Symptom prevalence and quality of life of patients with end-stage liver disease: A systematic review and meta-analysis

Examining the Relationship Between Healthy Life Awareness and Psychological Well-Being in Liver Transplantation Patients: A Structural Equation Model

This study aimed to evaluate the mediating role of healthy life awareness in the relationship between the sociodemographic characteristics and psychological well-being of liver transplant patients. The sample of the study consisted of 202 patients aged between 18 and 69 years who underwent liver transplantation surgery at a hospital in Turkey. The data were collected using a sociodemographic information form, the "Healthy Life Awareness Scale" and the "Psychological Well-Being Scale." Healthy life awareness directly predicted psychological well-being (β: 0.68, p < 0.01). Education positively predicted psychological well-being both directly (β: 0.14, p < 0.05) and indirectly through healthy life awareness (β: 0.76, p < 0.05). Age indirectly predicted healthy life awareness and psychological well-being through employment status and education. The income level positively predicted healthy life awareness (β: 0.14, p < 0.05), whereas gender (male) negatively predicted healthy life awareness (β: -0.22, p < 0.01). Healthy life awareness was a significant predictor of psychological well-being. The results of this study may offer valuable information for healthcare providers to tailor interventions that also support mental and emotional health, which is critical to the long-term success of transplant outcomes.

Evaluating Performance of the Surprise Question to Predict 12-Month Mortality in Patients With End-Stage Liver Disease

INTRODUCTION

Patients diagnosed with end-stage liver disease (ESLD) often struggle with a heavy symptom burden that compromises their quality of life. Introduction of specialty palliative care (PC) may help address these issues but is underutilized in ESLD. This study aimed to assess the performance of the surprise question (SQ) in this population as a potential screen to identify patients with a life expectancy of less than 12 months.

METHODS

A retrospective cohort analysis was performed. In a previous study (COMPASS Trial, NCT03022630), attending hepatologists were asked the SQ: "Would you be surprised if this patient were to die in the next 12 months?" as a prompt to consider consultation to specialty PC. Here, we consider the full collection of SQ answers and reconcile against record of death to examine the accuracy of the SQ as a predictor in this patient population.

RESULTS

The SQ had high sensitivity (93%) but low specificity (38%) for predicting 12-month mortality in ESLD patients. The SQ also had a positive predictive value of 42% and a negative predictive value of 92%. Patients who were SQ+ (physician responded: No, I would not be surprised) were more likely to die within the year than those who were SQ-.

CONCLUSION

In ESLD, the SQ may serve as a useful screening test to identify patients at higher risk of mortality which may prompt PC engagement.

The mediating role of social support in self-management and quality of life in patients with liver cirrhosis

Patients with liver cirrhosis often experience factors such as malnutrition and lack of exercise, leading to reduced quality of life. Insufficient social support is related to self-management in patients with chronic diseases. Therefore, this study explores the mediating role of social support in the relationship between self-management and quality of life, analyzing the impact of exercise frequency and malnutrition risk assessment on social support, self-management, and quality of life. Using a convenience sampling method, cross-sectional data were collected from 257 patients with liver cirrhosis at the infectious disease department of a tertiary hospital in Zunyi, China, from 2021 to 2022. The patients were evaluated using a demographic questionnaire, the Self-Management Behavior Scale for Liver Cirrhosis Patients, the Social Support Rating Scale (SSRS), the Chronic Liver Disease Questionnaire (CLDQ), and the Royal Free Hospital Nutritional Prioritizing Tool (RFH-NPT). Data were analyzed using SPSS and PROCESS software. (1) Patients in the decompensated stage of liver cirrhosis and those classified in Child-Pugh class B/C had lower scores in self-management, quality of life, and social support compared to patients in the compensated stage of liver cirrhosis and those classified in Child-Pugh Class A. (2) Quality of life was positively correlated with both social support and self-management (r = 0.668, r = 0.665, both P < 0.001). (3) Mediation analysis showed that self-management had a direct predictive effect on quality of life. Social support had a mediating effect between self-management and quality of life, with an indirect effect of 0.489 (95% CI: 0.362, 0.629), accounting for 40.58% of the total effect. (4) Exercise frequency and malnutrition risk assessment were independent influencing factors for social support, self-management, and quality of life. (5) In the regression model, after excluding confounding factors, Model I explained 14% of the variance in quality of life due to control variables, Model II explained 49.5%, and when social support was added, Model III explained 56.9% of the variance in quality of life. Under the mediating role of social support, self-management can improve quality of life. Exercise frequency and malnutrition risk assessment, as independent influencing factors, also modulate social support and self-management. These findings underscore the importance of strengthening social support and developing self-management programs targeting exercise and nutrition to enhance the quality of life in patients with liver cirrhosis.

The Role of Palliative Care in the Management of Patients with Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver, and 85% to 90% of cases of HCC occur in patients with underlying liver disease. This makes it a complex illness to treat, because disease burden occurs not only from the cancer, but also potential decompensation of the underlying liver disease. Palliative care is multifaceted care that addresses physical, spiritual, and psychosocial needs of patients and can provide support for their caregivers. It can help in advance care planning and hospice support. Early integration of palliative care can improve patient qualify of life and patient/caregiver satisfaction.

Pain in chronic liver disease compared to other chronic conditions: Results from a contemporary nationally representative cohort study

BACKGROUND

Pain is common in patients with chronic liver disease. Our limited understanding of patterns and severity of pain in this population hinders the development of effective cirrhosis-specific pain management strategies.

METHODS

Using cross-sectional data from the 2016-2021 National Health Interview Survey, we examined rates, severity, and functional limitations due to pain in respondents with liver disease (viral hepatitis, cirrhosis, and liver cancer), compared to the general population and those with other chronic conditions associated with pain (ie, arthritis, diabetes, and chronic kidney disease). Categorical and continuous variables were compared using χ2 and t test. Multivariable logistic regression was used to determine the predictors associated with pain and opioid use.

RESULTS

Our liver disease cohort comprised 5267 participants (63% viral hepatitis, 49% cirrhosis, and 2% liver cancer). Participants with liver disease were more likely to report pain than those without liver disease (42% vs. 22%); they were also more likely to report severe pain (42% vs. 30%) and functional limitations by pain (28% vs. 13%) (p < 0.001 for all). On multivariable logistic regression, liver disease is an independent predictor of pain (OR: 2.31, 95% CI: 2.05-2.59, p < 0.001), even after adjustment for demographic factors. Liver disease respondents had similar rates of pain as those with diabetes (p = 0.8) and were more functionally limited by pain than those with arthritis (p < 0.001). Adjusted for demographic and pain-related factors, liver disease was also an independent predictor of chronic opioid use (OR: 1.47, 95% CI: 1.12-1.92, p = 0.0054).

CONCLUSIONS

Liver disease independently increases the likelihood of experiencing widespread and debilitating pain. Clinicians should consider liver disease a painful condition, ensuring that they are frequently assessing and appropriately treating pain in all liver disease patients.

Demographic and clinical characteristics associated with utilization of alcohol use disorder treatment in a multicenter study of patients with alcohol-associated cirrhosis

BACKGROUND

Alcohol use disorder (AUD) treatment can help improve clinical outcomes among patients with alcohol-associated cirrhosis but is underutilized. Among socioeconomically disadvantaged patients with alcohol-associated cirrhosis, we examined rates of lifetime and past 12-month AUD treatment utilization and associated demographic and clinical characteristics.

METHODS

Racial/ethnically diverse patients with alcohol-associated cirrhosis who had at least one hepatology clinic visit in the prior 6 months were recruited from three Northern California medical centers serving veterans and safety-net populations. Participants self-reported their AUD treatment utilization, liver disease quality of life (LDQoL), history and current symptoms of anxiety and depression, and problematic drinking as measured by the Alcohol Use Disorders Identification Test (AUDIT). Clinical measures including liver disease severity were captured from medical records.

RESULTS

Among 196 participants, the majority were male (88%) with a mean age of 62 years. Two-thirds of participants (67%) reported ever utilizing AUD treatment and 32% reported utilizing AUD treatment in the past 12 months. Compared with those who did not utilize AUD treatment, participants who utilized lifetime or past 12-month AUD treatment were younger, had lower LDQoL scores, and had higher scores on current symptoms of anxiety, depression, and problematic drinking. In multivariable analyses, the odds of ever utilizing pharmacological treatment alone or both behavioral and pharmacological treatment (vs. none) were lower with older age or higher LDQoL, and higher among those with a history of anxiety/depressive disorder. For past 12-month treatment utilization, odds were lower with older age, and higher among those with current clinically significant anxiety/depression or problematic drinking.

CONCLUSIONS

Patients with alcohol-associated cirrhosis who were younger or had anxiety/depression and problematic drinking were more likely to utilize AUD treatment. To improve AUD treatment utilization, targeted outreach to patients less likely to receive care and the provision of integrated ALD and AUD treatment is warranted.

Supportive and palliative care needs in advanced non-malignant liver disease: systematic review

Advanced cirrhosis confers a significant symptom burden and has a 50% 2-year mortality rate in those with decompensated disease. There is increasing demand for supportive and palliative care (SAPC) for these patients, yet no consensus on the best model of delivery. It is necessary to identify the needs of such patients and their carers, and evaluate whether they are being met.A literature search was conducted using key words pertaining to adult patients with liver cirrhosis and their SAPC needs. Study quality was assessed and findings grouped by theme. 51 full texts were selected for inclusion, 8 qualitative studies, 33 quantitative studies, 7 systematic reviews, 2 mixed methods studies and 1 Delphi methods. Key findings were grouped into three main themes: SAPC needs, access to SAPC and models of care.Patients with cirrhosis have significant psychological and physical symptom burden with many unmet needs. These data failed to identify the best service model of care. The impact of specialist palliative care (SPC) referral was limited by small numbers and late referrals. With the majority of studies conducted in the USA, it is unclear how well these findings translate to other healthcare systems. Comparison between hepatology led services and SPC was limited by inconsistent outcome measures and prevented pooling of data sets. These data also had limited evaluation of patient-reported outcome measures. We propose the development of a core outcome set to ensure consistent and meaningful evaluation of the SAPC needs of patients with advanced non-malignant liver cirrhosis.

End-stage organ disease-Healthcare utilisation: Impact of palliative medicine

OBJECTIVES

Although patients living with end-stage organ disease (ESOD) suffer unmet needs from the physical and emotional burdens of living with chronic illness, they are less likely to receive palliative care.The aims of the study were to determine if palliative care referrals reduced healthcare utilisation and if impact on healthcare utilisation was dependent on the timing of the referral.

METHODS

Patients with ESOD who received palliative care support were matched with those who did not using coarsened exact matching and propensity score matching, and compared in this retrospective cohort study. Primary outcomes of interests were reduction in all-cause emergency department (ED) visits and costs, reduction in all-cause tertiary hospital admissions, length of hospital stay and inpatient hospital costs.

RESULTS

Patients with ESOD referred to palliative care experienced a reduction in the frequency of all cause ED visits and inpatient hospital admissions. Significant impact of a palliative care referral was at 3 months, rather than 1 month prior to death with a greater reduction in the frequency of ED visits, inpatient hospital admissions, length of stay and charges (p all <0.05). The most common ESOD referred to palliative care for 1110 matched patients was end-stage renal failure (57.7%), and least commonly for respiratory failure (7.6%).

CONCLUSION

Palliative care can reduce healthcare utilisation, with reduction greatest when the referral is timed earlier in the disease trajectory. Cost savings can be judiciously redirected to the development of palliative care resources for integrated support of patients and caregivers.

Health-related quality of life and frailty in liver cirrhosis

BACKGROUND AND OBJECTIVES

There is limited evidence concerning the predictive value of health-related quality of life (HRQoL) on the presence of frailty in the context of cirrhosis. We aimed to elucidate the relationship between HRQoL and multidimensional frailty and to determine which HRQoL dimension independently impacted frail phenotype in our established cohort.

METHODS

This was a prospective observational study by consecutively enrolling 355 patients with cirrhotic with decompensated signs in China. The HRQoL and frail phenotype were evaluated by the EuroQol-5D (EQ-5D) Questionnaire and Frailty Index, respectively. The relationship between EQ-5D utility index, as well as respective EQ-5D dimension, and Frailty Index was analysed according to the multiple linear regression analyses.

RESULTS

More than half of the patients (56.3%) reported problems in any dimension of the EQ-5D, suggestive of impaired HRQoL. Moreover, the proportion of patients experiencing some/extreme problems significantly increased across all five dimensions (all p<0.001) in correspondence to transition from the robust to frail phenotype. Multiple linear regression analyses demonstrated that age, ascites and hepatic encephalopathy were positively associated with Frailty Index, while EQ-5D utility index (standardised β coefficient= -0.442, p<0.001) negatively associated with Frailty Index. Notably, usual activities, self-care and mobility were the most influencing predictors associated with frailty.

CONCLUSIONS

Our results support a rapid HRQoL assessment via EQ-5D may assist in predicting multidimensional frailty, and usual activities, self-care and mobility tend to be remediable targets while taking their effect on frail phenotype into consideration among patients with cirrhosis.

Palliative Homecare in Chronic Liver Disease: A Cohort Analysis of Factors and Outcomes Associated with Home Palliative Care in Patients with End-Stage Liver Disease

Objective: The prevalence and mortality of chronic liver disease has risen significantly. In end-stage liver disease (ESLD), the survival of patients is approximately 2 years. Despite the poor prognosis and high symptom burden, integration of palliative care in ESLD is reduced, and the majority of patients continue to die in inpatient care. We aim to assess predictors and outcomes of home palliative care, as well as factors associated with death at home in patients with ESLD. Methods: Retrospective cohort study of patients with ESLD, followed by a palliative care team between 2017 and 2022. Information regarding patient demographics, ESLD etiology, decompensations, and interventions was collected. Two-sided tests were used to identify factors associated with home palliative care. Results: We analyzed 75 patients: 44% had home palliative care and 33% died at home. ESLD patients with home palliative care were older (72.52 vs 64.45; p = 0.002), had a longer palliative care intervention time (149.97 ± 196.23 vs 43.69 ± 100.60 days; p = 0.007), higher rates of ascites or hepatic encephalopathy (χ2 = 11.024; p = 0.029), and hepatocarcinoma (90.9% vs 64.3%; p = 0.007). Patients with home palliative care had a reduction in-hospital admissions (2.61 vs 1.06; p = 0.000) and a greater probability of death at home (66.7% vs 33.3%; p = 0.000). Patients who died at home (33.3%) were older (72.20 vs 64.40; p = 0.000) and had longer palliative care intervention time (178.80 ± 211.78 vs 46.28 ± 99.67 days; p = 0.006). Conclusion: Home palliative care in ESLD differs based on demographics and disease complications, with a positive impact of homecare translated into a reduction in hospital admissions and an increased probability of death at home.

Commonly encountered symptoms and their management in patients with cirrhosis

This exhaustive review, explored the multifaceted symptoms and their management in patients with cirrhosis. Patients frequently endure pain, muscle cramps, sleep disturbances, psychological distress, and gastrointestinal issues, significantly impairing their quality of life. Pain is prevalent, often requiring analgesics, while muscle cramps affect up to 68% of patients, treated with supplements like zinc and taurine despite limited evidence. Sleep disturbances, including insomnia and excessive daytime sleepiness, afflict up to 80% of patients, managed through lactulose, melatonin, and cognitive behavioral therapies. Gastrointestinal symptoms, affecting 80%, include abdominal pain and bloating, necessitating lifestyle and dietary adjustments. Mental health disorders, such as depression and anxiety, are common, managed with a combination of pharmacotherapy and psychotherapy. Sexual dysfunction, often overlooked, profoundly impacts both men and women, requiring holistic treatment approaches. Pruritus, another distressing symptom, is managed with moisturizers and antihistamines, though many treatments show limited success. Hair loss and skin changes add to the psychological burden, highlighting the need for a comprehensive, multidisciplinary approach. The review underscores the imperative for tailored, compassionate care to enhance patient outcomes and quality of life in cirrhosis.

Efficacy and safety of acupuncture for pain relief: a systematic review and meta-analysis

OBJECTIVE

This study aims to evaluate the efficacy and safety of traditional acupuncture for pain relief based on rigorously designed RCTs with double-blind. The findings seek to provide valuable insights for clinical practice and inform future research.

METHODS

A literature search was conducted in PubMed, Web of Science, Cochrane Library, and Embase databases for randomized controlled trials on traditional acupuncture for pain management using a double-blind design, published from database inception to November 22, 2023. The Risk of Bias 2 (RoB2) tool was used to assess potential biases in the included studies, followed by a comprehensive analysis to evaluate efficacy and safety.

RESULTS

The findings show a significant positive effect on pain improvement, evidenced by changes in visual analog scale scores (mean difference 0.97 [95% confidence interval (CI) 0.66-1.27]). Safety analysis showed no significant differences in adverse reactions between the acupuncture and control groups (relative risk 1.40 [95% CI 0.52-3.74]), with no serious adverse effects reported.

CONCLUSION

Traditional acupuncture is effective and safe in pain management. This suggests that acupuncture can be a valuable approach in clinical practice. Future studies should explore optimal treatment durations and frequency, using larger sample sizes for more comprehensive insights.

Clinical Characteristics and Outcomes Associated With Distinct Hemodynamic Patterns in End-stage Liver Disease: A Retrospective Cohort Analysis

Introduction

Despite advances in the diagnosis and therapeutics strategies for pulmonary hypertension (PH) in patients with end-stage liver disease (ESLD), the impact of hemodynamic patterns among ESLD patients identified through right heart catheterization (RHC) on clinical outcomes remains poorly understood.

Methods

This single-center retrospective cohort study identified patients diagnosed with ESLD who underwent RHC from August 2018 to June 2023. Demographic and clinical data, including comorbidities, transthoracic echocardiography, and RHC findings, were obtained. Our outcomes of interest were all-cause mortality and the chance of receiving orthotopic liver transplantation (OLT) within a year after RHC. Kaplan-Meier with log-rank test was employed to generate survival curves.

Results

We identified 415 ESLD patients with the RHC results. The median (IQR) age was 59 years (52-66), and 62% were male. Caucasians accounted for 43%, followed by African Americans (30%). Up to 89% had a diagnosis of portal hypertension. Median MELD-Na score was 30 (19-36). The etiology of ESLD was mainly from alcohol use (55%). Patients were classified based on RHC results as pre-capillary PH (19%), post-capillary PH (28%), and non-PH (53%) groups. Overall, one-year mortality post-RHC was 22%, with no significant difference in mortality regardless of hemodynamic group. However, the pre-capillary PH group was less likely to receive OLT compared to other groups (P < 0.001).

Conclusion

We observed no difference in all-cause mortality among hemodynamic groups. However, pre-capillary PH group were less likely to undergo OLT compared to others. Further investigations are necessary to determine how this should be addressed in clinical practice.

Prediction of Whole Liver Graft Weight Based on Biometric Variables in Paediatric and Adult Liver Donors

BACKGROUND/OBJECTIVES

In paediatric liver transplantation, donor-recipient compatibility depends on graft size. We explored whether the graft weight can be predicted using the donor's biometric parameters.

METHODS

We used seven easily available biometric variables in 142 anonymised paediatric and adult donors, with data collected between 2016 and 2022. The whole or partial liver was transplanted in our hospital from these donors. We identified the variables that had the strongest correlation to our response variable: whole liver graft weight.

RESULTS

In child donors, we determined two linear models: using donor weight and height on the one hand and using donor weight and right liver span on the other hand. Both models had a coefficient of determination R2 = 0.86 and p-value < 10-5. We also determined two models in adult donors using donor weight and height (R2 = 0.33, p < 10-4) and donor weight and sternal height (R2 = 0.38, p < 10-4). The models proved valid based on our external dataset of 245 patients from two institutions.

CONCLUSIONS

In clinical practise, our models could provide rapidly accessible estimates to determine whole graft dimension compatibility in liver transplantation in children and adults. Determining similar models predicting the left lobe and lateral segment weight could prove invaluable in paediatric transplantation.

Treatment of Pain in Cirrhosis: Advice to Caregivers of Those with Rock Livers

PURPOSE

When one considers the significant role of the liver in medication absorption and metabolism, clinicians must appreciate the important ramifications for medication dosing and monitoring in patients with cirrhosis. For many medications, dose adjustments may be necessary to minimize toxicities or avoid adverse effects from drug accumulation. Clinicians could be well served if they can understand in some detail how pharmacokinetic properties are altered in cirrhosis.

METHODS

A PubMed search of the English medical literature starting with 1980 using keywords cirrhosis, pain management, and analgesics was performed, and additional papers were found using references from the first round of papers.

FINDINGS

Patients with cirrhosis often have significant reductions in first-pass metabolism, altered volumes of distribution, and marked reductions in both renal and hepatic elimination of drugs. These factors may contribute to much higher levels of drug exposure compared to the general population. In terms of drug dosing, FDA labeling is often ambiguous and even incongruous with observed pharmacokinetic changes.

IMPLICATIONS

This article may provide guidance for clinicians to optimize pain management in people living with cirrhosis.

KEY MESSAGE

Current FDA labeling for dosing analgesic drugs in patients with cirrhosis is either vague or not consistent with findings from newer pharmacokinetic research. With this review, we hope to provide insight and guidance to clinicians on how to dose-adjust medications commonly utilized in pain management in these patients.

A sex-oriented analysis concerning skeletal muscle quantity and quality and associations to quality of life in hospitalized patients with cirrhosis

BACKGROUND

There is a paucity of data regarding sex-oriented analyses of connection between muscle quantity and quality and health-related quality of life (HRQoL), taking into account the pathophysiological differences of sarcopenia/myosteatosis in males versus females. We sought to investigate the associations between skeletal muscle index (SMI)-defined sarcopenia and intramuscular adipose tissue content (IMAC)-defined myosteatosis and EuroQol-5D (EQ-5D)-defined HRQoL in patients with decompensated cirrhosis concerning sex disparities.

METHODS

Totally, 382 patients were enrolled. The relationship between SMI/IMAC and HRQoL was evaluated with restricted cubic spline and Pearson correlation analyses. Furthermore, association between SMI or sarcopenia and EQ-5D utility index was determined by multiple linear regression, adjusted for age, BMI and concurrent disease severity.

RESULTS

The study population comprised evenly distributed male and female patients (190: 192), mean age 61.9 years. The prevalence of sarcopenia (40.5 versus 9.9%, P < 0.001) and SMI (48.8 versus 42.2 cm2/m2, P < 0.001) were significantly higher in males relative to females, with comparable myosteatosis prevalence (15.3 versus 16.7%, P = 0.708). Self-care, usual activities and pain within EQ-5D scale were more prevalent in the sarcopenia compared with non-sarcopenia groups across entire population and stratified by sex. The SMI values exhibited a significantly linear correlation with EQ-5D utility index in male but not female patients (P for non-linearity = 0.281). In multiple analysis, SMI or the presence of sarcopenia was both significantly associated with EQ-5D utility index. Subgroup analyses unveiled no discernible interactions between sarcopenia and EQ-5D utility index.

CONCLUSIONS

Muscle quantity measured by SMI was associated with declined HRQoL in males rather than females, whereas no associations were found regarding muscle quality measured by IMAC in both sexes. It is tempting to manage sarcopenia by increasing SMI levels as high as possible in hopes of achieving better health consequence. Our findings represent the importance of connecting CT-demarcated body composition abnormalities to meaningful patient-centered outcomes. Future targeted studies with sizable multi-center populations are warranted to clarify this causality, and in consequence develop optimized intervention against sarcopenia/myosteatosis or key determinants concerning impaired HRQoL.

Palliative care in terminally ill advanced chronic liver disease patients

While mortality rates from advanced chronic liver disease (ACLD) are rapidly increasing, patients with an advanced disease stage have a comparable or even higher symptom burden than those with other life-limiting diseases. Although evidence is limited there is increasing recognition of the need to improve care for patients with ACLD; however, there are many limiting factors to providing good palliative care for these patients, including unpredictable disease progression, the misconception of palliative care and end of life care as being equivalent, a lack of confidence in prescribing medication and a lack of time and resources. Health professionals working with these patients need to develop the skills to ensure effective palliative care, while referral to specialized palliative care centers should be reserved for patients with complex needs. Basic palliative care, along with active disease management, is best delivered by the treating hepatologists. This includes discussions about disease progression and advance care planning, alongside the active management of disease complications. Liver disease is closely associated with significant social, psychological, and financial burdens for patients and their caregivers. Strategies to engage the discussion in multidisciplinary teams early in disease progression help to ensure addressing these issues proactively. This review summarizes the evidence on palliative care for patients with ACLD, provides examples of current best practice and offers suggestions on how disease-modifying and palliative care can coexist, to ensure that patients do not miss opportunities for quality of life improving interventions.

Past trends and future projections of palliative care needs in Chile: analysis of routinely available death registry and population data

BACKGROUND

The number of people with palliative care needs is projected to increase globally. Chile has recently introduced legislation for universal access to palliative care services for patients with severe and terminal illnesses, including non-cancer conditions. We aimed to estimate the number of people affected by serious health-related suffering and need for palliative care in Chile to 2050.

METHODS

We used data on all deaths registered in Chile between 1997-2019 and population estimates for 1997-2050. We used Poisson regression to model past trends in causes of death adjusted by age, sex and population estimates, to project the number of deaths for each cause from 2021 to 2050. We applied the Lancet Commission on Palliative Care and Pain Relief weights to these projections to identify decedents and non-decedents with palliative care needs.

RESULTS

Population palliative care needs in Chile are projected to increase from 117 (95% CI 114 to 120) thousand people in 2021 to 209 (95% CI 198 to 223) thousand people in 2050, a 79% increase (IRR 1.79; 95% CI 1.78-1.80). This increase will be driven by non-cancer conditions, particularly dementia (IRR 2.9, 95% CI 2.85-2.95) and cardiovascular conditions (IRR 1.86, 95% CI 1.83-1.89). By 2050, 50% of those estimated to need palliative care will be non-decedents (not expected to die within a year).

CONCLUSIONS

Chile will experience a large increase in palliative care needs, particularly for people with dementia and other non-cancer conditions. Improved availability of high-quality services, expanded clinician training and new sustainable models of care are urgently required to ensure universal access to palliative care.

Palliative care and end stage liver disease: A cohort analysis of palliative care use and factors associated with referral

INTRODUCTION AND OBJECTIVES

Prevalence and mortality of chronic liver disease have risen significantly. In end stage liver disease, the survival of patients is approximately two years. Despite the poor prognosis and high symptom burden of these patients, integration of palliative care is limited. We aim to assess associated factors and trends in palliative care use in recent years.

MATERIALS AND METHODS

A Multicenter retrospective cohort of patients with end stage liver disease who suffered in-hospital mortality between 2017 and 2019. Information regarding patient demographics, hospital characteristics, comorbidities, etiology, decompensations, and interventions was collected. Two-sided tests and logistic regression analysis were used to identify factors associated with palliative care use.

RESULTS

A total of 201 patients were analyzed, with a yearly increase in palliative care consultation: 26.7 % in 2017 to 38.3 % in 2019. Patients in palliative care were older (65.72 ± 11.70 vs. 62.10 ± 11.44; p = 0.003), had a lower Karnofsky functionality scale (χ=18.104; p = 0.000) and had higher rates of hepatic encephalopathy (32.1 % vs. 17.4 %, p = 0.007) and hepatocarcinoma (61.7 % vs. 26.2 %; p = 0.000). No differences were found for Model for End-stage Liver Disease (19.28 ± 6.60 vs. 19,90 ± 5.78; p = 0.507) or Child-Pugh scores (p = 0.739). None of the patients who die in the intensive care unit receive palliative care (0 % vs 31.6 %; p = 0.000). Half of the palliative care consultations occurred 6,5 days before death.

CONCLUSIONS

Palliative care use differs based on demographics, disease complications, and severity. Despite its increasing implementation, palliative care intervention occurs late. Future investigations should identify approaches to achieve an earlier and concurrent care model.

The Effect of Enhanced Recovery After Surgery Nursing on the Recovery in Patients After Liver Transplantation

OBJECTIVE

To explore the effect of enhanced recovery after surgery nursing on the recovery in patients after liver transplantation.

METHODS

This study was performed in 128 patients underwent liver transplantation in our hospital. According to the random number table, these patients were divided into the control group (n = 64) and the experimental group (n = 64). Patients in the control group received traditional nursing, while those in the experimental group received enhanced recovery after surgery nursing. Completion time of the operation, the amount of infused red blood cells during operation, intraoperative anhepatic period, intensive care unit (ICU) stay, the total length of hospitalization, the number of patients reintubated after surgery, the survival rate within 1 year after surgery, and the incidence of postoperative complications were compared between the two groups.

RESULTS

Intraoperative anhepatic period and the amount of infused red blood cells during operation in the experimental group were lower than those in the control group (both P < .05). Postoperative ICU stay, the total length of hospitalization, and the number of patients reintubated after surgery in the experimental group were decreased when compared with the control group, while postoperative ventilator weaning time was increased (all P < .05). The survival rates at 3 months, 6 months, and 1 year after surgery in the experimental group were higher than those in the control group (all P < .05). Compared with the control group, the total incidence of complications in the experimental group was reduced (P < .05).

CONCLUSION

The application of enhanced recovery after surgery nursing in liver transplantation patients contributes to the accelerated recovery of body function, shortened total length of hospitalization and ICU stay, declined complications, and increased survival rate within 1 year.

Associations of tumor-related psychiatric symptoms and healthy behaviors with dynamic quality of life after hepatocellular carcinoma hepatectomy

OBJECTIVE

To assess the independent and combined associations of tumor-related psychiatric symptoms (TRPS) with dynamic health-related quality of life (HRQL) in patients with hepatocellular carcinoma (HCC) after hepatectomy and to identify related patterns of health behaviors.

METHODS

This prospective study included patients with HCC who underwent hepatectomy between September 2021 and May 2022. Independent and combined associations between TRPS and HRQL were identified by generalized linear model and weighted quantile sum model, respectively. Trajectories of HRQL were identified by latent class mixed model.

RESULTS

Among the 205 patients, 174 (84.9%) were male. For the outcome of HRQL at 6 months: Anxiety, depression, fatigue, and sleep disorder were independently associated with a decrease of HRQL (all P < 0.05). A negative combined effect of TRPS was also found (β =  - 5.07, 95% CI, - 10.01 to - 0.13), with depression emerged as the predominant contributor (49%). The health behaviors of body mass index, smoking, drinking, or physical exercise were not significantly modified the associations between combined TRPS and HRQL (all P > 0.05 for interaction). Similar results were also found for the HRQL at baseline and at 1 and 3 months. Three HRQL trajectory groups were identified: recover (44.9%), poor (44.4%), and deteriorating (10.7%). Deteriorating group was associated with higher incidence of TRPS (all P < 0.05).

CONCLUSIONS

TRPS were associated with a decrease of HRQL regardless of healthy behaviors in HCC patients. Therefore, healthy behaviors promotion alone might not substantially increase HRQL associated with TRPS, and other measures tackling TRPS are warranted.

Symptom burden in chronic liver disease

Chronic liver disease (CLD) is a significant contributor to global mortality. For people who are living with CLD, however, there is a substantial and often overlooked burden of physical and psychological symptoms that significantly affect health-related quality of life. CLD frequently presents with a multitude of interrelated and intricate symptoms, including fatigue, pruritus, muscle cramps, sexual dysfunction, and falls. Increasingly, there is interest in studying and developing interventional strategies to provide a more global approach to managing these complex patients. Moreover, in addition to established guidelines for the management of conventional complications, such as ascites and hepatic encephalopathy, there have been efforts in developing evidence-based guidance for the treatment of the more subjective yet still problematic elements. This review will address the management of these less "classical" but nonetheless important symptoms.

Palliative care and end stage liver disease: A survey study comparing perspectives of hepatology and palliative care physicians and clinical scenarios that could require palliative care intervention

BACKGROUND AND AIMS

The prevalence and mortality of chronic liver disease has risen significantly. In end stage liver disease (ESLD) the survival of patients is approximately 2 years. Despite the poor prognosis and high symptom burden of these patients, integration of palliative care is reduced. We aim to analyze the agreement between palliative care and hepatology physicians of clinical scenarios that could require palliative care intervention.

METHODS

A cross-sectional study was conducted. Palliative care and hepatology physicians were surveyed. Using a five-point Likert scale, their perceptions of palliative care in ESLD were rated. Their agreement in clinical scenarios that could require palliative care intervention were evaluated. Analyses were conducted to assess any differences by primary role (hepatology vs. palliative care) and length of practice (<10 years vs. 10 years).

RESULTS

A total of 123 responses were obtained: 52% from palliative care and 48% from hepatology. The majority (66.7%) work in the field for up to ten years. There was a great consensus in 4 of the 8 clinical scenarios. In scenarios with less consensus, the area of activity and length of practice influence the reliance of physicians on palliative care. Involvement of palliative care in ESLD was considered "rare" by 30% and 61% consider difficult to predict the prognosis. More than 90% support medical training in both areas of activity.

CONCLUSION

The current involvement of palliative care is considered low, but there are clinical conditions that reveal a clear consensus and there's a unanimous view of the relevance of training.

Distinct Longitudinal Trajectories of Symptom Burden Predict Clinical Outcomes in End-Stage Liver Disease

INTRODUCTION

Little has been reported about the clinical relevance and trajectories of symptoms in end-stage liver disease (ESLD). The purpose of this prospective study was to identify trajectories of change in symptom burden over the course of 12 months in adults with ESLD.

METHODS

Patients were recruited from hepatology clinics at 2 healthcare systems. Validated measures were used to assess physical and psychological symptoms. Latent growth mixture modeling and survival and growth modeling were used to analyze the survey data.

RESULTS

Data were available for 192 patients (mean age 56.5 ± 11.1 years, 64.1% male, mean Model for ESLD (MELD) 3.0 19.2 ± 5.1, ethyl alcohol as primary etiology 33.9%, ascites 88.5%, encephalopathy 70.8%); there were 38 deaths and 39 liver transplantations over 12 months. Two symptom trajectories were identified: 62 patients (32.3%) had high and unmitigated symptoms, and 130 (67.7%) had lower and improving symptoms. Patients with high and unmitigated symptoms had twice the hazard of all-cause mortality (subhazard ratio 2.53, 95% confidence interval: 1.32-4.83) and had worse physical ( P < 0.001) and mental quality of life ( P = 0.012) compared with patients with lower and improving symptoms. Symptom trajectories were not associated with MELD 3.0 scores ( P = 0.395). Female sex, social support, and level of religiosity were significant predictors of symptom trajectories ( P < 0.05 for all).

DISCUSSION

There seems to be 2 distinct phenotypes of symptom experience in patients with ESLD that is independent of disease severity and associated with sex, social support, religiosity, and mortality. Identifying patients with high symptom burden can help optimize their care.

Global Assessment of Palliative Care Need: Serious Health-Related Suffering Measurement Methodology

CONTEXT

Inequities and gaps in palliative care access are a serious impediment to health systems especially in low- and middle-income countries and the accurate measurement of need across health conditions is a critical step to understanding and addressing the issue. Serious Health-related Suffering (SHS) is a novel methodology to measure the palliative care need and was originally developed by The Lancet Commission on Global Access to Palliative Care and Pain Relief. In 2015, the first iteration - SHS 1.0 - was estimated at over 61 million people worldwide experiencing at least 6 billion days of SHS annually as a result of life-limiting and life-threatening conditions.

OBJECTIVES

In this paper, an updated methodology - SHS 2.0 - is presented building on the work of the Lancet Commission and detailing calculations, data requirements, limitations, and assumptions.

METHODS AND RESULTS

The updates to the original methodology focus on measuring the number of people who die with (decedents) or live with (non-decedents) SHS in a given year to assess the number of people in need of palliative care across health conditions and populations. Detail on the methodology for measuring the number of days of SHS that was pioneered by the Lancet Commission, is also shared, as this second measure is essential for determining the health system responses that are necessary to address palliative care need and must be a priority for future methodological work on SHS.

CONCLUSIONS

The methodology encompasses opportunities for applying SHS to future policy making assessment of future research priorities particularly in light of the dearth of data from low- and middle-income countries, and sharing of directions for future work to develop SHS 3.0.

The rise of multidisciplinary clinics in hepatology: A practical, how-to-guide, and review of the literature

Multidisciplinary clinics (MDCs) are gaining momentum throughout the medical field, having initially been pioneered in oncology clinics due to their inherent ability to streamline complex care and improve both patient outcomes and the patient care experience. Liver transplant and hepatobiliary tumor clinics are examples of established MDCs in hepatology. With the changing landscape of liver disease in regard to etiology and patient complexity and acuity, there is a clear need for efficient, highly coordinated care. These changes highlight opportunities for hepatology MDCs in alcohol-associated liver disease, metabolic dysfunction-associated steatotic liver disease, and palliative care. This review provides practical advice in navigating the complex logistics of establishing and maintaining a hepatology MDC while also reviewing the emerging evidence on clinical outcomes for patients seen in these MDCs. As hepatology looks to the future, establishment of MDCs in key clinical areas will be the cornerstone of patient care.

A Qualitative Study Supporting Optimal Nutrition in Advanced Liver Disease-Unlocking the Potential for Improvement

Malnutrition rates in Advanced Liver Disease (ALD) are significantly higher than those in well-compensated liver disease. In addition to its physiological impact, malnutrition is detrimental for quality of life and social, emotional, and psychological well-being. Studies within oncology and renal supportive care have identified the influence of non-physiological factors on malnutrition risk. Integrating similar factors into malnutrition screening for ALD could improve identification of at-risk patients to optimize treatment planning. This qualitative study aimed to understand the holistic factors influencing nutritional status in the ALD population. Semi-structured interviews with 21 patients, carers, and clinicians explored the experiences of malnutrition in ALD. Thematic analysis revealed five key themes: (i) appropriateness of healthcare delivery; (ii) health- and food-related factors; (iii) high symptom burden, (iv) social support impacting well-being, and (v) physical and structural supports. Current screening methods do not adequately capture all potential drivers of malnutrition in the ALD population. Adopting a more supportive approach including both physiological and non-physiological factors in ALD malnutrition screening may promote more timely and comprehensive nutritional interventions that address the complex and holistic needs of patients living with ALD.

British Society of Gastroenterology guidelines for the management of hepatocellular carcinoma in adults

Deaths from the majority of cancers are falling globally, but the incidence and mortality from hepatocellular carcinoma (HCC) is increasing in the United Kingdom and in other Western countries. HCC is a highly fatal cancer, often diagnosed late, with an incidence to mortality ratio that approaches 1. Despite there being a number of treatment options, including those associated with good medium to long-term survival, 5-year survival from HCC in the UK remains below 20%. Sex, ethnicity and deprivation are important demographics for the incidence of, and/or survival from, HCC. These clinical practice guidelines will provide evidence-based advice for the assessment and management of patients with HCC. The clinical and scientific data underpinning the recommendations we make are summarised in detail. Much of the content will have broad relevance, but the treatment algorithms are based on therapies that are available in the UK and have regulatory approval for use in the National Health Service.

Non-pharmacological Interventions for Muscle Cramps and Pain in Patients With Cirrhosis: A Systematic Review

Despite the high prevalence of pain and challenges associated with traditional pharmacological pain management in patients with cirrhosis, little is known about the safety and effectiveness of non-pharmacological management of pain in this patient population. A systematic literature search of published studies was conducted in nine databases from inception through January 11, 2023, including any clinical trial, cohort, or case-control study of non-pharmacological pain interventions in adult patients with cirrhosis. Studies using nutritional supplements were included. The primary and secondary outcomes for this review were pain/analgesic effect and safety, respectively. Two reviewers independently performed data extraction and risk of bias assessment. Of the 4,087 studies initially screened, 11 studies representing 340 patients ultimately met inclusion criteria, including seven observational and four randomized controlled trials. Five studies reported muscle cramp severity, four reported muscle cramp frequency, and two reported non-cramp pain. Oral zinc sulfate, L-carnitine, and taurine were reported to decrease cramp frequency. Oral vitamin E, oral zinc sulfate, L-carnitine, taurine, and pickle juice decreased cramp severity. Curcumin supplementation, resistance training, and stretching and walking programs improved non-cramp pain. Mild adverse events were reported in four studies. The risk of bias was moderate to high for all studies, largely due to missing data, study design, and a lack of blinding of participants. Numerous nutritional and non-pharmacological interventions have been reported to be safe and effective for the treatment of pain and painful muscle cramps in patients with cirrhosis. However, further research is needed to better determine the efficacy, safety, and optimal frequency and dosage of interventions.

Pre-hospital symptom clusters and symptom network analysis in decompensated cirrhotic patients: A cross-sectional study

AIMS

To generate pre-hospital symptom networks, explore core, bridge and sentinel symptoms, identify pre-hospital symptom clusters and analyse relationship between influencing factors and symptom clusters in decompensated cirrhosis patients.

DESIGN

A cross-sectional study design using the Strengthening the Reporting of Observational Studies in Epidemiology checklist.

METHODS

Demographical, physiological, psychological and sociological characteristics and the pre-hospital symptoms of 292 decompensated cirrhotic patients were collected from October 2021 to March 2023 in China. Frequencies, percentages, means, standard deviations, independent samples t-tests, one-way analysis of variance, exploratory factor analysis, multiple stepwise regression analysis and network analysis were used for data analysis.

RESULTS

'I don't look like myself' and itching were core and bridge symptoms, while bloating and lack of energy were sentinel symptoms in decompensated cirrhotic patients. Monthly family income, anxiety, depression, social support and disease duration influenced the neuropsychological symptom cluster, with worrying as the strongest predictor symptom. Influential factors for cirrhosis-specific symptom cluster included Child-Pugh class, monthly family income, disease duration, anxiety and depression, with itching being the strongest predictor symptom. Monthly family income, disease duration and depression were influential factors for gastrointestinal symptom cluster, with loss of appetite as the strongest predictor symptom.

CONCLUSIONS

Neuropsychological, cirrhosis-specific and gastrointestinal symptom clusters were formed in decompensated cirrhotic patients. Through network analysis, direct connections between symptoms, symptom clusters and their influencing factors were revealed, thereby offering clinicians a foundation for effectively managing patients' pre-hospital symptoms.

IMPACT

Decompensated cirrhosis patients commonly have multiple symptoms, while the management of pre-hospital symptoms is often suboptimal. This study identified neuropsychological, cirrhosis-specific, gastrointestinal symptom clusters and recognized core, bridge and sentinel symptoms in these patients. It also revealed the most prominent symptoms within each cluster. This provides insight into the hierarchy of symptoms, improving symptom management in decompensated cirrhosis.

PATIENT AND PUBLIC INVOLVEMENT

There was no patient or public involvement.

Protein truncating variants in mitochondrial-related nuclear genes and the risk of chronic liver disease

BACKGROUND

Mitochondrial (MT) dysfunction is a hallmark of liver diseases. However, the effects of functional variants such as protein truncating variants (PTVs) in MT-related genes on the risk of liver diseases have not been extensively explored.

METHODS

We extracted 60,928 PTVs across 2466 MT-related nucleus genes using whole-exome sequencing data obtained from 442,603 participants in the UK Biobank. We examined their associations with liver dysfunction that represented by the liver-related biomarkers and the risks of chronic liver diseases and liver-related mortality.

RESULTS

96.10% of the total participants carried at least one PTV. We identified 866 PTVs that were positively associated with liver dysfunction at the threshold of P value < 8.21e - 07. The coding genes of these PTVs were mainly enriched in pathways related to lipid, fatty acid, amino acid, and carbohydrate metabolisms. The 866 PTVs were presented in 1.07% (4721) of participants. Compared with participants who did not carry any of the PTVs, the carriers had a 5.33-fold (95% CI 4.15-6.85), 2.82-fold (1.69-4.72), and 4.41-fold (3.04-6.41) increased risk for fibrosis and cirrhosis of liver, liver cancer, and liver disease-related mortality, respectively. These adverse effects were consistent across subgroups based on age, sex, body mass index, smoking status, and presence of hypertension, diabetes, dyslipidemia, and metabolic syndrome.

CONCLUSIONS

Our findings revealed a significant impact of PTVs in MT-related genes on liver disease risk, highlighting the importance of these variants in identifying populations at risk of liver diseases and facilitating early clinical interventions.

Construction and Application of Patient-Participated Health Care Guidance Plan for Patients with Decompensated Hepatitis B Cirrhosis

Objective

The goal of this study was to develop and assess the effectiveness of a patient-engaged healthcare guidance plan for individuals with decompensated hepatitis B cirrhosis.

Methods

This study employed literature review, situational analysis, and expert consultations to create a healthcare guidance plan that includes patient participation for those suffering from decompensated hepatitis B cirrhosis. Between January 2022 and January 2023, 86 patients with this condition admitted to our hospital were selected through convenience sampling and randomly assigned into two groups using a random number table. The control group (n=43) received standard care, while the intervention group (n=43) received the novel patient-engaged healthcare guidance in addition to standard care. We compared both groups in terms of anxiety and depression levels, self-care capability, uncertainty about their illness, and overall quality of life.

Results

Upon discharge, scores for the Self-Rating Anxiety Scale (SAS), Self-Rating Depression Scale (SDS), and Mishel's Uncertainty in Illness Scale (MUIS) decreased in both groups compared to their scores at admission (P<0.05), with the intervention group showing more significant improvements than the control group (P<0.05). Additionally, scores for the Self-Care Ability Scale (ESCA) and the component threshold scores of the Health Survey Short Form (SF-36) increased for both groups from admission to discharge (P<0.05), with the intervention group showing greater improvements than the control group (P<0.05).

Conclusion

The patient-engaged healthcare guidance plan developed for individuals with decompensated hepatitis B cirrhosis proved to be highly effective. It significantly reduced patient anxiety and depression, enhanced self-care capabilities, diminished illness uncertainty, and improved overall quality of life.

The burden of significant pain in the cirrhosis population: Risk factors, analgesic use, and impact on health care utilization and clinical outcomes

BACKGROUND

We aimed to characterize pain and analgesic use in a large contemporary cohort of patients with cirrhosis and to associate pain with unplanned health care utilization and clinical outcomes in this population.

METHODS

We included all patients with cirrhosis seen in UCSF hepatology clinics from 2013 to 2020. Pain severity and location were determined using documented pain scores at the initial visit; "significant pain" was defined as moderate or severe using established cutoffs. Demographic, clinical, and medication data were abstracted from electronic medical records. Associations between significant pain and our primary outcome of 1-year unplanned health care utilization (ie, emergency department visit or hospitalization) and our secondary outcomes of mortality and liver transplantation were explored in multivariable models.

RESULTS

Among 5333 patients with cirrhosis, 32% had a nonzero pain score at their initial visit and 25% had significant (ie moderate/severe) pain. Sixty percent of patients with significant pain used ≥1 analgesic; 34% used opioids. Patients with cirrhosis with significant pain had similar Model for End-Stage Liver Disease-Sodium scores (14 vs. 13), but higher rates of decompensation (65% vs. 55%). The most common pain location was the abdomen (44%). Patients with abdominal pain, compared to pain in other locations, were more likely to have decompensation (72% vs. 56%). Significant pain was independently associated with unplanned health care utilization (adjusted odds ratio: 1.3, 95% CI: 1.1-1.5) and mortality (adjusted hazard ratio: 1.4, 95% CI: 1.2-1.6).

CONCLUSIONS

Pain among patients with cirrhosis is often not well-controlled despite analgesic use, and significant pain is associated with unplanned health care utilization and mortality in this population. Effectively identifying and treating pain are essential in reducing costs and improving quality of life and outcomes among patients with cirrhosis.

Embedding Public Involvement in a PhD Research Project With People Affected by Advanced Liver Disease

BACKGROUND

Liver disease is an increasing cause of morbidity and mortality in the United Kingdom and can be challenging to live with in the advanced stages. There has been little research exploring the healthcare experiences of UK individuals with decompensated disease when the liver cannot carry out its functions properly. A PhD research project was developed with people who have liver disease to explore care experiences in decompensated advanced liver disease. Public involvement (PI) is an essential aspect of meaningful health research, and this paper reports on the progression of our PI approach in this ongoing study.

OBJECTIVE

To embed PI throughout the research project to ensure that the study is meaningful to individuals with liver disease and the people who support them.

METHODS

The research adopts a Constructivist Grounded Theory methodology to develop a theory of care experience. Various PI approaches were considered in developing the PI strategy for this qualitative study. Initially, Embedded consultation was the preferred model, which has evolved to include aspects of collaboration and coproduction. A PI group was set up to oversee the project through the national public engagement website VOICE, and reflections on PI from three members of the group are included in this paper to illuminate the PI process.

RESULTS

Six individuals with liver disease and three carers from across the United Kingdom are part of an ongoing PI group. Their role includes commenting on the findings of the systematic literature review for this project and contributing to decisions about recruitment, data collection and data analysis. Additionally, they had a direct impact on changing the focus of the research. The PI group will continue involvement until the completion of the project.

CONCLUSION

Successfully embedding PI into doctoral research, as demonstrated in this project, requires commitment, planning and dedication to reciprocal working for the benefit of PI contributors as well as the research. This approach could be adopted by other postgraduate researchers.

PATIENT OR PUBLIC CONTRIBUTION

This project is overseen by the PI group, whose contribution is described throughout, including reflections from three PI group members.

Frailty and transplant-free survival of patients with liver cirrhosis: A meta-analysis

BACKGROUND

Frailty is a common condition among patients with liver cirrhosis. Nonetheless, its role in predicting liver transplant-free survival (TFS) remains unclear.

AIM

This systematic review and meta-analysis were conducted to elucidate the relationship between frailty and TFS in patients with cirrhosis.

METHODS

Cohort studies addressing the objective of this meta-analysis were extracted from PubMed, Embase, and Web of Science databases. Between-study heterogeneity was assessed with the Cochrane Q test, and the I^2 statistic was estimated. Random-effect models, considering potential heterogeneity, were employed to combine the results.

RESULTS

The meta-analysis encompassed 17 cohort studies involving 6273 patients with cirrhosis, of whom 1983 (31.6%) were classified as frail at baseline. The follow-up periods in the included studies ranged from 3 to 29 months, with an average duration of 11.5 months. The analysis revealed that frailty was significantly associated with a poor TFS (risk ratio [RR]: 2.07, 95% confidence interval: 1.72 to 2.50, p<0.001; I2 = 51%). Sensitivity analyses that sequentially omitted one dataset consistently supported these findings (RR: 1.95 to 2.17, p<0.05 in all cases). Subgroup analyses based on variables such as study design, mean age of patients, baseline Model for End-Stage Liver Disease score, tool used for frailty evaluation, follow-up duration, and study quality score also yielded congruent results.

CONCLUSIONS

The evidence suggests that frailty may be an independent risk factor for poor TFS in patients with liver cirrhosis, thus emphasizing the importance of early identification and management of frailty in this population.

Social Impact of Hepatic Encephalopathy

Hepatic encephalopathy is a medical condition that stems from liver dysfunction, leading to the accumulation of toxins in the bloodstream. This can result in cognitive impairments, mood changes, and motor dysfunction. Its social impact includes challenges in employment, relationships, and daily functioning for affected individuals. Stigma and misunderstanding around the condition can further exacerbate the difficulties faced by both patients and their caregivers. Efforts to raise awareness, improve medical management, and provide support systems can help mitigate the social impact of hepatic encephalopathy.

The Edmonton Symptom Assessment System is a valid, reliable, and responsive tool to assess symptom burden in decompensated cirrhosis

BACKGROUND

While there is a growing need for interventions addressing symptom burden in patients with decompensated cirrhosis (DC), the lack of validated symptom assessment tools is a critical barrier. We investigated the psychometric properties of the revised Edmonton Symptom Assessment System (ESAS-r) in a longitudinal cohort of patients with DC.

METHODS

Adult outpatients with DC were prospectively recruited from a liver transplant center and completed ESAS-r at baseline and week 12. We examined reliability, floor/ceiling effects, structural validity, and known-groups validity. We examined the convergent and predictive validity of ESAS-r with health-related quality of life using the Short Form Liver Disease Quality of Life (SF-LDQOL) and responsiveness to changes in anxiety and depression using the Hospital Anxiety and Depression Scale and Patient Health Questionnaire-9 from baseline to week 12.

RESULTS

From August 2018 to September 2022, 218 patients (9% Child-Pugh A, 59% Child-Pugh B, and 32% Child-Pugh C) were prospectively recruited and completed the ESAS-r, SF-LDQOL, Patient Health Questionnaire-9, and Hospital Anxiety and Depression Scale at baseline and week 12 (n = 135). ESAS-r had strong reliability (Cronbach's alpha 0.86), structural validity (comparative fit index 0.95), known-groups validity (Child-Pugh A: 25.1 vs. B: 37.5 vs. C: 41.4, p = 0.006), and convergent validity (r = -0.67 with SF-LDQOL). Floor effects were 9% and ceiling effects were 0.5%. Changes in ESAS-r scores from baseline to week 12 significantly predicted changes in SF-LDQOL (β = -0.36, p < 0.001), accounting for 30% of the variation. ESAS-r was strongly responsive to clinically meaningful changes in SF-LDQOL, Patient Health Questionnaire-9, and Hospital Anxiety and Depression Scale.

CONCLUSIONS

ESAS-r is a reliable, valid, and responsive tool for assessing symptom burden in patients with DC and can predict changes in health-related quality of life. Future directions include its implementation as a key outcome measure in cirrhosis care and clinical trials.

Unmet Needs and Burden of Caregivers of Patients Being Evaluated for a Liver Transplant Are Similar to Those of Cancer Caregivers

BACKGROUND

The caregivers (CG) of patients with serious illnesses often experience stress and psycho-social issues. High burden is expected for CG of patients for whom liver transplant (LT) is the only curative option. This study aims to measure the burden, unmet needs, and quality of life (QoL) of CG of patients being evaluated for LT.

METHODS

This cross-sectional study enrolled CG of patients being evaluated for LT. CaTCoN (Caregiving Tasks, Consequences and Needs Questionnaire) was used to assess caregiving consequences and needs related to interactions with healthcare professionals (HCPs). ZBI-12 (Zarit Burden Interview) was used to assess CG burden, and PROMIS-29 (Patient Reported Outcomes Measurement Information System) to assess QoL. Caregivers completed the study instruments in person, while they were in the clinic. CaTCoN scores from our study were compared with cancer caregivers' historical data.

RESULTS

18 CG were enrolled, mean age 54 [14] years; 72% were white and 77% were women. 61% worked full time; 45% provided >20 hours of care per week. Two-thirds cared for patients with alcoholic liver disease. All CaTCoN scores were no different from CGs of cancer patients (all P > .05). The total ZBI score (mean SD 12.4 [8.3]) did not differ from published scores for CG of cancer patients (12.0 [8.5]). 44% had high (≥12) ZBI scores reflecting "high burden." Their PROMIS-29 T scores, compared to those with low burden, showed more anxiety (P = .01), depression (P = .04), fatigue (P = .02) and deteriorated social function (P = .009). Physical function and social function were diminished among these CGs compared to the general population (P < .0001).

CONCLUSION

CGs of patients being evaluated for LT suffer from high burden similar to cancer CGs and have reduced physical and social function. Despite the small sample size, the data completion rate was almost 100%.

Symptoms experienced after transcatheter arterial chemoembolization in patients with primary liver cancer: A network analysis

Objective

This study aimed to establish a symptom network for patients with primary liver cancer posttranscatheter arterial chemoembolization (TACE), identifying core and bridge symptoms. The goal is to provide a foundation for precise and comprehensive nursing interventions.

Methods

A total of 1207 post-TACE patients were included using a consecutive sampling method. Data collection involved a general information questionnaire, the Anderson Symptom Assessment Scale, and a primary liver cancer-specific symptom module. The symptom network was constructed using the R language.

Results

In the overall network, distress exhibited the highest strength (rs = 1.31) and betweenness (rb = 62). Fatigue had the greatest closeness (rc = 0.0043), while nausea and vomiting (r = 0.76 ± 0.02) had the highest marginal weights. Nausea had the highest bridge strength (rbs = 5.263). In the first-time TACE-treated symptom network, sadness (rbs = 5.673) showed the highest bridge strength, whereas in the non-first-time symptom network, fever (rbs = 3.061) had the highest bridge strength.

Conclusions

Distress serves as a core symptom, and nausea acts as a bridge symptom after TACE treatment in liver cancer patients. Interventions targeting bridge symptoms should be tailored based on the number of treatments, enhancing the quality of symptom management.

The experiences of people with liver disease of palliative and end-of-life care in the United Kingdom-A systematic literature review and metasynthesis

BACKGROUND

Liver disease is a growing health concern and a major cause of death. It causes multiple symptoms, including financial, psychological and social issues. To address these challenges, palliative care can support people alongside active treatment, and towards the end of life, but little is known about the care experiences of individuals with liver disease in the United Kingdom. This review aimed to explore the palliative and end-of-life care experiences of people with liver disease in the United Kingdom.

METHOD

A systematic review was conducted using a five-stage process and following Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines. Searches were across Web of Science, Scopus, EBSCO and grey literature until 10 May 2023. The review was registered through International Prospective Register of Systematic Reviews (PROSPERO). NVivo 12.5 was used to facilitate data analysis (systematic review registration: PROSPERO CRD42022382649).

RESULTS

Of 6035 papers (excluding duplicates) found from searches, five met the inclusion criteria of primary research related to adults with liver disease receiving palliative and/or end-of-life care in the United Kingdom, published in English. Reflexive thematic analysis of the data was conducted. The themes identified were the experiences of people with liver disease of relating to healthcare professionals, using services, receiving support, and experiences of information and communication. These were connected by an overarching concept of disempowerment versus empowerment, with the notion of person-centred care as an important feature.

CONCLUSION

This review has found variations in the care experiences of people with advanced liver disease towards the end of life and an overall lack of access to specialist palliative care services. Where services are designed to be person-centred, experiences are more empowering. Further research is needed but with recognition that it is often unclear when care for people with liver disease is palliative or end-of-life.

PATIENT AND PUBLIC CONTRIBUTION

An online public involvement workshop was held on 18 April 2023 through Voice (2023). This included four people with liver disease and four carers to discuss the review findings and to design a qualitative research study to further explore the topic.

Brief PROMIS Assessment Screens for Frailty and Predicts Hospitalizations in Liver Transplant Candidates

BACKGROUND

Frailty is prevalent in patients with end-stage liver disease and predicts waitlist mortality, posttransplant mortality, and frequency of hospitalizations. The Liver Frailty Index (LFI) is a validated measure of frailty in liver transplant (LT) candidates but requires an in-person assessment.

METHODS

We studied the association between patient-reported physical function and LFI in a single-center prospective study of adult patients with cirrhosis undergoing LT evaluation from October 2020 to December 2021. Frailty was assessed with the LFI and 4-m gait speed. Patient-reported physical function was evaluated using a brief Patient-Reported Outcomes Measurement Information System (PROMIS) survey.

RESULTS

Eighty-one LT candidates were enrolled, with a mean model of end-stage liver disease-sodium of 17.6 (±6.3). The mean LFI was 3.7 (±0.77; 15% frail and 59% prefrail) and the mean PROMIS Physical Function score was 45 (±8.6). PROMIS Physical Function correlated with LFI ( r  = -0.54, P  < 0.001) and 4-m gait speed ( r  = 0.48, P  < 0.001). The mean hospitalization rate was 1.1 d admitted per month. After adjusting for age, sex, and model of end-stage liver disease-sodium, patient-reported physical function-predicted hospitalization rate ( P  = 0.001).

CONCLUSIONS

This study suggests that a brief patient-reported outcome measure can be used to screen for frailty and predict hospitalizations in patients with cirrhosis.

Quality of death in patients in advanced chronic liver disease and cancer patients managed by gastroenterologists in Portugal: are we doing it right?

INTRODUCTION

The incidence of chronic progressive diseases is rising and investment on quality of death and dying is of utmost importance to minimize physical and emotional suffering. There is still a gap in palliative care (PC) between patients with cancer and those with advanced chronic liver disease (ACLD). Our objectives were to characterize clinical attitudes and therapeutic interventions and to evaluate the differences in end-of-life care between inpatients with cancer and ACLD under gastroenterology care.

METHODS

Retrospective cohort study, including patients with cancer or ACLD who died in a Gastroenterology department between 2012 and 2021. Demographic characteristics, clinical and endoscopic procedures and symptom control were compared between the groups.

RESULTS

From 150 patients, 118 (78.7%) died with cancer and 32 (21.3%) died from ACLD without concomitant hepatocellular carcinoma. ACLD patients were more frequently male ( P  = 0.001) and younger ( P  = 0.001) than patients with cancer. Median time of hospitalization in the last month of life was 16 days for both groups. Discussion of prognosis with the patient was more frequent for cancer patients (35.6% versus 3.2%, P  < 0.001). Referral to PC occurred in 18.8% and 61% of the patients with ACLD and cancer respectively ( P  < 0.001). Endoscopic procedures were performed in half of the patients and were more likely to be unsuccessful in those with cancer.

CONCLUSION

Clinical decisions were different between groups in terms of PC access and discussion of prognostic with the patient. It is urgent to define and implement metrics of quality of death and dying to prevent potentially inappropriate treatment.

The Safe Use of Analgesics in Patients with Cirrhosis: A Narrative Review

Pain is prevalent in patients with cirrhosis. Due to potential alterations in drug metabolism, risk for adverse effects, and complications from cirrhosis, physicians are often faced with difficult choices when choosing appropriate analgesics in these patients. Overall, acetaminophen remains the preferred analgesic. Despite its potential for intrinsic liver toxicity, acetaminophen is safe when used at 2 g/d. In contrast, non-selective nonsteroidals should be avoided due to their multiple side effects, including worsening renal function, blunting diuretic response, and increasing risk of portal hypertensive and peptic ulcer bleeding. Celecoxib can be administered for short term (≤5 days) in patients with Child's A and Child's B cirrhosis (50% dose reduction). Opioids carry the risk of precipitating hepatic encephalopathy and should generally be avoided, when possible. If clinical situation demands their use, opioid use should be limited to short-acting agents for short duration. Gabapentin and pregabalin are generally safe. Duloxetine should be avoided in hepatic impairment. Topical diclofenac and lidocaine seem to be safe in patients with cirrhosis.

Early palliative care referral may improve end-of-life care in end-stage liver disease patients: A retrospective analysis from a non-transplant center

BACKGROUND

Patients with end-stage liver disease (ESLD) who are not transplant candidates often have a trajectory of rapid decline and death similar to patients with stage IV cancer. Palliative care (PC) services have been shown to be underutilized for such patients. Most studies examining the role of PC in ESLD have been done at transplant centers. Thus, determining the utilization and benefit of PC at a non-transplant tertiary center may help establish a standard of care in the management of patients with ESLD not eligible for transplant.

METHODS

We conducted a retrospective analysis of adult (>18 years) patients with ESLD admitted to Rochester Regional Health (RRH) system hospitals from 2012 to 2021. Patients were divided into groups based on the presence or absence of PC involvement. Baseline characteristics were recorded. The impact of PC was assessed by comparing the number of hospitalizations before and after the involvement of PC, comparing code status changes, health care proxy (HCP) assignments, Aspira catheter placements, and frequency of repeated paracentesis.

RESULTS

In our analysis of 576 patients, 41.1% (237 patients) received a PC consult (PC group), while 58.9% (339 patients) did not (no-PC group). Baseline characteristics were comparable. However, their mean number of admissions significantly decreased (15.66 vs. 3.49, p < 0.001) after PC involvement. Full code status was more prevalent in the no-PC group (67.8% vs. 18.6%, p < 0.001), while comfort care code status was more common in the PC group (59.9% vs. 20.6%, p < 0.001). Changes in code status were significantly higher in the PC group (77.6% vs. 29.2%, p < 0.001). The PC group had a significantly higher mortality rate (83.1% vs. 46.4%, p < 0.01). Patients in the PC group had a higher likelihood of having an assigned HCP (63.7% vs. 37.5%, p < 0.001). PC referral was associated with more frequent use of an Aspira catheter (5.9% vs. 0.9%, p < 0.001) and more frequent paracentesis (30.8% vs. 16.8%, p < 0.001).

CONCLUSIONS

In conclusion, our study provides compelling evidence of the diverse advantages of palliative care for patients with end-stage liver disease, including reduced admissions, improved goals of care, code status modifications, enhanced healthcare proxy assignments, and targeted interventions. These findings highlight the potential significance of early integration of palliative care in the disease trajectory to provide comprehensive, patient-centered care that addresses the unique needs and preferences of individuals with advanced liver disease.

The Prevalence of Pain in Chronic Diseases: An Umbrella Review of Systematic Reviews

Since pain is common in many diseases, it is important to summarize the precise prevalence data on pain and high-impact pain, which frequently worsens the quality of life and work activities. This umbrella review aims to estimate the prevalence of pain among patients with different chronic diseases/conditions. We followed the PRISMA guidelines. We identified the following areas addressing the prevalence of pain: (1) pain in cancer patients; (2) neurodegenerative diseases; (3) chronic heart failure; (4) chronic obstructive pulmonary disease; (5) chronic kidney diseases; (6) liver diseases and failure; (7) nursing home seniors; and (8) postamputation (phantom) pain. We included systematic reviews and meta-analyses that reported pain in patients from the mentioned populations. The prevalence of pain in chronic diseases is high, in some cases even higher than the cardinal symptoms of these diseases/conditions. Most patients who suffer from any of these diseases/conditions can develop chronic pain at later stages. Pain in chronic diseases does not receive enough attention and is not properly managed. Future studies are warranted to establish a more precise prevalence of chronic pain and develop better methods of pain screening, detection, and management.