Quality of life after liver transplantation. A systematic review

Impact of Adding Bedside Cycling to Intensive Care Unit Rehabilitation on Physical Function and Length of Stay After Liver Transplantation: A Randomized Controlled Trial

OBJECTIVE

To assess the effectiveness of early bedside cycling training in enhancing recovery among patients following liver transplantation.

METHODS

A total of 64 patients who underwent liver transplantation were randomly assigned to either an experimental group or a control group, with 32 patients in each group. Patients in the control group received routine rehabilitation training after postoperative consciousness recovery and tracheal extubation. The experimental group received supplemental lower limb bedside cycling training in addition to the routine rehabilitation. Differences in physical function, length of intensive care unit, and hospital stays were compared between the two groups.

RESULTS

The experimental group showed significantly greater improvements in physical function, such as activities of daily living scores and Berg Balance Scale scores, compared to the control group (P < .05). While the experimental group also exhibited decreased length of intensive care unit and hospital stays compared to the control group, these differences lacked statistical significance.

CONCLUSION

Early bedside cycling training contributes to enhanced physical function, such as balance function and activities of daily living, among patients undergoing liver transplantation.

Observational cohort study of long-term outcomes of liver transplantation in haemophilia

INTRODUCTION

Gene therapy is now a reality for individuals with haemophilia, yet little is known regarding the quality-of-life impact of factor correction. As few data exist, and recognizing the analogy to liver transplantation (OLTX), we identified OLTX+ and OLTX- men in the ATHNdataset to compare post-OLTX factor VIII and IX on quality of life (QoL) by Haem-A-QoL and PROMIS-29.

METHODS

OLTX- were matched to OLTX+ by age, race, and haemophilia type and severity. Deidentified demographic data, including post-transplant factor levels, genotype and target joint disease were analysed by descriptive statistics. Haem-A-Qol and PROMIS-29 were compared in OLTX+ and OLTX- by student's t-test and univariate regression models.

RESULTS

Of 86 people with haemophilia A (HA) or haemophilia B (HB) cared for at 10 haemophilia treatment centers (HTCs), 21 (24.4%) OLTX+ and 65 (75.6%) OLTX- were identified. OLTX+ and OLTX- had a similar frequency of target joint disease (p = .806), HA genotypes, null versus non-null (p = .696), and HIV infection (p = .316). At a median 9.2 years post-OLTX, median FVIII, .63 IU/mL [IQR 0.52-0.97] and FIX, .91 IU/mL [IQR .63-1.32], Haem-A-QoL, PROMIS-29, and HOT scores were comparable. Severe HA/HB had lower post-OLTX 'dealing with haemophilia' scores (p = .022) and higher 'sports and leisure' (p = .010) and 'view of yourself' scores (p = .024) than OLTX+ non-severe participants. Non-caucasian OLTX+ had significantly lower scores in sports and leisure (p = .042), future expectations (p = .021) and total score (p = .010).

CONCLUSION

Nine years after OLTX, QoL is comparable to OLTX-, but significantly better in OLTX+ with severe than non-severe disease and in caucasians than non-caucasians.

Individuals living with a liver transplant - a follow-up study exploring mental, emotional and existential issues 10 years after transplantation

BACKGROUND

Going through a liver transplantation is by many recipients considered mentally and emotionally burdensome.

AIM

The aim of this study was to explore individuals' mental, emotional and existential experiences living with a liver transplant during a period of approximately ten years.

METHODOLOGICAL DESIGN

The methodology in this study is based on Gadamer's hermeneutics. Galvin and Todres' conceptual framework on well-being was applied in the interpretation process.

RESEARCH METHODS

Both researchers conducted interviews, which took the form of conversations. We made use of Brinkmann and Kvales' three types of interpretation.

ETHICAL ISSUES AND APPROVAL

The study was approved by the Ombudsman for Privacy of the Norwegian Social Data Services and is based on informed consent and confidentiality.

RESULTS

Three themes emerged through interpretation: 1. From great suffering to gratitude and a humble attitude towards life. 2. From living in uncertainty to leading a normal life. 3. From hopelessness and anxiety to an indifferent attitude towards life.

CONCLUSION

This study showed that the process of receiving a new liver and living with it, had changed most of the participants' attitudes towards life in a humble way. Some persons struggled with life and experienced depression anxiety, as well as lack of energy.

Health-related Quality of Life and Fatigue in Liver Transplant Recipients Receiving Tacrolimus Versus Sirolimus-based Immunosuppression: Results From a Randomized Trial

BACKGROUND

The impact of different immunosuppression regimes on the health-related quality of life (HRQoL) and the severity of fatigue in liver transplant recipients is largely unknown. We investigated the impact of a sirolimus-based regimen compared with a tacrolimus (TAC)-based regimen on the HRQoL and the severity of fatigue.

METHODS

In this multicenter, open-label, randomized, controlled trial, 196 patients were randomized 90 d after transplantation to (1) once daily normal-dose TAC or (2) once daily combination therapy of low-dose sirolimus and TAC. HRQoL was measured with the EQ-5D-5L questionnaire, the EQ-visual analog scale, and the severity of fatigue questionnaire Fatigue Severity Score (FSS). The EQ-5D-5L scores were translated to societal values. We examined the HRQoL and the FSS over the course of the study by fitting generalized mixed-effect models.

RESULTS

Baseline questionnaires were available for 87.7% (172/196) of the patients. Overall, patients reported the least problems in the states of self-care and anxiety/depression and the most problems in the states of usual activities and pain/discomfort. No significant differences in HrQol and FSS were seen between the 2 groups. During follow-up, the societal values of the EQ-5D-5L health states and the patient's self-rated EQ-visual analog scale score were a little lower than those of the general Dutch population in both study arms.

CONCLUSIONS

The HRQoL and FSS were comparable in the 36 mo after liver transplantation in both study groups. The HRQoL of all transplanted patients approximated that of the general Dutch population, suggesting little to no residual symptoms in the long term after transplantation.

Is socioeconomic deprivation associated with worse quality of life, anxiety and depression in liver transplant recipients? A cross-sectional study in a national transplantation programme

OBJECTIVE

To identify whether socioeconomic deprivation is associated with worse health-related quality of life (HR-QoL), anxiety and depression following liver transplantation.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

Liver transplant recipients within a national transplantation programme.

METHODS

Participants completed the condition-specific 'Short Form of Liver Disease Quality of Life' Questionnaire, the Generalised Anxiety Disorder-7 (GAD-7) Questionnaire and the Patient Health Questionnaire-9 (PHQ-9). The aggregate HR-QoL Score (range 0-100) was derived, and multivariable linear regression was performed based on sociodemographic and clinical variables to estimate its independent association with Scottish Index of Multiple Deprivation (SIMD) quintiles. The GAD-7 Questionnaire and PHQ-9 were used to screen respondents for anxiety and depression, and multivariable logistic regression was performed to estimate their independent association with SIMD quintiles.

RESULTS

Some 331 patients completed the questionnaires. Quintiles were equally distributed in the cohort, with no significant differences observed in underlying patient characteristics. Following multivariable adjustment, greater socioeconomic deprivation was associated with lower post-transplantation HR-QoL scores, with a difference of 9.7 points (95% CI: 4.6 to 14.9, p<0.001) between the most and least deprived quintiles. Recipients living in areas of least deprivation were less likely to suffer from anxiety (OR 0.05, 95% CI: 0.00 to 0.28, p=0.003) or depression (OR 0.13, 95% CI: 0.02 to 0.56, p=0.009).

CONCLUSION

Despite the highly selected nature of liver transplant recipients, those living in the most deprived areas have a significantly lower HR-QoL and are more likely to suffer from anxiety and depression.

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.

Patients are pragmatic and physicians are perfectionists? Comparing success after liver transplantation among patients and physicians

Although both patients and physicians are key stakeholders in health care outcomes, patients and physicians often define success differently. The purpose of this study was to compare patient and physician perceptions of success 1 year after liver transplantation. This was a single-institution, qualitative study. We conducted in-person, semi-structured interviews with liver transplant recipients 1 year after transplantation and virtual interviews with transplant surgeons and hepatologists. Transcripts were coded and iteratively analyzed for themes using the principles of phenomenology. Twenty patients, 8 caregivers, 5 transplant surgeons, and 4 hepatologists were interviewed. Subject interviews averaged 57 (patient) and 27 (physician) minutes. Overall, patients and physicians had significant agreement in their definitions of success, which included avoidance of death, restoration of physical and mental function, return to society, acquisition of new health care knowledge, and open communication between the patient and the physician. Patients highlighted relief from worry about their future health status, and physicians highlighted decreased health care costs. Patients noted that a liver transplant did not have to be perfect, that is free from complications, to be successful. Physicians had a more stringent view and felt that any deviation from an ideal course reduced the relative success of a transplant. Detailed assessment of patient and physician responses reveals similar overall goals of regaining physical, mental, and emotional function. Complications are perceived differently by patients and physicians. Awareness of this discordance may serve to enhance relationships between transplant patients and their providers.

Main factors influencing long-term outcomes of liver transplantation in 2022

Liver transplant (LT) outcomes have markedly improved in the recent decades, even if long-term morbidity and mortality are still considerable. Most of late deaths are independent from graft function and different comorbidities, including complications of metabolic syndrome and de novo neoplasms, seem to play a key role in determining long-term outcomes in LT recipients. This review discusses the main factors associated with late mortality and suggests possible strategies to improve long-term management and follow-up after liver transplantation. In particular, the reduction of drug toxicity, the use of tools to identify high-risk patients, and setting up a multidisciplinary team also for long-term management of LT recipients may further improve survival after liver transplantation.

Association of Frailty With Health-Related Quality of Life in Liver Transplant Recipients

Importance

Frailty has been recognized as a risk factor for mortality after liver transplant (LT) but little is known of its association with functional status and health-related quality of life (HRQL), termed global functional health, in LT recipients.

Objective

To evaluate the association between pre-LT and post-LT frailty with post-LT global functional health.

Design, Setting, and Participants

This prospective cohort study was conducted at 8 US LT centers and included adults who underwent LT from October 2016 to February 2020.

Exposures

Frail was defined by a pre-LT Liver Frailty Index (LFI) score of 4.5 or greater.

Main Outcomes and Measures

Global functional health at 1 year after LT, assessed using surveys (Short Form-36 [SF-36; summarized by physical component scores (PFC) and mental component summary scores (MCS)], Instrumental Activities of Daily Living scale) and performance-based tests (LFI, Fried Frailty Phenotype, and Short Physical Performance Battery).

Results

Of 358 LT recipients (median [IQR] age, 60 [53-65] years; 115 women [32%]; 25 [7%] Asian/Pacific Islander, 21 [6%] Black, 54 [15%] Hispanic White, and 243 [68%] non-Hispanic White individuals), 68 (19%) had frailty pre-LT. At 1 year post-LT, the median (IQR) PCS was lower in recipients who had frailty vs those without frailty pre-LT (42 [31-53] vs 50 [38-56]; P = .002), but the median MCS was similar. In multivariable regression, pre-LT frailty was associated with a -5.3-unit lower post-LT PCS (P < .001), but not MCS. The proportion who had difficulty with 1 or more Instrumental Activities of Daily Living (21% vs 10%) or who were unemployed/receiving disability (38% vs 29%) was higher in recipients with vs without frailty. In a subgroup of 210 recipients with LFI assessments 1 year post-LT, 13% had frailty at 1 year post-LT. Recipients who had frailty post-LT reported lower adjusted SF-36-PCS scores (coefficient, -11.4; P < .001) but not SF-36-MCS scores. Recipients of LT who had frailty vs those without frailty 1 year post-LT also had worse median (IQR) Fried Frailty Phenotype scores (1 [1-2] vs 1 [0-1]) and higher rates of functional impairment by a Short Physical Performance Battery of 9 or less (42% vs 20%; P = .01).

Conclusions and Relevance

In this cohort study, pre-LT frailty was associated with worse global functional health 1 year after LT. The presence of frailty after LT was also associated with worse HRQL in physical, but not mental, subdomains. These data suggest that interventions and therapeutics that target frailty that are administered before and/or early post-LT may help to improve the health and well-being of LT recipients.

Association between hospital acquired disability and post-discharge mortality in patients after living donor liver transplantation

BACKGROUND

Hospital-acquired disability (HAD) in patients who undergo living donor liver transplantation (LDLT) is expected to worsen physical functions due to inactivity during hospitalization. The aim of this study was to explore whether a decline in activities of daily living from hospital admission to discharge is associated with prognosis in LDLT patients, who once discharged from a hospital.

METHODS

We retrospectively examined the relationship between HAD and prognosis in 135 patients who underwent LDLT from June 2008 to June 2018, and discharged from hospital once. HAD was defined as a decline of over 5 points in the Barthel Index as an activity of daily living assessment. Additionally, LDLT patients were classified into four groups: low or high skeletal muscle index (SMI) and HAD or non-HAD. Univariate and multivariate Cox proportional hazard models were used to evaluate the association between HAD and survival.

RESULTS

HAD was identified in 47 LDLT patients (34.8%). The HAD group had a significantly higher all-cause mortality than the non-HAD group (log-rank: p < 0.001), and in the HAD/low SMI group, all-cause mortality was highest between the groups (log-rank: p < 0.001). In multivariable analysis, HAD was an independent risk factor for all-cause mortality (hazard ratio [HR]: 16.54; P < 0.001) and HAD/low SMI group (HR: 16.82; P = 0.002).

CONCLUSION

HAD was identified as an independent risk factor for all-cause mortality suggesting that it could be a key component in determining prognosis after LDLT. Future larger-scale studies are needed to consider the overall new strategy of perioperative rehabilitation, including enhancement of preoperative physiotherapy programs to improve physical function.

The role of acute in-patient rehabilitation on short-term outcomes after liver transplantation: A systematic review of the literature and expert panel recommendations

BACKGROUND

The indication and surgical complexity of orthotopic liver transplantation underscore the need for strategies to optimize the recovery for transplant recipients. We conducted a systematic review aimed at identifying, evaluating, and synthesizing the evidence examining the effect of in-patient rehabilitation for liver transplant recipients and provide related practice recommendations.

METHODS

Health research databases were systematically reviewed for studies that included adults who received liver transplantation and participated in acute, post-transplant rehabilitation. Postoperative morbidity, mortality, length of hospital stay, length of intensive care unit stay, and other markers of surgical recovery were extracted. Practice recommendations are provided by an international panel using GRADE.

RESULTS

Twelve studies were included in the review (including 3901 participants). Rehabilitation interventions varied widely in design and composition; however, details regarding intervention delivery were poorly described in general. The quality of evidence was rated as very low largely owing to "very serious" imprecision, poor reporting, and limited data from comparative studies. Overall, the studies suggest that in-patient rehabilitation for recipients of liver transplantation is safe, tolerable, and feasible, and may benefit functional outcomes.

CONCLUSION

Two practice recommendations related to in-patient rehabilitation following LT were yielded from this review: (1) it is safe, tolerable, and feasible; and (2) it improves postoperative functional outcomes. Each of the recommendations are weak and supported by low quality of evidence. No recommendation could be made related to benefits or harms for clinical, physiological, and other outcomes. Adequately powered and high quality randomized controlled trials are urgently needed in this area.

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.

Safe pregnancy after liver transplantation: Evidence from a multicenter Italian collaborative study

BACKGROUND

Women who have undergone liver transplantation (LT) enjoy better health, and possibility of childbearing. However, maternal and graft risks, optimal immunosuppression, and fetal outcome is still to clarify.

AIM

Aim of the study was to assess outcomes of pregnancy after LT at national level.

METHODS

In 2019, under the auspices of the Permanent Transplant Committee of the Italian Association for the Study of the Liver, a multicenter survey including 14 Italian LT-centers was conducted aiming at evaluating the outcomes of recipients and newborns, and graft injury/function parameters during pregnancy in LT-recipients.

RESULTS

Sixty-two pregnancies occurred in 60 LT-recipients between 1990 and 2018. Median age at the time of pregnancy was 31-years and median time from transplantation to conception was 8-years. During pregnancy, 4 recipients experienced maternal complications with hospital admission. Live-birth-rate was 100%. Prematurity occurred in 25/62 newborns, and 8/62 newborns had low-birth-weight. Cyclosporine was used in 16 and Tacrolimus in 37 pregnancies, with no different maternal or newborn outcomes. Low-birth-weight was correlated to high values of AST, ALT and GGT.

CONCLUSION

Pregnancy after LT has good outcome; however, maternal complications and prematurity may occur. Compliance with the immunosuppression is fundamental to ensure the stability of graft function and prevent graft-deterioration.

Factors affecting anxiety, depression, and self-care ability in patients who have undergone liver transplantation

BACKGROUND

Depression, anxiety, and altered self-care ability are among the most important factors affecting the quality of life of liver transplant recipients. Depending on the severity of the underlying liver disease, signs and symptoms of anxiety and depression may become more pronounced.

AIM

To evaluate the factors affecting depression, anxiety and self-care abilities of liver transplant recipients.

METHODS

Recipients who are ≥ 18 years and who underwent liver transplantation at Inonu University Liver Transplantation Institute were included in this descriptive and cross-sectional study. Sample size analysis showed that the minimum number of recipients should be 301 (confidence level = 95%, confidence interval = 2.5, population = 1382). Three hundred and twenty recipients were interviewed and 316 recipients that have answered the questionnaires accurately were analyzed. The dependent variables were the Beck Depression Scale, State-Trait Anxiety Scale (Form I and II), and Self-Care Agency Scale. The independent variables of the study were sociodemographic characteristics, biliary complications, hepatocellular carcinoma, recommending liver transplantation to other patients, and the interval of out-patient clinic visits.

RESULTS

Self-care ability scores were lower (P = 0.002) and anxiety scores were higher (P = 0.004) in recipients with biliary complications. On the other hand, in recipients with hepatocellular carcinoma, self-care scores were lower (P = 0.006) while depression (P = 0.003) and anxiety scores (P = 0.009) were higher. Liver transplantation recipients with a monthly income < 3000 Turkish liras had higher depression (P < 0.001) and anxiety (P = 0.003) scores. The recipients who stated that they would not recommend liver transplantation to others had lower self-care scores (P = 0.002), higher depression (P < 0.001), higher state anxiety (P = 0.02), and trait anxiety (P < 0.001) scores.

CONCLUSION

Presence of biliary complications and hepatocellular carcinoma, low income level, and an obligation for monthly visits to the outpatient clinic are factors that are found to affect self-care capability, depression, and anxiety.

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.

Bittencourt P, Cavalcanti A, Paraná R, Lins-Kusterer L. Poor Oral Health-Related Quality of Life in Pre- and Post-Liver Transplantation Patients

Background:

Oral health is associated with Chronic Liver Disease (CLD) and may play a relevant role in oral (OHRQoL) and general health-related quality of life (HRQoL) among people with chronic liver disease (CLD).

Objective:

To explore the correlations between OHRQoL and HRQoL in pre- and post-liver transplantation (LT) patients.

Methods:

A cross-sectional study with 189 patients: 63 per group (pre-LT, post-LT, and without liver disease). The Oral Health Impact Profile-14 (OHIP-14), the 36-Item Short-Form Health Survey, and the Work Ability Index (WAI) were used to measure oral health-related quality of life, health-related quality of life, and work ability, respectively. Oral health was evaluated according to the World Health Organization criteria. The relationship between the OHIP-14 and independent variables was analysed by multiple linear regression.

Results:

Pre-LT group presented the highest OHIP-14 total mean score, followed by the post-LT group, compared to the group without liver disease (p=0.001). All HRQoL and WAI mean scores were lower in the pre-LT group than in the other groups (p≤0.013). In the pre-LT group, the OHIP-14 total mean score was negatively correlated with the Mental Health, Physical Functioning, and General Health mean scores (p=0.01) and negatively and significantly (p<0.05) associated with decayed teeth and with poor workability. In the post-TL group, OHRQOL of life was associated with decayed and missing teeth, lower educational level, and poor workability.

Conclusion:

Patients in the pre- and post-LT groups presented poorer OHRQoL compared to patients without liver disease. OHRQoL was strongly correlated with HRQoL in the pre-LT group.

Effects of liver transplantation on sexual function and quality of life

This descriptive study aimed to determine patients' sexual dysfunction and quality of life before and after liver transplantation. The study was conducted with 64 patients who underwent liver transplantation at a university hospital between January 2015 and 2017. The patients were aged 18 or over, able to answer relevant questions and volunteered to participate in the study. The population of the study included patients who underwent liver transplantation on the specified dates and agreed to participate in the study. Descriptive Characteristics Form, Short Form-36 (SF-36), Female Sexual Function Index (FSFI) and International Index of Erectile Function (IIEF) were used for data collection. A significant increase was found in all subscale scores of males on the IIEF scale after transplantation (p = 0.000). The total FSFI score of the females was 24.27 ± 18.60 before transplantation and 29.62 ± 25.19 after transplantation. The results were not statistically significant (p = 0.072). After transplantation, a highly significant increase was observed in the Physical Component Summary and Mental Component Summary subscale scores of the SF-36 both in males and females (p = 0.000). An increase was observed in the sexual functions of males and females after transplantation. A statistically significant increase was found in the mean scores of both males and females on the quality of life after transplantation (p = 0.000). This study concluded that sexual functions of male (p < 0.05) and female (p > 0.05) patients improved after transplantation.

Selective internal radiation therapies for unresectable early-, intermediate- or advanced-stage hepatocellular carcinoma: systematic review, network meta-analysis and economic evaluation

BACKGROUND

Hepatocellular carcinoma is the most common type of primary liver cancer. Treatment choice is dependent on underlying liver dysfunction and cancer stage. Treatment options include conventional transarterial therapies for patients with intermediate-stage disease and systemic therapy [e.g. sorafenib (Nexavar®; Bayer plc, Leverkusen, Germany)] for patients with advanced-stage disease. Selective internal radiation therapies deliver radiation to liver tumours via microspheres that are injected into the hepatic artery. There are three selective internal radiation therapies: TheraSphere™ [BTG Ltd, London, UK (now Boston Scientific, Marlborough, MA, USA)], SIR-Spheres® (Sirtex Medical Ltd, Woburn, MA, USA) and QuiremSpheres® (Quirem Medical BV, Deventer, the Netherlands).

OBJECTIVE

To assess the clinical effectiveness and cost-effectiveness of selective internal radiation therapies for treating patients with unresectable early-, intermediate- or advanced-stage hepatocellular carcinoma.

METHODS

A search was undertaken to identify clinical effectiveness literature relating to selective internal radiation therapies and relevant comparators for the treatment of hepatocellular carcinoma. Studies were critically appraised and summarised. The network of evidence was mapped to estimate the relative effectiveness of the different selective internal radiation therapies and comparator treatments. An economic analysis evaluated the cost-effectiveness.

RESULTS

Twenty studies were included in the clinical effectiveness review. Two large randomised controlled trials rated as having a low risk of bias [SARAH: Vilgrain V, Pereira H, Assenat E, Guiu B, Ilonca AD, Pageaux GP, et al. Efficacy and safety of selective internal radiotherapy with yttrium-90 resin microspheres compared with sorafenib in locally advanced and inoperable hepatocellular carcinoma (SARAH): an open-label randomised controlled Phase 3 trial. Lancet Oncol 2017;18:1624-36; and SIRveNIB: Chow PKH, Gandhi M, Tan SB, Khin MW, Khasbazar A, Ong J, et al. SIRveNIB: selective internal radiation therapy versus sorafenib in Asia-Pacific patients with hepatocellular carcinoma. J Clin Oncol 2018;36:1913-21] found no significant difference in overall survival or progression-free survival between SIR-Spheres and sorafenib (systemic therapy) in an advanced population, despite greater tumour response in the SIR-Spheres arm of both trials. There were some concerns regarding generalisability of the SARAH and SIRveNIB trials to UK practice. All other studies of SIR-Spheres, TheraSphere or QuiremSpheres were either rated as being at a high risk of bias or caused some concerns regarding bias. A network meta-analysis was conducted in adults with unresectable hepatocellular carcinoma who had Child-Pugh class A liver cirrhosis and were ineligible for conventional transarterial therapies. The analysis included the SARAH and SIRveNIB trials as well as a trial comparing lenvatinib (Kisplyx®; Eisai Ltd, Tokyo, Japan) (systemic therapy) with sorafenib. There were no meaningful differences in overall survival between any of the treatments. The base-case economic analysis suggested that TheraSphere may be cost-saving relative to both SIR-Spheres and QuiremSpheres. However, incremental cost differences between TheraSphere and SIR-Spheres were small. In a fully incremental analysis, which included confidential Patient Access Scheme discounts, lenvatinib was the most cost-effective treatment and dominated all selective internal radiation therapies. In pairwise comparisons of sorafenib with each selective internal radiation therapy, sorafenib also dominated all selective internal radiation therapies.

LIMITATIONS

The existing evidence cannot provide decision-makers with clear guidance on the comparative effectiveness of treatments in early- and intermediate-stage hepatocellular carcinoma or on the efficacy of TheraSphere or QuiremSpheres.

CONCLUSIONS

In the advanced-stage hepatocellular carcinoma population, two large randomised trials have shown that SIR-Spheres have similar clinical effectiveness to sorafenib. None of the selective internal radiation therapies was cost-effective, being more costly and less effective than lenvatinib, both at list price and with Patient Access Scheme discounts.

FUTURE WORK

Future studies may wish to include early- and intermediate-stage hepatocellular carcinoma patients and the low tumour burden/albumin-bilirubin 1 subgroup of advanced-stage patients. Future high-quality studies evaluating alternative selective internal radiation therapies would be beneficial.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42019128383.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 48. See the NIHR Journals Library website for further project information.

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.

Emerging drugs for the treatment of primary biliary cholangitis

INTRODUCTION

Primary biliary cholangitis (PBC) is a progressive inflammatory autoimmune cholestatic liver disease. Without treatment, it may result in fibrosis and eventually end stage liver disease. In addition to the disease burden, the symptom impact on the quality of life for PBC patients is significant. Ursodeoxycholic acid, and the second-line therapy, Obeticholic acid, are the only available licensed treatments. Although there has been rapid development of novel therapies in recent years for the treatment of PBC, there are very few symptoms directed therapies.

AREA COVERED

This literature review aims to review the current treatment landscape in PBC and to explore how the next few years may unfold in the field. The current guidelines and emerging therapies in phase 2, 3 and 4 clinical trials have been included.

EXPERT OPINION

The currently available therapies are effective, but their use has limitations and challenges and there is still significant unmet need. Although there have been promising therapeutic interventions in recent years, further research into personalizing therapeutic strategies with available treatments and new agents is needed.

An exploratory study of the experiences of deceased-donor liver transplant recipients and their need for psychotherapeutic support

AIMS AND OBJECTIVES

This study aimed to explore the experiences of liver transplant recipients during their journey through the treatment and their need for psychotherapeutic support related to this process.

BACKGROUND

Over time, measures of survival and quality of life in liver transplant recipients have continued to improve but their emotional needs remain under explored. In the longer-term recovery from transplantation, the focus shifts from physical health to psychological health. In the UK, there are no known embedded adult psychological services in liver transplant centres to react to this need.

DESIGN

A qualitative descriptive design was used.

METHODS

Grounded theory analysis was used to study the narratives of six adult liver transplant recipients. Through a process of coding, conceptual categories were established to describe the participant experiences. The study adhered to the EQUATOR checklist, SRQR.

RESULTS

Four categories emerged that were related to the experience of liver transplantation for the recipients. These were a process of adjustment, the phenomenon of waiting, liver transplant as a transformative experience and on the value of support. The participants identified a lack of psychotherapeutic support provided by the liver transplant service and felt that an embedded psychotherapeutic service would promote accessing such support during challenging times.

CONCLUSION

Through the process of liver transplantation, recipients experience challenges with adjustment, waiting, feeling transformed and they value support with these feelings. In correlation with other studies, the findings of this study highlight the need for providing psychotherapeutic support within liver transplant services.

RELEVANCE TO CLINICAL PRACTICE

The study provides evidence to support recommendations for a conjoined psychotherapy service within liver transplant services to support patients with their holistic needs.

Physical Function, Physical Activity, and Quality of Life After Liver Transplantation

Robust physical activity after liver transplantation is an important determinant of longterm health, similar in its importance to the value of pretransplant activity for withstanding the immediate stress of transplantation. Although transplantation normally enables rapid recovery of liver synthetic and metabolic functions, the recovery of physical capacity and performance to normal levels is delayed and often incomplete. Anatomic measurements of sarcopenia and the physical performance indicators of frailty both tend to improve slowly, and they may, in fact, decrease further in the posttransplant period, especially when the common extrahepatic drivers of muscle loss, such as the elements of the metabolic syndrome, persist or intensify after transplantation. Posttransplant exercise improves fitness, which is a conclusion based on 2 observational studies and 3 randomized trials that assessed endpoints of strength testing, energy expenditure in metabolic equivalents, and peak or maximal oxygen uptake. Importantly, 1 controlled trial found that exercise also improved quality of life (QOL) measured by the Short Form 36 survey, consistent with multiple reports of the value of social support and engagement in sports activity for improving posttransplant QOL. Developing evidence-based standards for post-liver transplant physical activity baseline testing and sustainment of intensity and quality is a key unmet need in transplant hepatology. At present, it is reasonable for transplant teams to assess fitness and design a tailored exercise program when a recipient is first discharged, to record and reinforce progress at all posttransplant visits, and to set realistic longterm performance goals that will often achieve recommended standards for the healthy general population.

Telemedicine Based Remote Home Monitoring After Liver Transplantation: Results of a Randomized Prospective Trial

OBJECTIVE

This study assesses the impact of a telemedicine-based home management program (THMP) on patient adherence, hospital readmissions, and quality of life (QOL) after liver transplantation (LT).

SUMMARY OF BACKGROUND DATA

Telemedicine interventions represent an opportunity to personalize care and can lead to improved adherence and patient satisfaction. However, there is limited data on impact of these interventions on outcomes after LT. Therefore, we conducted the first randomized controlled trial (RCT) of a THMP compared to standard of care (SOC) after LT.

METHODS

One hundred six consecutive LT recipients were randomized (1:1) to 1 of 2 posttransplant care strategies: SOC or THMP. The THMP included an electronic tablet and bluetooth devices to support daily text messages, education videos, and video FaceTime capability; data was cyber-delivered into our electronic medical record daily. Endpoints were THMP participation, 90-day hospital readmission rate, and QOL.

RESULTS

One hundred patients completed the study with 50 enrolled in each arm. Participation and adherence with telemedicine was 86% for basic health sessions (vital sign recording), but only 45% for using messaging or FaceTime. The THMP group had a lower 90-day readmission rate compared to SOC (28% vs 58%; P = 0.004). The THMP cohort also showed improved QOL in regards to physical function (P = 0.02) and general health (P = 0.05) at 90 days.

CONCLUSIONS

To our knowledge, this is the first RCT demonstrating the impact of THMP after LT. The magnitude of effect on LT outcomes, hospital readmissions, and QOL suggests that the adoption of telemedicine has great potential for other major operations.

A Scoping Review of Key Health Items in Self-Report Instruments Used Among Solid Organ Transplant Recipients

The overall aim of this scoping review of the literature is twofold: (1) to provide an overview of all instruments that have been used to assess health-related quality of life (HRQoL) after solid organ transplantation and (2) to provide a list of health items they include to support future studies on the development of a new-generation HRQoL instrument. All studies that administered any form of HRQoL instrument to post-transplant solid organ recipients were identified in a comprehensive search of PubMed (MEDLINE), Embase, and Web of Science, with a cut-off date of May 2018. The search used various combinations of the following keywords: lung, heart, liver, kidney, or pancreas transplantation; quality of life; well-being; patient-reported outcome; instrument; questionnaire; and health survey. In total, 8013 distinct publications were identified and 1218 of these were selected for review. Among the instruments applied, 53 measured generic, 51 organ-specific, 271 domain-specific, and 43 transplant-specific HRQoL. A total of 78 distinct health items grouped into 16 sub-domains were identified and depicted graphically. The majority of publications did not report a logical rationale for the choice of specific HRQoL instrument. The most commonly used types of instruments were generic health instruments, followed by domain-specific instruments. Despite the availability of transplant-specific instruments, few studies applied these types of instruments. Based on the 78 items, further research is planned to develop a patient-centered, transplant-specific HRQoL instrument that is concise, easy to apply (mobile application), and specifically related to the health issues of solid organ recipients.

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.

Pictorial Representation of Illness and Self Measure (PRISM): A Novel Visual Instrument to Quantify Suffering in Liver Cirrhosis Patients and Liver Transplant Recipients

Background

The level of suffering of chronically ill patients does not necessarily correlate with illness severity. In this study, we evaluated the burden of suffering and its impact on health-related quality of life in liver transplant recipients and liver cirrhosis patients.

Material/Methods

The Pictorial Representation of Illness and Self Measure (PRISM) was used to explore levels of suffering in outpatients of Münster University Hospital, Germany. Self-illness separation scores were analyzed as a measure of disease-specific burden of suffering. Health-related quality of life was measured using the Short Form Health Survey (SF-36).

Results

Data from 201 subjects were statistically analyzed. Median Self-illness separation scores for liver transplant recipients and patients with liver cirrhosis were 13.5 (minimum/maximum: 0.2/25.6) cm and 6.3 (0.1/25.6) cm (p<0.001), respectively. The median SF-36 Mental Component Summary and Physical Component Summary scores were 46.4 (12.5/66.2) and 40.1 (12.3/61.1), respectively. Higher health-related quality of life was associated with greater self–illness separation. Liver transplant recipients showed normal Mental Component Summary scores compared with the general German population; patients with liver cirrhosis had significantly lower Mental Component Summary scores. Physical Component Summary scores were significantly higher in liver transplant recipients than in patients with liver cirrhosis, but still lower than in the general population.

Conclusions

PRISM is a novel, simple tool for measuring the illness burden in liver transplant recipients and patients with liver cirrhosis. This measure may help to identify patients at a higher risk of psychological disorders.

Health-related quality of life burden of nonalcoholic steatohepatitis: a robust pragmatic literature review

Objective

Nonalcoholic steatohepatitis (NASH) is a form of chronic liver disease (CLD): patients have an increased risk of developing cirrhosis, liver failure, and complications (e.g. hepatocellular carcinoma). NASH has a high clinical burden, and likely impairs patients' health-related quality of life (HRQoL), but there are currently no licensed therapies. The objective of this robust pragmatic literature review was to identify and describe recent studies on the HRQoL burden of NASH from the patient perspective.

Methods

English-language primary research studies were identified that measured HRQoL in adults with NASH (population-based studies or clinical trials of pharmacological therapy). Searches were conducted in the following bibliographical databases: MEDLINE, EMBASE, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE), and Health Technology Assessment Database (HTA). Abstracts from selected congresses (2015/2016) were hand searched. Articles were assessed for relevance by two independent reviewers, and HRQoL data were extracted.

Results

A total of 567 de-duplicated abstracts were identified, and 20 full-text articles were reviewed. Eight studies were included: five quantitative, two interventional, and one qualitative. The quantitative and interventional studies measured HRQoL using the Short-Form 36 (SF-36) and the Chronic Liver Disease Questionnaire (CLDQ), and the qualitative study involved focus groups and individual interviews. Overall, the studies showed that NASH affects HRQoL, especially physical functioning, with many patients reporting being fatigued. In quantitative studies, overall, patients with NASH had a reduced HRQoL versus normative populations and nonalcoholic fatty liver disease (NAFLD) patients, but not versus chronic liver diseases. A longitudinal study showed that when weight loss was achieved, HRQoL improvement over 6 months was greater in patients with NASH versus NAFLD. Qualitative research suggested that, in addition to fatigue, other symptoms are also burdensome, having a broad negative impact on patients' lives. The impact of pharmacological treatment on HRQoL was explored in only two included studies.

Conclusions

HRQoL is impaired in patients with NASH. Patients experience a range of symptoms, especially fatigue, and the impact on their lives is broad. Further research is needed to understand the HRQoL burden of NASH (e.g. assessing NASH-specific impacts not captured by SF-36 and CLDQ) and the impact of future NASH therapies on HRQoL.

Impact of metabolic syndrome on quality of life of liver transplant recipients

Objective

The incidence of metabolic syndrome (MS) increases after liver transplantation. This study was performed to evaluate the impact of MS on patients’ quality of life after liver transplantation.

Methods

We collected the medical records of 152 patients during their post-liver transplantation outpatient follow-up. Quality of life was assessed using the Medical Outcomes Study 36-Item Short Form Health Survey. Data on the patients’ general condition as well as MS-related indicators were assessed in all patients. Based on the MS diagnostic criteria proposed by the International Diabetes Federation in 2005, the patients were divided into two groups: those with and without MS. We then analyzed the factors influencing MS and their impact on the patients’ quality of life.

Results

After liver transplantation, age and underlying liver disease were significantly associated with MS and diabetes, and sex and body mass index were associated with central obesity. Central obesity affected the patients’ general health (GH) score and health transition (HT) score, and hypertension affected their GH score and physical component score (PCS).

Conclusions

After liver transplantation, central obesity had a negative impact on patients’ GH score and HT score, and hypertension affected their GH score and PCS.

Physical exercise in cirrhotic patients: Towards prehabilitation on waiting list for liver transplantation. A systematic review and meta-analysis

BACKGROUND

Early survival after Liver Transplantation (LT) is reduced among sarcopenic patients. Despite, Adapted Physical Activity (APA) before LT is rarely proposed for the risk to impair portal hypertension and its resulting complications.

OBJECTIVES

To assess the effects of APA program in adults affected by End Stage Liver Disease (ESLD) on hospital stay, 1-year mortality and morbidity after LT, adverse events (Primary outcomes). Secondary outcomes were changes in VO2 peak, muscle morphology, 6minutes walking distance test (6MWD), Body Mass Index (BMI), MELD, CHILD score and Hepatic Venous Pressure Gradient (HVPG).

SEARCH METHODS

MEDLINE, EMBASE, Google Scholar and the Cochrane Library database were explored for randomized clinical trials (RCT).

DATA COLLECTION AND ANALYSIS

Data were collected by one review author on the type of study, participants, treatments used for primary and secondary outcomes. Review Manager 5.2 was used for the analysis.

MAIN RESULTS

Four RCT with 81 patients were included. Primary outcomes: no severe adverse event was observed, but no published data were available on hospital stay or mortality after LT.

SECONDARY OUTCOMES

CHILD, MELD and BMI were not worsened by physical activity. No significant muscle diameter, 6MWD and VO2 peak changes were observed after exercise. Significant reduction in HVPG in the treatment group was observed in a single study (MD-2.5mmHg; 95%CI [-04.76, -0.24]; P=0.03).

AUTHORS' CONCLUSIONS

Knowledge in this field is still at an early stage. Evidence derived from small trials of medium quality on ESLD patients suggests that APA is safe, without increasing portal hypertension. Further research is very likely to have an important impact on our confidence in the intervention effect.

Subjective Satisfaction and Quality of Life in Patients Prior to Listing for Liver Transplantation

Objectives

Differences in health-related quality of life (HR-QoL) perception between alcohol-abusing and non-substance-dependent subjects with liver cirrhosis could depend on differences in personality profile and influence management of patients awaiting liver transplant.

Methods

We compared the perceptions of disease state in 78 male patients of similar disease severity divided into 2 groups based on etiology of cirrhosis: 47% had alcoholic cirrhosis, and 53% had hepatitis C virus (HCV)-related cirrhosis without alcohol abuse. Patients’ perception of disease state was determined using the SAT-P questionnaire (a self-administered questionnaire that provides a global assessment of perceived HR-QoL and subjective well-being). The assessment yields 2 scales: an analytic scale based on 32 variables and a synthetic scale based on 5 factors.

Results

In patients with alcohol-related disease, “psychological function” was found to be more impaired, while “sleep, diet, and free time” was less impaired compared with subjects with HCV-related cirrhosis, suggesting dysfunction related to substance abuse with personality disturbance.

Conclusions

The perception of disease state is different in alcohol-abusing patients with cirrhosis compared with those with cirrhosis unrelated to alcohol.

Predictors of decision ambivalence and the differences between actual living liver donors and potential living liver donors

Background

The decision to become a living liver donor is a stressful event. Ambivalence in decision making may result in psychological distress. Thus, the purpose of this study was to provide a description of the ambivalence of potential living liver donors, to examine the predictors of ambivalence, and to compare the ambivalence of potential living liver donors with that of actual living liver donors.

Methods

This descriptive and correlational study was conducted in a medical center from August 2013 to December 2015. Self-reported questionnaires were used to collect data. A total of 263 potential living liver donors who were assessed for donation to their parents were included in this study.

Results

The mean age of the total sample was 30.7 years (SD = 6.39, range = 20–47), and males comprised 53.6% of the sample. The majority of the potential donors had a college education (70.8%) and were single (63.5%). Of the total sample, the mean score for ambivalence was 4.27 (SD = 1.87, range = 0–7). Multivariate analysis revealed that the Mental Component Summary (MCS) of quality of life (β = -0.24, p < 0.01), family support (β = -0.17, p = 0.007), and intimacy (β = -0.13, p = 0.04) were significant protective predictors of ambivalence. Actual living liver donors had significantly lower ambivalence (3.82 versus 4.60), higher intimacy with recipients (3.55 versus 3.34), higher MCS (45.26 versus 42.80), and higher family support (34.39 versus 29.79) than did the remaining potential living liver donors.

Conclusion

Ambivalence is common in potential living liver donors. The MCS of quality of life, family support, and intimacy were protective predictors in terms of ambivalence. Future research should explore other factors and design interventions targeted toward reducing ambivalence, promoting family support, and enhancing the mental dimensions of quality of life in potential living liver donors.

Changes in Muscle Strength and Six-Minute Walk Distance Before and After Living Donor Liver Transplantation

BACKGROUND

Impaired exercise capacity and muscle weakness are important characteristics of liver transplantation recipients. Perioperative rehabilitation has been introduced to promote early mobilization of patients and to prevent postoperative pulmonary complications. However, it is unknown how physical status recovers during the hospital stay after a liver transplant. The purpose of this study was to evaluate the changes in clinical indicators that represent the functional exercise capacity and muscle strength before and after living donor liver transplantation (LDLT).

METHODS

We retrospectively reviewed 21 consecutive patients who underwent LDLT with perioperative rehabilitation from April 2014 to December 2015. Twelve patients who were tested for 6-minute walk distance, hand-grip strength, and isometric knee extensor muscle strength before and 4 weeks after LDLT were enrolled.

RESULTS

At the preoperative baseline, the 6-minute walk distance significantly correlated with the Model for End-stage Liver Disease score and pulmonary functions (vital capacity, forced vital capacity, and forced expiratory volume in 1 second of predictive values). Comparisons between the preoperative and postoperative values revealed significant decreases in weight, Barthel Index, hand-grip strength, and isometric knee extensor muscle strength. Changes in hand-grip strength and isometric knee extensor muscle strength after LDLT correlated with the preoperative Model for End-stage Liver Disease score.

CONCLUSIONS

Physical functional status had not been fully recovered 4 weeks after LDLT. Further investigation regarding developing a strategy for prevention of muscle atrophy before LDLT and recovery of physical fitness after LDLT would be helpful.

Health-related quality of life after pediatric liver transplantation: A systematic review

With improved survival rates after pediatric liver transplantation (LT), attention is targeting improving the health-related quality of life (HRQOL) as an outcome metric. We conducted a systematic review of the literature to examine HRQOL after pediatric LT, focusing on assessment tools and factors associated with HRQOL. A literature search was conducted through PubMed, Web of Science, Ovid, and Google Scholar for all studies matching the eligibility criteria between January 2004 and September 2016. Titles and abstracts were screened independently by 2 authors and consensus for included studies was achieved through discussion. A total of 25 (2 longitudinal, 23 cross-sectional) studies were reviewed. HRQOL in pediatric LT recipients is lower than healthy controls, but it is comparable to children with chronic diseases or other pediatric solid organ transplant recipients. Domain scores were lowest in school functioning on the Pediatric Quality of Life Inventory (PedsQL) Generic Core Scale 4.0 and general health perception on the Child Health Questionnaire, the 2 most commonly used generic HRQOL instruments. Identified predictors of poor HRQOL include sleep disturbances, medication adherence, and older age at transplantation. Two recently validated disease-specific HRQOL tools, Pediatric Liver Transplant Quality of Life tool and the Pediatric Quality of Life Inventory 3.0 Transplant Module, have enabled enhanced representation of patient HRQOL, when used in conjugation with generic tools. Heterogeneity in study design and instruments prevented a quantitative, meta-analysis of the data. In conclusion, continued optimization of durable outcomes for this population mandates prioritization of research focusing on the gap of targeted intervention studies aimed at specific HRQOL subdomains and longitudinal studies to predict the trajectory of HRQOL over time. Liver Transplantation 23 361-374 2017 AASLD.

Pre-operative volume rather than area of skeletal muscle is a better predictor for post-operative risks for respiratory complications in living-donor liver transplantation

OBJECTIVE

To demonstrate the superiority of total psoas volume (TPV) over total psoas area (TPA) in terms of predicting post-operative complications in living-donor liver transplantation (LDLT).

METHODS

The TPA and TPV were assessed in 32 recipients who underwent CT before LDLT. The TPA was measured using an axial CT image at the level of the upper margin of the fourth lumbar vertebral body. The TPV was calculated using all the CT images from the muscle origin through the level of the pubic symphysis. Patients were divided into a sarcopenia group and no-sarcopenia group based on the medians of normalized TPA (nTPA) and normalized TPV (nTPV). We calculated the odds ratio (OR) of post-operative respiratory complications in relation to nTPA and nTPV, respectively.

RESULTS

Out of 32 recipients, 17 recipients experienced at least 1 post-operative respiratory complication. The OR for males according to nTPV [OR = 15.00, 95% confidence interval (CI) = 1.03-218.31; p = 0.031] was higher than that for nTPA (OR = 3.33, 95% CI = 0.36-30.70; p = 0.280). The OR for females according to nTPV (OR = 4.00, 95% CI = 0.56-28.40; p = 0.16) was the same as that for nTPA (OR = 4.00, 95% CI = 0.56-28.40; p = 0.16).

CONCLUSION

Pre-operative volume of the skeletal muscle might be a better predictor for post-operative risks in LDLT recipients than pre-operative area of the skeletal muscle. Advances in knowledge: Post-operative risks for respiratory complications in LDLT recipients might be evaluated more accurately by using TPV instead of TPA.

Identifying Improved and Non-improved Aspects of Health-related Quality of Life After Liver Transplantation Based on the Assessment of the Specific Questionnaire Liver Disease Quality of Life

INTRODUCTION

The specific questionnaire Liver Disease Quality of Life (LDQOL) is a valid tool for measuring quality of life (QOL) and has been used to show that liver transplantation (LT), which is an effective treatment for end-stage liver disease, may improve QOL.

OBJECTIVES

This study aims to identify aspects of QOL that improve after LT and those that do not.

PATIENTS AND METHODS

Patients accepted for LT were invited to answer the LDQOL at baseline and after transplantation at 6 and 12 months. LDQOL contains the 36-item Short Form Health Survey (SF-36) and 12 specific dimensions. Responsiveness was assessed using the paired Student t test.

RESULTS

The study included a cohort of 156 patients, 73% males, of an average age of 53 (26-67) years, with the following common indications: tumor (35%), hepatitis C (23%), and alcohol-related (21%) liver disease. Mean scores showed a statistically significant (P < .05) improvement after 1 year in 6 of 8 SF-36 dimensions, in the physical component summary score, and in 7 of 12 disease-specific dimensions. The two dimensions that showed no improvement in the SF-36 dimensions were "social functioning" and "vitality," whereas the specific dimensions to not improve were "sleep problems," "social interaction," "activities of daily living," and "concerns about the future."

CONCLUSION

Findings suggest that perceived QOL after LT improves but could be further enhanced with the use of specific programs for amending sleep disorders and physical aspects.

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.

Soluble tumor necrosis factor receptors as predictors of 1-year mortality and renal dysfunction after liver transplantation

BACKGROUND

Several risk factors influence survival after liver transplantation (LT). Some research has demonstrated a relationship between soluble tumor necrosis factor receptors (sTNFRs) and worse clinical liver disease outcomes, but there are no data showing an association between sTNFRs and outcomes after LT. The primary aim of this study was to determine whether an association exists between perioperative sTNFRs and renal dysfunction or mortality after LT.

METHODS

Data were collected prospectively from 122 patients submitted to deceased-donor orthotopic LT. Blood samples were collected at seven different perioperative times and analyzed by ELISA. The statistical analysis included univariate analysis followed by logistic regression. The predictive value of significant variables was assessed using ROC curves.

RESULTS

One-month and 1-year LT survivals were 91% and 81%, respectively. Increased levels of soluble tumor necrosis factor receptor 1 (sTNF-R1) after 24h of graft perfusion were associated with postoperative Renal Replacement Therapy (RRT) (OR 1.25) and 1-year mortality (OR 1.1). RRT was associated with 30-day and 1-year LT mortality, with OR 19.78 and 45.45, respectively.

CONCLUSION

A higher sTNF-R1 level measured 24h after graft perfusion is an independent predictor of RRT and 1-year mortality after LT.

The impact of osteoporosis on health-related quality of life in patients after liver transplantation - a pilot study

Introduction

Liver transplantation (LT) is now a well-established procedure with 5-year survival rates over 70%, and one of its ultimate goals is the improvement of patient health-related quality of life (HRQOL). Osteoporosis remains a serious potential complication of LT, leading to fragility fractures, pain, and functional impairment.

Aim

To assess the degree of osteoporosis and the impact of fragility fractures on HRQOL in patients with chronic liver diseases treated with LT.

Material and methods

Twenty-seven patients (14 female, 13 male) at a median period of 3.5 years post LT participated in the study. HRQOL was assessed by Short Form-36 and PBC-40 instruments. Bone mineral density (BMD) in the lumbar spine and hip neck were measured by dual-energy X-ray absorptiometry. Physical activity was assessed by questionnaire. Data on the duration of the liver disease, time from LT, and fragility fractures were also collected.

Results

As many as 74.1% of the patients had reduced BMD (t-score < -1.0 SD) in the hip. Mean values of the spine and hip BMD z-scores were -1.1 and -0.9 SD, respectively. Time after LT, percentage of lean tissue, and physical activity were positively associated with BMD. The prevalence of fractures was 48%. We did not find significant differences in age, gender, body composition parameters, physical activity, BMD, and HRQOL scores between the subjects with and without fractures.

Conclusions

We found a high prevalence of fragility fractures and a decreased BMD in LT recipients. Patients with a history of fractures had similar HRQOL scores to those without fractures.

Assessment of health-related quality of life in Egyptian HCV-infected recipients after living donor liver transplantation

OBJECTIVE

Understanding issues pertaining to quality of life is essential for any disease, particularly in recipients of liver transplantation. The aim of this study was to evaluate the impact of liver transplantation on Egyptian recipients' health-related quality of life (HRQOL).

METHODS

A prospective study carried out at the Ain Shams Center for Organ Transplantation (Cairo, Egypt), including 35 recipients for the evaluation of HRQOL using short form 36 score (Arabic version) and Beck Depression Inventory scores pre-transplantation and 1 and 6 months afterwards.

RESULTS

The mean age of the recipients was 49.27 ± 8.16 years. Among them, 17 patients were highly educated. A statistically significant improvement in all dimensions of their HRQOL was observed after liver transplantation. Their physical functioning was 45.00 ± 34.34 before liver transplantation while after 1 and 6 months it was 57.50 ± 20.66 and 74.83 ± 19.27, respectively (P < 0.001). All 17 patients completed their first year after transplantation, showing a statistically significant improvement in all dimensions of their HRQOL one year after liver transplantation except that in mental health, role limitation due to emotional health emotional and social functioning domains.

CONCLUSION

HRQOL is an important aspect of liver transplantation that should not be neglected.

Sleep disturbances and quality of life in patients after living donor liver transplantation

BACKGROUND

Following improvements in patient and graft survival after liver transplantation (LT), the recipients' quality of life has become an important focus of patient care. Sleep is closely related to physical and mental health; however, sleep disturbances in LT patients have not yet been evaluated.

METHODS

We assessed 59 LT patients (aged ≥18 years) between September 2011 and September 2012. The patients completed the restless legs syndrome (RLS), 36-item short-form health survey (SF-36), Pittsburgh Sleep Quality Index (PSQI), and Epworth Sleepiness Scale (ESS) questionnaires. In addition, laboratory data were obtained and neuropsychological tests (NPT) were performed during study entry.

RESULTS

Thirty-eight patients (64%) were included in the poor sleep group (PSQI ≥6 or ESS ≥10). The SF-36 scores were lower in the poor sleep group than in the good sleep group. Eleven patients (18%) had RLS. An NPT score ≥3 indicated minimal hepatic encephalopathy (MHE3). The MHE3 group consisted of 22 patients (43%). The time after LT was shorter; serum albumin, branched chain amino acid/tyrosine molar ratio (BTR), and role limitations due to poor physical health were lower; and serum ammonia levels were higher in the MHE3 group than in the MHE0-2 group. When the poor sleep group was divided into subgroups (control, MHE, RLS, and unknown), MHE patients had high model for end-stage liver disease scores, high ammonia levels, and low BTR, whereas RLS patients showed a short time after LT.

CONCLUSION

Sixty-four percent of recipients were classified as poor sleepers. SF-36 scores were lower for poor sleepers than good sleepers. RLS and MHE are major diseases that cause sleep disturbances in patients after LT.

Outcomes of pregnancy following liver transplantation: The King's College Hospital experience

Reports of pregnancy in liver transplantation (LT) patients have largely favorable outcomes. Concerns remain with regards to maternal and graft risk, optimal immunosuppression (IS), and fetal outcomes. We review all post-LT pregnancies at our center with regard to the outcomes and safety for the patient, graft, and fetus. A total of 117 conceptions occurred in 79 patients. Median age at conception was 29 years. Maternal complications included graft loss (2%), acute cellular rejection (ACR; 15%), pre-eclampsia/eclampsia (15%), gestational diabetes (7%), and bacterial sepsis (5%). ACR was significantly more common in those women who conceived within 12 months of LT (P = 0.001). The live birth rate was 73%. Prematurity occurred in 26 (31%) neonates, and 24 (29%) neonates were of low or very low birth weight. IS choice (cyclosporine versus tacrolimus) had no significant effect on pregnancy outcomes and complications. No congenital abnormalities occurred, and only 1 child born at 24 weeks had delayed developmental milestones. In conclusion, pregnancy following LT has a favorable outcome in the majority, but severe maternal risks remain. Patients should be counseled with regard to the above information so informed decisions can be made, and pregnancy must be considered high risk with regular monitoring by transplant clinicians and specialist obstetricians.