Health-related quality of life and employment status of liver transplant patients

Anxiety and Depression and Health-Related Quality of Life in Adults with Gastroesophageal Reflux Disease: A Population-Based Study

BACKGROUND

Adults with gastroesophageal reflux disease (GERD) are susceptible to mental disorders that might significantly affect their health-related quality of life (HRQoL). Therefore, the purpose of this study was to evaluate how HRQoL in individuals with GERD is related to coexisting anxiety and depression.

METHODS

A cross sectional study was conducted among 3068 adult patients 22 years of age and older with GERD diagnoses have been identified using the data from the Medical Expenditure Panel Survey from 2017 to 2020 for United States adults. Data are gathered by MEPS using an overlapping panel design over a period of two and a half years. HRQoL was established using the Physical and Mental Component Summary (PCS & MCS) values from the SF-12. Multivariate forward linear regression analysis was used to assess the relationship between anxiety, depression, and HRQoL in people with GERD after accounting for various factors.

RESULTS

Of the 3068 people with GERD who had been identified, 56.4% were women, 59.4% were in their 50s or 60s and 64.8% were employed. Thirteen per cent of people with GERD had depression, thirteen per cent had anxiety, and ten per cent had both. Adults with concurrent anxiety and depression had the lowest mean PCS and MCS scores compared to those with GERD. After adjusting for all independent factors, GERD patients with anxiety (MCS = -10.819, p-value < 0.0001), depression (MCS = -6.395, p-value < 0.0001), and both (MCS= -42.869, p-value < 0.0001) had substantially worse HRQoL than those without these comorbidities. Notably, better HRQoL scores were positively associated with marital status, employment, perceived overall health, and physical activity.

CONCLUSIONS

The results from this nationally representative sample shed insight into the relationships between low HRQoL and anxiety and depression among individuals with GERD. It also demonstrated the detrimental impacts of co-occurring chronic illnesses, low socioeconomic status, and the positive benefits of employment and exercise on HRQoL. This study emphasizes the clinical, policy, and public health implications for better healthcare, allocation of resources, and promotion of lifestyle modifications to improve the HRQoL in patients with GERD.

Post-liver transplantation patient experience

Given improvements in post-transplant patient and graft survival, there is a growing need to focus on patient experience and health-related quality of life (HRQOL). Though liver transplantation can be life-saving, it can also be associated with significant morbidity and complications. Patient HRQOL improves after transplantation, but it may not improve to that of age-matched cohorts. Understanding patient experience and the factors that contribute to it, including physical and psychological health, immunosuppression and medication adherence, return to employment or school, financial burden, and expectations, helps when thinking creatively about potential interventions to improve HRQOL.

Reviewing Patient-Reported Outcomes 1 Year after Orthotopic Liver Transplantation

BACKGROUND

With improved survivorship in liver transplantation (LT), there is an emerging focus on functional recovery and health-related quality of life (HRQoL) after surgery. The present study aimed to assess HRQoL after LT using the Patient-Reported Outcomes Measurement Information System (PROMIS).

STUDY DESIGN

This was a prospective analysis of LT recipients between 2020 and 2021. A total of 238 patients were contacted by phone at 3, 6, and 12 months postoperatively using the PROMIS 29-Profile. Scores were recorded and computed using the HealthMeasures Scoring Service.

RESULTS

PROMIS was available for 174 patients at 3 (n = 58), 6 (n = 57), and 12 months (n = 59). Overall, mean PROMIS scores were 47.6 ± 3, 47.6 ± 3, and 47.6 ± 3 at 3, 6, and 12 months, respectively. Most domains improved postoperatively by 12 months except for anxiety and sleep disturbance measures. The lowest domain in the immediate postoperative period was physical functioning, but this had the closest return to normative population values. Pain interference was above the population reference during the initial postoperative period, improving by 12 months where they were below mean population values. Depression and fatigue scores improved by 6 months and appeared to stabilize by 12 months post-LT. Patients demonstrated increased social participation, and scores were remarkably higher than general population means at each timepoint.

CONCLUSION

LT can impact physical, mental, and social health which, in this setting, remains largely unexplored using PROMIS instruments. We report that although overall patient well being can improve, some mental health domains require further consideration during the postoperative period.

Quality of Life and Its Determinants in Liver Transplantation Candidates: A Missed Link in Liver Care Program during the Waiting Time for Liver Transplantation

Background

The health-related quality of life (HRQOL) in the before liver transplantation (LT) stage has not been studied as much as that after the LT stage. We aimed to assess HRQOL and its determinants before the LT stage.

Methods

As a cross-sectional study, HRQOL of all adult patients (n=632) referred to the LT center of Shiraz, Iran in 2018-2019 were assessed. Demographic, socioeconomic, medical, and paraclinical data were requested. Physical (PCS) and mental (MCS) aspects of HRQOL were assessed using the SF36 questionnaire. Univariable, multivariable (linear regression), and confirmatory factor analysis were performed utilizing SPSS 20 and Mplus 6.1 software. P<0.05 was considered to be significant.

Results

The mean age of the patients was 47.6±12.3 years, while 414 (65.6%) were men, and the mean, score of the model for end-stage liver disease (MELD) was 18.36±5.58. The mean score of QOL, PCS, and MCS was 50.01±21.73, 46.23±23.23, and 53.78±23.91 (out of 100), respectively. Vitality had the most association with HRQOL, while role limitations had the lowest. The multivariable analysis revealed that unemployment (P<0.001), anemia (P=0.005), weight loss (P=0.005), diabetes mellitus (DM) (P=0.009), low MELD score (P=0.027), and drug use (P=0.03) were the significant determinants of HRQOL, respectively.

Conclusion

The present study showed that HRQOL in the LT candidates was at the intermediate level, while their PCS and MCS are at the low and moderate levels, respectively. Furthermore, physical performance, job status, anemia, weight loss, MELD score, DM, and drug use should be considered as the significant determinants of HRQOL in the LT candidates.

Health-related quality of life, workability, and return to work of patients after liver transplantation

Background

Health-related quality of life (HrQoL) and workability are related parameters to measure success of therapy. Both have been insufficiently explored in patients after liver transplantation (LT). Particularly little is known about patients’ attitude to return to work, employment status before LT, and how frequently there is any employment at any time after LT.

Methods

This is a single-center retrospective cohort study including 150 adult outpatients after LT. Liver transplantations had been performed between 1993 and 2018. The study was carried out from February to July 2018. The exclusion criteria were combined transplantations, positive screening for current alcohol abuse, and anxiety or depression. To evaluate HrQoL and fitness to work, the patients were tested using the Short Form 36, the Chronic Liver Disease Questionnaire, and the Work Ability Index.

Key results

The return rate of sufficiently filled-in questionnaires was 46.8% (66 patients). The mean age of patients was 59.9 years (SD=10.8), ranging from 25 to 78 years old. HrQoL was partly comparable to the normal population. Workability sum scores with a mean value of 31.61 (SD 9.79) suggested moderate workability at present. While only 28.8% of respondents were ever employed after LT, 45.5% currently wished to work or would have wished to work.

Conclusions

HRQL seems to be partly similar to population data, and subjective workability seems to be moderate in patients after LT. Despite a positive attitude to return to work in almost half of respondents, a lower rate of actual return to work was found in this study.

Quality of life after liver transplantation

Liver transplantation (LT) enables rapid transition from critical illness and poor prognosis back to health. After LT, health-related quality of life (HRQoL) generally becomes comparable to that of the general population, although some deficits in mainly physical domains are frequent. However, recipients continue to have symptoms related to immunosuppression, complications, and other things, which impact HRQoL and the recipient's ability to regain independence and re-establish function in everyday life. Less than half of LT recipients return to work. Reportedly, HRQoL seems to deteriorate slightly over the long-term, but still remains satisfactory. Physical fatigue is common, but recent studies show that structured exercise programs improve both fatigue and HRQoL. Emerging evidence also suggests that continued patient information, structured psychosocial support systems, and caregiver involvement might further help improve long-term HRQoL. More research is needed to gain better understanding of the factors affecting long-term HRQoL, and how to best improve HRQoL.

The correlation of patients' anxiety after a liver or kidney transplantation with functional and self-reported work ability

Organ transplantation has become the treatment of choice for end-stage organ failure, including renal and liver failure. The benefits of patient employment after transplantation are numerous, but factors determining the ability to work among these patients are not clearly defined. The growing interest in these factors has strong practical implications for organizations creating vocational rehabilitation programs. Given the interconnection between psychological and physical functioning in patients after transplantation, the present study examined the impact of anxiety on vocational rehabilitation and its relationship with functional tests. A total of 100 patients after liver or kidney transplantation underwent functional tests, including the 6-minute walking test and 30-second chair stand test (30"CST), and psychological tests, specifically the Inventory of Physical Activity Objectives, Work Ability Index, and State-Train Anxiety Inventory. Working ability was affected by psychological factors. State and trait anxiety exhibited inverse relationships with subjective readiness to occupational activity (P < .001, r = -.59 and P < .001, r = -.56, respectively). The level of anxiety was negatively related to the results of the 30"CST. State-Train Anxiety Inventory, State Anxiety subscale and State-Train Anxiety Inventory, State-Trait Anxiety subscale vs 30"CST: P < .001, r = -.43 P < .001, r = -.44). Thus, state and trait anxiety influence perceived work ability and partially functional status. These observations may indicate the potential benefits of including psychologists in interdisciplinary teams for physical and especially vocational rehabilitation of patients after liver or kidney transplantation.

Health-related quality of life before and after liver transplantation in patients with primary sclerosing cholangitis

Background and aims: Liver transplantation (LTx) remains the only curative treatment in patients with primary sclerosing cholangitis (PSC) and liver failure. In Helsinki we have also performed pre-emptive LTx in PSC patients without liver insufficiency but considered to have a high risk for cholangiocarcinoma. The present study evaluates the possible differences in health-related quality of life (HRQoL) in these two PSC groups before and after LTx.Methods: The total study population was 48 patients, 16 were transplanted due to increased risk of cholangiocarcinoma without liver insufficiency (the premalignant group) and 32 patients with end-stage liver disease (the symptomatic group).Results: HRQoL remained good after LTx in the premalignant group, and this difference was also clinically important compared with the symptomatic group, although not statistically significant. Both groups had slightly lower mean HRQoL scores after LTx than the age- and gender-standardized general population, and this difference was not clinically important in either group and statistically significant only in the symptomatic group.Conclusions: HRQoL does not decrease markedly after LTx in the premalignant PSC group, and this group does cope better than the symptomatic PSC group. After LTx, mean HRQoL of the premalignant group stays close to that of the age- and gender-standardized general population.

Insights Into the Experience of Liver Transplant Recipients With Alcoholic Liver Disease: A Descriptive Qualitative Study

Background.

Alcoholic liver disease (ALD) due to alcohol use disorder (AUD) is the primary cause of liver transplantation (LT) in the United States. Studies have found that LT recipients experience a range of physical and emotional difficulties posttransplantation including return to alcohol use, depression, and anxiety. The aim of this study is to better understand the experiences of LT recipients with ALD because they recovered posttransplant to inform the development of a patient-centered intervention to assist patients during recovery.

Methods.

Using qualitative methods, researchers conducted semi-structured interviews with 16 ALD LT recipients. The primary topics of the interview were physical recovery, mental health, substance use including alcohol and tobacco use, and financial experiences. Common patient themes were identified and coded.

Results.

Within the domain of physical health, patients stressed that undergoing LT was a near-death experience, they were helpless, changes in weight influenced their perception of their illness, and they have ongoing medical problems. In the domain of mental health, patients described cognitive impairments during their initial recovery, difficulty in processing the emotions of having a terminal condition, ongoing depression, anxiety, and irritability. The patients also described their perception of having AUD, the last time they used alcohol and their attitude to AUD treatment posttransplant. Patients also described their reliance on one member of their social support network for practical assistance during their recovery and identified one member of their medical team as being of particular importance in providing emotional as well as medical support during recovery.

Conclusions.

The patient’s description of their lived experience during the months following transplant informed the development of a patient-centered intervention that colocates behavioral health components with medical treatment that helps broaden their social network while addressing topics that emerged from this study.

Multivariate analysis of biopsychosocial determinants of professional activity among patients after kidney or liver transplantation in Poland

OBJECTIVE

The aim of the present study was to assess the employment rate among kidney and liver transplant recipients in Poland and identify the predictors of employment.

SETTINGS

The study was based on a self-prepared questionnaire containing five parts: demographic data and professional, medical, physical and psychological factors. This is a multicentre study involving four hospitals in Poland.

PARTICIPANTS

The investigated group consisted of 285 individuals (92 women and 185 men; 8 no sex given) aged between 18 and 45 years who underwent kidney or liver transplantation 1-5 years prior. Because of missing data, 279 questionnaires were considered regarding employment status after transplantation and 277 when sex differences were considered.

RESULTS

A total of 120 patients (43%) worked full-time, 42 (15%) part-time and 117 (42%) remained unemployed, with a higher employment rate post-transplantation among men than women (60% vs 55%, p=0.04). More women performed white collar work (74% vs 41%, p=0.0003) and had to modify their working position than men (22% vs 7%, p=0.0118). Factors determining employment after transplantation included higher level of education (OR=27.08; p=0.0096), employment 1 year prior to transplantation (OR=11.05; p<0.001) and good psychological adaptation (OR=4.23; p<0.001). Men working the year before transplantation had higher education (OR=9.66; p=0.0356). Among men, more kidney recipients worked compared with liver recipients (OR=3.567; p=0.0417). Among women, age determined employment status (OR=0.89; p=0.0234).

CONCLUSION

Higher education is the most important predictor of employment after transplantation. Therefore, rehabilitation programmes including vocational activity should be directed to increase the level of education, both pretransplantation and post-transplantation if possible.

Predictors of Return to Work 12 Months After Solid Organ Transplantation: Results from the Swiss Transplant Cohort Study

Background Return to work with or after a chronic disease is not a very well understood process, influenced by a variety of personal, professional, societal and medical factors. The aim of this study is to identify predictors for return to work 12 months after a solid organ transplant applying a bio-psycho-social model. Methods This study is based on patients included in the Swiss Transplant Cohort Study, a national prospective multicentre cohort, who underwent a first solid organ transplant (kidney, liver, heart, lung). Bio-psycho-social factors were tested and predictors of return to work identified using logistic regression models. Results Among the 636 patients included in the study, 49.8% (317) were employed 12 months post-transplant. The major predictor for returning to work 12 months posttransplant was pre-transplant employment status (OR 10.8). Accordingly, the population was stratified in employed and not employed pre-transplant groups. Age, self-perceived health (6 months post-transplant) and the transplanted organ were significantly associated with post-transplant employment status in both groups. Return to work was influenced by education, depression (6 month post-transplant) and waiting time in the employed pre-transplant group and by invalidity pension in the not employed pre-transplant group. Conclusion Employment status pre-transplant being highly associated with employment status post-transplant, the process promoting return to work should be started well before surgery. Biomedical, psychological and social factors must be taken into account to promote return to work in transplanted patients.

The effect of liver transplantation on patient-centred outcomes: a propensity-score matched analysis

It is unclear whether liver transplantation confers an increase in health-related quality of life (HR-QoL) across all dimensions of health. This study aimed to estimate the effect of liver transplantation on HR-QoL. Pre- and post-transplantation patients attending an outpatient clinic were invited to complete the condition-specific 'Short form of liver disease QOL' questionnaire. Mixed-effect linear regression and propensity-score matching (PSM) on pretransplantation characteristics were used to estimate the difference in overall HR-QoL associated with transplantation. Of 454/609 (74.5%) eligible patients who were included in the analysis, 102 (22.5%) patients fall under pretransplantation category, and 352 (77.5%) were under post-transplantation category. Overall HR-QoL post-transplantation significantly increased in patients without hepatocellular carcinoma (HCC) (β = 16.84, 95% CI: 13.33 to 20.35, P < 0.001), but not with HCC (β = 1.25, 95% CI: -5.09 to 7.60, P = 0.704). Donation after circulatory death (DCD) organ recipients had a significantly lower HR-QoL (β = -4.61, 95% CI: -8.95 to -0.24, P = 0.043). Following PSM, transplantation was associated with a significant increase in overall HR-QoL (average treatment effect: 6.3, 95% CI: 2.1-10.9). There is a significant improvement in HR-QoL attributable to transplantation in this cohort. Post-transplantation HR-QoL was affected by several factors, including HCC status and DCD transplantation, which has important implications for counselling prior to liver transplantation.

Effects of liver transplantation on health-related quality of life in patients with primary biliary cholangitis

BACKGROUND

Patients with primary biliary cholangitis (PBC) have decreased health-related quality of life (HRQoL). Here, we investigate HRQoL in two cohorts of transplanted patients with PBC and compare their results to healthy subjects.

PATIENTS AND METHODS

We used generic SF-36 and disease-specific PBC-40 questionnaires to evaluate HRQoL in 26 patients with PBC (23 females, age 59.4 ± 5.7 years) before and after liver transplantation (LT), and in 107 patients with PBC (99 females, age 62.8 ± 6.7 years) who were previously transplanted. The control group was comprised of 60 healthy controls (55 females, age 54.6 ± 8.8 years).

RESULTS

Health-related quality of life improved after LT in 85% of PBC patients. The SF-36 measure showed significant (all P < 0.05) improvements in the majority of domains after LT, and in the summary scores both physical and mental. We also documented significant improvements in pruritus and fatigue after LT (all P < 0.01). However, liver graft recipients had significantly worse physical functioning, physical role, and emotional role domains, and physical component score (all P < 0.001), as compared to healthy subjects. No differences in HRQoL were detected between patients evaluated after short and prolonged post-LT periods (P > 0.05).

CONCLUSION

Liver transplantation substantially improves most aspects of life quality in PBC patients. Nevertheless, their HRQoL remains worse in comparison to healthy individuals, mainly in physical aspects.

Patient Quality of Life After Liver Transplantation in Terms of Emotional Problems and the Impact of Sociodemographic Factors

INTRODUCTION

Liver transplantation is recognized as an effective and necessary treatment of chronic as well as acute hepatic failure. The assessment of quality of life (QoL) after transplantation represents an ancillary tool to evaluate the efficacy of solid organ transplantation in addition to graft and patient survival rates and complications. The global assessment of QoL after transplantation usually confirms improvement compared to pretransplant conditions.

PURPOSE

An attempt to evaluate the quality of life of patients after liver transplantation, with particular reference to sociodemographic factors and emotional problems.

MATERIALS AND METHODS

The study group included 121 patients (55 women and 66 men) at the age of 19 to 71 years who underwent surgery in the Central Teaching Hospital of the Medical University of Warsaw and the Infant Jesus Teaching Hospital in Warsaw, and were subsequently treated in an outpatient transplant clinic. The scoring procedure for the areas analyzed was based on the 36-Item Short Form Health Survey (SF-36) and the Hospital Anxiety and Depression Scale (HADS).

RESULTS

Higher patients age was correlated with lower quality of life of patients after liver transplantation, including physical functioning (patients >40 years of age declared lower physical performance, and patients <30 years of age indicated greatest limitations in their kind of work or other activities). The frequency of pain was also age-dependent (mostly patients >50 years of age). Women more often than men had worrying thoughts, were feeling tense or wound up, and had sudden feelings of anxiety or panic. By contrast, older people often declared that they felt to be slowed down.

CONCLUSIONS

To reduce pain and to improve physical performance of the study patients, rehabilitation procedures should be considered. Patients indicating symptoms associated with anxiety and depression should be referred to a clinical psychologist.

Patient-reported health outcomes in long-term lung transplantation survivors: A prospective cohort study

During the last three decades lung transplantation (LTx) has become a proven modality for increasing both survival and health-related quality of life (HRQoL) in patients with various end-stage lung diseases. Most previous studies have reported improved HRQoL shortly after LTx. With regard to long-term effects on HRQoL, however, the evidence is less solid. This prospective cohort study was started with 828 patients who were on the waiting list for LTx. Then, in a longitudinal follow-up, 370 post-LTx patients were evaluated annually for up to 15 years. For all wait-listed and follow-up patients, the following four HRQoL instruments were administered: State-Trait Anxiety Inventory, Zung Self-rating Depression Scale, Nottingham Health Profile, and a visual analogue scale. Cross-sectional and generalized estimating equation (GEE) analysis for repeated measures were performed to assess changes in HRQoL during follow-up. After LTx, patients showed improvement in all HRQoL domains except pain, which remained steady throughout the long-term follow-up. The level of anxiety and depressive symptoms decreased significantly and remained constant. In conclusion, this study showed that HRQoL improves after LTx and tends to remain relatively constant for the entire life span.

Quality of life at 6 years after occupational injury

PURPOSE

Occupational injuries have considerable impact on workers' lives. However, data regarding workers' health-related quality of life (HRQOL) at several years after the injury are lacking. This study assessed workers' HRQOL at 6 years after occupational injury and determined related factors in each HRQOL domain.

METHODS

Workers who sustained an occupational injury in 2009 and who responded to a previous survey at 3 or 12 months after their injury were followed up in 2015. A total of 1715 participants were candidates for this study. The Taiwanese version of the World Health Organization Quality of Life scale-abbreviated version (WHOQOL-BREF) was used to assess their HRQOL. Multiple linear regression analysis identified predictive factors for HRQOL at 6 years after occupational injury.

RESULTS

A total of 563 workers completed the questionnaire (response rate, 32.8%). Adverse life events and additional severe occupational injuries that occurred within the follow-up period, and decreased salary after the injury were significant factors for low scores in all domains of the WHOQOL-BREF. In addition, unmarried participants had low scores in the social relationship domain. Workers with family members requiring care scored low in the physical and environment domains. Workers whose injuries had major effects on their physical appearance had low scores in the physical and psychological domains. Workers with unstable employment had low scores in physical, psychological, and environment domains.

CONCLUSION

At 6 years after occupational injury, workers' HRQOL was poor among those whose salaries decreased after the injury, after adjustment for other factors.

Primary liver transplantation and liver retransplantation: comparison of health-related quality of life and mental status - a cross-sectional study

Background

Liver Retransplantation (Re-LT) procedures are associated with an increased risk of morbidity and mortality. Up to date, there is no knowledge on the health-related quality of life and the mental status of these patients.

Methods

Health-Related Quality of Life (HRQoL) was assessed by using the Short Form 36 (SF-36) Health Survey and Mental Status was assessed by using the Hospital Anxiety and Depression Scale (HADS). The patients were examined in different assessments: During regular check-up examinations in the LT outpatient department in 2011 (Survey 1) and in a postal survey in 2013 (Survey 2). Their medical data was collected by using an established database.

Results

We received eligible surveys of 383 patients (55.6%) with a history of LT, of which 15 (3.9%) had undergone Re-LT (Re-LT group). These patients were compared to a group of 60 patients who had undergone only one LT. With regard to their HRQoL, the Re-LT group had significantly lower scores on the scales of physical function (PF, p = 0.026), their role-physical (RP, p = 0.008), their vitality (VIT, p = 0.040), and their role-emotional (RE, p = 0.005). The scores for anxiety and depression did not differ significantly between the groups. In a multiple regression analysis, chronic kidney disease was found to be an independent risk factor for decreased scores of PF (p = 0.023).

Conclusions

Patients who have to undergo Re-LT procedures are faceing impairments in physical aspects of a HRQoL. Together with clinical results from other studies, the findings of the present examination underline the need for an optimized organ distribution strategy since not all patients listed for Re-LT appear to benefit from it.

Resting and Exercise Energy Metabolism After Liver Transplantation for Nonalcoholic Steatohepatitis

Background

Nonalcoholic steatohepatitis (NASH) is a leading indication for liver transplantation (LT). We hypothesized that weight gain after LT may be exacerbated by reduced metabolic rates due to the LT procedure, particularly during exercise. We aimed to compare resting and exercise energy expenditure between patients transplanted for NASH and nontransplant nonalcoholic fatty liver disease (NAFLD) subjects.

Methods

NASH LT recipients (>1-year post, n = 14) and NAFLD controls (n = 13) underwent analysis of body composition, resting energy expenditure (REE), and exercise energy expenditure (VO_2max), the latter using a ramped-Bruce protocol assessed by expired gas analysis and peak heart rate.

Results

Participants were mean 61.5 ± 7.9 years, 48.1% men, and 66.7% white. Baseline comorbidities were similar between groups. Among men, mean REE adjusted for total (17.7 vs 18.8, P = 0.87) and lean body mass (23.5 vs 26.9, P = 0.26), as well as VO₂ (20.1 vs 23.9, P = 0.29), was lower in NASH LT recipients compared with NAFLD controls, respectively, although not statistically significant. However, female NASH LT recipients had significantly lower mean REE than NAFLD controls when adjusted for total (14.2 vs 18.9, P = 0.01) and lean body mass (19.3 vs 26.5, P = 0.002), as well as significantly lower VO_2max (14.4 vs 20.6, P = 0.017).

Conclusions

NASH LT recipients, particularly women, have lower REE and exercise energy expenditure compared with nontransplant NAFLD patients. More aggressive diet and exercise programs for post-LT NASH recipients to account for reduced resting and exercise metabolic rates may attenuate weight gain in this vulnerable population.

Direct and Indirect Economic Burden of Chronic Liver Disease in the United States

BACKGROUND & AIMS

Chronic liver (CLD) is a major public health concern. We assessed its effects on quality of life and work productivity, as well as its economic burden in the United States.

METHODS

We performed a cross-sectional study of data from the Medical Expenditure Panel Survey (MEPS; 2004-2013). We extracted participants' sociodemographic parameters and medical histories. Subjects with CLD were identified based on Clinical Classification Software codes. MEPS participants were compared between those with and without CLD, and then between employed and unemployed patients with CLD. Outcomes were quality-of-life scores, employment, and health care use.

RESULTS

We collected data from 230,406 adult participants (age, ≥18 y) in the MEPS; 1846 had current CLD (36.7% with viral hepatitis and 5.3% with liver cancer). Individuals with CLD were less likely to be employed (44.7% vs 69.6% patients without CLD), were not working owing to illness/disability (30.5% vs 6.6% without CLD), lost more work because of disability (10.2 vs 3.4 d without CLD), and had more health care use, producing greater health care expenses ($19,390 vs $5567/y without CLD) (all P < .0001). Patients with CLD also had more comorbidities and worse self-reported general and mental health status, and reported more health-related limitations in their daily activities than individuals without CLD (all P < .0001). They also indicated more psychologic distress and depressive symptoms and had a lower quality of life and health utility scores (P < .0001). In multivariate analysis, after adjustment for sociodemographic factors and comorbidities, the presence of CLD was an important predictor of unemployment (odds ratio, 0.60; 95% confidence interval, 0.50-0.70), annual health care expenditure (β = $9503 ± $2028), and impairment in all aspects of health-related quality of life (all P < .0001). In patients with CLD, the presence of liver cancer had the most profound impact on health care expenditures (β = $17,278 ± $5726/y) and physical health (β = -7.2 ± 1.7 for SF-12 physical component) (all P < .005).

CONCLUSIONS

In a cross-sectional analysis of MEPS participants, we associated CLD with large economic and quality-of-life burdens.

Decision modeling in donation after circulatory death liver transplantation

Donation after circulatory death (DCD) liver allografts are increasingly used for transplantation. However, the posttransplantation clinical and quality of life outcomes of DCD recipients are traditionally considered to be inferior compared with donation after brain death (DBD) allograft recipients. Decision making for such marginal organs can be difficult. This study investigated the optimal decision to accept or decline a DCD liver allograft for a patient based on their current health. A Markov decision process model was constructed to predict the 5-year clinical course of patients on the liver transplant waiting list. Clinical outcomes were determined from the UK transplant registry or appropriate literature. Quality-adjusted life years (QALYs) were determined using the condition-specific short form of liver disease quality of life (SF-LDQoL) questionnaire. There were 293/374 (78.3%) eligible patients who completed the SF-LDQoL questionnaire. A total of 73 respondents (24.9%) were before transplant and 220 were after transplant (DBD recipient, 56.3%; DCD recipient, 8.5%; ischemic cholangiopathy patient, 2.4%; retransplant recipient, 7.9%). Predictive modeling indicated that QALYs gained at 5 years were significantly higher in DCD recipients (3.77; 95% confidence interval [CI], 3.44-4.10) compared with those who remained on the waiting list for a DBD transplant with Model for End-Stage Liver Disease (MELD) scores of 15-20 (3.36; 95% CI, 3.28-3.43), or >20 (3.07; 95% CI, 3.00-3.14). There was no significant advantage for individuals with MELD scores <15 (3.55; 95% CI, 3.47-3.63). In conclusion, this model predicts that patients on the UK liver transplant waiting list with MELD scores >15 should receive an offered DCD allograft based on the QALYs gained at 5 years. This analysis only accounts for donor-recipient risk pairings seen in current practice. The optimal decision for patients with MELD scores <15 remains unclear. However, a survival benefit was observed when a DCD organ was accepted. Liver Transplantation 23 594-603 2017 AASLD.

Factors contributing to employment patterns after liver transplantation

BACKGROUND

Many liver transplant recipients return to work, but their patterns of employment are unclear. We examine patterns of employment 5 years after liver transplantation.

METHODS

First-time liver transplant recipients ages 18-60 years transplanted from 2002 to 2009 and surviving at least 5 years were identified in the United Network for Organ Sharing registry. Recipients' post-transplant employment status was classified as follows: (i) never employed; (ii) returned to work within 2 years and remained employed (continuous employment); (iii) returned to work within 2 years, but was subsequently unemployed (intermittent employment); or (iv) returned to work ≥3 years post-transplant (delayed employment).

RESULTS

Of 28 306 liver recipients identified during the study period, 12 998 survived at least 5 years and contributed at least 1 follow-up of employment status. A minority of patients (4654; 36%) were never employed, while 3780 (29%) were continuously employed, 3027 (23%) were intermittently employed, and 1537 (12%) had delayed employment. In multivariable logistic regression analysis, predictors of intermittent and delayed employment included lower socioeconomic status, higher local unemployment rates, and post-transplant comorbidities or complications.

CONCLUSION

Never, intermittent, and delayed employment are common after liver transplantation. Socioeconomic and labor market characteristics may add to clinical factors that limit liver transplant recipients' continuous employment.

Hepatic encephalopathy before and neurological complications after liver transplantation have no impact on the employment status 1 year after transplantation

AIM

To investigate the impact of hepatic encephalopathy before orthotopic liver transplantation (OLT) and neurological complications after OLT on employment after OLT.

METHODS

One hundred and fourteen patients with chronic liver disease aged 18-60 years underwent neurological examination to identify neurological complications, neuropsychological tests comprising the PSE-Syndrome-Test yielding the psychometric hepatic encephalopathy score, the critical flicker frequency and the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), completed a questionnaire concerning their occupation and filled in the short form 36 (SF-36) to assess health-related quality of life before OLT and 12 mo after OLT, if possible. Sixty-eight (59.6%) patients were recruited before OLT, while on the waiting list for OLT at Hannover Medical School [age: 48.7 ± 10.2 years, 45 (66.2%) male], and 46 (40.4%) patients were included directly after OLT.

RESULTS

Before OLT 43.0% of the patients were employed. The patients not employed before OLT were more often non-academics (employed: Academic/non-academic 16 (34.0%)/31 vs not employed 10 (17.6%)/52, P = 0.04), had more frequently a history of hepatic encephalopathy (HE) (yes/no; employed 15 (30.6%)/34 vs not employed 32 (49.2%)/33, P = 0.05) and achieved worse results in psychometric tests (RBANS sum score mean ± SD employed 472.1 ± 44.5 vs not employed 443.1 ± 56.7, P = 0.04) than those employed. Ten patients (18.2%), who were not employed before OLT, resumed work afterwards. The patients employed after OLT were younger [age median (range, min-max) employed 47 (42, 18-60) vs not employed 50 (31, 29-60), P = 0.01], achieved better results in the psychometric tests (RBANS sum score mean ± SD employed 490.7 ± 48.2 vs not employed 461.0 ± 54.5, P = 0.02) and had a higher health-related quality of life (SF 36 sum score mean ± SD employed 627.0 ± 138.1 vs not employed 433.7 ± 160.8; P < 0.001) compared to patients not employed after OLT. Employment before OLT (P < 0.001), age (P < 0.01) and SF-36 sum score 12 mo after OLT (P < 0.01) but not HE before OLT or neurological complications after OLT were independent predictors of the employment status after OLT.

CONCLUSION

HE before and neurological complications after OLT have no impact on the employment status 12 mo after OLT. Instead younger age and employment before OLT predict employment one year after OLT.

A cost-utility analysis of prolonged-release tacrolimus relative to immediate-release tacrolimus and ciclosporin in liver transplant recipients in the UK

BACKGROUND

Calcineurin inhibitors (CNIs) represent the cornerstone of immunosuppressive therapy after liver transplantation. A recent network meta-analysis (NMA) evaluated the relative efficacy of CNIs ciclosporin, prolonged-release (PR) tacrolimus, and immediate-release (IR) tacrolimus in adult liver transplant recipients based on randomized and large observational trials published since 2000. Based on the NMA findings, the present study evaluated the cost-utility of PR tacrolimus relative to ciclosporin or IR tacrolimus in liver transplant recipients in the UK.

METHODS

A Markov model was developed to evaluate the cost-utility of immunosuppressive regimens in liver transplant recipients, capturing costs associated with immunosuppression, retransplantation, acute rejection (AR), and cytomegalovirus infection. Mortality, graft loss, and AR odds ratios were derived from the NMA. Costs were taken from the British National Formulary and the NHS National Tariff and expressed in 2016 pounds sterling. Future costs and effects were discounted at 3.5% annually.

RESULTS

Over 25 years, PR tacrolimus resulted in increased life expectancy and quality-adjusted life expectancy (QALE) relative to IR tacrolimus and ciclosporin. Relative to ciclosporin, QALE increased by 1.17 quality-adjusted life years (QALYs) with PR tacrolimus while costs increased by GBP £4645, yielding an incremental cost-effectiveness ratio (ICER) of £3962 per QALY gained. Relative to IR tacrolimus, QALE increased by 0.78 QALYs and costs by £1474, resulting in an ICER of £1889 per QALY gained. Sensitivity analysis showed the analysis to be most sensitive to dosing assumptions.

CONCLUSIONS

Based on a UK-specific analysis of the projected cost-utility of PR tacrolimus relative to IR tacrolimus and ciclosporin, PR tacrolimus was cost-effective, improving life expectancy and QALE relative to both IR tacrolimus and ciclosporin, yielding ICERs below £20 000 per QALY gained. The main limitations of the study were data source heterogeneity and omitting the economic and clinical effects of treating aspects of recurrent liver disease.

Quality of life in liver transplant recipients and the influence of sociodemographic factors

Abstract OBJECTIVE To verify the influence of sociodemographic factors on the quality of life of patients after liver transplant. METHOD Cross-sectional study with 150 patients who underwent liver transplant at a referral center. A sociodemographic instrument and the Liver Disease Quality of Life questionnaire were applied. The analysis of variance (ANOVA) was performed, as well as multiple comparisons by the Tukey test and Games-Howell tests when p <0.05. RESULTS Old age had influence on domains of symptoms of liver disease (p = 0.049), sleep (p = 0.023) and sexual function (p = 0.03). Men showed better significant mean values than women for the loneliness dimension (p = 0.037). Patients with higher educational level had higher values for the domain of stigma of liver disease (p = 0.014). There was interference of income in the domains of quality of social interaction (p = 0.033) and stigma of the disease (p = 0.046). CONCLUSION In half of the quality of life domains, there was influence of some sociodemographic variable.

From prolonging life to prolonging working life: Tackling unemployment among liver-transplant recipients

Return to active and productive life is a key goal of modern liver transplantation (LT). Despite marked improvements in quality of life and functional status, a substantial proportion of LT recipients are unable to resume gainful employment. Unemployment forms a threat to physical and psychosocial health, and impairs LT cost-utility through lost productivity. In studies published after year 2000, the average post-LT employment rate is 37%, ranging from 22% to 55% by study. Significant heterogeneity exists among studies. Nonetheless, these employment rates are lower than in the general population and kidney-transplant population. Most consistent employment predictors include pre-LT employment status, male gender, functional/health status, and subjective work ability. Work ability is impaired by physical fatigue and depression, but affected also by working conditions and society. Promotion of post-LT employment is hampered by a lack of interventional studies. Prevention of pre-LT disability by effective treatment of (minimal) hepatic encephalopathy, maintaining mobility, and planning work adjustments early in the course of chronic liver disease, as well as timely post-LT physical rehabilitation, continuous encouragement, self-efficacy improvements, and depression management are key elements of successful employment-promoting strategies. Prolonging LT recipients’ working life would further strengthen the success of transplantation, and this is likely best achieved through multidisciplinary efforts ideally starting even before LT candidacy.

Mode of allocation and social demographic factors correlate with impaired quality of life after liver transplantation

Background

Health-related Quality of life (HRQoL) is a major goal of clinical management after liver transplantation (LTx). There is still disagreement on the effects of social-demographic factors and changes in the allocation system on HRQoL. The aim of this study was to evaluate the impact of social-demographic factors, mode of organ-allocation, waiting time and hepatocellular carcinoma (HCC) on HRQoL after LTx.

Methods

HRQoL was assessed using the EORTC-QLQ-C30 questionnaire, which was sent to 238 recipients. Investigated parameters included age, sex, distance to transplant center, follow-up at hospital, size of hometown, highest education, marital status, having children, background liver disease, waiting time, mode of allocation, HCC, hospitalization after LTx and diagnosis of malignancy after LTx. All evaluated parameters were entered into multivariate linear regression analysis.

Results

Completed questionnaire were returned by 73 % of the recipients. After LTx, the HRQoL-function scales increased over time. Age, marital status, highest education, completed professional training, working status, job position, duration of waiting time to LTx, distance to transplant center, place offollow, HU-statuts, mode of organ allocation and duration of hospitalization were associated with significantly worse function- and significantly lower symptom scales. HCC as a primary disease did not affect HRQoL.

Conclusions

Low HRQoL correlated significantly with MELD-based organ allocation, more than 28-day hospitalization, divorced status, lower education- and non-working status, higher distance to transplant center, follow up at transplant center, HU-status, shorter waiting time to LTx and younger age. Improvement of HRQoL after LTx may require clinical management of pain, psychotherapy and financial support.

Return to work after organ transplantation: a cross-sectional study on working ability evaluation and employment status

INTRODUCTION

Organ transplantation has increased in Italy over the last decade. Thus, an increasing number of workers may face the problem of returning to work. The aim of this study was to provide an assessment of working ability of transplant recipients in comparison with their actual employment status.

METHODS

This study was based on 150 patients who underwent transplantation since 1994 and who underwent periodic post-transplantation examination during 2012. Fifty patients who had undergone heart transplantation (HT), 50 liver transplantation (LT), and 50 kidney transplantation (KT) and survived at least 12 months after surgery were eligible for this study. All patients underwent the International Classification of Functioning, Disabilities and Health (ICF) questionnaire; ten questions were further applied to those who were employed at the time of the study. X(2) statistics were used to compare working ability evaluation and employment status and for internal comparison among different organ recipients.

RESULTS

The employment status was as follows: 92 (61%) patients were in paid employment, 6 (4%) were students or housewives, 36 (24%) were unemployed, and 17 (11%) were retired because of invalidity benefits. According to our fitness evaluation only 4% to 10% of the patients were unfit for any job. When we excluded retired subjects, the X(2) statistics for correlated observations showed a highly significant statistical difference (P < .0001) between unemployed and unfit. As a result of the ICF questionnaire administration, there was a marked difference, although not statistically significant, in the fitness for previously performed jobs between KT and LT recipients (62% and 58%, respectively) and HT recipients (42%).

DISCUSSION AND CONCLUSION

In this cross-sectional study we found a relatively high rate of unemployment as compared with the working ability evaluation by ICF questionnaire and other questions. This may be due to several factors including health status and the possibility of gaining an adequate job. The ICF questionnaire proved to be a useful framework that can be used for research but also by occupational physicians in their usual practice after specific training.

Health-related quality of life in long-term survivors of paediatric liver transplantation

BACKGROUND

Long-term survival after paediatric liver transplantation is now the rule rather than the exception. Improving long-term outcomes after transplantation must consider not only the quantity but also the quality of life years restored.

OBJECTIVES

To characterize health-related quality of life (HRQOL) of LT recipients ≥15 years after paediatric LT.

METHODS

Recipients of a paediatric LT performed before December 1996 in a single institution with continuous follow-up at either the paediatric or adult partner centre were identified. Patients with severe developmental or neurological impairment were excluded. HRQOL was assessed using the Pediatric Quality of Life Inventory 4.0, the Medical Outcomes Study Short Form-36 version 2 and the Pediatric Liver Transplant Quality of Life Tool.

RESULTS

A total of 27 (67% male) subjects (mean age 24.3±6.7 years [median 23.2 years; range 16.6 to 40.3 years]) participated. The median age at transplant was 1.7 years (range 0.5 to 17.0 years). Seven (26%) participants underwent retransplantation. Seventeen (63%) participants were engaged in full-time work/study. Mean Short Form-36 version 2 scores included physical (49.6±11.1) and mental (45.3±12.5) subscale scores. The mean score for the disease-specific quality of life tool for paediatric liver transplant recipients (the Pediatric Liver Transplant Quality of Life Tool) was 64.70±15.2. The physical health of the young adults strongly correlated with level of involvement in work/study (r=0.803; P<0.05).

CONCLUSIONS

The self-reported HRQOL of participants <18 years of age was comparable with a standardized healthy population. In contrast, participants between 18 and 25 years of age had HRQOL scores that were more similar to a group with chronic illness. Participants engaged in full-time work/study experienced enhanced physical health.

Self-management and self-efficacy status in liver recipients

BACKGROUND

Liver transplantation (LT) is a viable treatment for patients with end-stage chronic liver diseases. The main aim of LT is to prolong life and improve life quality. However, although survival after LT continues to improve, some aspects of recipient's health-related quality of life such as self-management and self-efficacy have been largely ignored.

METHODS

A total of 124 LT recipients were included in this study. Questionnaires for general health status information and a "Self-Management Questionnaire for Liver Transplantation Recipients" modified from the Chinese version of "Chronic Disease Self-Management Program Questionnaire Code Book" were used in the survey. Data were collected by self-administered questionnaires.

RESULTS

The overall status of self-management in LT recipients was not optimistic. The major variables affecting the self-management of LT recipients were marital status, educational level and employment. The overall status of self-efficacy in LT recipients was around the medium-level. Postoperative time and self-assessment of overall health status were found as the factors impacting on self-efficacy.

CONCLUSIONS

The self-management behavior of LT recipients needs to be improved. The health care professionals need to offer targeted health education to individual patients, help them to establish healthy lifestyle, enhance physical activity and improve self-efficacy. The development of the multilevel and multifaceted social support system will greatly facilitate the self-management in LT patients.

Liver transplantation: a systematic review of long-term quality of life

BACKGROUND & AIMS

Liver transplantation is the only curative intervention for terminal liver disease. Accurate long-term quality of life (QOL) data are required in the context of improved surgical outcomes and increasing post-transplant survival. This study reviews the long-term QOL after primary liver transplantation in adult patients surviving 5 or more years after surgery.

METHODS

A literature search was conducted on PubMed for all studies matching the eligibility criteria between January 2000 and October 2013. Bibliographies of included studies were also reviewed. Two authors independently performed screening of titles and abstracts. Consensus for studies included for review was achieved by discussion between authors based on predetermined eligibility criteria. Quality appraisal and data tabulation were performed using predetermined forms. Results were synthesized by narrative review.

RESULTS

Twenty-three studies (5402 patients) were included. QOL following liver transplantation remains superior to preoperative status up to 20 years post-operatively. More post-operative complications predicted worse QOL scores especially in physical domains. Benefits in functional domains persist long-term with independence in self-care and mobility. Employment rates recover in the short-term but decline after 5 years, and differ significantly between various aetiologies of liver disease. Overall QOL improves to a similar level as the general population, but physical function remains worse. Participation in post-operative physical activity is associated with superior QOL outcomes in liver transplant recipients compared to the general population. QOL improvements are similar compared to lung, kidney and heart transplantation. Heterogeneity between studies precluded quantitative analysis.

CONCLUSIONS

Liver transplantation confers specific long-term QOL and functional benefits when compared to preoperative status. This information can assist in providing a more complete estimate of the overall health of liver transplant recipients and the effectiveness of surgery. Guidelines for future studies are provided.

Health-related quality of life after kidney transplantation: who benefits the most?

The influence of dialysis modalities on HRQoL before and after kidney transplantation (KT) and the role of adherence to medication on HRQoL have not been fully studied. Sixty four dialysis patients who answered the 15D HRQoL survey during dialysis were surveyed again after KT. Adherence and employment were also investigated. The mean 15D score was highest among home hemodialysis patients (HHD) and lowest among in-center hemodialysis patients (icHD). After KT, the mean 15D score improved significantly in 78.6% of peritoneal dialysis patients (PD), 47.6% of HHD, and 53.8% of icHD. Then, mean 15D score remained unchanged in 28.6% of HHD and in 23.1% of icHD patients. A deterioration in the 15D score occurred in 14.3% of PD, 23.1% of icHD, and 23.8% of HHD patients, and this was influenced by the number of pills (P = 0.04). Adherence to medication was the lowest in PD, timing being the most challenging task showing a connection to higher creatinine concentration (never forgot 1.41 mg/dl vs. forgot 2.08 mg/dl P = 0.05). Employed patients had a higher mean 15D score. The icHD and PD patients benefited the most from KT and HHD the least. Low pill burden and employment were linked to a better HRQoL.

Estimating the minimum important change in the 15D scores

PURPOSE

To facilitate the interpretation of empirical results produced by the 15D, a generic, preference-based instrument for measuring health-related quality of life (HRQoL), a subjective five-category global assessment scale (GAS) was used as an external anchor to determine the minimum important change (MIC) in the 15D scores.

METHODS

Altogether 4,903 hospital patients representing sixteen disease entities and having the 15D score at baseline repeated the HRQoL assessment at 6 months after treatment and answered the question: compared to the situation before treatment, my overall health status is now (1) much better, (2) slightly better, (3) much the same, (4) slightly worse, (5) much worse. Regression analysis was used to estimate the MIC for improvement/deterioration, defined as the lower/upper limit of 99.9 % confidence interval of the regression coefficient, standardized for baseline HRQoL, for categories (2) and (4), respectively, and confirmed by ROC curve analysis.

RESULTS

The limits or intervals for classifying the changes of 15D scores into GAS categories were >.035 for (1), .015-.035 for (2),>-.015 and<.015 for (3), -.035--.015 for (4) and <-.035 for (5). The lower/upper limits of ±.015 for categories (2) and (4) can be regarded as the generic MIC thresholds for improvement/deterioration, respectively.

CONCLUSIONS

The generic MICs for the change of 15D scores are ±.015. Follow-up studies using the 15D should report the mean change in the 15D score, its statistical significance, relationship to the MIC, and the distribution of the changes of the 15D scores into the five categories.

Health-related quality of life after solid organ transplantation: a prospective, multiorgan cohort study

BACKGROUND

Short-term posttransplantation survival and health-related quality of life (HRQoL) is exceptionally high for all patients after organ transplantation; however, predictors of the HRQoL outcome are not well understood. Trajectories of patients' perceived benefit/burden ratio associated with the transplant procedure may differ when taking the organ type for transplantation into account.

METHODS

A prospective, single-center cohort study assessed the trajectories of 354 patients after kidney (n=165), liver (n=53), heart (n=24), and lung (n=112) transplantation at 2, 6, 12, and 24 months with respect to psychosocial outcomes (HRQoL, anxiety, depression, social support, and work performance).

RESULTS

Mean age was 50±13 years, and 61.6% were male in the overall sample. Demographics differed with respect to organ type. HRQoL measured by the mean SF-36 Physical Component Scale was 36.8 (95% confidence interval, 35.7-37.8) and 48.9 (95% confidence interval, 47.2-49.7) for the Psychosocial Component Scale for the entire sample at 2 months and showed a marginal decrease until 24 months after transplantation. Overall, HRQoL increased for all organ types with differing trajectories. Liver patients reported the lowest HRQoL benefit for the majority of the physical (P≤0.01) and psychosocial (P≤0.01) SF-36 subscales. Anxiety (17.4%) and depression (13.8%) were prevalent in the overall sample. Depression symptoms impaired HRQoL outcomes in both SF-36 components and unemployment impacted the SF-36 psychosocial outcomes.

CONCLUSIONS

HRQoL improved after transplantation for all four types of transplant, but the trajectories were different. Regular screening for depression symptoms may diminish psychologic disorders and distress after transplantation and thus may further improve outcomes.

Health-related quality of life: two decades after liver transplantation

In this study, we describe a cohort of patients who received liver transplants before January 1, 1989 at the University of Minnesota Medical Center (UMMC), and we evaluate the health-related quality of life (HRQOL) of the survivors of this group. One hundred sixty-one patients--66 adults and 95 children--received whole deceased donor liver transplants. Thirteen transplants occurred before 1980, and all these patients died within 6 months; they were excluded from the survival analysis because they came from the pre-cyclosporine era. The survival rates at 1, 5, 10, and 20 years were 72%, 57%, 49%, and 37%, respectively (34% when pre-1980 patients were included). The median survival time was approximately 10 years for adult and pediatric recipients. The causes of death were ascertained by chart reviews. Technical failures were common between the years 1980 and 1984, and they decreased to 0% by 1988. As for HRQOL, 53 patients (36%) survived and were contacted to complete a 12-item health survey [Short Form 12 (SF-12)]. Retransplants were excluded. Sixty-eight percent returned the SF-12 survey. The median age for all respondents was 31.4 years: the median was 67.4 years for adult survivors and 28.8 years for pediatric survivors. The Mental Component Summary (MCS) score was 54.6 for adult survivors and 48.6 for pediatric survivors. The Physical Component Summary (PCS) score was 39.3 for adult survivors and 49.2 for pediatric survivors. Both the MCS and the PCS were norm-based to the US population with a mean of 50 and a standard deviation of 10. In conclusion, 35.8% of liver transplant recipients from UMMC were alive 20 years after liver transplantation. Technical failure-related deaths decreased dramatically from 1980 to 1988. The mental health of pediatric and adult survivors was similar to that of the general population. The physical health of the pediatric survivors was equivalent to that of the general population, but it was slightly less than what was expected with adjustments for age. The physical health of the adult survivors was approximately 1 standard deviation below that of the general population.

Factors affecting health-related quality of life and physical activity after liver transplantation for autoimmune and nonautoimmune liver diseases: a prospective, single centre study

Background/Aim. With the improvement of the outcomes after liver transplantation (LTx), health-related quality of life (HRQoL) and physical activity are becoming significant outcome parameters. We prospectively assessed these parameters in patients with autoimmune and nonautoimmune liver disorders undergoing LTx. Materials and Methods. Patients (n = 107) were subdivided into 3 groups depending on the time after LTx: group-A (n = 21): 6–12 months; group-B (n = 48): 13–36 months; and group-C (n = 38): >37 months. SF-36 and IPAQ were applied in HRQoL and physical activity assessment. Results. Females had impaired HRQoL in most SF-36 domains. Younger patients showed higher scores at SF-36 physical functioning domain but IPAQ was not influenced by age. Group-B had higher general health and physical component summary than group-A (P = 0.037, P = 0.04, resp.) and total IPAQ than group-C (P = 0.047). The sitting time domain was longer in group-A than in group-B and group-C (P = 0.0157;  P = 0.042, resp.). Employed patients had better HRQoL and higher physical activity than those not working. SF-36 and IPAQ were unrelated to the autoimmune etiology of liver disease. Conclusions. These findings show that female and unemployed patients have worse HRQoL, while gender and age at LTx time do not affect IPAQ's physical activity. The autoimmune etiology of liver disease does not influence HRQoL and physical activity after LTx.

The effect of self-efficacy, depression and symptom distress on employment status and leisure activities of liver transplant recipients

AIM

To examine the effect of self-efficacy, subjective work ability, depression and symptom distress on and to provide a description of, the employment and leisure activities of liver transplant recipients.

BACKGROUND

Return to work and leisure activities have become an important aspect of life for liver transplant recipients worldwide. An investigation of the factors that influence the employment status and leisure activities has been recommended as a means to help transplant recipients restore their productivity.

DESIGN

This was a cross-sectional, descriptive and correlational study in 2010.

METHODS

A convenience sampling method was used. Data were collected using a set of questionnaires that were administered retrospectively. A total of 106 liver transplant patients were included in this study.

RESULTS

The post-transplantation employment rate was 45.2%. The positive predictors of employment were higher subjective work ability and higher symptom distress. Gender (female), monthly family income (<US $2,000), depression and unemployment pre-transplantation were negatively associated with employment status. Of the 106 patients, 62 (58.5%) were in the low-diversity group (score of less than 3) of leisure activities. Monthly family income of <US $2,000 was associated with a low diversity of participation in leisure activities.

CONCLUSION

Subjective work ability and symptom distress were positive predictors of employment, while depression was a negative predictor. Nurses in the transplant team should focus on increasing a sense of confidence, decreasing depressive symptoms and monitoring the severity of symptoms to improve the employment status of liver transplant recipients.

Factors predicting health-related quality of life in pediatric liver transplant recipients in the functional outcomes group

Data from 997 pediatric LT recipients were used to model demographic and medical variables as predictors of lower levels of HRQOL. Data were collected through SPLIT FOG project. Patients were between 2 and 18 yr of age and survived LT by at least 12 months. Parents and children (age ≥ 8 yr) completed PedsQL™ 4.0 Generic Core and CF Scales at one time point. Demographic and medical variables were obtained from SPLIT. HRQOL scores were categorized as "poor" based on lower 25% of scores for each measure. Logistic regression models were generated. Single-parent households (OR 1.94, CI 1.13-3.33, p = 0.017), anti-seizure medications (OR 3.99, CI 1.26-12.70, p = 0.019), and number of days hospitalized (OR 1.03, CI 1.01-1.06, p = 0.0067) were associated with lower self-reported HRQOL. Parent data identified increasing age at transplant, age 5-12 yr at survey, hospitalization >21 days at LT, re-operations, diabetes, and growth failure at LT as additional predictors of generic HRQOL. Male gender, single-parent households, higher bilirubin levels at LT, and use of anti-seizure medication predicted lower cognitive function scores. HRQOL following pediatric LT is related to medical and demographic variables.

Health-related quality of life, anxiety and depression in young adults with disability benefits due to childhood-onset somatic conditions

BACKGROUND

As the treatment of chronic or life-threatening diseased children has dramatically over recent decades, more and more paediatric patients reach adulthood. Some of these patients are successfully integrating into adult life; leaving home, developing psychosocially, and defining a role for themselves in the community through employment. However, despite careful guidance and support, many others do not succeed. A growing number of adolescents and young adults who have had a somatic disease or disability since childhood apply for disability benefits. The purpose of this study was to assess the health-related quality of life (HRQoL), anxiety and depression of young adults receiving disability benefits because of somatic conditions compared to reference groups from the general Dutch population and to explore factors related to their HRQoL, anxiety and depression.

METHODS

Young adults (N = 377, 22-31 yrs, 64.3% female) claiming disability benefits completed the RAND-36 and an online version of the HADS. Differences between respondents and both reference groups were tested using analysis of variance and logistic regression analysis by group and age (and gender). Regression analyses were conducted to predict HRQoL (Mental and Physical Component Scale; RAND-36) and Anxiety and Depression (HADS) by demographic and disease-related variables.

RESULTS

The respondents reported worse HRQoL than the reference group (-1.76 Physical Component Scale; -0.48 Mental Component Scale), and a higher percentage were at risk for an anxiety (29.7%) and depressive (17.0%) disorder. Better HRQoL and lower levels of anxiety and depression were associated with a positive course of the illness and the use of medical devices.

CONCLUSIONS

This study has found worse HRQoL and feelings of anxiety and depression experienced by young adults claiming disability benefits. Healthcare providers, including paediatric healthcare providers, should pay systematic attention to the emotional functioning of patients growing up with a somatic condition in order to optimise their emotional well-being and adaptation to society during their transition to adulthood. Future research should focus on emotional functioning in more detail in order to identify those patients that are most likely to develop difficulties in emotional functioning and who would benefit from specific psychosocial support aimed at workforce participation.

Self-reported oral symptoms and signs in liver transplant recipients and a control population

Recipients of liver transplantation (LT) receive lifelong immunosuppression, which causes side effects. We investigated self-reported oral symptoms and associated risk factors with the following hypothesis: symptoms and signs would differ between LT recipients of different etiology groups and also between LT recipients and a control population. Eighty-four LT recipients (64 with chronic liver disease and 20 with acute liver disease) were recruited for clinical oral and salivary examinations (median follow-up = 5.7 years). A structured questionnaire was used to record subjective oral symptoms. Matched controls (n = 252) came from the National Finnish Health 2000 survey. The prevalence of symptoms was compared between the groups, and the risk factors for oral symptoms were analyzed. Xerostomia was prevalent in 48.4% of the chronic LT recipients and in 42.1% of the acute LT recipients. This subjective feeling of dry mouth was only partly linked to objectively measured hyposalivation. The chronic transplant recipients had significantly lower unstimulated salivary flow rates than the acute transplant recipients (0.34 ± 0.31 versus 0.61 ± 0.49 mL/minute, P = 0.005). Among the chronic transplant recipients, hyposalivation with unstimulated salivary flow was associated with fewer teeth (17.7 ± 8.2 versus 21.9 ± 8.4, P = 0.047) and more dentures (33.3% versus 12.2%, P = not significant). The chronic patients reported significantly more dysphagia than their controls (23.4% versus 11.5%, P = 0.02). Increases in the number of medications increased the symptoms in all groups. In conclusion, dysphagia was significantly more prevalent among the chronic LT recipients versus the controls. The number of medications was a risk factor for dry mouth-related symptoms for both the LT recipients and the controls. The chronic transplant recipients presented with lower salivary flow rates than the acute transplant recipients. Hyposalivation correlated with generally worse oral health among the chronic transplant recipients. These differences between the chronic and acute LT recipients may have been due to differences in their medical conditions due to the different etiologies.

Health-related quality of life of 256 recipients after liver transplantation

AIM: To investigate health-related quality of life (HRQoL) and psychological outcomes in 256 adults who had undergone liver transplantation (LT).

METHODS: A stratified random sampling method was used in this follow-up multicenter study to select a representative sample of recipients undergoing either living donor liver transplantation (LDLT) or deceased donor liver transplantation (DDLT). HRQoL was measured by using the Chinese version of Medical Outcome Study Short Form-36 (SF-36), and psychological outcomes by using the beck anxiety inventory (BAI) and the self-rating depression scale (SDS). Clinical and demographic data were collected from the records of the Chinese Liver Transplant Registry and via questionnaires.

RESULTS: A total of 256 patients were sampled, including 66 (25.8%) receiving LDLT and 190 (74.2%) undergoing DDLT; 15 (5.9%) recipients had anxiety and four (1.6%) developed severe depression after the operation. Compared with LDLT recipients, DDLT patients had higher scores in general health (60.33 ± 16.97 vs 66.86 ± 18.42, P = 0.012), role-physical (63.64 ± 42.55 vs 74.47 ± 36.46, P = 0.048), role-emotional (61.11 ± 44.37 vs 78.95 ± 34.31, P = 0.001), social functioning (78.60 ± 22.76 vs 88.16 ± 21.85, P = 0.003), vitality (70.30 ± 15.76 vs 75.95 ± 16.40, P = 0.016), mental health (65.88 ± 12.94 vs 71.85 ± 15.45, P = 0.005), physical component summary scale (PCS, 60.07 ± 7.36 vs 62.58 ± 6.88, P = 0.013) and mental component summary scale (MCS, 52.65 ± 7.66 vs 55.95 ± 10.14, P = 0.016). Recipients > 45 years old at the time of transplant scored higher in vitality (77.33 ± 15.64 vs 72.52 ± 16.66, P = 0.020), mental health (73.64 ± 15.06 vs 68.00 ± 14.65, P = 0.003) and MCS (56.61 ± 10.00 vs 54.05 ± 9.30, P = 0.037) than those aged ≤ 45 years. MCS was poorer in recipients with than in those without complications (52.92 ± 12.21 vs 56.06 ± 8.16, P = 0.017). Regarding MCS (55.10 ± 9.66 vs 50.0 ± 10.0, P < 0.05) and PCS (61.93 ± 7.08 vs 50.0 ± 10.0, P < 0.05), recipients scored better than the Sichuan general and had improved overall QoL compared to patients with chronic diseases. MCS and PCS significantly correlated with scores of the BAI (P < 0.001) and the SDS (P < 0.001).

CONCLUSION: Age > 45 years at time of transplant, DDLT, full-time working, no complications, anxiety and depression were possible factors influencing postoperative HRQoL in liver recipients.

Change in the type of work of postoperative liver transplant patients

BACKGROUND

Returning to work has been recognized as an indicator of functional recovery. Few studies have aimed to explore whether one's type of work changes after transplantation.

PURPOSE

This study aims to describe the change in types of work in liver transplant patients.

METHODS

A retrospective and descriptive study was conducted at a medical center in northern Taiwan. The data were collected by a self-report questionnaire between July and September 2010. Descriptive statistics an correlational analysis were used to analyze the data.

RESULTS

A convenience sample of 111 adult liver transplant patients was included in this study. Of the sample, 20 patients remained unemployed, 44 had a change in status by becoming unemployed (n=42) or employed (n=2), and 47 patients remained employed after transplantation. At the time of data collection, 49 (44.1%) liver transplant patients were gainfully employed, a rate that was lower than that of the pretransplantation stage (n=89, 80.2%). The number of workers engaged in manual labor decreased from 40 to 18 between pre- and posttransplantation. Of the 47 still-employed patients, 6 (12.8%) changed their occupation after transplantation.

CONCLUSION

The rate of gainful employment after liver transplantation was low, and those patients who had done manual labor pretransplantation were no longer able to do this type of work and were unemployed. The still-employed patients who worked in management or were professionals did not change their type of work after transplantation; however, service and labor workers did change their type of work.

Health-related quality of life after liver transplantation: the experience from a single Chinese center

BACKGROUND

Few studies have been performed to assess health-related quality of life (HRQOL) in liver transplantation (LT) patients in the mainland of China. This study aimed to investigate the HRQOL of post-LT patients in a single center.

METHODS

HRQOL was evaluated by the SF-36 (Chinese version) questionnaire in 60 patients (LT group) who had received LT for benign end-stage liver disease (BELD). Fifty-five patients with BELD (BELD group) and 50 healthy volunteers from the general population (GP group) were also evaluated, and the results were compared among the three groups.

RESULTS

There was a significant difference among the three groups in terms of the scores of eight domains in the SF-36 (P<0.01). Patients in the BELD group had lower scores in each domain of the SF-36 in comparison with those in the GP group (P<0.025). The LT group had mental health scores equivalent to those of the BELD group (P>0.025), but higher scores for the remaining seven domains (P<0.025). Compared with the GP group, the LT group scored equivalently for role physical, body pain, vitality, social function and role emotion (P>0.025), but had lower scores for the remaining three domains (P<0.025). Lower family income was found to be associated with reduced physical function and mental health scores (P<0.05). Better education was associated with increased mental health scores (P<0.05).

CONCLUSIONS

LT patients generally have a good HRQOL although some respects of their HRQOL remains to be improved. Lower family income and poor education are important factors relating to the poor HRQOL of LT patients.

Factors influencing posttransplantation employment: does depression have an impact?

BACKGROUND

Depressive disorders are the leading cause of disability in the United States. Liver transplant recipients often have significant psychiatric morbidity, including depression. One of the potential consequences of depression is the inability to work.

OBJECTIVE

The objective of this study was to determine if there is any relationship between depression and posttransplantation employment status in liver transplant recipients.

METHODS

Patients, 18 years of age or older, who had received liver transplants from January 2007 to July 2009 were identified for the retrospective analysis. Individual posttransplantation patient charts were reviewed for patient demographics, transplantation indication, employment history, depression diagnosis, and medications. The pretransplantation charts were used to obtain family psychiatric history, patient psychiatric history, past drug, alcohol, and tobacco use, and pretransplantation employment status.

RESULTS

A total of 91 patients were evaluated, of which 59.3% were males and 40.7% were females, with a mean age of 56 years. In our sample, 23% and 29% of patients were depressed pretransplantation and posttransplantation, respectively. The number of unemployed patients also increased from 10.9%-23.1%. A logistic regression was performed to identify the factors influencing employment posttransplantation, which indicated pretransplantation employment, gender (males more likely to return to work), and depression post transplantation as significant factors with odds rations of 128, 4.1, and 11.5 and corresponding P values of <.0001, .04 and .008, respectively.

CONCLUSION

Posttransplantation depression is significantly associated with post-liver transplantation unemployment. Improved management of depression may facilitate a patient's return to work after transplantation.

Influence of liver-disease etiology on long-term quality of life and employment after liver transplantation

The etiology of liver disease would expectedly affect health-related quality of life (HRQoL) and employment after liver transplantation (LT), but studies are scarce. We sent the 15D HRQoL instrument and an employment questionnaire to all 401 adult LT patients alive in Finland in 2007. The response rate was 89% (n = 353; mean of eight yr since LT). In age-adjusted analysis, patients transplanted for primary sclerosing cholangitis (PSC; n = 56), primary biliary cirrhosis (PBC; n = 72), acute liver failure (ALF; n = 76), alcoholic cirrhosis (n = 38), or liver tumor (n = 22) exhibited comparable HRQoL, whereas the combined group of miscellaneous chronic liver diseases (n = 89) exhibited significantly higher HRQoL scores (p = 0.003). Among working-aged patients (20-65 yr at LT), employment rates were highest in the PSC (56%) group and lowest in the ALF (39%) and PBC (29%) groups. In age-adjusted logistic regression, patients with PSC or alcoholic cirrhotics were 2.4- and 2.5-fold more likely to resume work after LT than patients with PBC. In conclusion, HRQoL scores late after LT were in general relatively high and comparable among disease groups. Patients with PSC or alcoholic cirrhosis were most likely to resume work after LT. The relatively low employment among patients with ALF may merit enhanced rehabilitation efforts.

General health, health-related quality of life and sexual health after pediatric liver transplantation: a nationwide study

The long-term impact of pediatric liver transplantation (LT) and its complications on general health, health-related quality of life (HRQoL) and sexual health were assessed. We conducted a national cross-sectional study of all pediatric recipients who underwent LT between 1987 and 2007. Of 66 survivors, 57 participants (86%) were compared to randomly chosen healthy controls (n = 141) at 10.7 ± 6.6 years posttransplant. PedsQL4.0, SF-36, DISF-SR and AUDIT questionnaires for appropriate age groups were used. Patients and controls <7 years had similar HRQoL and 54% of patients aged over 7 scored within the controls' normal range on all HRQoL domains. In adult survivors, physical functioning and general health were decreased (p < 0.05). Biliary complications, reoperations and obesity were independently associated with reduced HRQoL (p < 0.05 for all). Still 64% of adult survivors considered their health excellent. Sexual health was similar to controls but LT recipients may experience problems with their orgasm strength (p = 0.050) and condom-based contraception was more common after LT than among controls (58% and 12%, p < 0.001). In conclusion, normal HRQoL and sexual health are achievable post-LT.