Virtual Home-based Multimodal Physical Pre-habilitation in Kidney Transplant Candidates

The goal of this RCT is to address the feasibility to conduct a multimodal physical pre-habilitation intervention in kidney transplant candidates. The main questions it aims to answer are: estimate the proportion of screened patients who meet eligibility criteria estimate the proportion of eligible patients who consent to randomization estimate the proportion of patients who adhere to the interventions estimate follow-up completion rates inform the calculation of sample size requirements for a full-scale RCT assess the acceptability of the intervention by the participants. The 12-week virtual home-based supervised exercise program and 5-month maintenance phase with independent home exercises will also include nutrition, education, and psychological support. Participants in the control group will receive usual outpatient care.

While waiting for kidney transplant, candidates face many challenges related to their physical and psychological health. These physical impairments are strongly associated with pre- and post-transplant mortality and morbidity. Pre-habilitation is the process of enhancing patient functional capacity prior to surgery with the objective of improving tolerance for the stressor. In the context of this protocol, pre-habilitation is referring to an exercise-based program with nutritional counselling and psychological support prior to transplant. Pre-habilitation has been shown to contribute to a reduction of postoperative recovery time and quicker return to functional ability after thoracic and abdominal surgery. There is, however, limited evidence for the effects of pre-habilitation in kidney transplant candidates. The investigators are following up previous work conducted with a very small (n=8) pilot pre-post study on pre-habilitation (MUHC REB number = 2020-5951) specifically with kidney transplant candidates. The results were encouraging. The current multicenter pilot randomized controlled trial (RCT) will address the following research question: is it feasible to conduct a full-scale multicenter RCT to assess the comparative-effectiveness of a virtual home-based pre-habilitation versus usual care for kidney transplant candidates? The investigators' specific objectives are to: (1) estimate the proportion of screened patients who meet eligibility criteria, (2) estimate the proportion of eligible patients who consent to randomization, (3) estimate the proportion of patients who adhere to the interventions, (4) estimate follow-up completion rates, (5) inform the calculation of sample size requirements for a full-scale RCT and, (6) assess the acceptability of the intervention by the participants. The assessor-blind pilot RCT will be conducted in three hospitals in Canada: MUHC, CHUM and University of Alberta Hospital. Eligible subjects will be randomized 1:1 to receive either i) virtual home-based multimodal pre-habilitation plus usual outpatient care, or ii) usual outpatient care. Participants will be drawn from the transplant clinics at the 3 sites, and the investigators aim to recruit 30 participants (22 of which will be recruited from MUHC over 9 months). This study's pre-habilitation intervention consists of three components: exercise, nutrition, and psychological support. While some of the assessment appointments will be in person, the intervention is virtual so as not to burden the participants with extra hospital visits. The exercise portion of the study will include a 12-week virtual home-based supervised exercise program and a 5-month maintenance phase with independent home exercises (maximum of 8 months of intervention/ended early if the participant undergoes transplantation). The nutrition intervention will include a comprehensive nutrition assessment by a dietitian that includes malnutrition assessment, weight and body composition and dietary assessment. Participants will then have an in-person visit with the nutritionist and be encouraged to meet their estimated nutrients needs according to chronic kidney disease stage, presence of diabetes and dialysis treatment. The psychological intervention will include an initial in-person consultation with a graduate student supervised by a psychologist to identify participant's needs. If there are issues with depression and anxiety, participants will be referred to a web-based resource with evidence-based strategies and resources to cope with depression and anxiety, including cognitive reframing and relaxation techniques. Participants who score 'abnormal' on the assessment tools will be referred to a psychiatrist if this has not been done by the transplant team yet. Patients in the control group will receive usual outpatient care.

The control group will receive usual outpatient care provided to kidney transplant candidates (which includes medical visits, nutritional, and psychological support).

Exercise Intervention: 12-weeks of supervised, individualized virtual exercise sessions, delivered by an accredited kinesiologist. Independent unsupervised sessions start at week 5. After 12 weeks, a 5-month maintenance phase is followed, continuing to exercise three times weekly for 30 minutes per session. Nutritional Intervention: this will include a comprehensive nutrition assessment by a dietitian, followed by a visit with a nutritionist to address individual needs and convey recommendations (in-person for those in Quebec, and online for those in Alberta). Psychological Intervention: this will include an initial in-person consultation to identify participants' needs. If anxiety or depression are identified, participants will be referred to a web-based resource with evidence-bases strategies and resources to help develop coping skills. Some participants may be referred to a psychiatrist if this has not already been done by the transplant team.

Usual Care for kidney transplant candidates, which may include medical visits, nutrition, and psychological support.

Data generated from this pilot RCT will inform the feasibility of a full-scale RCT by testing the study procedures; therefore, no inferential statistical analyses will be performed to compare groups. Socio-demographic, anthropometric and clinical data will be described using means and standard deviation or median and interquartile range for continuous variables and number and percentage for categorical variables. The variables will be presented at baseline, end of the 12 weeks (induction phase), at 6 months (during maintenance phase), at 8 months (end of maintenance phase) at 3-month post-transplant. Descriptive statistics (frequencies and percentages) will be used to report the feasibility and safety outcomes.

Data generated from this pilot RCT will inform the feasibility of a full-scale RCT by testing the study procedures; therefore, no inferential statistical analyses will be performed to compare groups. Socio-demographic, anthropometric and clinical data will be described using means and standard deviation or median and interquartile range for continuous variables and number and percentage for categorical variables. The variables will be presented at baseline, end of the 12 weeks (induction phase), at 6 months (during maintenance phase), at 8 months (end of maintenance phase) at 3-month post-transplant. Descriptive statistics (frequencies and percentages) will be used to report the feasibility and safety outcomes.

Data generated from this pilot RCT will inform the feasibility of a full-scale RCT by testing the study procedures; therefore, no inferential statistical analyses will be performed to compare groups. Socio-demographic, anthropometric and clinical data will be described using means and standard deviation or median and interquartile range for continuous variables and number and percentage for categorical variables. The variables will be presented at baseline, end of the 12 weeks (induction phase), at 6 months (during maintenance phase), at 8 months (end of maintenance phase) at 3-month post-transplant. Descriptive statistics (frequencies and percentages) will be used to report the feasibility and safety outcomes.

Rate of follow-up completion as assessed by number of randomized patients completing assessments pre- and post-induction phase.

Data generated from this pilot RCT will inform the feasibility of a full-scale RCT by testing the study procedures; therefore, no inferential statistical analyses will be performed to compare groups. Socio-demographic, anthropometric and clinical data will be described using means and standard deviation or median and interquartile range for continuous variables and number and percentage for categorical variables. The variables will be presented at baseline, end of the 12 weeks (induction phase), at 6 months (during maintenance phase), at 8 months (end of maintenance phase) at 3-month post-transplant. Descriptive statistics (frequencies and percentages) will be used to report the feasibility and safety outcomes. Completeness to follow-up will be compared between trial arms.

Frailty status as measured at the timepoints described below will use the Fried's phenotype method, identified by 3 or more of the following criteria. (please see each component outlined as its own outcome measure). Weight loss Weakness will be assessed using the handgrip strength test ith cut-off values provided by the Frailty index to determine weakness. Exhaustion: Slow gait: Low physical activity: Scoring for the Fried Phenotype: Each indicator can have 0 or 1 as a score, resulting in a total of maximum 5 points, where 0 is being robust, 1-2 pre-frail, 3-4 frail and 5 very frail.

Rate of change in bodyweight obtained from electronic medical chart (contributing to frailty status score for Fried's phenotype method).

Rate of change in handgrip strength as assessed by hand dynamometer (contributing to frailty status score for Fried's phenotype method).

Weakness will be assessed using the handgrip strength test (Jamar hydraulic hand Dynamometer). Patients will do six measurements (three times for each hand, with a rest break of 30 seconds between each). The highest measurement will be compared with cut-off values provided by the Frailty index to determine weakness.

Incidence of exhaustion as assessed by Center for Epidemiological Studies Depression (CES-D) (contributing to frailty status score for Fried's phenotype method).

Exhaustion will be measured by self-reported information based on two questions relating to feeling unusually tired and/or weak, taken from the Center for Epidemiological Studies Depression (CES-D) scale.

Rate of change in gait speed as assessed by the 4-metre gait speed test (contributing to frailty status score for Fried's phenotype method).

Slow gait: the 4-meter gait speed test will be used to analyze walking time. Participants will be timed as they walk 4 metres at their usual walking pace.

Rate of change in low physical activity status as assessed by the Rapid Assessment of Physical Activity (RAPA) questionnaire (contributing to frailty status score for Fried's phenotype method).

Low physical activity: energy expenditure weekly rate calculated using the Rapid Assessment of Physical Activity (RAPA) questionnaire; its 7 items assess habits of volume and intensity of weekly exercise. The score will determine whether participants are active or under-active. The scale ranges from 1 (sedentary) to 7 (active). A score of 5 (under-active regular) or less qualifies as low physical activity.

Rate of change in lower-extremity function will be assessed using the short physical performance battery (SPPB).

The short physical performance battery (SPPB) includes 3 brief physical fitness tests contributing to an overall score demarcating level of frailty. The tests include a 4-metre usual pace walk, a five-repetition sit-to-stand test, and balance tests.

Functional exercise capacity will be measured using the 6-minute walking test (6MWT), which uses the distance walked within 6 minutes in metres. The 6MWT has been shown to be a reliable and viable alternative to the gold standard test (cardiopulmonary exercise test) in individuals with chronic kidney disease.

Rate of change in Health Related Quality of Life scores as assessed by the Kidney Disease Quality of Life Short Form Instrument (KDQOL-SF)

Kidney Disease Quality of Life Short Form Instrument (KDQOL-SF) is a self-report measure developed for individuals with kidney disease and those on dialysis. It includes both generic (36 items) and disease-specific (43 items) components for the assessment of HRQoL. Life Participation will be assessed using sub-scales of the KDQOL-SF questionnaire which include questions about personal relationships, work, and activities of daily living. The minimum and maximum scores vary by question, as does the scoring for those items. In some of the items, a higher numerical score (5/5) indicates a favourable health state, whereas the opposite is true for other items (1/5) indicates a more favourable health state. The scoring procedure for the KDQOL-SF transforms the numeric values into a 1-100 range, with higher transformed scores reflecting a better quality of life.

A 3-day food record and 24-hour food record will be taken via self-report. Participants will note the type, quantity, level of satiety, and location/feeling at each feeding time during the day. The same record template is used for each the 3-day and 24 hour. This measure will contribute to overall nutrition status.

At baseline (3-day food record), post-induction phase (12 weeks), at 6 months, at 8 months, at 3-month post-transplant (24-hour food record).

Patient-Generated Subjective Global Assessment (PG-SGA) Scale Information: this is a patient-scored questionnaire in which participants will note changes in food intake, appetite changes, and activity levels. This scale ranges from 0 (no problems) to 36 (worst problem), with a higher score reflecting a greater risk for malnutrition. A score of 9 or above indicates a need for nutritional intervention.

Bioelectrical impedance will measure measure body composition through phase angle for participants from CHUM and MUHC (not UAH). Phase angle will be the measure used, representing the ratio of resistance to reactance, as an angle. This is part of the nutrition assessment/overall nutrition status.

Biochemistry will be taken at the timepoints described below, with one test needed to assess for all 3 measures: phosphorus, potassium, and A1C%.

Biochemistry will be taken at the timepoints described below, with one test needed to assess for all 3 measures: phosphorus, potassium, and A1C%.

Biochemistry will be taken at the timepoints described below, with one test needed to assess for all 3 measures: phosphorus, potassium, and A1C%.

Generalized Anxiety Disorder Seven-Item Scale (GAD-7): this is a 7-question self-report questionnaire completed by participants at the timepoints specified below, indicating the possibility of presence of anxiety. The GAD-7 ranges from 0 to 21, with a lower score indicating minimal anxiety, and a higher score indicating severe anxiety.

Patient Health Questionnaire (PHQ-8); this is an 8-question self-report questionnaire completed by participants at the timepoints specified below, indicating the possibility of presence of depression. The PHQ-8 ranges from 0 to 24, with a higher score indicating worse health outcomes. Specifically, a score of 3-6/6 for the first 2 questions indicates anxiety, and a score of 3-6/6 on the last 2 questions indicates depression. Higher scores indicate indicate increasing severity of anxiety or depression.

Level of safety as assessed by number/severity of recorded adverse events related to the intervention

All adverse events will be recorded. Upon review by the investigator, adverse events will be categorized by "related to the intervention" or "unrelated to the intervention" and categorized into three categories: musculoskeletal (e.g., pain, fall), cardiovascular or kidney related. Adverse events will be graded in terms of severity (Grade 1: Mild; Grade 2: Moderate; Grade 3: Severe; Grade 4: Life-threatening; and Grade 5: Death).

Trends identified in post-transplant recovery trajectory as sourced from electronic medical chart information

Information collected will include (1) intensive care unit length of stay, (2) hospital length of stay, (3) number of readmissions to hospital within 3 months after the surgery, (4) discharge destination, (5) allograft function.

Acceptability of the intervention will be assessed in a subset of patients in the intervention group using both quantitative and qualitative data. Quantitative data will include results from a semantic differential scale and from the closed-ended questions of a semi-structured telephone interview (see outcome measure 25). Based on the semantic differential scale, the intervention will be acceptable if a total score of a minimum of 16 is obtained.

Acceptability of the intervention will be assessed in a subset of patients in the intervention group using both quantitative and qualitative data. Quantitative data will include results from a semantic differential scale (see outcome measure 24) and from the closed-ended questions of a semi-structured author-generated telephone questionnaire (guided by previous usability/acceptability studies).

Inclusion Criteria: consecutive individuals with end stage kidney disease (ESKD) (aged ≥18 years), classified as pre-frail (1-2 points), frail (3-4 points) or very frail (5 points) on the Fried's frailty phenotype and who are accepted or in the process of being accepted to enter in the deceased or living donor KT waiting list of the McGill University Health Centre (MUHC), Centre Hospitalier de l'Université de Montreal (CHUM) or University of Alberta Hospital (UAH) for first-time transplantation or re-transplantation English or French speakers is technologically capable of connecting (either independently or through household members/next-of-kin) with an online videoconferencing platform through an e-mail invitation (Patients who do not have access to internet will borrow a tablet with internet for the period of the study) Exclusion Criteria: Individuals who: are classified as robust (0 points) on their Fried's frailty phenotype score are participating in a structured exercise program (hospital-based or home-based or another trial) are waiting for kidney-pancreas or kidney-liver transplant as those have much longer waiting time are hospitalized for any reason during the assessment for eligibility have a cPRA (calculated panel reactive antibodies) >95% and are on the highly sensitized exchange program and expected to have a prolonged waiting times on the waiting list are expected to have a transplant before the end of the 12 week-intervention (e.g. individuals who will receive an organ from a living donor or are type A blood have pre-existing or newly identified significant cognitive impairment have pre-existing or newly identified cardiac, musculoskeletal, neuropathy or neurological condition that might affect their exercise performance or otherwise render rehabilitation participation unsafe

Summary results will be available on the trial registry site within 12 months from the last visit of the last participant. Other data will be shared on request.