Transplantation medicine involves the surgical transfer of a donated organ for an organ that has failed or is at its end stage. Kidney is the most commonly transplanted major organ, followed by liver. Organ transplantation is recognized as a treatment option in end stage liver and kidney disease.
Common causes for renal transplantation include diabetes mellitus, chronic glomerulonephritis, polycystic kidney disease, nephrosclerosis, Lupus and interstitial nephritis. The most common reason for liver transplant is cirrhosis, which can be related to viral diseases such as hepatitis C and B, alcohol abuse, and hepatocellular carcinoma. However, the most common reason for liver transplant in children is biliary atresia.1
More than 270,000 kidney transplants have been performed in the U.S. and about 100,000 individuals are living with a functional kidney transplant. The median survival time among recipients is 12.4 years, compared to 5 years for those on a waiting list One-year survival is up to 93% for first time recipients of deceased donor transplants and up to 97% for living donor transplants. 2,3
The national rate of graft survival five years after first adult deceased donor kidney only transplant is 86%. These rates vary between centers ranging from 76% to 93% (risk-adjusted). The equivalent rate after first pediatric deceased donor kidney only transplant is 86%, ranging from 79% to 100%. The national rate of graft survival five years after first adult living donor kidney only transplant is 93%. These rates vary between centers, ranging from 88% to 97% (risk-adjusted). The equivalent rate after first pediatric living donor kidney only transplant is 91%, ranging from 85% to 100%. The national rate of ten-year patient survival from listing for deceased donor kidney only transplants in adult patients is 75%. These rates vary between centers, ranging from 69% to 88% (risk-adjusted).
About 8,200 liver transplants are performed annually in the US. Liver transplant patients have approximately 90% one-year survival rate for both deceased and living donor. Patients who being 78% and 71% for deceased donor recipients. The most common cause of failure for a successful transplant is rejection, which is seen in up to one in every three patients, usually within weeks or months after a transplant. 3,4
Once glomerular damage reaches a certain point, the progression of renal disease is irreversible. Tubulointerstitial injury is considered a mediator of kidney disease progression, resulting in the loss of peritubular capillaries, impairing blood flow delivery.5 However, age related kidney function failure, is associated with glomerulosclerosis, interstitial fibrosis, tubular atrophy and vascular sclerosis.6
In chronic liver disease there is permanent scarring of the liver tissue, or cirrhosis, which ends up affecting normal blood flow. The persistent affected circulation into the liver will lead to portal hypertension, and consequent varicosities. Varices break and produce serious bleeding. Blood flow into the liver will affect breakdown of substances leading to accumulation and toxicity.
Once there is significant loss of the liver metabolic and synthetic function, complications such as coagulopathies, metabolic encephalopathy, hemodynamics disturbances and predisposition to infection and systemic inflammations may occur independently or simultaneously. The loss of normal hemostasis and alteration of the coagulation pathways is the result of inadequate synthesis, enhanced consumption of clotting factors and their inhibitors, and platelet abnormalities. Pro-thrombin time is one of the best indicators of changing liver function, and therefore its prophylactic correction is contraindicated in patients who are been considered for liver transplant.7 Acute as well acute-on-chronic liver injury results in impairment of cerebral function that ranges from abnormal mentation, with drowsiness, euphoria and confusion that may progress to deep coma. Other important manifestation of patients with liver failure is the presence of a hyperdynamic circulation that resembles that of septic shock characterized by hypotension due to low systemic vascular resistance with increased cardiac output.
A proinflammatory state is also known to cause multisystem dysfunction that may trigger also injury to the others’ organs systems and not only the primary organ who is been considered for transplantation. Systemic inflammation can be induced by the presence in body fluids of pathogen-associated molecular patterns (PAMPs) and damage-associated molecular patterns (DAMPs).8 As an example, this inflammatory response may trigger a neurohormonal activation leading to intense vasoconstriction that may perpetuate kidney injury secondary to renal hypoperfusion.9
The progression of kidney and liver disease is managed differently.
New onset/acute: Patients are often critically ill. Supportive measures are key to minimizing complications until an organ is available. Supportive measures include airway protection, management of hepatic encephalopathy, coagulopathy, detection of cerebral edema, and prevention of sepsis.
Chronic:11 A 3-month survival rate is estimated, using the Model for End stage Liver Disease (MELD). The MELD score is used to accurately gauge the severity of liver disease and effectively assess the risk of mortality. It also aids in determining organ allocation priority in patients on waiting list for liver transplant [LT] in the US as well as in other countries around the world. MELD score incorporates the international normalized ratio (INR), serum creatinine, and serum bilirubin. Given hyponatremia’s role as a marker for the severity of cirrhosis, the MELD Na score was developed with the intention of including sodium as a factor.12 Currently, the average MELD score for a patient undergoing a liver transplant is 20 nationally. As a patient’s MELD score increases, the priority to receive a liver transplant increases. If a patient’s condition improves, and the MELD score decreases, the priority to receive a liver transplant decreases.
Merion and colleagues evaluated the survival benefit of Liver Transplant [LT]. They reported that the benefit of LT at 1 year was highest among those with MELD scores > 18. Recipient mortality was higher among candidates with low MELD scores. For example, for patients with MELD scores between 6 and 11, the risk of mortality was 3.6 times higher by undergoing LT rather than remaining on the waitlist. For MELD 12–14, the risk remained significantly increased. Subsequently, these findings led to a change in allocation policy – an organ would need to be shared within the larger region prior to use for a local candidate with a MELD score < 15.13
Pre-Terminal: characterized by recurrent hospitalizations. To decrease morbidity and mortality associated with wait time, the possibility of accepting organs from high risk deceased donors or from living donor allograft is contemplated.
The National Kidney Foundation (NKF) has divided chronic kidney disease (CKD) into five stages, using GFR for each stage
1. Normal or high GFR (>90ml/min)
2. Mild CKD (GFR=60-89 ml/min)
3A. Moderate CKD (GFR=45-59 ml/min)
3B. Moderate CKD (GFR=30-44 ml/min)
4. Severe CKD (GFR=15-29 ml/min)
5. End Stage CKD (GFR<15 ml/min)
Albuminuria and eGFR are independently associated with progression to ESRD. Reduced eGFR should be complemented with urinary albumin to predict progression to ESRD.15 As the disease progresses in stages, morbidity and mortality increase, and the patient’s functional status declines. The levels of albumin in urine in healthy people are generally in the range within 0 to 8 mg/dl. Urine samples accumulated over a time frame of 24 hours should not have albumin levels in excess of 150 mg.
Specific secondary or associated conditions and complications:16
Rejection is the most common complication and occurs in one in every three people following transplant surgery. To prevent the body from rejecting the new organ, immunosuppressants medications are used to suppress the immune response that rejects the foreign tissue. Immunosuppressants in turn can cause hypertension, kidney failure, hyperlipidemia and diabetes. The risk of infection from bacteria and viruses is greatest in the early period after transplant, when immune suppressant dosages are at their highest, making the patient more vulnerable to infection. People with organ transplantations have an increased risk of developing some types of cancers, such as non-melanoma skin cancer, melanoma skin cancer, cervical cancer or post-transplant lymphoproliferative disorder. After a liver transplant, more than one person in every 10 people experiences a problem affecting their biliary tract, such as a bile leak or an obstruction caused by scar tissue in the bile ducts. The ureter can become blocked after a kidney transplant. It can be blocked soon after the transplant, for example by blood clots, or this can happen months or even years later, usually due to scar tissue forming. Complications after transplantation do not seem to vary from center to center nor on the experience of clinicians. The success rate of organ transplantation depends more so on whether the donated organ is from a living or a deceased donor and the medical circumstances of the recipient.16, 17
History: Patients who require solid organ transplant have chronic diseases pre-operatively leading to muscle weakness, fatigue, de-conditioning, gait abnormalities, anemia, and cardiopulmonary dysfunction. Sequelae to organ transplant are immobility leading to deconditioning and debility, neurological complications (neuropathies, myopathies), medications side effects and cognitive impairments based on the nature of the disease and its treatment.18
Physical examination: A comprehensive examination should be performed, before and after surgery. Patients that undergo transplantation have associated co-morbidities involving multiple organ systems, due to which impairments will not be limited to the type of transplant performed. Full examination should include: 1. Cardiovascular System for heart rate, blood pressure and auscultation-bruits may indicate renal artery stenosis/A-V malformations 2. Respiratory System for respiratory rate and air exchange. 3. Musculoskeletal System for ROM, joint stability, muscle strength and endurance. 4. Neurological System for mental status, speech/language, cranial nerves, reflexes, sensation, coordination, muscle tone or involuntary movements. 5. Psychiatric Exam for behavioral symptoms of anxiety, depression, and suicidal risk. 6. Additionally, the graft site should be palpated for any tenderness, swelling, erythema/warmth; which may be signs of rejection.19
Clinical functional assessment: Functional evaluation should be performed, and not merely estimated. This includes a comprehensive ADL and IADL evaluation. Deficits and preserved function should be quantified for optimization and/or compensation in order to achieve maximal independence.
Standardized scales assist in evaluation of current status, monitor progress and aid in prognosis. Examples are the 6-minute walk test, Fatigue Severity Scale (FSS), Visual Analog Scale and Systematic Isokinetic. Current literature reports the use of the 6-minute walk test as a submaximal exercise test to measure functional exercise capacity (i.e., the ability to engage in physically demanding activities of daily living) in individuals with a wide variety of characteristics. It is a practical and simple test that can be repeated to determine changes associated with the implementation of an intervention designed to improve functional capacity.20 The FSS scale is a self-reported scale that is easy to administer. The scale has been shown to be both valid and reliable with a variety of populations. It has been shown to have good internal consistency and is sensitive to change in fatigue levels over time. Regardless of the tool selected, consistency with its use is crucial for accurate assessment.21
Pre-transplant: It is recommended for transplant candidate to be evaluated with general bloodwork including CBC, BMP, LFT and coagulation factors. Screening for viral infections should be done and these include HIV, Hep C, Hep B, CMV, EBV, HSV, VZV, MMR, BK, and HTLV. Non-viral infections should be screened as well including syphilis, strongyloidiasis, Chagas and malaria. Routine cancer screening should be followed as per local guidelines for the general population.23 Immunologic assessment is recommended including ABO, HLA typing, Antibodies to HLA and cross-matching.24
Post-transplant: At least annually, serum creatinine with GFR estimation and the presence of albuminuria should be monitored.25 HbA1c, Vitamin D, PTH, Urinalysis/protein to creatinine ratio, CBC, CMP/eGFR, LFT, immunosuppressive agent levels, CPK, INR and cultures should be ordered as well.24
Close monitoring of patients after transplant is imperative since most are on complex immunosuppressive agents that will make them more susceptible to infections, cardiovascular complications and in certain cases, malignancy.
Pre-transplant: ECG, CXR, Exercise/pharmacology test, echocardiogram. If indicated consider coronary arteriography, endoscopy/colonoscopy, ultrasound of native kidneys, peripheral arterial doppler, Pulmonary function test, carotid doppler, voiding cystourethrography, and urodynamic pressure flow studies.
Post-transplant: ultrasound to diagnose possible obstruction, fluid collections, abscess, pyelonephritis, and infection, color flow doppler to diagnose possible vascular occlusion or stenosis, bone density scan, CT or MRI as indicated and ultimately biopsy to diagnose graft dysfunction.
Supplemental assessment tools:
Selection of an assessment tool has to be based on the outcomes that are to be measured. Good pre-screening instruments include: Psychosocial Assessment of Candidates for Transplantation and the Transplant Evaluation Rating Scale which are useful for identifying areas of particular concern or areas requiring additional information from patients and/or families.26 The health care professional performing the evaluation (eg, social worker, psychiatrist, psychiatric nurse practitioner) should be knowledgeable of and experienced in the psychosocial aspects of transplantation.23 For functional capacity or mobility, the 6 Minute Walk Test and Timed Up and Go are good choices. Appropriate Quality of life assessment instruments include Medical Outcomes Study Short Form-36 (SF-36). Nutritional evaluation tools include global assessment and mid-upper arm circumference. Imaging studies serve as prognosticators. In kidney transplants, the Nuclear renal scan reflects early renal function and Doppler ultrasonography and Resistive and Pulsatile Index assist in predicting early and long-term outcomes.19 Depending on the pattern of liver test, magnetic resonance imaging, computed tomography, endoscopic retrograde cholangiopancreatography, and sonography may be appropriate in liver transplant recipients. 16
Early prediction of outcomes: Several things may be used for early outcome prediction, such as the trend in creatinine level, especially in the first 6 months after kidney transplantation. For liver, post-operative day one is used to predict morbidity and mortality using serum bilirubin (for morbidity) and aspartate-aminotransferase (AST) (for mortality).
Environmental: Patients are advised to protect themselves from sun exposure due to the increased risk of skin cancer. Drinking water should be filtered; raw food is discouraged. Travel should be halted at least for six months after the transplant and travel to third world countries is discouraged due to immunosuppression and the risk of infections.16
Social role and social support: Demand for solid organ transplantation is higher than the existent capacity. Efforts to increase awareness are necessary to support volunteerism in organ donation. However, there are still ethical issues around having family members approve to donate, even when the donor has already expressed his/her wish.
Professional issues: 27,28
Clinical competency in the early identification of brain death is key for early preparation of the donor, the donor’s family, and the consequent timely match of the recipient. It is imperative that the physician who determines brain death should not be associated with the transplant team and he should be consistent with the institutions clinical and ethical standards. It should not be overlooked that patients have the right to receive information and ask questions about the transplant procedure and give voluntary consent. In the setting of directed donation, organs for transplantation should be allocated to recipients on ethically sound criteria (eg, urgency of need, change in quality of life, likelihood of benefit). Physicians should place candidates on a single waiting list, instead of multiple transplant centers.
Rehabilitation Management and Treatments
Available or current treatment guidelines
Patients who undergo a solid organ transplant are living longer lives making the short- and long-term recovery the most important priority; rehabilitation will play a critical role in this goal, seeking to take these patients to their highest level of function.
The existing clinical guidelines will provide direction on the anticipated morbidity areas that these survivors may encounter throughout their life span, including organ rejection, infections, cardiovascular/renal disease, diabetes, osteoporosis and cancer, among some. Rehabilitation specialists should take into consideration these potential complications in all stages of care to timely refer and/or a adjust treatment plans.16, 29 From the rehabilitation perspective, it is recommended that a functional and medical baseline be established before surgery, which includes mobility status, use of assistive devices, level of independence in activities of daily living, community and household activities, cognition, communication, as well as vocation.30
At different disease stages
Due to the duration of time a patient may be waiting for a donor, physical deconditioning may play a role on the patient’s decremental functional activity. In both end-stage kidney disease and end-stage liver disease, frailty, cardiovascular fitness and sarcopenia will not only influence the patient’s ability to recovered functional abilities but may play a role as well on the post – surgical clinical and functional outcomes and mortality risk.31
Adjusted exercise routines and training, even of two weeks duration, before surgical events may improve the patient’s physiologic state. Pre-operative rehabilitation, also known as prehab, can be as simple as daily pedometer-based-walking routines, and it has shown to improve cardiorespiratory fitness, self-reported physical function and pain. 32 Benefits of prehab is stronger for liver than for kidney transplanted patients.33
Rehabilitation after solid organ transplant starts immediately after surgery, where the initial focus is on maintenance of bodily systems, as well as pulmonary hygiene and chest wall mobility in order to assist with the ventilator/supplemental oxygen weaning process.30 The rehabilitation team must take into consideration that this population has more immediate transfers or readmissions to an acute hospital within the first week of its rehabilitation admission.34
Preventive measures towards complications from immobilization such as contractures, DVT, pulmonary embolism, as well as skin maintenance and preservation of bowel/bladder function are imperative. The use of bedside isometric exercise protocols may help in the prevention of disuse atrophy of major muscle groups.30 Rehabilitation programs include maintaining/improving ROM, transfer/gait training, posture, and pulmonary toileting assuring adequate gas exchange through airway clearance, endurance/activity tolerance and functional mobility.
Patient’s heart rate, rating the perceived excretion, blood pressure, dyspnea index, and signs of fatigue as well as signs suggesting acute rejection should be monitored. In renal patients, acute rejection is often heralded by anorexia, malaise, fever, hypertension, leukocytosis, blood urea nitrogen (BUN) elevation, and enlarged tender kidney.30 In the liver patient, fatigue, fever, dark yellow/orange urine, clay-colored stools, decreased exercise tolerance and abdominal pain/tenderness may occur. Special considerations to have with patients after liver transplant are delayed cognitive recovery, malnutrition, delayed liver function, primary graft nonfunctioning and side effects of immunosuppressive therapy.
In the subacute phase, exercise capacity increases significantly to near-normal values for sedentary healthy individuals. Exercise tolerance can be improved through low to moderate intensity exercise and activities of daily living (ADL’s). During this stage, activities are aimed at increasing MET level, improving ADL independence, increasing endurance, and discharge education including home exercise programs. The goal is to continue with progression of exercises to preserve muscle strength/endurance, emphasizing proximal muscles groups to preserve upper and lower extremity function as well as counteracting the effects of corticosteroids and decreased mobility.35
Priorities should include restoration of muscle mass and strength, enhancement of aerobic endurance leading to increase in tolerance to functional activities. Even though quality of life on organ survivors persists in the long term, the rehabilitation team should keep in mind common morbidities associated to long term surgical complications or immunosuppression. Other manifestations to monitor are insomnia and neuropathy, which may interfere with rehabilitation efforts. Neuromusculoskeletal complications such as paraparesis, delirium, stroke, peripheral neuropathy, tremors, myopathy, contractures, and osteoporotic should be monitored.30
Pre-terminal or end of life care
At this stage, palliative care will play a critical role in caring for this population with its main goal focused on providing comfort measures and the best quality of life possible. An interdisciplinary approach is used permitting comprehensive conversations between the patient and the treating team that allow improved advanced care planning, symptoms management, lower healthcare utilization, and enhanced patient and caregiver satisfaction.36
Coordination of care
The team caring for a patient who will be undergoing solid organ transplant is of interdisciplinary composition including immunologists, internists, nephrologists, hematologists, surgeons and physiatrists, who work to assess patients, retrieve organs, monitor immunologic status, provide immunosuppression, and assure adequate rehabilitation. Other team members may include nurses, physical and occupational therapists, social workers and respiratory technologists, among some.
Due to vast number of providers involved, coordination of care is usually carried by a single individual who may be called transplant coordinator as well. This role seeks to enhance efficient communication between the interdisciplinary team and the patient during any stage of the transplantation process involving activities related to the donor and/or recipient, and including functions like tracking organ recovery, preservation and recipient management. After the transplant, care coordinators may facilitate the transition to a new lifestyle, the education on what to expect and potential medical complications, the tracking of laboratories and diagnostic studies, for timely actions.37 Care coordination is identified by the Institute of Medicine as core for improved safety and clinical outcomes.38
Patient & family education
The physiatrist must consider the psychological aspects of each patient and the impact it will have on their quality of life and function, particularly when living with highly impairing chronic disease. Patients and their families may experience confusion and emotional burden associated to waiting for a donor, but in addition, there may be other stressors like loss of roles, loss of work, sexual dysfunction and marital issues among some.39 Emphasis on the underlying functional, medical, socioeconomic, and psychological needs of the patient should be done.6 Family education is crucial to provide the support needed.
Measurement of Treatment Outcomes including those that are impairment-based, activity participation-based and environmentally based.
Medical outcomes have significantly advanced and improved for patients who undergo a solid organ transplant due to improvements in immunosuppression therapy, diagnostic studies, and the pairing of the donor-recipient match, among some. Costs continue high for this type of care in the United States.
When liver transplantation is successful the recipient is usually fully rehabilitated, and quality of life is improved. 40 Most patients return to a regular lifestyle six months to a year after a successful liver transplant. Programs specialized on organ transplant rehabilitation have shown up to 91% improvement in mobility, and at discharge, over 80% of patients demonstrated improvements in self-care, functional ability, locomotion, communication and cognition. Beyer et al showed that a liver transplant combined with a supervised post-transplant exercise program improves physical fitness, muscle strength and functional performance in individuals with chronic liver diseases.
To improve environmental outcomes, patients are recommended to practice frequent handwashing to minimize infections with direct contact pathogens, wear sock and long pants and sleeves in activities in which soil exposure is possible, avoid exposure to large groups in periods of immunosuppression, avoid consumption of unfiltered water, avoid smoking, and to avoid sun exposure, among some. 16
Exercise capacity improves soon after successful kidney transplant, with removal of uremia.26 Exercise capacity is measured by maximal oxygen uptake (VO2), improved muscle strength, blood pressure control, and evidence of bone remodeling, which also improve with successful transplantation.41 High frailty scores are associated to lower survival rates. There are objective assessments that could be used to measure frailty and cardiovascular fitness changes like the short physical performance battery (SPPB), activities of daily life (ADL), instrumental ADL (IADL) scales and the 6-minute walk test.31
Translation into Practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills
Medical advancements have improved allogenic organ transplanted women increased chances of conceiving and carrying a pregnancy to its full term. These pregnancies are considered high risk and require close monitoring by a specialized team. In liver recipients, organ failure is fairly uncommon. Some recommendations for this population include daily blood pressure monitoring, close monitoring of graft function, and regular obstetric evaluations among many others.42
Cutting Edge/ Emerging and Unique Concepts and Practice
There is a growing awareness in the role of exercise and physical activity and its impact in the quality of life and health outcomes of patients with solid organ transplants. 43 However guidelines regarding the rehabilitation of such patients are still limited. In a randomized controlled study by Tzvetanov et al. they applied the Greg Hachaj (GH) method as a program for rehabilitation in obese renal transplant patients; that incorporated physical fitness, psychology, and nutrition. 44 It consisted of individual physical training using low-impact, low-repetition, resistance-based weight training with two one-hour sessions each week. Results showed a 100% adherence to training in the intervention group compared to 25% in control group; also, higher glomerular filtration, greater improvement in quality of life and a higher employment rate in the intervention group. Painter et al., demonstrated that an individualized home program improved peak VO2, muscle strength and self-reported physical functioning. 26 Ferreira et al., concluded that exercise training should be offered in the pre- and post-transplant phases for both adult and children. 43
State of the art technology continue to emerge as a key component in many rehabilitation centers in order to assist with patient recovery. Robotics and gaming centers are examples of interventions used with the goal of assisting in achieving the maximum level of independence possible. Examples include, antigravity treadmills and weight supported systems for gait retraining and increasing aerobic functional capacity; task oriented arm movements systems and touch screen computer systems which help with visuomotor training, improve hand-eye coordination, upper extremity coordination/movement, problems solving and pose cognitive challenges and visual-vestibular integration.45 Such technology continues evolving, improving, helping or compensating for functions that patients might have lost, therefore promoting independence and the decreasing the need for assistance.
Another unique concept to consider is that of diversity and the need of donors from different ethnic groups. In 2019, 67% of patients waiting over 5 years for an organ where of ethnic or multiracial backgrounds whereas, 67% of those who were solid organ donors were of Caucasian decent.46 Successful organ transplantation depends on a strong tissue match which many times occurs within the same ethnic groups. In addition, health disparities among races places certain groups(ie., African America, Hispanics) at a higher risk of subsequently needing a solid organ transplant due to a higher incidence or prevalence of conditions such as hypertension, diabetes, or even inadequate/limited access to healthcare or education in regards to transplant option.
Gaps in the Evidence- Based Knowledge
Controversies and gaps in the evidence-based knowledge
There is limited evidence-based medicine available to follow in rehabilitation protocols after solid organ transplantation. Many transplant centers have established rehabilitation programs but still standard rehabilitation protocols or exercise outcome measures regarding both renal and kidney transplant are limited. Potential barriers for such may be lack of funding, shortage of qualified personnel, compliance issues, low volume of patients and insufficient standardized rehabilitation protocols. This in turn causes a gap in allowing research and/or evaluation of transplanted patients’ response to a rehabilitation protocol to improve evidence-based knowledge.
Solid organ transplant has been dramatically impacted by the COVID 19 pandemic. It has had a global impact affecting transplant donors, recipients and transplant related research. It resulted in decreased numbers of transplants and an increased mortality, as uncertainties and limited understanding of the effects of COVID on transplantation emerged. Selection and timing of organ transplantation was also affected early during the pandemic, limiting transplantation to only those that were life-saving procedures (ie. Heart, lung, living). Thus, there is currently a gap in knowledge in regard to the impact, outcomes and effects of the virus in solid organ transplant, its rehabilitation and on future practice/policy procedures of transplantation. 47
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- Zaccherini, Giacomo, Weiss, Emmanuel & Moreau, Richard. Acute-on-chronic liver failure: Definitions, pathophysiology and principles of treatment. JHEP Reports, Volume 3, Issue 1, 100176 JHEP Rep. 2021 Feb; 3(1): 100176. doi: 10.1016/j.jhepr.2020.100176
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Original Version of the Topic
Isabel Borras-Fernandez, MD, Maricarmen Cruz, MD, Brenda Castillo, MD, Nataly Montes, MD. Solid Organ Transplant Rehabilitation. 5/2/2016
Maricarmen Cruz-Jimenez, MD
VA Office of Rural Health to VA Caribbean Healthcare System; Research Grant; Healthcare disparity research project
Isabel Borras, MD
Office of Rural Health, Veterans Administration;Research Grant;CoPi in research study in Telehealth in TBI
Office of Rural Health, Veterans Administration; Research Grant; CoPi in research study in Sociodemographic and mortality in TBI
Francisco Merced-Ortiz, MD
Nothing to Disclose
Carolina Diaz, MD
Nothing to Disclose
Juan Vazquez-Fuster, MD
Nothing to Disclose