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Qian Q, Wu Y, Cui N, Li Y, Zhou Y, Li Y, Lian M, Xiao X, Miao Q, You Z, Wang Q, Shi Y, Cordell HJ, Timilsina S, Gershwin ME, Li Z, Ma X, Ruqi Tang. Epidemiologic and genetic associations between primary biliary cholangitis and extrahepatic rheumatic diseases. J Autoimmun 2024; 148:103289. [PMID: 39059058 DOI: 10.1016/j.jaut.2024.103289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 07/14/2024] [Accepted: 07/14/2024] [Indexed: 07/28/2024]
Abstract
Patients with primary biliary cholangitis (PBC) commonly experience extrahepatic rheumatic diseases. However, the epidemiologic and genetic associations as well as causal relationship between PBC and these extrahepatic conditions remain undetermined. In this study, we first conducted systematic review and meta-analyses by analyzing 73 studies comprising 334,963 participants across 17 countries and found strong phenotypic associations between PBC and rheumatic diseases. Next, we utilized large-scale genome-wide association study summary data to define the shared genetic architecture between PBC and rheumatic diseases, including rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), systemic sclerosis (SSc) and Sjögren's syndrome (SS). We observed significant genetic correlations between PBC and each of the four rheumatic diseases. Pleiotropy and heritability enrichment analysis suggested the involvement of humoral immunity and interferon-associated processes for the comorbidity. Of note, we identified four variants shared between PBC and RA (rs80200208), SLE (rs9843053), and SSc (rs27524, rs3873182) using cross-trait meta-analysis. Additionally, several pleotropic loci for PBC and rheumatic diseases were found to share causal variants with gut microbes possessing immunoregulatory functions. Finally, Mendelian randomization revealed consistent evidence for a causal effect of PBC on RA, SLE, SSc, and SS, but no or inconsistent evidence for a causal effect of extrahepatic rheumatic diseases on PBC. Our study reveals a profound genetic overlap and causal relationships between PBC and extrahepatic rheumatic diseases, thus providing insights into shared biological mechanisms and novel therapeutic interventions.
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Affiliation(s)
- Qiwei Qian
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, NHC Key Laboratory of Digestive Diseases, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai, China
| | - Yi Wu
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, NHC Key Laboratory of Digestive Diseases, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai, China
| | - Nana Cui
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, NHC Key Laboratory of Digestive Diseases, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai, China
| | - Yikang Li
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, NHC Key Laboratory of Digestive Diseases, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai, China
| | - Yujie Zhou
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, NHC Key Laboratory of Digestive Diseases, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai, China
| | - You Li
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, NHC Key Laboratory of Digestive Diseases, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai, China
| | - Min Lian
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, NHC Key Laboratory of Digestive Diseases, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai, China
| | - Xiao Xiao
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, NHC Key Laboratory of Digestive Diseases, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai, China
| | - Qi Miao
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, NHC Key Laboratory of Digestive Diseases, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai, China
| | - Zhengrui You
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, NHC Key Laboratory of Digestive Diseases, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai, China
| | - Qixia Wang
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, NHC Key Laboratory of Digestive Diseases, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai, China
| | - Yongyong Shi
- Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders (Ministry of Education), Collaborative Innovation Center for Brain Science, Shanghai Jiao Tong University, Shanghai, China; Affiliated Hospital of Qingdao University and Biomedical Sciences Institute of Qingdao University (Qingdao Branch of SJTU Bio-X Institutes), Qingdao University, Qingdao, China
| | - Heather J Cordell
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Suraj Timilsina
- Division of Rheumatology, Department of Medicine, Allergy and Clinical Immunology, University of California at Davis, Davis, CA, USA
| | - M Eric Gershwin
- Division of Rheumatology, Department of Medicine, Allergy and Clinical Immunology, University of California at Davis, Davis, CA, USA
| | - Zhiqiang Li
- Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders (Ministry of Education), Collaborative Innovation Center for Brain Science, Shanghai Jiao Tong University, Shanghai, China; Affiliated Hospital of Qingdao University and Biomedical Sciences Institute of Qingdao University (Qingdao Branch of SJTU Bio-X Institutes), Qingdao University, Qingdao, China.
| | - Xiong Ma
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, NHC Key Laboratory of Digestive Diseases, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai, China; Institute of Aging & Tissue Regeneration, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Ruqi Tang
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, NHC Key Laboratory of Digestive Diseases, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai, China.
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Zou J, Li J, Wang X, Tang D, Chen R. Neuroimmune modulation in liver pathophysiology. J Neuroinflammation 2024; 21:188. [PMID: 39090741 PMCID: PMC11295927 DOI: 10.1186/s12974-024-03181-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 07/19/2024] [Indexed: 08/04/2024] Open
Abstract
The liver, the largest organ in the human body, plays a multifaceted role in digestion, coagulation, synthesis, metabolism, detoxification, and immune defense. Changes in liver function often coincide with disruptions in both the central and peripheral nervous systems. The intricate interplay between the nervous and immune systems is vital for maintaining tissue balance and combating diseases. Signaling molecules and pathways, including cytokines, inflammatory mediators, neuropeptides, neurotransmitters, chemoreceptors, and neural pathways, facilitate this complex communication. They establish feedback loops among diverse immune cell populations and the central, peripheral, sympathetic, parasympathetic, and enteric nervous systems within the liver. In this concise review, we provide an overview of the structural and compositional aspects of the hepatic neural and immune systems. We further explore the molecular mechanisms and pathways that govern neuroimmune communication, highlighting their significance in liver pathology. Finally, we summarize the current clinical implications of therapeutic approaches targeting neuroimmune interactions and present prospects for future research in this area.
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Affiliation(s)
- Ju Zou
- Hunan Key Laboratory of Viral Hepatitis, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
- Department of Infectious Diseases, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Jie Li
- Hunan Key Laboratory of Viral Hepatitis, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
- Department of Infectious Diseases, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Xiaoxu Wang
- Hunan Key Laboratory of Viral Hepatitis, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
- Department of Infectious Diseases, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Daolin Tang
- Department of Surgery, UT Southwestern Medical Center, Dallas, TX, USA
| | - Ruochan Chen
- Hunan Key Laboratory of Viral Hepatitis, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China.
- Department of Infectious Diseases, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China.
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China.
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Berthoud HR, Münzberg H, Morrison CD, Neuhuber WL. Hepatic interoception in health and disease. Auton Neurosci 2024; 253:103174. [PMID: 38579493 PMCID: PMC11129274 DOI: 10.1016/j.autneu.2024.103174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 03/14/2024] [Accepted: 03/28/2024] [Indexed: 04/07/2024]
Abstract
The liver is a large organ with crucial functions in metabolism and immune defense, as well as blood homeostasis and detoxification, and it is clearly in bidirectional communication with the brain and rest of the body via both neural and humoral pathways. A host of neural sensory mechanisms have been proposed, but in contrast to the gut-brain axis, details for both the exact site and molecular signaling steps of their peripheral transduction mechanisms are generally lacking. Similarly, knowledge about function-specific sensory and motor components of both vagal and spinal access pathways to the hepatic parenchyma is missing. Lack of progress largely owes to controversies regarding selectivity of vagal access pathways and extent of hepatocyte innervation. In contrast, there is considerable evidence for glucose sensors in the wall of the hepatic portal vein and their importance for glucose handling by the liver and the brain and the systemic response to hypoglycemia. As liver diseases are on the rise globally, and there are intriguing associations between liver diseases and mental illnesses, it will be important to further dissect and identify both neural and humoral pathways that mediate hepatocyte-specific signals to relevant brain areas. The question of whether and how sensations from the liver contribute to interoceptive self-awareness has not yet been explored.
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Affiliation(s)
- Hans-Rudolf Berthoud
- Neurobiology of Nutrition & Metabolism Department, Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, LA, USA.
| | - Heike Münzberg
- Neurobiology of Nutrition & Metabolism Department, Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, LA, USA
| | - Christopher D Morrison
- Neurobiology of Nutrition & Metabolism Department, Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, LA, USA
| | - Winfried L Neuhuber
- Institute for Anatomy and Cell Biology, Friedrich-Alexander University, Erlangen, Germany.
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Almishri W, Altonsy MO, Swain MG. Cholestatic liver disease leads to significant adaptative changes in neural circuits regulating social behavior in mice to enhance sociability. Biochim Biophys Acta Mol Basis Dis 2024; 1870:167100. [PMID: 38412926 DOI: 10.1016/j.bbadis.2024.167100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 02/16/2024] [Accepted: 02/19/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND & AIMS Cholestatic liver diseases (CLD) are commonly associated with behavioral changes, including social isolation, that negatively affects patient quality of life and remains unaltered by current therapies. It remains unclear whether CLD-associated social dysfunction stems from a direct effect on the brain, or from the psychological impact of CLD. The psychological component of disease is absent in animals, so we investigated the impact of CLD on social behavior and gene expression profiles in key social behavior-regulating brain regions in a mouse model. METHODS CLD due to bile duct ligation was used with the three-chamber sociability test for behavioral phenotyping. Differentially expressed gene (DEG) signatures were delineated in 3 key brain regions regulating social behavior using RNA-seq. Ingenuity Pathway Analysis (IPA®) was applied to streamline DEG data interpretation and integrate findings with social behavior-regulating pathways to identify important brain molecular networks and regulatory mechanisms disrupted in CLD. RESULTS CLD mice exhibited enhanced social interactive behavior and significantly altered gene expression in each of the three social behavior-regulating brain regions examined. DEG signatures in BDL mice were associated with key IPA®-identified social behavior-regulating pathways including Oxytocin in Brain Signaling, GABA Receptor Signaling, Dopamine Receptor Signaling, and Glutamate Receptor Signaling. CONCLUSIONS CLD causes complex alterations in gene expression profiles in key social behavior-regulating brain areas/pathways linked to enhanced social interactive behavior. These findings, if paralleled in CLD patients, suggest that CLD-associated reductions in social interactions predominantly relate to psychological impacts of disease and may inform new approaches to improve management.
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Affiliation(s)
- Wagdi Almishri
- Department of Medicine, Snyder Institute for Chronic Diseases, University of Calgary, Calgary, AB, Canada
| | - Mohammed O Altonsy
- Department of Medicine, Snyder Institute for Chronic Diseases, University of Calgary, Calgary, AB, Canada; Department of Zoology, Faculty of Science, Sohag University, Sohag, Egypt
| | - Mark G Swain
- Department of Medicine, Snyder Institute for Chronic Diseases, University of Calgary, Calgary, AB, Canada; University of Calgary Liver Unit, Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, AB, Canada.
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Arenas YM, Izquierdo-Altarejos P, Martinez-García M, Giménez-Garzó C, Mincheva G, Doverskog M, Jones DEJ, Balzano T, Llansola M, Felipo V. Golexanolone improves fatigue, motor incoordination and gait and memory in rats with bile duct ligation. Liver Int 2024; 44:433-445. [PMID: 38010893 DOI: 10.1111/liv.15782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 09/11/2023] [Accepted: 10/23/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND AND AIMS Many patients with the chronic cholestatic liver disease primary biliary cholangitis (PBC) show fatigue and cognitive impairment that reduces their quality of life. Likewise, rats with bile duct ligation (BDL) are a model of cholestatic liver disease. Current PBC treatments do not improve symptomatic alterations such as fatigue or cognitive impairment and new, more effective treatments are therefore required. Golexanolone reduces the potentiation of GABAA receptors activation by neurosteroids. Golexanolone reduces peripheral inflammation and neuroinflammation and improves cognitive and motor function in rats with chronic hyperammonemia. The aims of the present study were to assess if golexanolone treatment improves fatigue and cognitive and motor function in cholestatic BDL rats and if this is associated with improvement of peripheral inflammation, neuroinflammation, and GABAergic neurotransmission in the cerebellum. METHODS Rats were subjected to bile duct ligation. One week after surgery, oral golexanolone was administered daily to BDL and sham-operated controls. Fatigue was analysed in the treadmill, motor coordination in the motorater, locomotor gait in the Catwalk, and short-term memory in the Y-maze. We also analysed peripheral inflammation, neuroinflammation, and GABAergic neurotransmission markers by immunohistochemistry and Western blot. RESULTS BDL induces fatigue, impairs memory and motor coordination, and alters locomotor gait in cholestatic rats. Golexanolone improves these alterations, and this was associated with improvement of peripheral inflammation, neuroinflammation, and GABAergic neurotransmission in the cerebellum. CONCLUSION Golexanolone may have beneficial effects to treat fatigue, and motor and cognitive impairment in patients with the chronic cholestatic liver disease PBC.
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Affiliation(s)
- Yaiza M Arenas
- Laboratory of Neurobiology, Centro de Investigación Príncipe Felipe, Valencia, Spain
| | | | - Mar Martinez-García
- Laboratory of Neurobiology, Centro de Investigación Príncipe Felipe, Valencia, Spain
| | - Carla Giménez-Garzó
- Laboratory of Neurobiology, Centro de Investigación Príncipe Felipe, Valencia, Spain
| | - Gergana Mincheva
- Laboratory of Neurobiology, Centro de Investigación Príncipe Felipe, Valencia, Spain
| | | | - David E J Jones
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK
- Freeman Hospital, Newcastle-upon-Tyne, UK
| | - Tiziano Balzano
- Centro Integral de Neurociencias, Hospital Universitario Puerta del Sur CINAC, Madrid, Spain
| | - Marta Llansola
- Laboratory of Neurobiology, Centro de Investigación Príncipe Felipe, Valencia, Spain
| | - Vicente Felipo
- Laboratory of Neurobiology, Centro de Investigación Príncipe Felipe, Valencia, Spain
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Henriksson I, Udumyan R, Nilsson E, Önnerhag K, Rorsman F, Werner M, Marschall HU, Wahlin S, Nyhlin N. Clinical outcomes and sick leave in relation to UDCA treatment in Swedish patients with primary biliary cholangitis. Scand J Gastroenterol 2023; 58:70-75. [PMID: 35993428 DOI: 10.1080/00365521.2022.2103729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Primary biliary cholangitis (PBC) is an autoimmune liver disease that may progress into liver cirrhosis. Ursodeoxycholic acid (UDCA) is known to prevent or delay the disease progression, but little is known about work incapacity in PBC patients. We aimed to compare clinical outcomes (transplantation-free survival; cirrhosis development) and sick leave in patients with PBC with and without UDCA therapy. METHODS The medical records of 526 patients with PBC diagnosed from 2004 to 2016 were reviewed retrospectively. Sick leave data retrieved from the Swedish Social Insurance Agency were analysed for a sub-cohort of patients and matched controls. Cox regression was used for analysis of clinical outcomes. Logistic and conditional logistic regressions were used for sick leave analysis. RESULTS A total of 10.6% of patients died and 3.4% received liver transplantation over a median follow-up time of 5.7 years. UDCA-untreated patients (HR 3.62 (95%CI 2.02-6.49)) and UDCA non-responders (HR 3.78 (95% CI 1.87-7.66)) had higher mortality or transplantation rates than UDCA responders. Patients with PBC had higher odds of sick leave (OR 2.50; 95% CI 1.69-3.70) than matched controls. Untreated patients were more likely to be on sick leave (OR 3.22; 95% CI 1.12-9.25) two years after diagnosis than UDCA responders. CONCLUSION Both untreated patients and UDCA non-responders had lower liver transplantation-free survival rates than UDCA responders. Patients with PBC were more likely to be on sick leave compared to matched controls from the general population.
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Affiliation(s)
- Ida Henriksson
- Department of Internal Medicine, Division of Gastroenterology, Örebro University Hospital, Örebro, Sweden
| | - Ruzan Udumyan
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Emma Nilsson
- Department of Clinical Sciences, Gastroenterology Division, Skåne University Hospital, Lund, Sweden
| | - Kristina Önnerhag
- Department of Gastroenterology and Hepatology, Skåne University Hospital, Malmö, Sweden
| | - Fredrik Rorsman
- Department of Gastroenterology and Hepatology, Uppsala University Hospital, Uppsala, Sweden
| | - Mårten Werner
- Department of Public Health and Clinical Medicine, Umeå University Hospital, Umeå, Sweden
| | - Hanns-Ulrich Marschall
- Sahlgrenska Academy, Institute of Medicine, Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Staffan Wahlin
- Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Nils Nyhlin
- Department of Internal Medicine, Division of Gastroenterology, Örebro University Hospital, Örebro, Sweden
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Liu Y, Tian S, Jia G, Han Z, Guo C, Shang Y, Han Y. Symptoms Burden and Health-related Quality of Life in Chinese Patients with Primary Biliary Cholangitis. J Clin Transl Hepatol 2021; 9:860-867. [PMID: 34966649 PMCID: PMC8666377 DOI: 10.14218/jcth.2020.00119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 03/04/2021] [Accepted: 04/09/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND AND AIMS Primary biliary cholangitis (PBC) is a chronic liver disease that negatively affects the health-related quality of life (HRQoL) of patients. Furthermore, the HRQoL of Chinese patients has been neglected for a long time. The present study aimed to assess the HRQoL of Chinese patients with PBC and explore the clinical variables correlating to the improvement of itch and fatigue. METHODS This was an observational, cross-sectional study. The PBC-40 and itch numerical rating scales were used to evaluate the symptoms and HRQoL of patients. RESULTS A total of 383 patients were recruited, and 86.4% were female, with a median age of 55 years (range: 49-63 years). We found that females had significantly higher scores than males in symptoms (p=0.033) and cognitive domains (p=0.021), and the fatigue domain was higher in elderly patients (p=0.007). Meanwhile, patients whose body mass index was <18.5 had the highest scores in the symptoms (p=0.009), fatigue (p=0.010), and cognitive (p=0.019) domains. Age at participation (odds ratio [OR]=1.068, p=0.015) and albumin level at 12 months after ursodeoxycholic acid treatment (OR=208.807, p=0.025) were independent factors that affected the improvement of the itch and fatigue domains, respectively. CONCLUSIONS The HRQoL of Chinese patients with PBC was significantly impaired depending on sex, age, and body mass index. Age and albumin level were significantly associated with the improvement of itch and fatigue, respectively. Therefore, treatment and support aimed at these two factors can be provided to improve the HRQoL of patients.
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Affiliation(s)
| | | | | | | | | | - Yulong Shang
- Correspondence to: Ying Han and Yulong Shang, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Xijing Hospital, Air Force Military Medical University, Xi’an, Shaanxi 710032, China. ORCID: https://orcid.org/0000-0003-3046-9507 (YH) and https://orcid.org/0000-0002-8576-3175 (YS). Tel: +86 29 84771509; Fax: +86 29 82539041; E-mail: (YH) or (YS)
| | - Ying Han
- Correspondence to: Ying Han and Yulong Shang, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Xijing Hospital, Air Force Military Medical University, Xi’an, Shaanxi 710032, China. ORCID: https://orcid.org/0000-0003-3046-9507 (YH) and https://orcid.org/0000-0002-8576-3175 (YS). Tel: +86 29 84771509; Fax: +86 29 82539041; E-mail: (YH) or (YS)
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Grønkjær LL, Lauridsen MM. Quality of life and unmet needs in patients with chronic liver disease: A mixed-method systematic review. JHEP REPORTS : INNOVATION IN HEPATOLOGY 2021; 3:100370. [PMID: 34805816 PMCID: PMC8585663 DOI: 10.1016/j.jhepr.2021.100370] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 08/23/2021] [Accepted: 09/21/2021] [Indexed: 02/06/2023]
Abstract
Background & Aims In an attempt to uncover unmet patient needs, this review aims to synthesise quantitative and qualitative studies on patients’ quality of life and their experience of having liver disease. Methods Three databases (CINAHL, Embase, and PubMed) were searched from January 2000 to October 2020. The methodological quality and data extraction of both quantitative and qualitative studies were screened and appraised using Joanna Briggs Institute instruments for mixed-method systematic reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A convergent, integrated approach to synthesis and integration was used. Studies including patients with autoimmune and cholestatic liver disease, chronic hepatitis B and C, non-alcoholic fatty liver disease and non-alcoholic steatohepatitis, cirrhosis, and hepatocellular carcinoma were considered. Results The searches produced 5,601 articles, of which 95 (79 quantitative and 16 qualitative) were included in the review. These represented studies from 26 countries and a sample of 37,283 patients. The studies showed that patients´ quality of life was reduced. Unmet needs for information and support and perceived stigmatisation severely affected patients’ quality of life. Conclusions Our study suggests changes to improve quality of life. According to patients, this could be achieved by providing better education and information, being aware of patients’ need for support, and raising awareness of liver disease among the general population to reduce misconceptions and stigmatisation. Registration number PROSPERO CRD42020173501. Lay summary Regardless of aetiology, patients with liver diseases have impaired quality of life. This is associated with disease progression, the presence of symptoms, treatment response, and mental, physical, and social factors such as anxiety, confusion, comorbidities, and fatigue, as well as limitations in daily living, including loneliness, low income, stigmatisation, and treatment costs. Patients highlighted the need for information to understand and manage liver disease, and awareness and support from healthcare professionals to better cope with the disease. In addition, there is a need to raise awareness of liver diseases in the general population to reduce negative preconceptions and stigmatisation. Patients with liver disease regardless of aetiology and severity have impaired quality of life. Patients call for better education and information to understand and manage their liver disease, and for increased awareness and support from healthcare professionals. Owing to the limited knowledge of liver diseases among the general population, patients experience stigmatisation, resulting in loneliness and social isolation. Addressing unmet needs of patients with liver disease could improve their quality of life.
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Key Words
- CLDQ, Chronic Liver Disease Questionnaire
- EQ-5D, European Quality of Life
- FACT-Hep, Functional Assessment of Cancer Therapy Hepatobiliary Carcinoma
- HBQOL, Hepatitis B Quality of Life
- HCC, hepatocellular carcinoma
- JBI, Joanna Briggs Institute
- LC-PROM, Liver Cirrhosis Patient Reported Outcome Measure
- LDQOL, Liver Disease Quality of Life
- Liver disease
- MELD, model for end-stage liver disease
- Mixed method
- NAFLD, non-alcoholic fatty liver disease
- NASH, non-alcoholic steatohepatitis
- PBC, Primary Biliary Cholangitis Questionnaire
- Patient experience
- Patient reported outcomes
- PedsQL, Pediatric Quality of Life Inventory
- Quality of life
- SF, Short Form
- SIP, Sickness Impact Profile
- Systematic review
- Unmet needs
- VAS, visual analogue scale
- WHOQOL-BREF, WHO Quality of Life
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Affiliation(s)
- Lea Ladegaard Grønkjær
- Department of Gastroenterology, University Hospital of Southern Denmark, Esbjerg, Denmark
- Corresponding author. Address: Department of Gastroenterology, University Hospital of Southern Denmark, Finsensgade 35, 6700 Esbjerg, Denmark. Tel.: +45-26668184; Fax: +45-79182316.
| | - Mette Munk Lauridsen
- Department of Gastroenterology, University Hospital of Southern Denmark, Esbjerg, Denmark
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Watt M, Spence JC, Tandon P. Development of a Theoretically Informed Web-Based Mind-Body Wellness Intervention for Patients With Primary Biliary Cholangitis: Formative Study. JMIR Form Res 2021; 5:e29064. [PMID: 34623317 PMCID: PMC8538029 DOI: 10.2196/29064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 06/06/2021] [Accepted: 06/11/2021] [Indexed: 11/17/2022] Open
Abstract
Background Mind-body interventions have the potential to positively impact the symptom burden associated with primary biliary cholangitis (PBC). Interventions are more likely to be effective if they are informed by a theoretical framework. The Behaviour Change Wheel (BCW) and the behaviour change technique taxonomy version 1 (BCTv1) provide frameworks for intervention development. Objective This study describes how theory has guided the development of a 12-week multicomponent mind-body wellness intervention for PBC. Methods The steps involved in developing the BCW intervention included specifying the target behavior; explaining barriers and facilitators using the Capability, Opportunity, Motivation, and Behaviour and the theoretical domains framework; identifying intervention functions to target explanatory domains; and selecting relevant behavior change techniques to address intervention functions. Qualitative data from patients with inflammatory bowel disease using an earlier version of the program and feedback from a PBC patient advisory team were used to guide intervention development. Results Barriers and facilitators to intervention participation associated with capability, opportunity, and motivation were identified. Intervention functions and behavior change techniques were identified to target each barrier and facilitator. Conclusions The Peace Power Pack PBC intervention was developed to help individuals with PBC manage their symptom burden. The theoretical frameworks employed in this intervention provide direction on targeting antecedents of behavior and allow standardized reporting of intervention components. Trial Registration ClinicalTrials.gov NCT04791527; https://clinicaltrials.gov/ct2/show/NCT04791527
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Sivakumar T, Kowdley KV. Anxiety and Depression in Patients with Primary Biliary Cholangitis: Current Insights and Impact on Quality of Life. Hepat Med 2021; 13:83-92. [PMID: 34483690 PMCID: PMC8409764 DOI: 10.2147/hmer.s256692] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 08/12/2021] [Indexed: 12/13/2022] Open
Abstract
Primary biliary cholangitis (PBC), formerly known as primary biliary cirrhosis, is a chronic cholestatic immune-mediated liver disease characterized by injury to intrahepatic bile ducts that may ultimately progress to cirrhosis and liver failure and result in the need for liver transplant or death without treatment. Ursodeoxycholic acid (UDCA) and obeticholic acid (OCA) are approved therapies for PBC and are associated with a reduced risk of progression of disease, although patients may continue to experience significant symptoms of pruritus and fatigue independent of liver disease. The two most commonly reported symptoms among patients with PBC are fatigue and pruritus which may be debilitating, and negatively impact physical, mental, emotional, and social wellbeing. Intense symptom burden has been associated with depressive symptoms, cognitive defects, poor sleep schedules, and social isolation. This literature review explores the presence of anxiety and depressive symptoms in chronic liver disease, the impact of symptom burden on patients' wellbeing, and available pharmaceutical and natural therapies.
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Grønkjær LL, Lauridsen MM. Impact of liver disease on patients' quality of life: a mixed methods systematic review protocol. JBI Evid Synth 2021; 19:1412-1417. [PMID: 33323778 DOI: 10.11124/jbies-20-00185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The objective of this systematic review is to explore the impact of liver disease on patients' quality of life in an attempt to develop effective evidence-based recommendations and strategies useful for clinical practice and health care professionals. INTRODUCTION Liver diseases are common worldwide and a major cause of illness and death due to health problems and serious complications, which not only cause hospitalization and death, but also emotional distress, depression, and impaired quality of life. INCLUSION CRITERIA This review will consider qualitative and quantitative studies on patients with liver disease of different severity and type. The qualitative component of this review will consider all studies that describe patients' lived experience and perception of having liver disease. The quantitative component will include studies that explore the quality of life in patients with liver disease. METHODS CINAHL (EBSCO), Embase (Ovid), MEDLINE (Ovid), PsycINFO (Ovid), Scopus (Elsevier), and Web of Science (Ovid) will be searched for articles published in Danish and English without any restriction in terms of year of publication. Articles describing both qualitative and quantitative studies will be screened for inclusion, critically appraised for methodological quality, and have data extracted using JBI instruments for mixed methods systematic reviews. A convergent integrated approach to synthesis and integration will be used. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO CRD42020173501.
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12
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Montali L, Gragnano A, Miglioretti M, Frigerio A, Vecchio L, Gerussi A, Cristoferi L, Ronca V, D’Amato D, O’Donnell SE, Mancuso C, Lucà M, Yagi M, Reig A, Jopson L, Pilar S, Jones D, Pares A, Mells G, Tanaka A, Carbone M, Invernizzi P. Quality of life in patients with primary biliary cholangitis: A cross-geographical comparison. J Transl Autoimmun 2021; 4:100081. [PMID: 33554101 PMCID: PMC7843515 DOI: 10.1016/j.jtauto.2021.100081] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 12/30/2020] [Indexed: 12/12/2022] Open
Abstract
Background & aims Several symptoms impair the quality of life (QoL) of patients with primary biliary cholangitis (PBC). They are reported to vary significantly in different countries. Aim of our study was to explore whether there is a geographical clustering that accounts for symptoms in PBC. Methods Data was analysed from four cohorts of PBC patients from the UK, Spain, Japan and Italy using the PBC-27 scale. Results Overall, 569 patients from four cohorts were identified, including 515 females (90.5%) with a mean age of 61 years. The analysis provided evidence for strict factorial invariance of the scale, a robust indicator of its validity for cross-cultural research. The mean of the fatigue domain of British patients was significantly greater than that of the Japanese (p < 0.05), Italian (p < 0.05), and Spanish patients (p < 0.001). The mean of the cognitive domain after 54 years of age, was significantly greater in the British patients than in the Japanese (p < 0.05) and Spanish patients (p < 0.01). However, after 69 years of age, there were not significant differences between countries. The mean of the emotion domain after 54 years of age, was greater in the British that in the Spanish (p < 0.01) and Italian patients (p < 0.01). Conclusions Differences in the four countries concerning fatigue, cognitive and emotional dysfunction were found. The association of latitude and symptoms might provide new insights into the role of sun exposure, genetics and/or cultural component into disease phenotype in PBC.
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Affiliation(s)
- Lorenzo Montali
- Department of Psychology, University of Milan Bicocca, Milan, Italy
| | - Andrea Gragnano
- Department of Psychology, University of Milan Bicocca, Milan, Italy
| | | | | | - Luca Vecchio
- Department of Psychology, University of Milan Bicocca, Milan, Italy
| | - Alessio Gerussi
- Division of Gastroenterology, Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Laura Cristoferi
- Division of Gastroenterology, Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Vincenzo Ronca
- Division of Gastroenterology, Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Daphne D’Amato
- Division of Gastroenterology, Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Sarah Elizabeth O’Donnell
- Division of Gastroenterology, Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Clara Mancuso
- Division of Gastroenterology, Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Martina Lucà
- Division of Gastroenterology, Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Minami Yagi
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Anna Reig
- Liver Unit, Hospital Clínic, University of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Laura Jopson
- Institute of Cellular Medicine, Newcastle University, Newcastle Upon Tyne, UK
| | - Sesé Pilar
- Liver Unit, Hospital Clínic, University of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Dave Jones
- Institute of Cellular Medicine, Newcastle University, Newcastle Upon Tyne, UK
| | - Albert Pares
- Liver Unit, Hospital Clínic, University of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | - George Mells
- Department of Medical Genetics, University of Cambridge, Cambridge, UK
| | - Atsushi Tanaka
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Marco Carbone
- Division of Gastroenterology, Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Pietro Invernizzi
- Division of Gastroenterology, Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
- Corresponding author. Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano - Bicocca, Via Cadore 48, 20900, Monza, (MB), Italy.
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Bernardes CM, Clark PJ, Brown C, Stuart K, Pratt G, Toombs M, Hartel G, Powell EE, Valery PC. Disparities in Unmet Needs in Indigenous and Non-Indigenous Australians with Cirrhosis: An Exploratory Study. Patient Prefer Adherence 2021; 15:2649-2658. [PMID: 34853510 PMCID: PMC8628121 DOI: 10.2147/ppa.s341566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 11/09/2021] [Indexed: 12/11/2022] Open
Abstract
PURPOSE Understanding and responding to the supportive care needs of people with cirrhosis is essential to quality care. Indigenous Australians, Aboriginal and Torres Strait Islander people, are overrepresented amongst patients with cirrhosis. This study documented the nature and extent of supportive care needs of Indigenous Australians with cirrhosis, in comparison with non-Indigenous Australians. PATIENTS AND METHODS The supportive care needs of adult patients diagnosed with cirrhosis attending public hospitals in Queensland were assessed through the Supportive Needs Assessment tool for Cirrhosis (SNAC). Patients indicated how much additional help they needed on four subscales: 1. psychosocial issues; 2. practical and physical needs; 3. information needs; and 4. lifestyle changes. We examined the rate of moderate-to-high unmet needs based on Indigenous status (Poisson regression; incidence rate ratio (IRR)). RESULTS Indigenous (n=20) and non-Indigenous (n=438) patients included in the study had similar sociodemographic and clinical characteristics except for a lower educational level among Indigenous patients (p<0.01). Most Indigenous patients (85.0%) reported having moderate-to-high unmet needs with at least one item in the SNAC tool. Following adjustment for key sociodemographic and clinical factors, Indigenous patients had a greater rate of moderate-to-high unmet needs overall (IRR=1.5, 95% CI 1.31-1.72; p<0.001), and specifically for psychosocial issues (IRR=1.7, 95% CI 1.39-2.15; p<0.001), and practical and physical needs subscales (IRR=1.5, 95% CI 1.22-1.83; p<0.001), compared to non-Indigenous patients. CONCLUSION Indigenous Australians with cirrhosis more frequently had moderate-to-high unmet supportive care needs than non-Indigenous patients. Specific targeting of culturally appropriate supportive care for psychosocial, practical and physical needs may optimize cirrhosis care and improve the quality of life for Indigenous Australians with cirrhosis.
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Affiliation(s)
| | - Paul J Clark
- Department of Gastroenterology and Hepatology, Mater Hospitals, Brisbane, QLD, Australia
| | - Cath Brown
- QIMR Berghofer Medical Research Institute, Herston, QLD, Australia
| | - Katherine Stuart
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Gregory Pratt
- QIMR Berghofer Medical Research Institute, Herston, QLD, Australia
| | - Maree Toombs
- Rural Clinical School, Faculty of Medicine, University of Queensland, Toowoomba, QLD, Australia
| | - Gunter Hartel
- QIMR Berghofer Medical Research Institute, Herston, QLD, Australia
| | - Elizabeth E Powell
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, QLD, Australia
- Centre for Liver Disease Research, Translational Research Institute, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Patricia C Valery
- QIMR Berghofer Medical Research Institute, Herston, QLD, Australia
- Correspondence: Patricia C Valery Tel +61 07 3362 0376 Email
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Gray-Renfrew A, Kimbell B, Finucane A. Emotional experience of people with advanced liver disease: Secondary data analysis. Chronic Illn 2020; 16:284-295. [PMID: 30286621 DOI: 10.1177/1742395318803668] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Patients with advanced liver disease live mainly in the community with treatment of complications provided for in-hospital. The illness trajectory of advanced liver disease is uncertain and most do not have access to end of life care. Gaps in knowledge and understanding of the patient experience of this condition have been identified. METHODS Secondary analysis of 15 transcripts from in-depth interviews with people with advanced liver disease collected as part of a previous longitudinal study on the experience of liver disease. Transcripts were thematically analysed for emotional content. RESULTS Fear, anger, sadness and guilt clearly featured in the person's experience of advanced liver disease. Certain causal factors were identified as provoking these emotional responses, including shock of diagnosis, uncertainty concerning illness, lack of coordinated care, worrying symptoms and sudden death. Humour emerged as a coping mechanism. CONCLUSION People living with advanced liver disease experience distressing emotions. It is helpful for clinicians, nurses and other healthcare support staff to have an appreciation of the person's emotional concerns in order to provide holistic care typical of a palliative approach.
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Affiliation(s)
| | - Barbara Kimbell
- Primary Palliative Care Research Group, Centre for Population Health Sciences, University of Edinburgh, Scotland, UK
| | - Anne Finucane
- Marie Curie Hospice Edinburgh, Usher Institute, University of Edinburgh, Scotland, UK
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Kim HP, Lieber SR, Rogers ME, Moon AM, Loiselle M, Walker J, Assis DN, Safer R, Gomel R, Evon DM. A Systematic Review of Patient-Reported Outcomes in Primary Biliary Cholangitis and Primary Sclerosing Cholangitis. Hepatol Commun 2020; 4:1502-1515. [PMID: 33024919 PMCID: PMC7527768 DOI: 10.1002/hep4.1567] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 06/03/2020] [Accepted: 06/14/2020] [Indexed: 12/17/2022] Open
Abstract
Primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC) are associated with decreased health-related quality of life and debilitating symptoms. These experiences can be defined as patient-reported outcome (PRO) concepts and measured using PRO instruments. We identified all PRO concepts and instruments used in the PBC and PSC literature. This systematic review identified PBC and/or PSC studies from January 1, 1990, to May 6, 2019, that measured at least one PRO concept. Study population, design, PRO concept, PRO instrument, and validation data for PRO instruments were investigated. We provided descriptive statistics of PRO concepts and instruments used, stratified by population type. Use of PRO concepts and instruments were assessed over time. The search yielded 318 articles (69% in PBC, 18% in PSC, 13% in both, and 24% in drug trials). Forty-nine unique PRO concepts were identified. The five most common PRO concepts included pruritus (25%), fatigue (19%), broad health-related quality of life (16%), gastrointestinal adverse events (6%), and physical adverse events (6%). Only 60% of PRO concepts were measured with a PRO instrument, most of which were nonvalidated visual analogue or numeric rating scales. Only three of 83 PRO instruments were developed with feedback from the target populations (one for PBC, one for PSC, and one for both), and only six documented any psychometric testing in the target populations. Use of PRO instruments increased over time from 30% in the 1990s to 67% by 2019. Conclusion: The overwhelming majority of PRO instruments used in PBC/PSC were nonspecific and lacked patient validation or empirical justification. Significant opportunities exist to use qualitative methods to better understand patient experiences, and translate this knowledge into meaningful, patient-driven study outcomes.
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Affiliation(s)
- Hannah P. Kim
- Division of Gastroenterology and HepatologyDepartment of MedicineUniversity of North CarolinaChapel HillNC
| | - Sarah R. Lieber
- Division of Gastroenterology and HepatologyDepartment of MedicineUniversity of North CarolinaChapel HillNC
| | - Michael E. Rogers
- Division of Pediatric GastroenterologyDepartment of PediatricsUniversity of North CarolinaChapel HillNC
| | - Andrew M. Moon
- Division of Gastroenterology and HepatologyDepartment of MedicineUniversity of North CarolinaChapel HillNC
| | - Marci Loiselle
- Department of Psychiatry and Behavioral SciencesDivision of Behavioral MedicineDuke University Medical CenterDurhamNC
| | - Jennifer Walker
- University of North CarolinaHealth Sciences LibraryChapel HillNC
| | - David N. Assis
- Digestive DiseasesDepartment of MedicineYale School of MedicineNew HavenCT
| | - Ricky Safer
- PSC Partners Seeking a CureGreenwood VillageCO
| | | | - Donna M. Evon
- Division of Gastroenterology and HepatologyDepartment of MedicineUniversity of North CarolinaChapel HillNC
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Gorospe FF, Istanboulian L, Puts M, Wong D, Lee E, Dale CM. A scoping review to identify and map the multidimensional domains of pain in adults with advanced liver disease. Can J Pain 2020; 4:210-224. [PMID: 33987500 PMCID: PMC7951148 DOI: 10.1080/24740527.2020.1785855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 05/26/2020] [Accepted: 06/04/2020] [Indexed: 11/16/2022]
Abstract
Background: Pain is a significant problem in adults living with advanced liver disease, having limited guidance available for its clinical management. While pain is considered a multidimensional experience, there have been limited reviews of the pain literature in advanced liver disease conducted with a multidimensional framework. Aims: The goal of this scoping review was to identify and map the multidimensional domains of pain in adults with advanced liver disease using the biopsychosocial model. Methods: We used Arksey and O'Malley's scoping framework. A search was conducted in MEDLINE, Embase, AMED, and CINAHL databases and the gray literature using specific eligibility criteria (1990-2019). Citation selection and data extraction were performed by two independent reviewers and in duplicate. Results: Of the 43 studies that met inclusion criteria, 51% were from North America and 93% utilized quantitative methods. The combined studies reported on 168,110 participants with ages ranging between 23 to 87 years. Only 9% reported an objective scoring system for liver disease severity. Few studies reported pain classification (9%) and intensity (16%). Pain prevalence ranged between 18% and 100%, with pain locations including joint, abdomen, back, head/neck, and upper/lower extremities. We identified and mapped 115 pain factors to the biopsychosocial model: physical (81%), psychological (65%), and sociocultural (5%). Only 9% measured pain using validated multidimensional tools. Pharmacological intervention (92%) prevailed among pain treatments. Conclusions: Pain is not well understood in patients with advanced liver disease, having limited multidimensional pain assessment and treatment approaches. There is a need to systematically examine the multidimensional nature of pain in this population.
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Affiliation(s)
- Franklin F. Gorospe
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- Perioperative Services, Toronto General Hospital–University Health Network, Toronto, Ontario, Canada
| | - Laura Istanboulian
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- Acute Inpatient Respiratory Unit, Michael Garron Hospital, Toronto East Health Network, Toronto, Ontario, Canada
| | - Martine Puts
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - David Wong
- Hepatology Division, Toronto General Hospital–University Health Network, Toronto, Ontario, Canada
| | - Elizabeth Lee
- Hepatology Division, Toronto General Hospital–University Health Network, Toronto, Ontario, Canada
| | - Craig M. Dale
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- Department of Critical Care, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Corrigan M, Hirschfield G, Greenfield S, Parry J. Barriers to implementation of stratified care in primary biliary cholangitis: a scoping exercise. BMJ Open Gastroenterol 2019; 6:e000226. [PMID: 31321066 PMCID: PMC6596962 DOI: 10.1136/bmjgast-2018-000226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 08/31/2018] [Accepted: 09/07/2018] [Indexed: 01/29/2023] Open
Abstract
Patients with primary biliary cholangitis (PBC) can be stratified into low-risk and high-risk groups based on their response to treatment. Newly published guidelines from the British Society of Gastroenterology suggest low-risk patients can be managed substantially in primary care. This represents a shift from existing practice and makes assumptions about service capacity and the willingness of both patients and health care practitioners (HCPs) to make this change. The aim of this paper is to identify possible barriers to the implementation of these new care pathways through review of the PBC-specific literature and by identifying the experiences of patients and HCPs managing a different condition with comparable patients and disease characteristics. Searches of MEDLINE, CINAHL and EMBASE were undertaken. Within the existing PBC literature there is little data surrounding stakeholder perspectives on place of care. Review of the breast cancer literature highlights a number of barriers to change including primary care practitioner knowledge and work load, communication between healthcare settings, and the significance of the established doctor-patient relationship. Further research is needed to establish the extent to which these barriers may surface when changing PBC care pathways, and the actions required to overcome them.
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Affiliation(s)
- Margaret Corrigan
- University of Birmingham, NIHR Birmingham Biomedical Research Centre, Centre for Liver Research, Birmingham, UK
- Department of Liver medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Gideon Hirschfield
- University of Birmingham, NIHR Birmingham Biomedical Research Centre, Centre for Liver Research, Birmingham, UK
- Department of Liver medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Sheila Greenfield
- University of Birmingham, Institute of Applied Health Research, Birmingham, UK
| | - Jayne Parry
- University of Birmingham, Institute of Applied Health Research, Birmingham, UK
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Mosher V, Swain M, Pang J, Kaplan G, Sharkey K, MacQueen G, Goodyear BG. Primary biliary cholangitis patients exhibit MRI changes in structure and function of interoceptive brain regions. PLoS One 2019; 14:e0211906. [PMID: 30735529 PMCID: PMC6368379 DOI: 10.1371/journal.pone.0211906] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 01/22/2019] [Indexed: 12/12/2022] Open
Abstract
Background Many patients with primary biliary cholangitis (PBC) experience non-hepatic symptoms that are possibly linked to altered interoception, the sense of the body’s internal state. We used magnetic resonance imaging (MRI) to determine if PBC patients exhibit structural and functional changes of the thalamus and insula, brain regions that process signals related to interoception. Methods Fifteen PBC patients with mild disease and 17 controls underwent 3 Tesla T1-weighted MRI, resting-state functional MRI, and quantitative susceptibility mapping (QSM), to measure thalamic and insular volume, neuronal activity and iron deposition, respectively. Group differences were assessed using analysis of covariance, and stepwise linear regression was used to determine the predictive power of clinical indicators of disease. Results PBC patients exhibited reduced thalamic volume (p < 0.01), and ursodeoxycholic acid (UDCA) non-responders exhibited lower left thalamus activity (p = 0.05). PBC patients also exhibited reduced anterior insula activity (p = 0.012), and liver stiffness positively correlated with MRI indicators of anterior insula iron deposition (p < 0.02). Conclusions PBC affects structure and function of brain regions critically important to interoception. Moreover, these brain changes occur in patients with early, milder disease and thus may potentially be reversible.
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Affiliation(s)
- Victoria Mosher
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Seaman Family MR Research Centre, University of Calgary, Calgary, Alberta, Canada
| | - Mark Swain
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Snyder Institute for Chronic Diseases, University of Calgary, Calgary, Alberta, Canada
- Liver Unit – Calgary Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Jack Pang
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Gilaad Kaplan
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Keith Sharkey
- Snyder Institute for Chronic Diseases, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Department of Physiology & Pharmacology, University of Calgary, Calgary, Alberta, Canada
| | - Glenda MacQueen
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada
- Mathison Centre for Mental Health Research and Education, University of Calgary, Calgary, Alberta, Canada
| | - Bradley Gordon Goodyear
- Seaman Family MR Research Centre, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- * E-mail:
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19
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Swain MG, Jones DEJ. Fatigue in chronic liver disease: New insights and therapeutic approaches. Liver Int 2019; 39:6-19. [PMID: 29935104 DOI: 10.1111/liv.13919] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 06/20/2018] [Indexed: 02/07/2023]
Abstract
The management of fatigue associated with chronic liver disease is a complex and major clinical challenge. Although fatigue can complicate many chronic diseases, it is particularly common in diseases with an inflammatory component. Fatigue can have both peripheral (i.e., neuromuscular) and central (i.e., resulting from changes in neurotransmission within the brain) causes. However, fatigue in chronic liver disease has strong social/contextual components and is often associated with behavioural alterations including depression and anxiety. Given the increasing awareness of patient-reported outcomes as important components of treatment outcomes and clinical research, there is a growing need to better understand and manage this poorly understood yet debilitating symptom. Although several pathophysiological mechanisms for explaining the development of fatigue have been generated, our understanding of fatigue in patients with chronic liver disease remains incomplete. A better understanding of the pathways and neurotransmitter systems involved may provide specific directed therapies. Currently, the management of fatigue in chronic liver disease can involve a combined use of methods to beneficially alter behavioural components and pharmacological interventions, of which several treatments have potential for the improved management of fatigue in chronic liver disease. However, evidence and consensus are lacking on the best approach and the most appropriate biochemical target(s) whilst clinical trials to address this issue have been few and limited by small sample size. In this review, we outline current understanding of the impact of fatigue and related symptoms in chronic liver disease, discuss theories of pathogenesis, and examine current and emerging approaches to its treatment.
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Affiliation(s)
- Mark G Swain
- Calgary Liver Unit, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - David E J Jones
- Institute of Cellular Medicine, University of Newcastle, Newcastle upon Tyne, UK
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Hirschfield GM, Dyson JK, Alexander GJM, Chapman MH, Collier J, Hübscher S, Patanwala I, Pereira SP, Thain C, Thorburn D, Tiniakos D, Walmsley M, Webster G, Jones DEJ. The British Society of Gastroenterology/UK-PBC primary biliary cholangitis treatment and management guidelines. Gut 2018; 67:1568-1594. [PMID: 29593060 PMCID: PMC6109281 DOI: 10.1136/gutjnl-2017-315259] [Citation(s) in RCA: 200] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 01/22/2018] [Accepted: 01/23/2018] [Indexed: 12/12/2022]
Abstract
Primary biliary cholangitis (formerly known as primary biliary cirrhosis, PBC) is an autoimmune liver disease in which a cycle of immune mediated biliary epithelial cell injury, cholestasis and progressive fibrosis can culminate over time in an end-stage biliary cirrhosis. Both genetic and environmental influences are presumed relevant to disease initiation. PBC is most prevalent in women and those over the age of 50, but a spectrum of disease is recognised in adult patients globally; male sex, younger age at onset (<45) and advanced disease at presentation are baseline predictors of poorer outcome. As the disease is increasingly diagnosed through the combination of cholestatic serum liver tests and the presence of antimitochondrial antibodies, most presenting patients are not cirrhotic and the term cholangitis is more accurate. Disease course is frequently accompanied by symptoms that can be burdensome for patients, and management of patients with PBC must address, in a life-long manner, both disease progression and symptom burden. Licensed therapies include ursodeoxycholic acid (UDCA) and obeticholic acid (OCA), alongside experimental new and re-purposed agents. Disease management focuses on initiation of UDCA for all patients and risk stratification based on baseline and on-treatment factors, including in particular the response to treatment. Those intolerant of treatment with UDCA or those with high-risk disease as evidenced by UDCA treatment failure (frequently reflected in trial and clinical practice as an alkaline phosphatase >1.67 × upper limit of normal and/or elevated bilirubin) should be considered for second-line therapy, of which OCA is the only currently licensed National Institute for Health and Care Excellence recommended agent. Follow-up of patients is life-long and must address treatment of the disease and management of associated symptoms.
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Affiliation(s)
- Gideon M Hirschfield
- NIHR Birmingham Biomedical Research Centre, Birmingham, UK
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Centre for Liver Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Jessica K Dyson
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Newcastle, United Kingdom
| | - Graeme J M Alexander
- Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, London, UK
- UCL Institute for Liver and Digestive Health, Division of Medicine, University College London, London, UK
| | - Michael H Chapman
- Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Jane Collier
- Translational Gastroenterology Unit, Oxford University Hospitals, University of Oxford, Oxford, UK
| | - Stefan Hübscher
- Centre for Liver Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- Department of Cellular Pathology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Imran Patanwala
- Department of Gastroenterology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
- University of Liverpool, Liverpool, UK
| | - Stephen P Pereira
- Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, London, UK
- UCL Institute for Liver and Digestive Health, Division of Medicine, University College London, London, UK
- Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Douglas Thorburn
- Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, London, UK
- UCL Institute for Liver and Digestive Health, Division of Medicine, University College London, London, UK
| | - Dina Tiniakos
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | | | - George Webster
- Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, London, UK
| | - David E J Jones
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Newcastle, United Kingdom
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21
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Magnetic resonance imaging evidence of hippocampal structural changes in patients with primary biliary cholangitis. Clin Transl Gastroenterol 2018; 9:169. [PMID: 29977030 PMCID: PMC6033882 DOI: 10.1038/s41424-018-0038-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 05/11/2018] [Accepted: 06/07/2018] [Indexed: 12/13/2022] Open
Abstract
Introduction Behavioral symptoms are commonly reported by patients with primary biliary cholangitis (PBC). In other patient populations, symptoms are commonly associated with hippocampal volume reduction linked to neuroinflammation (inferred from regional iron deposition), as demonstrated by magnetic resonance imaging (MRI). We hypothesized that PBC patients would exhibit reduced volume and increased iron deposition of the hippocampus. Methods Seventeen female non-cirrhotic PBC patients and 17 age/gender-matched controls underwent 3-Tesla T1-weighted MRI and quantitative susceptibility mapping (QSM; an indicator of iron deposition). The hippocampus and its subfields were segmented from T1 images using Freesurfer, and susceptibility of the whole hippocampus was calculated from QSM images. Volume and susceptibility were compared between groups, and associations with PBC-40 score and disease indicators (years since diagnosis, Fibroscan value, alkaline phosphatase level, clinical response to ursodeoxycholic acid (UDCA)) were investigated. Results PBC patients exhibited significantly reduced hippocampal volume (p = 0.023) and increased susceptibility (p = 0.048). Subfield volumes were reduced for the subiculum, molecular layer, granule cell layer of the dentate gyrus and CA4 (p < 0.05). Fibroscan value was significantly correlated with PBC-40 (Spearman’s rho = 0.499; p = 0.041) and disease duration (Spearman’s rho = 0.568; p = 0.017). Discussion Our findings suggest hippocampal changes occur early in the disease course of PBC, similar in magnitude to those observed in major depressive disorder and neurodegenerative diseases. Translational impact Clinical management of PBC could include early interventional strategies that promote hippocampal neurogenesis that may beneficially impact behavioral symptoms and improve quality of life.
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Mosher VAL, Swain MG, Pang JXQ, Kaplan GG, Sharkey KA, MacQueen GM, Goodyear BG. Primary Biliary Cholangitis Alters Functional Connections of the Brain's Deep Gray Matter. Clin Transl Gastroenterol 2017; 8:e107. [PMID: 28749455 PMCID: PMC5539342 DOI: 10.1038/ctg.2017.34] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 05/31/2017] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES Fatigue, itch, depressed mood, and cognitive impairment significantly impact the quality of life of many patients with primary biliary cholangitis (PBC). Previous neuroimaging studies of non-hepatic diseases suggest that these symptoms are often associated with dysfunction of deep gray matter brain regions. We used resting-state functional magnetic resonance imaging (rsfMRI) to determine whether PBC patients exhibit altered functional connections of deep gray matter. METHODS Twenty female non-cirrhotic PBC patients and 21 age/gender-matched controls underwent rsfMRI. Resting-state functional connectivity (rsFC) of deep gray matter brain structures (putamen, thalamus, amygdala, hippocampus) was compared between groups. Fatigue, itch, mood, cognitive performance, and clinical response to ursodeoxycholic acid (UDCA) were assessed, and their association with rsFC was determined. RESULTS Relative to controls, PBC patients exhibited significantly increased rsFC between the putamen, thalamus, amygdala, and hippocampus, as well as with frontal and parietal regions. Reduced rsFC of the putamen and hippocampus with motor and sensory regions of the brain were also observed. Fatigue, itch, complete response to UDCA, and verbal working memory performance were also associated with altered rsFC of deep gray matter. These rsFC changes were independent of biochemical disease severity. CONCLUSIONS PBC patients have objective evidence of altered rsFC of the brain's deep gray matter that is in part linked to fatigue severity, itch, response to UDCA therapy, and cognitive performance. These results may guide future approaches to define how PBC leads to altered brain connectivity and provide insight into novel targets for treating PBC-associated brain dysfunction and behavioral symptoms.
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Affiliation(s)
- Victoria A L Mosher
- Seaman Family MR Research Centre, University of Calgary, Calgary, Alberta, Canada.,Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - Mark G Swain
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Snyder Institute for Chronic Diseases, University of Calgary, Calgary, Alberta, Canada.,Liver Unit-Calgary Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Jack X Q Pang
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Gilaad G Kaplan
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Snyder Institute for Chronic Diseases, University of Calgary, Calgary, Alberta, Canada
| | - Keith A Sharkey
- Snyder Institute for Chronic Diseases, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.,Department of Physiology &Pharmacology, University of Calgary, Calgary, Alberta, Canada
| | - Glenda M MacQueen
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.,Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada.,Mathison Centre for Mental Health Research and Education, University of Calgary, Calgary, Alberta, Canada
| | - Bradley G Goodyear
- Seaman Family MR Research Centre, University of Calgary, Calgary, Alberta, Canada.,Department of Radiology, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.,Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada.,Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
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23
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EASL Clinical Practice Guidelines: The diagnosis and management of patients with primary biliary cholangitis. J Hepatol 2017; 67:145-172. [PMID: 28427765 DOI: 10.1016/j.jhep.2017.03.022] [Citation(s) in RCA: 781] [Impact Index Per Article: 111.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 03/23/2017] [Indexed: 02/07/2023]
Abstract
Primary biliary cholangitis (PBC) is a chronic inflammatory autoimmune cholestatic liver disease, which when untreated will culminate in end-stage biliary cirrhosis. Diagnosis is usually based on the presence of serum liver tests indicative of a cholestatic hepatitis in association with circulating antimitochondrial antibodies. Patient presentation and course can be diverse and risk stratification is important to ensure all patients receive a personalised approach to their care. The goals of treatment and management are the prevention of end-stage liver disease, and the amelioration of associated symptoms. Pharmacologic approaches in practice, to reduce the impact of the progressive nature of disease, currently include licensed therapies (ursodeoxycholic acid and obeticholic acid) and off-label therapies (fibric acid derivatives, budesonide). These clinical practice guidelines summarise the evidence for the importance of a structured, life-long and individualised, approach to the care of patients with PBC, providing a framework to help clinicians diagnose and effectively manage patients.
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A Randomized, Placebo-Controlled Clinical Trial of Efficacy and Safety: Modafinil in the Treatment of Fatigue in Patients With Primary Biliary Cirrhosis. Am J Ther 2017; 24:e167-e176. [PMID: 27148676 DOI: 10.1097/mjt.0000000000000387] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Fatigue is a common symptom of primary biliary cirrhosis (PBC), and is associated with an impaired quality of life. STUDY QUESTION No studies have assessed the use of modafinil in fatigue related to PBC in a controlled manner. STUDY DESIGN, MEASURES, AND OUTCOMES A randomized, double-blind, placebo-controlled study was conducted to determine the safety and efficacy of modafinil for the treatment of fatigue in PBC. Forty patients were randomized to modafinil (n = 20) or placebo (n = 20) for 12 weeks. A verbal report of fatigue for at least 6 months was required for enrollment. Modafinil was administered at 100 mg by mouth once daily; a change by 50 mg every 2 weeks (maximum: 200 mg once daily) was allowed, depending on the subject's response to treatment. The primary outcome was defined as a ≥50% improvement in fatigue severity [quantified by the Fisk Fatigue Impact Scale (FFIS)] after 12 weeks of treatment, compared with baseline values. RESULTS Thirty-three PBC patients completed the study. After 12 weeks of therapy, only 5 patients had a ≥50% reduction in FFIS scores: 3 patients (17.6%) in the modafinil arm and 2 (12.5%) in the placebo arm (P = 1.00). Change in median FFIS score was not statistically different between patients in the 2 treatment groups (P = 0.36). Modafinil was associated with minimal adverse events (headaches, diarrhea, and rash). CONCLUSIONS In patients with PBC who have fatigue, treatment with modafinil for 12 weeks was safe and fairly well tolerated; however, it did not result in beneficial effects on fatigue compared with patients treated with placebo (CONSORT Table 1). ClinicalTrials.gov identifier NCT00943176.
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26
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Dyson JK, Wilkinson N, Jopson L, Mells G, Bathgate A, Heneghan MA, Neuberger J, Hirschfield GM, Ducker SJ, Sandford R, Alexander G, Stocken D, Jones DEJ. The inter-relationship of symptom severity and quality of life in 2055 patients with primary biliary cholangitis. Aliment Pharmacol Ther 2016; 44:1039-1050. [PMID: 27640331 PMCID: PMC5082554 DOI: 10.1111/apt.13794] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Revised: 06/06/2016] [Accepted: 08/15/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Age at presentation with primary biliary cholangitis (PBC) is associated with differential response to ursodeoxycholic acid (UDCA) therapy. Younger-presenting patients are less likely to respond to treatment and more likely to need transplant or die from the disease. PBC has a complex impact on quality of life (QoL), with systemic symptoms often having significant impact. AIM To explain the impact of age at presentation on perceived QoL and the inter-related symptoms which impact upon it. METHODS Using the UK-PBC cohort, symptoms were assessed using the PBC-40 and other validated tools. Data were available on 2055 patients. RESULTS Of the 1990 patients reporting a global PBC-QoL score, 66% reported good/neutral scores and 34% reported poor scores. Each 10-year increase in age at presentation was associated with a 14% decrease in risk of poor perceived QoL (OR = 0.86, 95% CI: 0.75-0.98, P < 0.05). All symptom domains were similarly age-associated (P < 0.01). Social dysfunction was the symptom factor with the greatest impact on QoL. Median (interquartile range) PBC-40 social scores for patients with good perceived QoL were 18 (14-23) compared with 34 (29-39) for those with poor QoL. CONCLUSION The majority of patients with primary biliary cholangitis do not feel their QoL is impaired, although impairment is reported by a sizeable minority. Age at presentation is associated with impact on perceived QoL and the symptoms impairing it, with younger patients being more affected. Social dysfunction makes the greatest contribution to QoL impairment, and it should be targeted in trials aimed at improving life quality.
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Affiliation(s)
- J. K Dyson
- Institute of Cellular MedicineNewcastle UniversityNewcastle‐upon‐TyneUK,NIHR Newcastle Biomedical Research CentreNewcastle UniversityNewcastle‐upon‐TyneUK
| | - N. Wilkinson
- Institute of Health and SocietyNewcastle UniversityNewcastle‐upon‐TyneUK
| | - L. Jopson
- Institute of Cellular MedicineNewcastle UniversityNewcastle‐upon‐TyneUK
| | - G. Mells
- Department of HepatologyCambridge University Hospitals NHS Foundation TrustCambridgeUK,Academic Department of Medical GeneticsUniversity of CambridgeCambridgeUK
| | - A. Bathgate
- Scottish Liver Transplant UnitRoyal Infirmary of EdinburghEdinburghUK
| | - M. A. Heneghan
- Institute of Liver StudiesKing's College Hospital NHS Foundation TrustLondonUK
| | - J. Neuberger
- Centre for Liver ResearchNIHR Biomedical Research UnitUniversity of BirminghamBirminghamUK
| | - G. M. Hirschfield
- Centre for Liver ResearchNIHR Biomedical Research UnitUniversity of BirminghamBirminghamUK
| | - S. J. Ducker
- Institute of Cellular MedicineNewcastle UniversityNewcastle‐upon‐TyneUK,NIHR Newcastle Biomedical Research CentreNewcastle UniversityNewcastle‐upon‐TyneUK
| | | | - R. Sandford
- Academic Department of Medical GeneticsUniversity of CambridgeCambridgeUK
| | - G. Alexander
- Department of HepatologyCambridge University Hospitals NHS Foundation TrustCambridgeUK,Academic Department of Medical GeneticsUniversity of CambridgeCambridgeUK
| | - D. Stocken
- Institute of Health and SocietyNewcastle UniversityNewcastle‐upon‐TyneUK
| | - D. E. J. Jones
- Institute of Cellular MedicineNewcastle UniversityNewcastle‐upon‐TyneUK,NIHR Newcastle Biomedical Research CentreNewcastle UniversityNewcastle‐upon‐TyneUK
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27
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Raszeja-Wyszomirska J, Wunsch E, Krawczyk M, Rigopoulou EI, Kostrzewa K, Norman GL, Bogdanos DP, Milkiewicz P. Assessment of health related quality of life in polish patients with primary biliary cirrhosis. Clin Res Hepatol Gastroenterol 2016; 40:471-9. [PMID: 26621536 DOI: 10.1016/j.clinre.2015.10.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 10/09/2015] [Accepted: 10/19/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND Most patients with primary biliary cirrhosis (PBC) have impaired health related quality of life (HRQoL), as assessed by PBC-specific HRQoL (PBC-40) and generic (SF-36) questionnaires. Data on the applicability of PBC-27, a shorter version of PBC-40, have been limited. AIMS To assess HRQoL in Polish PBC patients, applying PBC-40, PBC-27 and SF-36 and to associate clinical or laboratory parameters with HRQoL factors. METHODS A total of 205 PBC patients (188 females) were analyzed using PBC-40, PBC-27 and SF-36; 85 disease-free demographically matched (in terms of age, gender, ethnicity) individuals were used as normal controls. RESULTS When compared to controls, PBC patients had significantly impaired HRQoL across all the domains of SF-36. HRQoL impairment by PBC-40 and PBC-27 was comparable between cirrhotics and non-cirrhotics, except for significantly worse Itch in cirrhotics (6.5±4.9 vs 5.1±4.3; P=0.03). In PBC-40/27, alkaline phosphatase (ALP) levels correlated with itch (P=0.0003). Female patients had marginally impaired cognitive function compared to males by PBC-40 (P=0.06). Other gender-related differences were not found. Anti-gp210 positive, as well as AMA negative PBC patients, had worse HRQoL features in itch and social/emotional domains of PBC-40/PBC-27 questionnaires. Very strong correlations (P<0.0001) between PBC-40/PBC-27 and SF-36 were seen for several domains. CONCLUSIONS HRQoL is significantly impaired in Polish patients with PBC, independently of gender and disease severity. PBC-40 and PBC-27 questionnaires are efficient in detecting HRQoL impairment in Polish PBC patients. The striking correlation between PBC-40/PBC-27 and SF-36 confirms the usefulness of the former HRQoL measures in PBC patients from Central-Eastern Europe.
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Affiliation(s)
- Joanna Raszeja-Wyszomirska
- Liver and Internal Medicine Unit, Department of General, Transplant and Liver Surgery of the Medical University of Warsaw, Warsaw, Poland
| | - Ewa Wunsch
- Department of Clinical and Molecular Biochemistry, Pomeranian Medical University, Szczecin, Poland
| | - Marek Krawczyk
- Department of General, Transplant and Liver Surgery of the Medical University of Warsaw, Warsaw, Poland
| | - Eirini I Rigopoulou
- Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | | | | | - Dimitrios P Bogdanos
- Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Liver Sciences, Division of Transplantation Immunology and Mucosal Biology, King's College London School of Medicine, King's College Hospital, London, UK
| | - Piotr Milkiewicz
- Liver and Internal Medicine Unit, Department of General, Transplant and Liver Surgery of the Medical University of Warsaw, Warsaw, Poland; Department of Clinical and Molecular Biochemistry, Pomeranian Medical University, Szczecin, Poland.
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Abstract
Stigma is one of the main problems of patients suffering from cirrhosis, and it causes many challenges for the patients and their treatment. The present study aimed to discover and define the perceived stigma by cirrhotic patients. This qualitative study was conducted through a content analysis approach. The participants were 15 patients suffering from cirrhosis. Data were collected via semistructured, in-depth interviews and analyzed on the basis of methods described by Granheme and Landman. During data analysis, stigma was categorized into four categories and 13 subcategories: external representation of social stigma (others' avoidance behaviors, inadmissible tag, discriminative behaviors of treatment personnel, blaming behaviors), internal representation of social stigma (social ostracism, social isolation, curiosity to perceive people's perceptions), external representation of self-stigma (fear of disclosure of illness, threatening situation, difficult emotional relationships), and internal representation of self-stigma (condemned to suffer, self-punishment, self-alienation). Experiencing stigma is common among cirrhotic patients and may affect patients' coping with the illness and treatment. Thus, it is specifically important that treatment personnel know patients' perception, provide comprehensive support for these patients, and plan to enhance public awareness about the disease recommended.
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29
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Jopson L, Newton JL, Palmer J, Floudas A, Isaacs J, Qian J, Wilkinson J, Trenell M, Blamire A, Howel D, Jones DE. RITPBC: B-cell depleting therapy (rituximab) as a treatment for fatigue in primary biliary cirrhosis: study protocol for a randomised controlled trial. BMJ Open 2015; 5:e007985. [PMID: 26297361 PMCID: PMC4550715 DOI: 10.1136/bmjopen-2015-007985] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Primary biliary cirrhosis (PBC) is an autoimmune liver disease with approximately 50% of patients experiencing fatigue. This can be a particularly debilitating symptom, affecting quality of life and resulting in social isolation. Fatigue is highlighted by patients as a priority for research and patient support groups were involved in designing this trial. This is the first randomised controlled trial to investigate a treatment for fatigue in PBC. The trial protocol is innovative as it utilises novel magnetic resonance spectroscopy (MRS) techniques as an outcome measure. The protocol will be valuable to research groups planning clinical trials targeting fatigue in PBC and also transferrable to other conditions associated with fatigue. METHODS AND ANALYSIS RITPBC is a Medical Research Council (MRC) and National Institute for Health Research (NIHR) Efficacy and Mechanism Evaluation Programme (EME)-funded project. It is a phase II, single-centre, randomised controlled, double-blinded trial comparing rituximab with placebo in fatigued PBC patients. 78 patients with PBC and moderate to severe fatigue will be randomised to receive two infusions of rituximab or placebo. The study aims to assess whether rituximab improves fatigue in patients with PBC, the safety, and tolerability of rituximab in PBC and the sustainability of any beneficial actions. The primary outcome will be an improvement in fatigue domain score of the PBC-40, a disease-specific quality of life measure, evaluated at 12-week assessment. Secondary outcome measures include novel MRS techniques assessing muscle bioenergetic function, physical activity, anaerobic threshold and symptom, and quality of life measures. The trial started recruiting in October 2012 and recruitment is ongoing. ETHICS AND DISSEMINATION The trial has ethical approval from the NRES Committee North East, has Clinical Trial Authorisation from MHRA and local R&D approval. Trial results will be communicated to participants, presented at national and international meetings and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER ISRCTN03978701.
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Affiliation(s)
- Laura Jopson
- Institute of Cellular Medicine, Medical School, Newcastle upon Tyne, UK
| | - Julia L Newton
- Institute of Health and Ageing, Medical School, Newcastle upon Tyne, UK
| | - Jeremy Palmer
- Institute of Cellular Medicine, Medical School, Newcastle upon Tyne, UK
| | - Achilleas Floudas
- Institute of Cellular Medicine, Medical School, Newcastle upon Tyne, UK
| | - John Isaacs
- Institute of Cellular Medicine, Medical School, Newcastle upon Tyne, UK
| | - Jessica Qian
- Newcastle Clinical Trials Unit, Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Jennifer Wilkinson
- Newcastle Clinical Trials Unit, Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Mike Trenell
- Movelab @ Newcastle University, Medical School, Newcastle upon Tyne, UK
| | - Andrew Blamire
- Institute of Cellular Medicine, Newcastle Magnetic Resonance Centre, Newcastle University, Newcastle upon Tyne, UK
| | - Denise Howel
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - David E Jones
- Institute of Cellular Medicine, Medical School, Newcastle upon Tyne, UK
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An K, Jallo N, Menzies V, Kinser P, Robins JLW, Starkweather A. Integrative Review of Co-Occurring Symptoms Across Etiologies of Chronic Liver Disease and Implications for Symptom Management Research and Practice. J Nurs Scholarsh 2015; 47:310-7. [DOI: 10.1111/jnu.12146] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2015] [Indexed: 12/17/2022]
Affiliation(s)
- Kyungeh An
- Gamma Omega , Associate Professor; Virginia Commonwealth University School of Nursing; Richmond VA USA
| | - Nancy Jallo
- Gamma Omega , Assistant Professor; Virginia Commonwealth University School of Nursing; Richmond VA USA
| | - Victoria Menzies
- Gamma Omega , Associate Professor; Virginia Commonwealth University School of Nursing; Richmond VA USA
| | - Patricia Kinser
- Gamma Omega , Assistant Professor; Virginia Commonwealth University School of Nursing; Richmond VA USA
| | - Jo Lynne W. Robins
- Gamma Omega , Assistant Professor; Virginia Commonwealth University School of Nursing; Richmond VA USA
| | - Angela Starkweather
- Gamma Omega , Associate Professor; Virginia Commonwealth University School of Nursing; Richmond VA USA
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31
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Raszeja-Wyszomirska J, Wunsch E, Krawczyk M, Rigopoulou EI, Bogdanos D, Milkiewicz P. Prospective evaluation of PBC-specific health-related quality of life questionnaires in patients with primary sclerosing cholangitis. Liver Int 2015; 35:1764-71. [PMID: 25388280 DOI: 10.1111/liv.12730] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Accepted: 11/03/2014] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Primary biliary cirrhosis and Primary sclerosing cholangitis are autoimmune cholestatic liver diseases sharing a lot in common, including a significant impairment of patients' health-related quality of life HRQoL HRQoL in PBC is assessed with disease-specific PBC-40 and PBC-27 questionnaires. A PSC-specific questionnaire has not been developed. Neither PBC-40 nor PBC-27s applicability for PSC has been evaluated. We applied these three questionnaires for HRQoL assessment in a large homogenous cohort of PSC patients. PATIENTS AND METHODS This cross-sectional study enrolled 102 Caucasian PSCs and 53 matched healthy controls and measured HRQoL using generic SF-36, and disease-specific (PBC-40/PBC-27) questionnaires. RESULTS (i) SF-36. Most SF-36 domains were significantly lower in PSCs than controls. Physical Functioning and Mental Component Summary scores were significantly lower in female patients and correlated negatively with age but not with concurrent inflammatory bowel disease. Cirrhosis was associated with lower Physical Functioning, Role Physical, General Health, Vitality and Physical Component Summary. (ii) PBC-40 and PBC-27. Both tools showed similar HRQoL impairment scoring. Fatigue and Cognitive were impaired in female patients. Several correlations existed between HRQoL and laboratory parameters, including cholestatic tests and Itch. Cirrhosis correlated with Other symptoms and Fatigue PBC-40. (iii) PBC-40 vs PBC-27. Strong correlations among most domains of both questionnaires were seen, as well as between (iv) SF-36 vs PBC-40 or SF-36 vs PBC-27. CONCLUSION This is the first study directly comparing PBC-40, PBC-27 and SF-36 in PSC. PSC patients, especially females, show HRQoL impairment. PBC-40 and PBC-27 questionnaires could be of potential use for HRQoL assessment in PSC.
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Affiliation(s)
- Joanna Raszeja-Wyszomirska
- Liver and Internal Medicine Unit, Department of General, Transplant and Liver Surgery of the Medical University of Warsaw, Warsaw, Poland
| | - Ewa Wunsch
- Department of Clinical and Molecular Biochemistry, Pomeranian Medical University, Szczecin, Poland
| | - Marek Krawczyk
- Department of General, Transplant and Liver Surgery of the Medical University of Warsaw, Warsaw, Poland
| | - Eirini I Rigopoulou
- Institute of Liver Studies, King's College London School of Medicine, King's College Hospital, London, UK
| | - Dimitrios Bogdanos
- Institute of Liver Studies, King's College London School of Medicine, King's College Hospital, London, UK.,Department of Medicine, School of Health Sciences, Larissa, Greece
| | - Piotr Milkiewicz
- Liver and Internal Medicine Unit, Department of General, Transplant and Liver Surgery of the Medical University of Warsaw, Warsaw, Poland.,Department of Clinical and Molecular Biochemistry, Pomeranian Medical University, Szczecin, Poland
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Untas A, Boujut E, Corpechot C, Zenasni F, Chazouillères O, Jaury P, Poupon R, Buffel du Vaure C, Sultan S. Quality of life and illness perception in primary biliary cirrhosis: a controlled cross-sectional study. Clin Res Hepatol Gastroenterol 2015; 39:52-8. [PMID: 25132012 DOI: 10.1016/j.clinre.2014.07.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Revised: 06/28/2014] [Accepted: 07/08/2014] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The aim of this study was to understand better the quality of life (QOL) and illness perception in women with primary biliary cirrhosis (PBC) through a comparison with women having diabetes. METHODS One hundred and ninety-four women took part in this study: 130 with PBC, 64 with type 2 diabetes. They were administered the SF-12 to measure QOL and the Brief Illness Perception Questionnaire to assess representations of their illness. Analysis of covariance with bootstrapping was used to compare QOL and illness perception scores by controlling age and mean disease duration. RESULTS Physical QOL was significantly worse for women with PBC than for women with diabetes. Women with PBC felt their disease would last longer and reported more symptoms and concerns related to their disease than women with diabetes. Significant differences were also observed for causes: women with PBC mainly reported autoimmune, emotional, unknown/unlucky and medical causes whereas women with diabetes reported mostly lifestyle and hereditary causes. Marginally significant differences were observed regarding consequences on daily life, feeling of control over the disease and emotional responses, which were shown to be worse in PBC. Mental QOL, treatment control and overall understanding of the disease was similar in both groups. CONCLUSIONS This study shows that women with PBC have a worse QOL and somewhat different illness perception than women with diabetes. Further research could help understand PBC specificities better in order to improve patient care, especially if factors such as fatigue or rarity of the disease explain these results.
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Affiliation(s)
- Aurélie Untas
- Laboratoire de Psychopathologie et Processus de Santé EA 4057, Institut Universitaire Paris Descartes de Psychologie, Université Paris Descartes, Sorbonne Paris Cité, 71, avenue Édouard-Vaillant, 92100 Boulogne-Billancourt, France.
| | - Emilie Boujut
- Laboratoire de Psychopathologie et Processus de Santé EA 4057, Institut Universitaire Paris Descartes de Psychologie, Université Paris Descartes, Sorbonne Paris Cité, 71, avenue Édouard-Vaillant, 92100 Boulogne-Billancourt, France
| | - Christophe Corpechot
- Centre de Référence des Maladies Inflammatoires des Voies Biliaires, Inserm UMR_S938, AP-HP, Université Pierre-et-Marie-Curie Paris 6, Hôpital Saint-Antoine, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France
| | - Franck Zenasni
- Laboratoire Adaptation Travail Individu EA 4469, Institut Universitaire Paris Descartes de Psychologie, Université Paris Descartes, Sorbonne Paris Cité, 71, avenue Édouard-Vaillant, 92100 Boulogne-Billancourt, France
| | - Olivier Chazouillères
- Centre de Référence des Maladies Inflammatoires des Voies Biliaires, Inserm UMR_S938, AP-HP, Université Pierre-et-Marie-Curie Paris 6, Hôpital Saint-Antoine, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France
| | - Philippe Jaury
- Département de Médecine Générale, Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine Cochin-Port Royal, 24, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - Raoul Poupon
- Centre de Référence des Maladies Inflammatoires des Voies Biliaires, Inserm UMR_S938, AP-HP, Université Pierre-et-Marie-Curie Paris 6, Hôpital Saint-Antoine, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France
| | - Céline Buffel du Vaure
- Département de Médecine Générale, Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine Cochin-Port Royal, 24, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - Serge Sultan
- Département de Psychologie, Université de Montréal, Montréal, Québec, Canada; CHU Sainte-Justine, Montréal, Québec, Canada
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Abstract
Primary biliary cirrhosis (PBC) is an autoimmune cholestatic liver disease characterised by a breakdown of immune tolerance to mitochondrial and nuclear antigens, causing injury to the biliary epithelial cells (BEC) lining the small intrahepatic bile ducts. This leads to bile duct injury and the retention of hydrophobic bile acids which cause further BEC injury leading to a self-sustaining cycle of bile duct injury. Initially the BEC respond to injury via a homeostatic response including through proliferation. Ultimately they become senescent; an active process with accompanying release of inflammatory cytokines ('the senescent secretome') which contributes to the process of interface hepatitis which is a feature of high-risk and treatment-unresponsive disease. This model for pathogenesis of PBC has implications for potential therapy approaches in targeting both the 'upstream' immune injury and 'downstream' BEC response to the immune injury. Fatigue is the commonest reported symptom in PBC and has a negative impact on patients' perceived quality of life, often through social isolation. It is unrelated to the severity of liver disease and appears unresponsive to current therapies, including ursodeoxycholic acid and transplantation. Fatigue in PBC is complex, with numerous associated peripheral and CNS features. Initially, cholestasis causes degenerative CNS change affecting areas of the brain regulating autonomic dysfunction and sleep, and these changes lead directly to some manifestations of fatigue and the associated cognitive impairment. In addition to this, the anti-mitochondrial antibody has direct muscle level metabolic effects leading to over-utilisation of anaerobic metabolism. Autonomic dysfunction contributes to the impact of this metabolic change by limiting the capacity of the muscle to respond through increased proton/lactate efflux from cells and outflow from tissues. The model has a number of implications for potential therapy approaches.
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Affiliation(s)
- Laura Griffiths
- Institute of Cellular Medicine, Newcastle University and Liver Unit, Freeman Hospital, Newcastle upon Tyne, UK
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Symptoms and Distress Among Patients With Liver Cirrhosis but Without Hepatocellular Carcinoma in Taiwan. Gastroenterol Nurs 2014; 37:49-59. [DOI: 10.1097/sga.0000000000000020] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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Kimbell B, Murray SA. What is the patient experience in advanced liver disease? A scoping review of the literature. BMJ Support Palliat Care 2013; 5:471-80. [DOI: 10.1136/bmjspcare-2012-000435] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 06/01/2013] [Indexed: 11/03/2022]
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Mells GF, Pells G, Newton JL, Bathgate AJ, Burroughs AK, Heneghan MA, Neuberger JM, Day DB, Ducker SJ, Sandford RN, Alexander GJ, Jones DEJ. Impact of primary biliary cirrhosis on perceived quality of life: the UK-PBC national study. Hepatology 2013; 58:273-83. [PMID: 23471852 DOI: 10.1002/hep.26365] [Citation(s) in RCA: 137] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2012] [Revised: 01/31/2013] [Accepted: 02/26/2013] [Indexed: 12/14/2022]
Abstract
UNLABELLED Primary biliary cirrhosis (PBC) has a complex clinical phenotype, with debate about the extent and specificity of frequently described systemic symptoms such as fatigue. The aim of this study was to use a national patient cohort of 2,353 patients recruited from all clinical centers in the UK to explore the impact of disease on perceived life quality. Clinical data regarding diagnosis, therapy, and biochemical status were collected and have been reported previously. Detailed symptom phenotyping using recognized and validated symptom assessment tools including the PBC-40 was also undertaken and is reported here. Perception of poor quality of life and impaired health status was common in PBC patients (35% and 46%, respectively) and more common than in an age-matched and sex-matched community control group (6% and 15%, P < 0.0001 for both). Fatigue and symptoms of social dysfunction were associated with impaired perceived quality of life using multivariate analysis. Fatigue was the symptom with the greatest impact. Depression was a significant factor, but appeared to be a manifestation of complex symptom burden rather than a primary event. Fatigue had its greatest impact on perceived quality of life when accompanied by symptoms of social dysfunction, suggesting that maintenance of social networks is critical for minimizing the impact of fatigue. CONCLUSION The symptom burden in PBC, which is unrelated to disease severity or ursodeoxycholic acid response, is significant and complex and results in significant quality of life deficit. The complexity of symptom burden, and its lack of relation to disease severity and treatment response, suggest that specific approaches to symptom management are warranted that address both symptom biology and social impact.
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Affiliation(s)
- George F Mells
- Department of Hepatology Cambridge University Hospitals NHS Foundation Trust Cambridge UK
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The impact of liver transplantation on the phenotype of primary biliary cirrhosis patients in the UK-PBC cohort. J Hepatol 2013; 59:67-73. [PMID: 23466308 PMCID: PMC6976302 DOI: 10.1016/j.jhep.2013.02.019] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 02/24/2013] [Accepted: 02/25/2013] [Indexed: 01/16/2023]
Abstract
BACKGROUND & AIMS Liver transplantation improves survival in end-stage primary biliary cirrhosis (PBC), but the benefit for systemic symptoms including fatigue is less clear. The aim of this study was to utilise the comprehensive UK-PBC Research Cohort, including 380 post-transplant patients and 2300 non-transplanted patients, to answer key questions regarding transplantation for PBC. METHODS Cross-sectional study of post-transplant PBC patients and case-matched non-transplanted patients. Detailed clinical information was collected, together with patient systemic symptom impact data using validated assessment tools. RESULTS Over 25% of patients in the transplant cohort were grafted within 2 years of PBC diagnosis suggesting advanced disease at presentation. Transplanted patients were significantly younger at presentation than non-transplanted (mean 7 years) and >35% of all patients in the UK-PBC cohort who presented under 50 years had already undergone liver transplantation at the study censor point (>50% were treatment failures (post-transplant or unresponsive to UDCA)). Systemic symptom severity (fatigue and cognitive symptoms) was identical in female post-transplant patients and matched non-transplanted controls and unrelated to disease recurrence or immunosuppression type. In males, symptoms were worse in transplanted than in non-transplanted patients. CONCLUSIONS Age at presentation is a major risk factor for progression to transplant (as well as UDCA non-response) in PBC. Although both confirmatory longitudinal studies, and studies utilising objective as well as subjective measures of function, are needed if we are to address the question definitively, we found no evidence of improved systemic symptoms after liver transplantation in PBC and patients should be advised accordingly. Consideration needs to be given to enhancing rehabilitation approaches to improve function and life quality after liver transplant for PBC.
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Carbone M, Mells GF, Pells G, Dawwas MF, Newton JL, Heneghan MA, Neuberger JM, Day DB, Ducker SJ, Sandford RN, Alexander GJ, Jones DEJ. Sex and age are determinants of the clinical phenotype of primary biliary cirrhosis and response to ursodeoxycholic acid. Gastroenterology 2013; 144:560-569.e7; quiz e13-4. [PMID: 23246637 DOI: 10.1053/j.gastro.2012.12.005] [Citation(s) in RCA: 276] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Revised: 11/30/2012] [Accepted: 12/06/2012] [Indexed: 12/02/2022]
Abstract
UNLABELLED BACKGROUND, & AIMS: Studies of primary biliary cirrhosis (PBC) phenotypes largely have been performed using small and selected populations. Study size has precluded investigation of important disease subgroups, such as men and young patients. We used a national patient cohort to obtain a better picture of PBC phenotypes. METHODS We performed a cross-sectional study using the United Kingdom-PBC, patient cohort. Comprehensive data were collected for 2353 patients on diagnosis reports, response to therapy with ursodeoxycholic acid (UDCA), laboratory results, and symptom impact (assessed using the PBC-40 and other related measures). RESULTS Seventy-nine percent of the patients reported current UDCA, therapy, with 80% meeting Paris response criteria. Men were significantly less likely to have responded to UDCA than women (72% vs 80% response rate; P < .05); male sex was an independent predictor of nonresponse on multivariate analysis. Age at diagnosis was associated strongly and independently with response to UDCA; response rates ranged from 90% among patients who presented with PBC when they were older than age 70, to less than 50% for those younger than age 30 (P < .0001). Patients who presented at younger ages also were significantly more likely not to respond to UDCA therapy, based on alanine aminotransferase and aspartate aminotransferase response criteria, and more likely to report fatigue and pruritus. Women had mean fatigue scores 32% higher than men's (P < .0001). The increase in fatigue severity in women was related strongly (r = 0.58; P < .0001) to higher levels of autonomic symptoms (P < .0001). CONCLUSIONS Among patients with PBC, response to UDCA, treatment and symptoms are related to sex and age at presentation, with the lowest response rates and highest levels of symptoms in women presenting at younger than age 50. Increased severity of fatigue in women is related to increased autonomic symptoms, making dysautonomia a plausible therapeutic target.
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Affiliation(s)
- Marco Carbone
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
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Abstract
Improved medical management and the changing disease demographic mean that the majority of patients with chronic liver disease are living with the disease rather than dying from it. Historically, the perception has been that the impact of chronic liver disease is related entirely to the consequences of endstage liver disease; however, more recently a number of systemic symptoms have been recognised that can occur at any point in the natural history of chronic liver disease and which can be associated with functional impairment and reduced quality of life. The most characteristic of these systemic symptoms is fatigue, which frequently associates with sleep disturbance and autonomic dysfunction, particularly manifest as abnormality of blood pressure regulation. Cognitive symptoms can occur even in non-cirrhotic patients. Falls can present in patients with autonomic dysfunction, complicated by the presence of peripheral muscle strength problems. Importantly for clinicians managing chronic liver disease, the severity of these systemic symptoms is typically not related to liver disease severity, and therefore despite optimal liver disease management, patients can often continue to experience debilitating symptoms. The similarity in systemic symptoms between different chronic liver diseases (and indeed chronic inflammatory conditions affecting other organs) suggests the possibility of shared pathogenetic processes and raises the possibility of common management strategies, although further research is urgently needed to confirm this. In primary biliary cirrhosis, where our understanding of systemic symptoms is arguably most developed, structured management strategies have been shown to improve the quality of life of patients. It is highly likely that similar approaches will have comparable benefits for other chronic liver disease groups. Here, we review the current understanding of systemic symptoms in chronic liver disease and offer recommendations regarding the successful management of these symptoms. Critical for successful treatment is use of a structured and systematic approach to management in which all contributing factors are addressed in an organised fashion. We believe that such a systematic approach, when applied to research as well as to clinical management, will allow us to reduce the overall burden of chronic liver disease, improve quality of life and enhance functional ability.
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Affiliation(s)
- Julia L Newton
- UK NIHR Biomedical Research Centre in Ageing and Age Related Diseases, Newcastle University, Newcastle, UK.
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40
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Lasker JN, Sogolow ED, Short LM, Sass DA. The impact of biopsychosocial factors on quality of life: women with primary biliary cirrhosis on waiting list and post liver transplantation. Br J Health Psychol 2011; 16:502-27. [PMID: 21722273 DOI: 10.1348/135910710x527964] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Judith N Lasker
- Department of Sociology and Anthropology, Lehigh University, Bethlehem, Pennsylvania 18015, USA.
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Pearce RM, Jones DE, Newton JL. Development of an Evidence-Based Patient Information Medium: Empowering Newly Diagnosed Patients With Primary Biliary Cirrhosis. J Vis Commun Med 2011; 34:4-13. [DOI: 10.3109/17453054.2011.548794] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Patients with primary biliary cirrhosis do not show post-exercise depression of cortical excitability. Clin Neurophysiol 2010; 121:1321-8. [DOI: 10.1016/j.clinph.2009.12.040] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2008] [Revised: 12/17/2009] [Accepted: 12/29/2009] [Indexed: 11/24/2022]
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Sogolow ED, Lasker JN, Sharim RR, Weinrieb RM, Sass DA. Stigma and Liver Disease. ACTA ACUST UNITED AC 2010. [DOI: 10.2190/il.18.3.e] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
This study explores stigma experienced by women with the autoimmune liver disease Primary Biliary Cirrhosis (PBC). Liver disease is commonly stigmatized due to an association with alcoholism and drug abuse, and persons with PBC may be subjected to stigma even though there is no etiological connection to substance use. Women with PBC (25 waiting list, 75 posttransplant), recruited through an online organization and two transplant centers, completed a survey regarding demographic, biomedical, psychological, and social contributors to overall quality of life (QOL). Two measures of stigma were analyzed in relation to the other variables and QOL. Open-ended questions concerned stigmatizing experiences and participants' reactions to them. Almost one in five reported experiencing stigmatizing behaviors from others, in particular from medical professionals, that resulted in hurt and anger. Higher stigma scores were associated with diminished mental and social dimensions of QOL as well as with greater uncertainty about illness, more symptoms from the disease and medication effects. Depression, fatigue, and age (younger) were key predictors of stigma. Those experiencing stigma should receive support and access to counseling. The knowledge and sensitivity of the public and medical professionals regarding the damage inflicted by stigmatizing any disease should be addressed through professional continuing education programs and public campaigns by organizations that support people with chronic liver disease.
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Affiliation(s)
| | | | | | - Robert M. Weinrieb
- University of Pennsylvania School of Medicine and Philadelphia Veterans Affairs Medical Center
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44
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Abstract
Primary biliary cirrhosis (PBC) is a chronic, autoimmune, cholestatic liver disease with a slowly progressive course. Without treatment, most patients eventually develop fibrosis of the liver and may need liver transplantation in the late stage of disease. Fatigue and pruritus are the most common symptoms of PBC, but the majority of patients are asymptomatic at first presentation. There is no specific treatment for fatigue in PBC, but modafinil has shown some potential beneficial effects, such as increased energy levels and decreased total sleep time. This Review article discusses the natural history and the measurement of fatigue in patients with PBC. The central and the peripheral mechanisms that have been suggested for the pathogenesis of fatigue in PBC are also discussed and treatment options are reviewed.
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Elliott C, Frith J, Newton J. Occupational Therapy in Chronic Liver Disease: A Preliminary Study to Explore the Views of Occupational Therapists and Physicians Working in Acute Medical Settings. Br J Occup Ther 2010. [DOI: 10.4276/030802210x12682330090451] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Chronic liver disease (CLD) is on the increase worldwide. Occupational therapists are well placed to address many of the symptoms associated with CLD; however, there is a dearth of literature to support this or to define the current working practice of occupational therapists in this clinical area. This study used questionnaires and mixed methodological analysis to describe both the current working practice of occupational therapists in CLD and the perceptions of the occupational therapist's role by physicians referring patients with CLD to occupational therapy. Thematic analysis of the structured data demonstrated an appropriate understanding of, and referral to, occupational therapy in the context of safe discharge from hospital and the provision of equipment. Cross-sectional analysis revealed a homogeneous approach to current occupational therapy working practice in CLD which, although expedient, lacks emphasis on the treatment of the symptoms experienced by this client group.
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Affiliation(s)
- Chris Elliott
- Institute for Ageing and Health, Newcastle University
| | - James Frith
- Institute for Ageing and Health, Newcastle University
| | - Julia Newton
- Institute for Ageing and Health, Newcastle University
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Björnsson E, Kalaitzakis E, Neuhauser M, Enders F, Maetzel H, Chapman RW, Talwalkar J, Lindor K, Jorgensen R. Fatigue measurements in patients with primary biliary cirrhosis and the risk of mortality during follow-up. Liver Int 2010; 30:251-8. [PMID: 19922590 DOI: 10.1111/j.1478-3231.2009.02160.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
BACKGROUND Fatigue was recently suggested to predict an increased risk of mortality in a primary biliary cirrhosis (PBC) cohort during follow-up. AIMS To analyse the impact of fatigue on prognosis in PBC. METHODS Patients with PBC who had earlier completed the fatigue impact scale (FIS) were identified. Prognosis in terms of death and liver transplantation (Tx) was determined. RESULTS FIS values at baseline were analysed from 208 patients (192 females; median age 59 years (interquartile range 51-67), median follow-up of 5 years. Overall, 181 patients were alive at follow-up, 22 (12%) died and five (2.4%) underwent transplantation. FIS at baseline was 28 (12-47) and FIS at follow-up was 25 (8-64) (P<0.001; r=0.69). Among survivors, FIS at baseline was 27 (12-43), 36 (12-72) in those who died (P=0.059) and 99 (41-102) in those who underwent transplantation (P=0.0008). FIS at baseline was 44 (12-88) in patients with death and/or Tx vs. 27 (12-43) in survivors (P=0.003). Age [hazard ratio (HR) 1.1 (confidence interval (CI) 1.0-1.2)] and aspartate aminotransferase [HR 2.0 (CI 1.3-3.0)] were independently associated with decreased survival on multivariate analysis. FIS scores over 40 [HR 9.6 (CI 2.3-39.7)] and bilirubin [HR 4.8 (CI 2.8-8.2)] were independently associated with a poor outcome in patients who underwent Tx or had a liver-related death. CONCLUSIONS Fatigue seems to change little over time in PBC. Fatigue levels were higher at baseline in those who died or underwent Tx. High fatigue levels seem to be a predictor of risk of liver-related mortality and need for transplantation over time but not a predictor of non-liver-related mortality.
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Affiliation(s)
- Einar Björnsson
- Department of Internal Medicine, Section of Gastroenterology and Hepatology, Sahlgrenska University Hospital, Gothenburg, Sweden.
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Abstract
BACKGROUND Studies have established that levels of fatigue vary between different patient groups. It is less clear whether the nature, as opposed to severity of fatigue differs between groups. OBJECTIVE To examine descriptions of fatigue by patients with a range of chronic diseases and determine the relationship between symptom domains. DESIGN Retrospective review of Fatigue Impact Scale (FIS) data. SETTING Fatigue Research Group. PARTICIPANTS Six hundred subjects in five chronic disease groups and one (n = 45) normal control group. MAIN OUTCOME MEASURES Statistical analysis was performed to assess the effect of increasing fatigue and the overlap of FIS domain scores between disease groups by calculation of geometric means as proportions summed to 1 in each FIS domains, whilst controlling for total score. RESULTS Those with lower scores exhibit relatively higher physical scores than patients with higher total scores. In contrast, as total score increases, so does the proportion accounted for by the cognitive and psychosocial scores. This was not related to a threshold effect as the maximum total score of 40 in the physical domain was only achieved in three patients (<1%). Average domain proportions between patient groups did not vary to any degree among physical (0.30-0.39), cognitive (0.15-0.23) and psychosocial (0.42-0.47) domain proportions of the patient groups. CONCLUSION Perceived fatigue is similar between patient groups. Increasing scores were not related to simply reaching the maximum threshold in the physical domain. Studies have confirmed a positive-structured approach to symptom management in one fatigue-associated chronic disease, primary biliary cirrhosis, leads to significant improvements in quality of life. We suggest that, with a similar approach, the same might be true in other chronic diseases where moderate fatigue is a significant problem.
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Affiliation(s)
- D E J Jones
- Institute of Cellular Medicine, Newcastle University, Newcastle, NE2 4HH, UK
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48
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Abstract
Chronic liver disease (CLD) is increasing worldwide (World Health Organisation 2004). The symptoms that affect people with CLD are nonspecific and include joint pain, fatigue, anxiety, depression and cognitive difficulties. In many chronic diseases, such as chronic fatigue syndrome/myalgic encephalomyelitis and cancer, evidence is available to inform the management of these nonspecific symptoms and the role of the occupational therapist. No literature is available, however, on the role of the occupational therapist in clients with CLD. This opinion piece discusses occupational therapy in other chronic conditions and its applicability in the investigation and management of the symptom burden in people with CLD. It concludes that there is a need for occupational therapists to be at the forefront of research in this clinical area, appreciating the symptoms affecting clients with CLD and working towards developing services and interventions appropriate to this client group.
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Abstract
Most care of liver disease is in the ambulatory setting, and therefore the clinical needs of patients represent those of any other chronic illness. Emphasis must be given to preventative strategies such that liver lifetime (including pre-emptive strategies related to potential allograft survival) is maximised through timely intervention and avoidance of side effects. This review addresses the pertinent practical clinical concerns faced by clinicians as they manage adult patients with chronic liver disease, with an emphasis on preventing and managing symptoms and complications directly and indirectly related to the underlying disease.
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Affiliation(s)
- Gideon M Hirschfield
- Toronto Western Hospital, University Health Network, University of Toronto, ON, Canada.
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50
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Crosignani A, Battezzati PM, Invernizzi P, Selmi C, Prina E, Podda M. Clinical features and management of primary biliary cirrhosis. World J Gastroenterol 2008; 14:3313-27. [PMID: 18528929 PMCID: PMC2716586 DOI: 10.3748/wjg.14.3313] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Primary biliary cirrhosis (PBC), which is characterized by progressive destruction of intrahepatic bile ducts, is not a rare disease since both prevalence and incidence are increasing during the last years mainly due to the improvement of case finding strategies. The prognosis of the disease has improved due to both the recognition of earlier and indolent cases, and to the wide use of ursodeoxycholic acid (UDCA). New indicators of prognosis are available that will be useful especially for the growing number of patients with less severe disease. Most patients are asymptomatic at presentation. Pruritus may represent the most distressing symptom and, when UDCA is ineffective, cholestyramine represents the mainstay of treatment. Complications of long-standing cholestasis may be clinically relevant only in very advanced stages. Available data on the effects of UDCA on clinically relevant end points clearly indicate that the drug is able to slow but not to halt the progression of the disease while, in advanced stages, the only therapeutic option remains liver transplantation.
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