OPAL: Online Prehabilitation for Patients Awaiting Liver Transplantation - a Multicenter Randomized Controlled Trial to Reduce Physical Frailty and Improve Health Outcomes

Inclusion Criteria

Inclusion Criteria: ≥18 years old with cirrhosis (confirmed with transient elastography by FibroScan, histology, or imaging-based assessment with compatible clinical picture), referred for transplant and are assessed to have a high likelihood of being listed according to a preliminary review by hepatologist or are already listed for LT, are pre-frail or frail on the liver frailty index (LFI) or (added August 30, 2024) pre-frail or frail on the TeLeFI (prefrail LFI 3.2-4.3 and frail LFI ≥4.4), have English or French language proficiency, and own an internet-connected device. Exclusion Criteria: * Listed for living related donor transplantation with expected time on the wait list \<12 weeks, or model for end-stage liver disease (MELD-Na) Score \>26 (Justification: time to transplant is very short) * Robust status on frailty testing (LFI 0-3.1) (Justification: unlikely to see benefit) * Unable to provide informed consent * Presence of a clinical condition that makes the intervention unsafe or infeasible (e.g. unable to follow instruction) or unsafe environment for virtual participation * Life expectancy less than 6 months, compassionate care (clinician judgment) (Justification: unlikely to see benefit) * Recent variceal bleed or history of varices not on adequate prophylaxis (Justification: acute exercise increases portal pressure * Transplant indication is cholangiocarcinoma.