End-stage renal disease (ESRD) is a disease of premature aging and is associated with impairments in functional status and quality of life. The dialysis population is growing older each year, and older patients with ESRD are at very high risk for functional impairment. Kidney transplantation (KT) is a well- established therapy that has the potential to ameliorate the detrimental effects of ESRD on physical activity, quality of life, and functional status. However, KT alone may not meet the full extent of this potential, particularly for older or more impaired adults. In fact, physical activity declines immediately post-KT and fails to return to expected levels even up to 5 years post-KT. Older patients waitlisted for KT (most of whom are on dialysis) are therefore reliant on their pre-KT levels of exercise, which are also predictive of post-KT mortality. ?Prehabilitation? has recently emerged as a strategy in other surgical populations to enhance recovery and minimize functional loss, and a structured exercise program may be beneficial in the pre-KT population. However, though exercise interventions have been successful in improving physical function and quality of life among patients with ESRD, only a small percentage of waitlisted patients may actually be able to participate in such interventions. Patients treated with dialysis in general have barriers such as severe fatigue, dyspnea, and lack of time or exercise partners. Older patients have additional barriers such as further impairments in mobility, fear of falling, and effects of polypharmacy. In addition, many older dialysis patients require caregiver support for transport and for adherence to such interventions. Therefore older patients are likely to have unique barriers to exercise interventions, and may also have specific goals for such an intervention. For an exercise intervention to be successful in this setting, it is necessary to conduct formal qualitative research that includes the voices of older adults awaiting KT as well the voices of their caregivers. The major goal of this study is to use qualitative research methodology to formally evaluate facilitators of and barriers to an exercise intervention for prehabilitation in older patients awaiting KT. We will perform one- on-one cognitive interviews of 30 older adults and 30 of their caregivers in paired dyads. We expect to elicit unmet needs of older patients awaiting KT and goals that may not be fully addressed by the procedure. We will then conduct semi-structured focus group interviews recruited from the cohort of patients and caregivers who have previously been interviewed to establish a consensus on prehabilitation, including details of a possible future intervention such as expected outcomes and specifics of coaching. Primary mentorship will be provided by Rebecca Sudore, MD (Geriatrics, Qualitative Research). Additional mentors are Jennifer C. Lai (Frailty in End-Organ Disease, Transplantation) and Kirsten Johansen (Exercise in ESRD). This study will provide valuable data on patient and caregiver experience of KT and potential prehabilitation and will serve as the foundation for future studies iterating, optimizing, and ultimately piloting the intervention in clinical trials.
The proposed research is highly relevant to public health, as nearly 95,000 patients in the United States (of whom more than 65% are 50 years of age or older) are currently awaiting kidney transplantation to treat end-stage renal disease (ESRD), which is a disease of premature aging associated with impairments in functional status and quality of life. Kidney transplantation has the potential to ameliorate some of the detrimental effects of ESRD upon aging but also carries greater risk for older or more impaired patients and does not completely restore physical function and quality of life - and thus may not meet expectations, particularly for older patients. An exercise intervention for prehabilitation prior to kidney transplantation has the potential to maximize the benefit of transplantation, but for such an intervention to be effective in this population we need to first elucidate the unique facilitators of and barriers to exercise prior to kidney transplantation in this population (e.g., fear of falls, caregiver support, effects of polypharmacy) from the perspective of not only older patients themselves, but also their caregivers, a goal that is particularly relevant to the National Institute on Aging's mission to promote health and well-being in older adults.