In recent years, the waiting period until a heart transplant has been increasing. Therefore, the need for rehabilitation after heart transplantation to patients who had severe heart failure before transplantation has been widely recognized. Cardiac rehabilitation is a type of comprehensive disease management including exercise therapy, patient education and counseling. Several reports have shown that even if the left ventricular contractility of the transplanted heart is normal, exercise tolerance is hardly improved. This involves such factors as mechanisms of exercise intolerance in chronic heart failure and deconditioning, denervation of transplanted hearts, and immunosuppressants. It is important to perform rehabilitation after transplantation with understanding of the conditions before transplantation, the specificity of the transplanted heart, type of rejection, and immunosuppressive therapy. In practice, starting from the ambulation in the postoperative acute phase, exercise therapy is performed with the aim of acquiring daily activities equivalent to or greater than those before transplantation and improving exercise capacity. Furthermore, patient education by a multi-disciplinary team is required so that self-management centering on complications of medication, dietary guidance, and infection prevention can be performed. Such comprehensive management is expected to improve exercise tolerance, prognosis, and quality of life (QOL).

With increasing survival rates after lung transplantation, more attention has been directed towards the importance of improving exercise capacity, independent functioning, and quality of life (QOL) in these patients. Pulmonary rehabilitation of lung transplant candidates and recipients plays an important in optimizing physical function prior to transplant and facilitating recovery of function post-transplant. This review provides a role for pulmonary rehabilitation based on research and clinical practice in the pre-transplant, early and late post-transplant periods.

Perioperative rehabilitation, provided in the form of a protocol for major abdominal and cardiothoracic surgeries, has been reported to reduce the frequency of postoperative pulmonary complications, to promote recovery of postoperative physical activity and to shorten postoperative hospital stay, all of which has also been essential for liver transplant recipients. Living-donor liver transplantation (LDLT), executed as standby surgery, meets the requirements to apply perioperative rehabilitation. In the period of postoperative intensive care, immobilization is directed for a certain number of days, because undesirable deviation of the graft liver is averted while the graft is not fixed, and possible risk of bleeding causedby any motion is an anxious matter after beginning postoperative anticoagulant therapy. In the same period, both respiratory rehabilitation and early ambulation have to be poorly performed, and therefore, another intervention should be flexibly considered. In both the stage out from intensive care and the stage of post-discharge, the patients can operate almost independently in their fundamental daily activities, but some articles reported that many of them experienced low physical endurance for social activities including return to employment. Sustained low endurance after LDLT may present for mixed causes. Further pursuit of a possible resolution of such a condition is needed in our field for improving the QOL of the recipients.

Kidney transplantation (KT) is a preferable treatment option for the patient with end-stage kidney disease to improve not only medical outcomes (patient- and kidney allograft outcome) but patient-centered outcomes (quality of life and physical function) as well, rather than dialysis therapy. However, KT recipients might obtain several disadvantages regarding physical function, such as obesity and skeletal muscle dysfunction induced by immunosuppression, compared with patients with non-transplant Chronic Kidney Disease (CKD). Furthermore, the average age of KT has been on the rise in the past few decades and severe vascular comorbid patients can be transplanted nowadays; thus frail KT recipients will steadily continue to increase. Several clinical practice guidelines recommend rehabilitation/physical exercise to KT recipients. Here, we introduce the consequence of fraility among KT recipients and the effect of rehabilitation/physical exercise for these KT recipients from the literature and our experience.

Intestinal failure is a challenging and complicated medical condition resulting in the loss of absorptive surface area or in severe gastrointestinal bacterial overgrowth. Prolonged use of parenteral nutrition (PN) places patients at a risk for multiple complications including catheter related blood stream infection (CRBSI), intestinal failure-associated liver disease (IFALD), and renal impairment. Intestinal rehabilitation programs (IRPs) recently have been recognized to have a significant role in the improvement of outcomes, care coordination, and prevention of complications. Therefore, all patients with permanent intestinal failure should be managed by dedicated multidisciplinary intestinal rehabilitation teams. Under the care of these teams, patients should be considered for intestinal transplantation in the case of progressive IFALD, loss of central venous access, and repeated life-threatening CRBSIs. We herein summarize the current status of IRPs and intestinal transplantation in Japan.

【Background】 In heart transplantation, with the rapid increase of bridge-to-transplant using an implantable left ventricular assist device and the continued donor shortage, the average waiting period is exceeding 3 years with unneglectable death on the waiting list. Therefore, it is crucial to reduce the waiting mortality possibly by expansion of the donor pool and revision of the heart allocation system.

【Objective】 The aim is to provide the basic information about mortality on the waiting list for heart transplantation in Japan.

【Methods】 The national data accumulated in Japan Organ Transplant Network from 1997 to the end of 2018 was utilized. The death on the waiting list was analyzed by survival curves for the categories of basic disease, age-group (under 11, 11 to under 18, over 18 years), and Status-1, 2 and 3.

【Results】 Among the total listed patients of 1,629, 26.5% received transplantation but 22.8% died on the list. The survival curves demonstrated that there was no significant difference in the age groups or between Status-1 and 2. In Status-1, 32% of all waiting deaths occurred during the first 6 months.

【Conclusion】 High mortality on the waiting list for heart transplantation was documented and detailed risk analysis of early death on the waiting list is needed to provide basic data for the amendment of the current heart allocation system.

A woman in her 20s underwent a left hepatectomy of living donor for her father who diagnosed with cryptogenic severe liver cirrhosis (CTP score of 13 (grade C), MELD score of 27). The preoperative enhanced CT examination revealed a normal liver appearance without steatosis and could not detect any aberrant hepatic vessels. The volume of left hepatic lobe was estimated 378 mL which was equivalent to 32.0% of graft volume / standard liver volume ratio. The graft was rather small in size but estimated eligible for a living donor as taking the donor age into consideration.

During left hepatectomy, the aberrant infraportal B2/3 bile duct was detected and confirmed by the intraoperative cholangiogram. We carefully dissected the hepatic hilum and transected the B2/3 and B4 ducts separately under real-time C-arm cholangiography. These two bile duct orifices were made into one on the back table. Both the donor and recipient were discharged with good post-transplant course without any clinical events. To perform a promising, a safe living donor liver transplantation, a gentle and careful maneuver with well-understanding, knowledge and expectation of the anatomical aberrant findings of the liver are necessary. To be cautiously aware of a rare aberrant anatomy at risk such as infraportal B2/3 bile duct guarantee the safety and high quality of living donor hepatectomy.