Patients Undergoing Liver Transplantation: Psychosocial Characteristics, Depressive Symptoms, and Quality of Life

Incidence and prevalence of depressive, anxiety, and insomnia symptoms among adult liver transplant recipients: A systematic review and meta-analysis

OBJECTIVE

Psychological morbidity among transplant recipients may negatively impact post-transplantation outcomes. Our objectives were to compute pooled incidence and prevalence estimates for depressive, anxiety, and insomnia symptoms among adults who underwent liver transplant.

METHODS

Electronic searches of MEDLINE, PubMed Central, CINAHL, and Google Scholar were carried out from inception to October 2022 to identify observational studies conducted among adult liver transplant recipients which measured depression, anxiety, and/or insomnia. We used the Joanna-Briggs tool for study quality appraisal.

RESULTS

Sixty-five studies (pooled N = 12,183) provided data for meta-analysis. The one-year pooled point prevalence rate for depressive symptoms was 25% (95% Confidence Intervals [CI]: 20% to 30%; I² = 94%; 37 studies; N = 6088) while that of anxiety and insomnia symptoms were 29% (95% CI: 21% to 38%; I² = 96%; 28 studies; N = 4016) and 28% (95% CI: 16% to 43%; I² = 98%; 14 studies; N = 1834), respectively. The findings remained robust across subgroup and sensitivity analyses. Most included studies had low or moderate risk of bias.

CONCLUSIONS

Depressive, anxiety, and insomnia symptoms are commonly prevalent following liver transplantation. Our findings, though limited by high heterogeneity across analyses, have important implications for screening, management, and prevention of psychological morbidity in this group.

SYSTEMATIC REVIEW REGISTRATION

This protocol was submitted for registration with the International Prospective Register of Systematic Reviews (PROSPERO) (CRD 42021276008).

Liver transplant candidates have impaired quality of life across health domains as assessed by computerized testing

INTRODUCTION AND OBJECTIVES

Liver transplantation candidates are among the most comorbid patients awaiting lifesaving intervention. Health related quality of life (HRQOL) measured by instruments that incorporate dynamic computerized adaptive testing, could improve their assessment. We aimed to determine the feasibility of administration of the Patient-Reported Outcomes Measurement Information System (PROMIS-CAT) in liver transplant candidates.

MATERIALS AND METHODS

Liver transplantation candidates were prospectively enrolled following a review of their available medical history. Subjects were given a tablet computer (iPad) to access the pre-loaded PROMIS CAT.

RESULTS

109 candidates with mean age 55.6±8.6 years were enrolled in this pilot study. Mean MELD-Na score was 16.3±6.3; 92.6% had decompensated liver disease. Leading etiologies of cirrhosis included hepatitis C (34.8%), nonalcoholic steatohepatitis (25.7%) and alcohol (21.1%). Subjects with MELD-Na score>20 had the most significant impairment in HRQOL (anxiety/fear+5.9±2.7, p=0.0289, depression+5.1±2.5, p=0.0428, fatigue+4.3±2.6, p=0.0973) and physical impairment (-7.8±2.5, p=0.0022). Stage of cirrhosis and decompensated liver disease were predictive of impaired HRQOL but Child-Pugh Turcotte score was not. Hepatic encephalopathy was the strongest independent predictor of impaired HRQOL, with significant impairment across all domains of health.

CONCLUSIONS

Liver transplant candidates have significantly impaired HRQOL across multiple domains of health as measured by PROMIS-CAT. HRQOL impairment parallels disease severity. Future study is needed to determine how best HRQOL could be systematically included in liver transplantation listing policy, especially in those candidates with hepatic encephalopathy.

Stability of Psychiatric Diagnoses in Candidates to Liver Transplantation Referred to a Consultation-Liaison Psychiatry Service

OBJECTIVE

To investigate the stability over time of the psychiatric diagnoses among candidates to liver transplantation referred to a consultation-liaison psychiatric service.

METHOD

Descriptive study, carried out at the Consultation-Liaison Psychiatry Service (CLPS) placed at the Modena (Italy) General University Hospital. All patients waiting for liver transplantation and repeatedly referred to the CLPS were enrolled. The observation period was from 1 January 2008 to 31 December 2013. Pearson's coefficients were calculated to measure diagnostic stability (index referral vs. last referral).

RESULTS

One hundred patients were assessed (males 67%; mean age 53 ± 7 years old). The mean number of referrals for patients was 3 ± 2. The stability rate of psychiatric diagnosis was 64%. The following diagnoses or conditions were all significantly stable (i.e., all featured by r > 0.5 and p < 0.05): Adjustment disorder, depressive disorder, comorbid anxiety/depressive disorder, substance use disorder (including alcohol), absence of any disorder, and presence of any disorder.

CONCLUSIONS

The good level of diagnostic stability displayed in the sample may be a function of the clinical and organizational "style" of the CLPS, namely the focus on identifying the prevailing personality traits, defensive mechanisms, and relational patterns.

Trajectories of Anxiety and Depression After Liver Transplantation as Related to Outcomes During 2-Year Follow-Up: A Prospective Cohort Study

OBJECTIVE

The aims of the study were to examine whether distinct trajectories of anxious and depressive symptoms are present among liver transplant recipients from before transplantation to 2 years afterward, to identify associated demographic, clinical, and individual characteristics, and to examine the influence of distinct trajectories on outcomes.

METHODS

A prospective, multicenter cohort study was performed among 153 liver transplant recipients. Data were retrieved using questionnaires administered before transplantation and at 3, 6, 12, and 24 months after transplantation. Clinical data were retrieved by medical record review. Latent class growth analysis was used to identify distinct trajectories. χ test, analyses of variance, and multinomial logistic regression were used to identify associated variables and the impact of the distinct trajectories on outcomes.

RESULTS

Three distinct trajectories for symptoms of anxiety (State-Trait Anxiety Inventory-short form) as well as depression (Center for Epidemiological Studies Depression Scale) were identified: "no symptoms," "resolved symptoms," and "persistent symptoms." The trajectories of persistent anxiety and depression comprised, respectively, 23% and 29% of the transplant recipients. Several clinical and individual variables were associated with the trajectories of persistent anxiety and/or depression: experiencing more adverse effects of the immunosuppressive medication, lower level of personal control, more use of emotion-focused coping, less disclosure about the transplant, and more stressful life events. The trajectories of persistent symptoms were associated with worse outcomes regarding medication adherence and health-related quality of life, but not with mortality.

CONCLUSIONS

A significant subset of transplant recipients showed persistent symptoms of anxiety and depression from before to 2 years after transplantation. These results emphasize the importance of psychosocial care in the transplant population.

Beliefs of Living Donors About Recipients' End-Stage Liver Failure and Surgery for Organ Donation

BACKGROUND

The concept of beliefs could provide a basis for how donors may perceive recipients' end-stage liver failure (ESLF) and surgery for organ donation. However, there is no such quantitative study. Therefore, the objective of this study was to explore beliefs of living donors about recipients' ESLF and surgery for organ donation.

METHODS

The sample comprised 16 living donors who donated a part of their liver to a patient who had ESLF. The data were analyzed by following established procedures for inductive qualitative analysis.

RESULTS

Analysis showed that donors' beliefs can be viewed in a number of groups. Beliefs about recipients' ESLF included diverse explanations for ESLF (blaming oneself and physicians) and physical symptoms (developmental slowing down). Beliefs about being a donor included reasons for being a donor (performing a good deed, being healed), barriers to being a donor (other people being ignorant and selfish), ways to manage these barriers (following one's gut feeling), and factors facilitating being a donor (the feeling that one does not have many people to leave behind). Beliefs about surgery for organ donation included physical effects (pain, feeling stiff). Beliefs about organ donation included views that general organ donation should be encouraged and that people's awareness should be raised.

CONCLUSIONS

Existing psychological perspectives could help to interpret some beliefs. Nevertheless, other beliefs, not previously reported, could be considered as targets for individual consultations/psycho-educational programs for fostering emotional well-being.

Higher MELD score increases the overall cost on the waiting list for liver transplantation: a micro-costing analysis based study

ABSTRACT BACKGROUND: The pre-transplant period is complex and includes lots of procedures. The severity of liver disease predisposes to a high number of hospitalizations and high costs procedures. Economic evaluation studies are important tools to handle costs on the waiting list for liver transplantation. OBJECTIVE: The objective of the present study was to evaluate the total cost of the patient on the waiting list for liver transplantation and the main resources related to higher costs. METHODS: A cost study in a cohort of 482 patients registered on waiting list for liver transplantation was carried out. In 24 months follow-up, we evaluated all costs of materials, medicines, consultations, procedures, hospital admissions, laboratorial tests and image exams, hemocomponents replacements, and nutrition. The total amount of each resource or component used was aggregated and multiplied by the unitary cost, and thus individual cost for each patient was obtained. RESULTS: The total expenditure of the 482 patients was US$ 6,064,986.51. Outpatient and impatient costs correspond to 32.4% of total cost (US$ 1,965,045.52) and 67.6% (US$ 4,099,940.99) respectively. Main cost drivers in outpatient were: medicines (44.31%), laboratorial tests and image exams (31.68%). Main cost drivers regarding hospitalizations were: medicines (35.20%), bed use in ward and ICU (26.38%) and laboratorial tests (13.72%). Patients with MELD score between 25-30 were the most expensive on the waiting list (US$ 16,686.74 ± 16,105.02) and the less expensive were those with MELD below 17 (US$ 5,703.22 ± 9,318.68). CONCLUSION: Total costs on the waiting list for liver transplantation increased according to the patient’s severity. Individually, hospitalizations, hemocomponents reposition and hepatocellular carcinoma treatment were the main cost drivers to the patient on the waiting list. The longer the waiting time, the higher the total cost on list, causing greater impact on health systems.

Family Members, Transplantation Candidates, and Patients Who Underwent Liver Transplantation Had Insufficient Information About the Procedure

INTRODUCTION

Adherence to treatment is essential for a successful liver transplantation (LT) because LT requires information, abilities, and competencies of patients and family members.

OBJECTIVES

This study sought to identify whether the information received about the LT process was enough for either patients or family members who attended a liver transplant center in a school hospital.

METHODS

This was a transversal study using questionnaires to verify received information on LT. It included 50 patients on the waiting list for LT, 50 transplanted patients, and 50 family members.

RESULTS

There was a prevalence of men (82%) among patients, age range from 19 to 67 years (average: 46.87 ± 10.99), and of women (74%) among family members, age range from 18 to 80 years (average: 43.5 ± 11.77). The majority of subjects (88%) had a low education level. The most frequent etiology of hepatic cirrhosis was viral hepatitis associated with alcohol. A significant number of the listed and transplanted patients as well as all family members reported insufficient information about the process of the transplantation. The kind of insufficient information varied according to the period of treatment. The best way to obtain information, as reported by patients and family members, was a combination of oral and written information.

CONCLUSIONS

Our data show the need for improvement in the means of delivering information to patients and family members, and an explanatory manual was created from this study.

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.

The core of social function after solid organ transplantation

BACKGROUND

Social function is a key aspect of health-related quality of life after solid organ transplantation (SOT). The focus of this study was to report how solid organ-transplanted patients change their social function after transplantation.

AIM

To investigate the main concerns associated with social function after SOT and how solid organ transplant recipients (SOTRs) deal with these concerns.

METHOD

Twenty SOTRs, 13 men and 7 women, with a mean age of 54 years (range 22-75 years) and due for their first-year follow-up were included in this study. The informants had received various types of solid organs. Data were collected through in-depth interviews, which were recorded and transcribed verbatim for analysis by the method of grounded theory (GT) developed by Charmaz.

RESULT

The GT of this study describes the efforts by the 20 SOTRs to adapt socially in order to maintain their social functioning and leading a normal life. The efforts summaries a process wherein the generated GT is present through three main categories: deconstruction, restriction and reconstruction, showing various ways to socially adapt. Through this process, a clear path of transition through adaptation is evident, starting before transplantation and continues beyond the first year after transplantation.

CONCLUSION

Social functions improved through a process of adaptation during the first year after transplantation. Working and travelling were the two most important aspects of social function. All the informants emphasised the importance of regaining a normal life, which was the outcome of a successful adaptation.

The meaning of social adaptation after solid organ transplantation

The aim of this study was to investigate the meaning of social adaptation among solid organ transplant recipients one year after transplantation. We analysed in-depth interviews from 16 solid organ transplant recipients by means of phenomenological hermeneutics. The informants comprised 11 men and five women with a mean age of 54 years, who had received a kidney, a liver or a heart. We found the organ recipients adjusted their everyday life in order to adapt socially and achieve a normal everyday life. The meaning of social adaptation comprised six main themes revealed by one structural analysis: being restricted, changing habits, re-evaluating one’s body image, redesigning life expectations and life goals, enjoying and expanding the social network and being disappointed in others. We conclude that the core meaning of social adaptation is living a normal life. Social support can be emotional or instrumental and is highly valued when it helps the organ recipient to adapt and achieve normality.

Health-related quality of life measurement in chronic liver disease patients

BACKGROUND AND OBJECTIVE

Health-related quality of life (HRQOL) is an important health indicator in medical outcome research and clinical practice. This issue tends to attract even more attention with the recent improvements of patient survival after liver transplantation. This review article aims at providing a deeper insight into practices used for evaluating HRQOL in chronic liver diseases (CLDs) and especially cirrhosis patients during different stages of the disease including liver transplantation.

MATERIALS AND METHODS

A systematic review of the MEDLINE database and Cochrane library was conducted. A search using the Medical Subject Headings (MeSH) major terms "liver disease" AND "quality of life" was applied for the period from 1966 to 2012.

RESULTS

Our review identified 1483 publications. The searched showed that significant increase of publications (from 362 to 1018) was observed during last decade (period 2003-2012) in comparison with previous. The majority of publications were in English (n=1179). The literature search and analysis provided information on the most common generic and disease-specific HRQOL instruments, which are used in CLD patients: Medical Outcomes Study Short Form-36, the National Institute of Diabetes and Digestive and Kidney Diseases Quality of Life questionnaire, the Chronic Liver Disease questionnaire, the Liver Disease Quality of Life questionnaire, and other.

CONCLUSIONS

Quality of life instruments are potentially powerful tools for evaluating the functional status, presenting gains of treatment and reflecting patients' ability to return to a normal lifestyle in CLD patients. More attention should be paid by clinicians for integrated use of clinical tests together with HRQOL instruments in liver transplantation for establishing the reference levels of mental, physical, and role-social functioning.

Social function after solid organ transplantation: An integrative review

The way organ transplant recipients depend on social interactions to develop and experience social health and well-being is similar to that of the general population. A transplant may result in a close to full recovery of health status, but the physical and social problems can persist in some patients. The focus on improving the recipients’ social participation has therefore become an important issue. The purpose of this integrative literature review was study social function after solid organ transplantation, that is, kidney, liver, lung or heart. An integrative review was performed on studies that matched the selection criteria and published in peer-reviewed journals from January 2000 to December 2014. The information from the text was extracted and patterns of social function were categorized into different subgroups that were further looked at, and five categories emerged: 1) work, 2) education, 3) daily activities and leisure, 4) social adaption and 5) barriers. The key aspects of social functioning involve five vital domains, that is, work, education, daily activities and leisure, social adaption and barriers. Returning to work appears to be the most important for the recipients independently of the transplanted organ.

Prevalence of psychological problems and associated transplant-related variables at different time periods after liver transplantation

After liver transplantation, recipients often experience psychological problems that are influenced by demographic, personal, and transplant-related variables. However, because previous studies have mostly reported on psychological problems and their influencing factors in the first years after transplantation, less is known about their prevalence and influence in the long run. The aims of this study were to examine point-prevalence rates of symptoms of anxiety, depression, and posttraumatic stress (PTS) at different time periods after transplantation and to examine the transplant-related variables associated with these problems. A cross-sectional survey was performed among 373 liver transplant recipients who received transplants between 1979 and 2009 at our center. Five clinically relevant time periods were identified: 0.5 to <2 years, 2 to <5 years, 5 to <10 years, 10 to <15 years, and ≥15 years after transplantation. The response rate was 75% (n=281). Overall, 33.4% of the respondents experienced clinically relevant symptom levels of anxiety (28.7%), depression (16.5%), or PTS (10.0%). Symptoms of anxiety and depression were more prevalent in the first 2 years and in the long term after transplantation. PTS symptoms were more prevalent in the first 5 years after transplantation. However, the prevalence rates did not differ significantly between time periods. Viral hepatitis and the number of side effects of the immunosuppressive (IS) medication were found to be associated with all psychological problems. Alcoholic liver disease was associated with anxiety and depression in the short term after transplantation. In conclusion, a significant subset of transplant recipients experience psychological problems, both shortly after transplantation and in the long run. These problems are often associated with side effects from the IS medication. Therefore, the monitoring of psychological problems, the offering of psychological counseling, and the management of the medication's side effects should be part of the routine care of transplant recipients.

Prevalence and predictors of sleep disturbance among liver diseases in long-term transplant survivors

BACKGROUND

Patients with cirrhosis are known to experience sleep disturbance, which negatively impacts health-related quality of life.

OBJECTIVE

To assess the prevalence and predictors of sleep disturbance before and after liver transplantation (LT).

METHODS

Both pre- and post-LT patients were administered the Basic Nordic Sleep Questionnaire. The primary outcome was overall sleep satisfaction; the secondary outcomes were sleep latency and sleep duration.

RESULTS

Eighty-three patients participated pre-LT and 273 post-LT. Overall, participants having completed both pre- and post-LT questionnaires reported satisfactory sleep 61% of the time before LT and 65% of the time after LT. However, on review of all questionnaires, patients with alcoholic liver disease (ETOH) experienced dramatically less sleep disturbance (OR 0.13 [95% CI 0.03 to 0.60]) post-LT, whereas those with hepatitis C remained without improvement (OR 0.90 [95% CI [0.38 to 2.15]). On logistic regression, patients with ETOH had statistically less sleep satisfaction pre-LT (OR 5.8 [95% CI 1.0 to 40.5]) and significantly better sleep satisfaction post-LT (OR 0.50 [95% CI 0.20 to 1.00]) compared with those with hepatitis C. In addition, both ETOH and other conditions had significantly better sleep latency than hepatitis C patients.

CONCLUSIONS

Sleep parameters for patients who undergo LT for hepatitis C do not improve following LT as much as they do in patients transplanted for ETOH. Following LT, patients transplanted for ETOH are significantly more satisfied with their sleep than those transplanted for hepatitis C. Physicians should address and manage sleep quality after LT, so as to ultimately improve quality of life.

The power of the liver transplant waiting list: a case presentation

End-stage liver disease (ESLD), the final stage of chronic liver disease, is treated with liver transplant. Many patients have serious ESLD-related complications and are admitted to the intensive care unit for treatment. Such patients are temporarily unsuitable to undergo transplant surgery and are placed into a temporarily inactive category, "status 7," on the transplant waiting list. Status 7 patients account for about 15% of all patients on the list. To describe the experience of a status 7 patient on the liver transplant waiting list from the perspectives of family members, 38 hours of bedside observation of participants, 9 semistructured interviews with 6 family members, and 9 semistructured interviews with 8 health care professionals from nursing, medicine, and other health care disciplines were done. Data were analyzed via conventional content analysis. Family members' perspectives fit into 3 phases that correspond to the progression of the patient's clinical condition: dealing with crisis, confusion and frustration, and back on the road to transplant. All 3 phases related to 1 goal: getting the patient's status reactivated on the liver transplant waiting list. This case exposes the struggles that patients with ESLD and their families may go through during the status 7 period and could serve as a starting point for further examination of this period.

Liver transplantation in older adults

Liver transplantation is the only definitive treatment therapy for end-stage liver disease. In the United States, approximately 15% of annual liver transplant recipients are 65 or older. The most common postoperative complications are infection, acute graft rejection, and acute renal failure. To prevent complications, recipients are treated with immunosuppressive medications and anti-infective agents. The long-term complications of liver transplantation are a consequence of long-term use of immunosuppressive medications and recurrence of the original disease in the liver. Nurses play a critical role in supporting and educating recipients and their primary support persons about post-transplant follow-up care, including laboratory test schedules, medication management, and infection prevention. Strict compliance with follow-up care provides the greatest possibility of avoiding complications or organ rejection.

Prevalence of psychiatric disorders and suicidal ideation in liver transplanted patients: a cross-sectional study

AIM

Liver transplantation is the first choice treatment for terminal liver disease, but its success is strictly related to the adherence to immunosuppressive therapy. Psychiatric disorders can decrease both adherence and quality of life of liver transplanted patients. We aimed to assess prevalence of post-transplant psychiatric disorders in liver transplanted patients and its association with quality of life, adherence, suicidal ideation.

METHODS

Psychiatric examination was performed with an internationally validated structured clinical interview: Mini International Neuropsychiatric Interview Plus. Quality of life was assessed using The Short Form (36) Health Survey (SF36). Adherence was established by the Siegal scale, a 7-point self-reported scale, and by collateral reports of relatives and transplant clinicians. The Scale for Suicide Ideation (SSI) was used for suicidal risk assessment.

RESULTS

Fifty-one liver transplanted patients (mean age: 60.06 years, SD: 6.49) were enrolled. Thirty patients (58.82%) suffered from one or more psychiatric disease. Patients diagnosed with psychiatric disease displayed worse scores at SSI (P=0.032) and at several SF36 items: physical health (P=0.038), vitality (P=0.012), social activities (P=0.027), emotional state (P=0.031), mental health (P=0.014). Both patients with major depression and patients with two or more psychiatric disorders displayed lower adherence (P≤0.001 and P=0.002). Diagnosis of major depression was associated with female sex (P=0.021), aggressiveness (P=0.042), chronic rejection (P=0.011).

CONCLUSIONS

We confirm the high prevalence of psychiatric disease in our cohort of liver transplanted patients. The presence of psychiatric disease is associated with decreased quality of life and increased suicide ideation. Patients with major depression should be considered significantly at risk for non-adherence.

Posttransplant sarcopenia: an underrecognized early consequence of liver transplantation

Liver transplantation is believed to reverse the clinical and metabolic abnormalities of cirrhosis. Reduced skeletal muscle mass or sarcopenia contributes to increased mortality and adverse consequences of cirrhosis. Failure of reversal of sarcopenia of cirrhosis after liver transplantation is not well recognized. Six temporally, geographically, and methodologically distinct follow-up studies in 304 cirrhotics reported conflicting data on changes in indirect measures of skeletal muscle mass after transplantation. Distinct measures of body composition but not skeletal muscle mass were used and did not focus on the clinical consequences of sarcopenia after transplantation. A number of studies reported an initial rapid postoperative loss of lean mass followed by incomplete recovery with a maximum follow-up of 2 years. Posttransplant sarcopenia may be responsible for metabolic syndrome and impaired quality of life after liver transplantation. Potential reasons for failure to reverse sarcopenia after liver transplantation include use of immunosuppressive agents [mammalian target of rapamycin (mTOR) and calcineurin inhibitors] that impair skeletal muscle growth and protein accretion. Repeated hospitalizations, posttransplant infections, and renal failure also contribute to posttransplant sarcopenia. Finally, recovery from muscle deconditioning is limited by lack of systematic nutritional and physical-activity-based interventions to improve muscle mass. Despite the compelling data on sarcopenia before liver transplantation, the impact of posttransplant sarcopenia on clinical outcomes is not known. There is a compelling need for studies to examine the mechanisms and consequences of sarcopenia post liver transplantation to permit development of therapies to prevent and reverse this disorder.

Liver transplant recipients quality of life instrument: development and psychometric testing

BACKGROUND

Liver transplantation is a life-saving intervention for many patients with end-stage liver disease. In the past, evaluation of successful liver transplantation was based on patients' survival rate. However, in recent years this evaluation has been based on patients' quality of life. Various instruments have been developed to evaluate patients' quality of life. Nonetheless, scholars still believe that it is crucial to develop a standardized and disease specific instrument for evaluating the quality of life in liver transplant recipients.

OBJECTIVES

The aim of this paper was to describe the development and psychometric testing process of a quality of life instrument specific to liver transplant recipients.

MATERIALS AND METHODS

Initial items of this instrument were extracted from a conventional content analysis study, and then were completed with findings of related international literature. The face validity was assessed by interviewing with four liver transplant recipients, and the content validity was evaluated by eleven experts in the field of transplantation. The construct validity was achieved by involving 250 liver transplant recipients through exploratory factor analysis method, and reliability was calculated by Cronbach's alpha.

RESULTS

Three main factors with 40 items were extracted from the exploratory factor analysis: Health Satisfaction, Concerns, and Complications. Reliability of the instrument was confirmed (alpha = 0.922).

CONCLUSIONS

Given the special considerations regarding liver transplant recipients, this questionnaire is more accurate in evaluating the success of liver transplantation.

Quality of life, risk assessment, and safety research in liver transplantation: new frontiers in health services and outcomes research

PURPOSE OF REVIEW

In this review, we briefly summarize three fruitful, emerging areas in liver transplantation research, quality of life; risk assessment; and patient safety. Our goal is to highlight recent findings in these areas, with a call for increased integration of social scientists and transplant clinicians to address how best to shape policy and improve outcomes.

RECENT FINDINGS

After liver transplantation, recipients generally experience clinically significant, sustained improvement in their physical, social and emotional well being. However, a sizeable minority of patients do experience excess morbidity that may benefit from ongoing surveillance and/or intervention. There is growing body of research that describes risks associated with liver transplantation, which can be useful aids to better inform decision making by patients, clinicians, payers, and policy makers. In contrast, there has been a relative lack of empirical data on transplant patient safety vulnerabilities, placing the field of surgery in stark contrast to other high-risk industries, wherein such assessments inform continuous process improvement.

SUMMARY

Health services and outcomes research has grown in importance in the liver transplantation literature, but several important questions remain unanswered that merit programmatic, interdisciplinary research.

Quality of life, depression, and psychosocial characteristics of patients awaiting liver transplants

BACKGROUND

The identification of the psychological issues that impair the quality of life and the adherence to treatment in transplant candidates are important.

OBJECTIVE

This study evaluated the presence of symptoms of depression and the quality of life of liver transplant candidates.

METHODS

One hundred liver transplant candidates underwent a psychological analysis using the following instruments: the short form-36 (SF-36) quality of life questionnaire, the Beck depression inventory (BDI), and Structured Interviews for liver transplant candidates.

RESULTS

Seventy-three (73%) of the patients were males. Interestingly, 63% of the patients were in a domestic partnership. At the time of the evaluation, 55 patients were not working due to illness, 27 patients were actively working, and 11 patients were retired. Importantly, fears related to the transplant (e.g., fear the surgery and of death) were identified in 38% of the patients. The data from this study demonstrated a significant negative correlation between depressive scores (BDI) and seven of the eight areas of quality of life (SF-36), such as functional capacity (r = .317, P = .0013), social aspects (r = -.469, P < .0001), economic aspects (r = -.319, P = .0012), and mental health (r = -.3832, P < .0001).

CONCLUSION

The data indicated that the psychological aspects related to transplants require psychological intervention because they can affect the recuperation process, the quality of life, and the adherence to treatment for potential transplant patients.

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.

Quality of life and physical activity in liver transplantation patients: results of a case-control study in Italy

The aim of the study was to assess the quality of life (QOL) and the physical activity of liver transplant recipients compared with the general population. The case-controlled pilot study was accomplished through the administration of 2 questionnaires: 36-item Medical Outcomes Study, Short-Form General Health Survey (SF-36) for quality of life (10 scores) and International Physical Activity Questionnaire (IPAQ) to estimate the physical activity (metabolic equivalent score). Fifty-four patients who underwent liver transplantation using the piggyback technique and 108 controls from the general population at the orthopedic ambulatories were enrolled between 2002 and 2009. Participants had a mean age of 55 years (range, 41-73). The multivariate analysis showed significant differences for some scales of the SF-36: liver transplant recipients displayed lower values for "Mental Composite Score" (P = .043), "physical activity" (P = .001), "role limitations due to physical health" (P = .006), "role limitations due to the emotional state" (P = .006), and "mental health" (P = .010). The metabolic equivalent positively associated with all examined SF-36 scales. The present study focused on the QOL and physical activity of liver transplant recipients, demonstrating that transplant recipients scored lower than the general population. Liver transplantation may allow full recovery of health status, but the physical and social problems persist in some patients. Interventions aimed at improving rehabilitation programs, regular psychosocial support, and follow-up in all phases of treatment may give patients a more satisfying lifestyle after transplantation.

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.

The impact of biopsychosocial factors on quality of life: women with primary biliary cirrhosis on waiting list and post liver transplantation

OBJECTIVES

Primary biliary cirrhosis (PBC) is the second most common reason for liver transplants among women in the USA. While survival rates are high, there is evidence of persistent problems post-transplant. This study aimed to identify significant contributors to quality of life (QOL) for women with PBC on waiting list (WL) and post-transplant (PT) and compare QOL in each group with US population norms.

DESIGN

A cross-sectional, two-group study design was used.

METHODS

WL and PT participants were recruited through medical centres and on-line. QOL was measured by the Short Form-36 and an indicator of Social QOL created for this study. A biopsychosocial model incorporating demographic, biomedical, psychological, and sociological factors guided choice of variables affecting QOL. Analyses examined (1) all factors for differences between WL and PT groups, (2) association between factors and QOL outcomes within each group, (3) multivariate regression of QOL on factors in the model for the sample as a whole, and (4) comparison of QOL outcomes with national norms.

RESULTS

One hundred women with PBC participated in the study, 25 on WL and 75 PT. Group comparisons showed improvement for PT participants in most biomedical and psychological variables and in QOL outcomes. QOL was related to many, but not all, of the variables in the model. In multivariate analysis, Fatigue, Depression, Coping, and Education - but not Transplant Status - were identified as indicators of QOL. Physical QOL improved significantly after 5 years PT, when it was no longer worse than national norms. Mental QOL remained worse than national norms despite distance in time from transplant.

CONCLUSIONS

The model proved useful in identifying a range of factors that contributed to QOL for women with PBC before and after transplant. Recommendations were made for clinical practice to improve QOL through a combination of treatment and self-management.

Reduction in functional ability is significant postliver transplantation compared with matched liver disease and community dwelling controls

We compared functional ability and symptom severity in liver transplant recipients and matched chronic liver disease (CLD) and community controls. A total of 103/140 consecutive liver transplant recipients from a single centre (73%) and matched controls completed the patient-reported functional outcome measure: Patient-Reported Outcomes Measurement Information System, Health Assessment Questionnaire (PROMIS HAQ). Symptoms frequently seen in CLD were quantified by (i) Fatigue Impact Scale (FIS), (ii) Orthostatic Grading Scale (OGS: autonomic dysfunction), (iii) Cognitive Failures Questionnaire (CFQ) and (iv) Epworth Sleepiness Scale (ESS: Daytime somnolence). Liver transplant recipients exhibited significant reduction in function (P<0.0001) across all domains of the PROMIS HAQ suggesting that functional impairment is broad-based. Seventy-seven per cent of all postliver transplants identified some difficulty with activities of daily living. There was no relationship between PROMIS HAQ and liver biochemistry (r²=0.04, P=NS) or time since transplant (r² =0.1, P=NS). Elevation in PROMIS HAQ (and therefore functional impairment) strongly associated with symptoms, particularly fatigue, cognitive impairment and daytime somnolence. Fatigue severity was independently associated with functional impairment (FIS) (Beta 0.727, P < 0.0001). Symptoms or functional ability was not different between liver transplant recipients and matched chronic liver disease controls. Although survival postliver transplantation is improving, our cross-sectional study suggests that functional ability may not improve postliver transplantation. Further study is warranted to address the mechanisms responsible for post-transplant functional impairment and to develop effective rehabilitation regimes to maximize function following liver transplantation.

A time series analysis performed on a 25-year period of kidney transplantation activity in a single center

Following the example of many Western countries, where a "minimum volume rule" policy has been adopted as a quality parameter for complex surgical procedures, the Italian National Transplant Centre set the minimum number of kidney transplantation procedures/y at 30/center. The number of procedures performed in a single center over a large period may be treated as a time series to evaluate trends, seasonal cycles, and nonsystematic fluctuations. Between January 1, 1983, and December 31, 2007, we performed 1376 procedures in adult or pediatric recipients from living or cadaveric donors. The greatest numbers of cases/y were performed in 1998 (n = 86) followed by 2004 (n = 82), 1996 (n = 75), and 2003 (n = 73). A time series analysis performed using R Statistical Software (Foundation for Statistical Computing, Vienna, Austria), a free software environment for statistical computing and graphics, showed a whole incremental trend after exponential smoothing as well as after seasonal decomposition. However, starting from 2005, we observed a decreased trend in the series. The number of kidney transplants expected to be performed for 2008 by using the Holt-Winters exponential smoothing applied to the period 1983 to 2007 suggested 58 procedures, while in that year there were 52. The time series approach may be helpful to establish a minimum volume/y at a single-center level.

Patients on the waiting list for liver transplantation: caregiver burden and stress

Over the last few decades, informal caregivers of patients with chronic diseases have received more attention, and there is a growing volume of studies demonstrating high rates of burden, stress, and mental disorders in this group of individuals. The objective of this study was to evaluate the burden, stress, and psychosocial characteristics of informal caregivers of liver transplantation candidates. Participants were assessed by individual evaluations with the following instruments: a semistructured interview, the Caregiver Burden Scale, the Inventário de Sintomas de Stress para Adultos de Lipp, and the Beck Depression Inventory. The Mann-Whitney test was used for statistical analysis with a significance level of 0.05. The characteristics of the study group (n = 61) were similar to those of groups in other studies with respect to gender (82% were women), kinship (64% were spouses), and age (the mean age was 47.6 years). The main stressors identified by the participants were as follows: doubts about ways to react in a crisis or in emergency situations (42.6%), mood swings of the patient (29.5%), and care involving food and medications (27.9%). Approximately 25% of the caregivers reported that they felt unprepared to adequately perform their roles. Data analysis indicated a greater burden overall on caregivers when the patient's Model for End-Stage Liver Disease score was greater than or equal to 15 points (P = 0.041). Furthermore, caregivers of patients with alcoholic liver disease showed higher depression (P = 0.034) and overall burden scores (P = 0.031) versus caregivers of patients with liver disease due to other etiologies. In conclusion, the participants showed significantly high levels of burden, stress, and depression. Support measures and caregiver preparation should be implemented by health care providers.

A review of quality of life instruments used in liver transplantation

With improvements in patient and graft survival after liver transplantation, recipient quality of life (QOL) has become an important focus of patient care and clinical outcomes research. To provide a better understanding of the instruments used to assess QOL in the adult liver transplant population, we conducted a systematic review of the MEDLINE database and Cochrane library. Our review identified 128 relevant articles utilizing more than 50 different QOL instruments. Generic health status instruments are the most commonly used, and among them the Medical Outcomes Study Short Form-36 (SF-36), the Hospital Anxiety and Depression Scale (HADS), and the Beck Depression Inventory (BDI) are the most prevalent. Few studies (16%) included targeted, disease-specific instruments. The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Quality of Life questionnaire, the Liver Disease Quality of Life questionnaire, and the Chronic Liver Disease questionnaire are the most frequently employed targeted instruments; however, these instruments have been designed to assess QOL in patients with chronic liver disease rather than patients after liver transplantation. The present review focuses on the psychometric properties of the existing QOL instruments and discusses their individual strengths and limitations in evaluating liver transplantation recipients. The lack of a gold-standard QOL instrument for liver transplant recipients is an impediment to cross-study comparisons. We conclude that the development of a QOL instrument specifically for liver transplant recipients will improve QOL assessment in this population leading to a more nuanced understanding of the factors that influence transplant recipients' well-being.