplantation, renal nutrition, gerontology, and physical medicine and rehabilitation. Next, using novel applications of marketing research methodology, as well as in-depth patient interviews, we will identify KT candidates' preferred component combination(s) to design an empirically designed, maximally implementable, KT-specific prehabilitation intervention that incorporates the aspects valued by experts and patients alike and is most likely to be embraced by patients. Finally, we will perform a randomized controlled pilot trial of this KT-specific intervention. Prehabilitation has the potential to improve outcomes for the 42,000 people in the US added to the KT waitlist each year. We will perform the foundational work necessary to define the “optimal,” maximally implementable, KT-specific prehabilitation program. If successful, the knowledge gained will provide compelling data that will inform the need for a multicenter clinical trial to test prehabilitation in KT candidates. This proposal will provide novel data essential to design and plan that trial.
