Digital interventions in the management of advanced liver disease: Prescription and monitoring of healthy living in homes

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INTRODUCTION

Sarcopenia and frailty are highly prevalent among patients with cirrhosis. ¹ , ² They are associated with several adverse outcomes, including higher (re)hospitalization rates and higher wait‐list and posttransplant mortality among those undergoing liver transplantation (LT). ¹ , ³ , ⁴ Patients with cirrhosis often have significant exercise intolerance, and they may spend up to 95% of a 24‐hour period in a sedentary state. ⁵ Exercise training is known to improve muscle mass, strength, functional mobility, and quality of life in this population, combating deleterious effects of sarcopenia. ³ , ⁶ , ⁷ Early forms of telehealth have previously been explored for patients with cirrhosis to help improve disease outcomes. ⁸ , ⁹ Recently, multiple studies have investigated the feasibility and effectiveness of digital interventions to promote sustainable lifestyle changes for patients with chronic liver disease (CLD) (Table 1).

TABLE 1.

General descriptions of included studies on digital interventions on physical activity.

First author (Publication year)	Aim of study	No. of participants	Intervention	Outcome	Limitation
Duarte‐Rojo (2021) 10	To determine the feasibility of end‐stage liver disease LT candidates using the EL‐FIT app and their interaction with app features	28	Use of EL‐FIT smartphone application in facilitating exercise in patients with end‐stage liver disease, as well as monitoring of daily steps, heart rate, sleep time	Variable app usability among participants, and 35% of participants had significant increase in physical performance	Small sample size, selection bias, and lack of control group
Lin (2021) 12	To determine the effect of novel prehabilitation strategy (home‐based exercise prescription) on changes in frailty metrics and survival	517	Home‐based exercise prescription based on deficits identified during baseline physical therapy evaluation, including aerobic and weight‐based exercise	A median improvement of 0.3 in liver frailty index was correlated to improved survival	Selection bias, possibility of immortal time bias, varying time interval between in‐person physical therapy visits
Chen (2020) 3	To assess the benefits of home‐based physical activity program in patients with cirrhosis	17	Personal activity tracker to monitor daily activities, 12 g/day of essential amino acid supplement and biweekly counseling sessions for 12 weeks	Improvement in the 6MWT and psoas muscle index in the intervention group	Small sample size, selection bias, loss of interest in participants after being randomized to control group
Kruger (2018) 14	To evaluate the safety and efficacy of 8 weeks of home‐based exercise training on peak aerobic power, 6‐minute walk distance, muscle mass, and quality of life in cirrhosis	40	8 weeks of home‐ based exercise training, including moderate‐ to high‐intensity cycling exercise, 3 days/week	Increases seen in peak aerobic power and 6‐minute walk distance in adherent group (defined as completing ≥80% of sessions)	Due to limitation in inclusion criteria, study results are limited in generalizability to compensated cirrhosis patients, small sample size, potential confounding effect with use of beta‐blockers in selected patients

DIGITAL DISRUPTION OF FRAILTY IN CIRRHOSIS

Duarte‐Rojo and colleagues ¹⁰ used a smartphone application, “EL‐FIT” (Exercise and Liver FITness), designed specifically for patients with cirrhosis for the purpose of exercise training at home while using a paired personal activity tracker. This program was developed by LT clinicians with consideration of physical and cognitive constraints of advanced cirrhosis. The application encompasses a variety of features, including educational videos, a profile page displaying their activities, and a community feed page that allows members to share their achievements. ¹⁰ Their study showed that 35% of the participants had notable increases in their physical performance with significant improvement in the number of steps taken in their most sedentary/inactive group. ¹⁰ Smartphones and wearable devices have become nearly ubiquitous, and these devices are equipped with multiple sensors that can be leveraged to accurately track activity and to capture one's functional status. ¹¹

Lin and colleagues ¹² investigated the role of home‐based prehabilitation exercise prescription among patients undergoing LT evaluation. Exercise prescription was 150 min/week based on deficits identified at baseline. These included seating and standing exercises, as well as weights, bands, pedal exerciser, and bikes. They found that median reduction of ≥0.3 in liver frailty index was associated with survival advantage. ¹²

In a separate study, participants received a personal activity tracker and nutritional supplements as part of a home‐based physical activity program. ³ The program consists of biweekly counseling sessions on exercise goals, such as (1) the need for exercise 30 min/day for 5 days/week, (2) examples of both aerobic and resistance training, and (3) instructions on how to maximize exercise safety. Total protein intake of 1.2–1.5 g/kg/day was recommended along with a provided drink supplement containing 12 g of essential amino acids. At the end of the study period, participants had improved 6‐minute walk test performance (6MWT), as well as improvement in psoas muscle index. ³ In addition to the physical benefits, Stine and colleagues ¹³ recently reported decreased thrombotic risk in patients with nonalcoholic steatohepatitis who engaged in moderate‐intensity exercise, irrespective of weight loss and dietary changes.

Finally, Kruger and colleagues ¹⁴ examined the effects of an 8‐week home‐based aerobic fitness program as informed by peak oxygen consumption (peak VO₂ in L/min), a parameter reported to have an independent association to the severity of hepatic dysfunction. Although there was no significant increase in peak aerobic power (L/min), there was a significant increase in aerobic endurance measured by 6MWT and a significant increase in thigh muscle thickness among the intervention group. ¹⁴

DIGITAL SOLUTIONS FOR MALNUTRITION IN CIRRHOSIS

Maintenance of well‐balanced nutrition is paramount among patients with CLD. The prevalence of malnutrition among patients with cirrhosis is 40%–90% and is associated with increased risk for posttransplant sepsis, prolonged mechanical ventilation, and mortality. Global Liver Institute, an advocacy group for patients with CLD and their families, recently announced the launch of a personalized nutrition application. The app allows for personalized meal plans to meet the unique nutritional guidelines set by the Global Liver Institute advisors for patients with nonalcoholic steatohepatitis (https://www.globalliver.org/news/2021/06/global‐liver‐institute‐nutristyle‐announce‐personalized‐nutrition‐app‐for‐liver‐health). However, there remains a significant gap in digital technology that allows for individually targeted macronutrient analysis, including tracking of calories and protein intake among patients with CLD.

DISCUSSION

Studies investigating the role of digital interventions in the care of patients with CLD show they are only in their infancy compared with advances already seen in other chronic diseases. Telerehabilitation includes exercises for which intensity and duration can be monitored with technology (“telemonitoring”) with a focus on improving exercise‐related outcomes. ¹⁵ In the cardiovascular literature, numerous studies exist on the use of telerehabilitation in frail patients with a variety of tools, including smartphone apps, smartwatches, and wearable sensors. ¹⁶ , ¹⁷ , ¹⁸ , ¹⁹ , ²⁰ Recent literature review by Cruz and colleagues ²¹ failed to identify any studies investigating the role of digital interventions in nutritional management in CLD as compared with studies in chronic kidney disease (n = 6), cancer (n = 6), and cardiovascular disease (n = 3).

One of the potential challenges in the CLD population may be acceptance and adequate access to technology (Figure 1). Louissaint and colleagues ²² examined technology acceptance in a select group of patients with cirrhosis using a modified technology acceptance model survey. Their study found that patients were more interested in the use of hypothetical health applications when there was the presence of a caregiver, history of decompensation, ascites, or use of cirrhosis‐related medication. In addition, greater potential acceptance was associated with higher perceived usefulness, perceived ease of use, and less computer anxiety. ²²

FIGURE 1.

Components that lead to successful utilization of digital interventions.

Another potential challenge includes loss of interest secondary to the “novelty effect” in which there is only brief and nonsustained engagement by participants in response to innovative technology. ¹⁰ In addition, patient “adherence,” which reflects patients' observance to medical, physical, and dietary recommendations provided by the care team, requires timely and in‐depth discussions to yield shared understanding of the benefits of interventions. ¹² Despite these challenges, it should be emphasized that home‐based programs have many advantages, including cost‐effectiveness, accessibility, and flexibility. ¹⁴ Further studies are needed to establish the impact of digital interventions to prevent and combat frailty and malnutrition in patients with cirrhosis, and to identify methods to increase patient engagement in a sustainable and equitable manner.

CONFLICT OF INTEREST

Nothing to report.

Choi C, Simonetto DA. Digital interventions in the management of advanced liver disease: Prescription and monitoring of healthy living in homes. Clin Liver Dis. 2022;20:162–165. 10.1002/cld.1253