The effect of Liver Transplantation on the quality of life of the recipient's main caregiver - a systematic review

What about the caregivers? Rethinking chronic illness support in the age of transplantation

Caregivers play an essential but often unacknowledged role in healthcare, particularly in chronic illness and post-transplantation scenarios. We highlight the profound emotional, physical, and logistical challenges caregivers face, as illuminated by recent studies, including the work of Virches et al about liver transplantation. Pre-transplant caregiving is marked by heightened stress, depression, and emotional strain, as caregivers navigate the unpredictability of conditions like cirrhosis. While liver transplantation significantly alleviates caregiver burden by stabilizing patient health, caregiving evolves rather than ends, requiring ongoing vigilance for post-transplant care, medication adherence, and lifestyle adjustments. We examine the disproportionate impact of caregiving on the family, due to entrenched cultural and gender norms and highlight how these disparities reinforce systemic neglect. Caregiving, often viewed as a familial duty, carries financial, mental, and physical health costs, perpetuating inequities and marginalization. We argue that caregivers are integral to healthcare outcomes and must be included in systemic frameworks to improve patient care. We also advocate for a paradigm shift from patient-centered to family-centered care, emphasizing caregiver inclusion as a core healthcare priority. Policy recommendations related to financial support, respite care, education, and mental health services should be tailored for caregivers. By addressing caregiver needs, healthcare systems can improve patient outcomes, reduce costs, and foster equity. This editorial underscores that caregivers are not ancillary but central to healthcare’s success. Recognizing and supporting them is both an ethical responsibility and a practical necessity for sustainable healthcare.

Burden, stress and depression in caregivers of cirrhosis patients before and after liver transplantation

BACKGROUND

Family caregivers of cirrhosis patients (CPs) often experience burden, stress, and depression. Investigating whether these conditions improve following the patient undergoing liver transplantation (LT) is crucial, as it would elucidate the comprehensive benefits of the procedure and demonstrate the positive impacts not only on the patients but also on their caregivers and society.

AIM

To compare the levels of burden, stress and depression among family caregivers of cirrhotic and liver transplant patients.

METHODS

This cross-sectional observational study evaluated caregivers of CPs and LT recipients at a quaternary Brazilian hospital. Instruments included identification cards, interview scripts, the caregiver burden scale Inventory, Lipp’s Stress Symptom Inventory, and the Beck Depression Inventory-Second Edition. Psychometric analyses involved confirmatory factor analysis and calculation of McDonald’s omega and composite reliability. Factor scores were compared with the Mann-Whitney U test, with effect size as the rank-biserial correlation coefficient (r). Statistical analysis was performed with R software (P < 0.05).

RESULTS

Seventy-seven CP caregivers and 65 LT recipient caregivers were included. Most were female (CP: 85.7% vs LT: 84.6%) and the patients’ spouses (76.6% vs 63.1%). The median age and caregiving duration were 55.4 (23.3-76.3) vs 54.6 (25.7-82.1) and 3.9 (1-20) vs 8 (1.5-24) years, respectively (P = 0.001). LT caregivers were less likely to be at risk of overload (21.5% vs 49.4%), to be under stress (33.8% vs 36.4%) and to show symptoms of depression (15.4% vs 35.1%). Compared with LT caregivers, CP caregivers had greater median factor scores for burden (general tension, P = 0.012; isolation, P = 0.014; disappointment, P = 0.004), depression (P = 0.008), and stress (P = 0.047), with small to moderate effect sizes. The disappointment (r = 0.240) and depression (r = 0.225) dimensions had the largest effect sizes.

CONCLUSION

Family caregivers of LT recipients are less likely to exhibit symptoms of burden, stress, and depression, suggesting that the benefits of LT extend to the patients’ family members.

Challenges and support needs among family caregivers involved in solid organ transplant care process: a scoping review protocol

INTRODUCTION

Family caregivers play an indispensable role in the care of solid organ transplant patients, undertaking a wide range of tasks from basic daily care to complex medical management. However, these responsibilities come with substantial challenges, placing additional strain on caregivers who bear significant physical, emotional, financial and social burdens, along with numerous unmet support needs. Currently, the exploration of challenges and support needs among family caregivers in the caregiving process is limited to primary research, lacking a synthesised and comprehensive understanding of the issues. Therefore, the aim of this scoping review is to summarise the available evidence to accentuate the diverse challenges encountered by family caregivers and to identify their specific supportive needs, while also pinpointing the areas of research that have yet to be explored.

METHODS AND ANALYSIS

Following the Joanna Briggs Institute methodology and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews, this review will be conducted. The initial search of PubMed to identify keywords was conducted on 16 November 2024. Additionally, Web of Science Core Collection, ProQuest, Scopus, CINAHL (EBSCOhost), China National Knowledge Infrastructure (CNKI) and China Wan Fang database will be systematically searched for relevant literature. No language or date restrictions will be applied. Two reviewers will independently screen the articles based on title, abstract and full text. Data extraction and analysis of results will be presented in tables or graphs.

ETHICS AND DISSEMINATION

Ethical approval is not necessary for this scoping review. The study findings will be published in open-access journals after peer review. These findings will provide information for healthcare providers to alleviate the plight of family caregivers and to pave the way forward towards more resilient caregiver support systems.

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%.

Neuropsychiatric sequelae after liver transplantation and their possible mechanism via the microbiota-gut-liver-brain axis

Patients after liver transplantation are often impacted by mental and even neuropsychiatric disorders, including depression, sleep disorders, anxiety, and post-traumatic stress disorder. Neuropsychiatric sequelae have an adverse impact on rehabilitation and can even incapacitate people, reducing their quality of life. Despite screening tools and effective treatments, neuropsychiatric sequelae after liver transplantation (NSALT) have not been fully diagnosed and treated. Current research suggests that NSALT may be partly related to intestinal microbial variation, but the detailed mechanism remains unclear. In this review, we describe the clinical and diagnostic features, prevalence, prediction, clinical course and outcome, management, and treatment of NSALT; we also summarize their mechanisms through the microbiota-gut-liver-brain axis. Finally, we propose to improve NSALT on the basis of adjusting the gastrointestinal flora, immune inflammation or vagus nerve (VN), providing a novel strategy for clinical prevention and treatment.

[The Caring Experience of Family Caregivers for Patients of Living Donor Liver Transplantation from the Family Members]

PURPOSE

The purpose of the study was to understand the care experiences of the family of living donor liver transplantation (LDLT) patients where the donation had occurred within the family.

METHODS

Participants were eight family caregivers who cared for recipients and donors of LDLT. Data were collected through individual in-depth interviews from November, 2020 to April, 2021. Data analysis was performed through a cyclical process of data collection and analysis by applying Giorgi's phenomenological research method.

RESULTS

The five main components extracted from the experiences of the family caregivers were: "A double-edged choice to save the family", "The harsh daily life of liver transplantation care", "The yoke of double care on both shoulders", "The power to withstand the adversity of caring", and "The recovery and growth of life pursued by trusting each other".

CONCLUSION

The participants tried to do their best in their daily lives, while providing reassurance and care to the LDLT patients in the family; however, they expressed some worry and hardship while doing so. The results of this study provide a deeper understanding of the caring experience of the family caregivers, which may contribute to the development of nursing interventions that will aid these caregivers in providing care to their LDLT family members. Furthermore, the development and application of an integrated management program for LDLT patients in the family is required.

Redefining Success After Liver Transplantation: From Mortality Toward Function and Fulfillment

Liver transplantation (LT), the only cure for end-stage liver disease, is a lifesaving, costly, and limited resource. LT recipients (LTRs) are aging with an increasing burden of medical comorbidities. Patient and graft survival rates exceed 70% at 5 years; however, patient-centered health outcomes beyond survival have received relatively little attention. LTRs must have strong self-management skills to navigate health systems, adhere to clinical monitoring, and take complex, multidrug regimens. All of these tasks require formidable cognitive abilities for active learning and problem solving. Yet, LTRs are at higher risk for impaired cognition as a result of the high prevalence of pretransplant hepatic encephalopathy, multiple chronic conditions, alcohol use, physical frailty, sarcopenia, and older age. Cognitive impairment after transplant may persist and has been causally linked to poor self-management skills, worse physical function, and inferior health outcomes in other health care settings, yet its impact after LT is largely unknown. There is a need to study potentially modifiable, posttransplant targets including caregiver support, physical activity, sleep, and treatment adherence to inform future health system responses to promote the long-term health and well-being of LTRs. Prospective, longitudinal data collection that encompasses key sociodemographic, cognitive-behavioral, psychosocial, and medical factors is needed to improve risk prediction and better inform patient and caregiver expectations. Interventions with proactive monitoring, reducing medical complexity, and improved care coordination can be tailored to optimize posttransplant care. We propose a research agenda focused on understudied, potentially modifiable risk factors to improve the long-term health of LTRs. Our conceptual model accounts for cognitive function, caregiver and patient self-management skills, health behaviors, and patient-centered outcomes beyond mortality. We propose actionable health-system, patient, and caregiver-directed interventions to fill knowledge gaps and improve outcomes.

Top Ten Tips Palliative Care Clinicians Should Know About End-Stage Liver Disease

End-stage liver disease (ESLD) is an increasingly prevalent condition with high morbidity and mortality, especially for those ineligible for liver transplantation. Patients with ESLD, along with their family caregivers, have significant needs related to their quality of life, and there is increasing attention being paid to integration of palliative care (PC) principles into routine care throughout the disease spectrum. To provide upstream care for these patients and their family caregivers, it is essential for PC providers to understand their complex psychosocial and physical needs and to be aware of the unique challenges around medical decision making and end-of-life care for this patient population. This article, written by a team of liver and PC experts, shares 10 high-yield tips to help PC clinicians provide better care for patients with advanced liver disease.

Findings and recommendations from the organ transplant caregiver initiative: Moving clinical care and research forward

Lay-caregivers are essential to the continuum of care in adult organ transplantation. However, we have a limited understanding of the experiences, exigencies, and outcomes associated with lay-caregiving for organ transplant patients. While much discussion and debate has focused on caregiver requirements in relation to transplant candidate selection, little focus has been given to understanding the needs of caregivers themselves. In response to this, the Organ Transplant Caregiver Initiative was created, and a meeting was held during October 6-7, 2019. Transplant healthcare professionals, researchers, and lay-caregivers discussed the experiences, educational needs, existing research, and research recommendations to improve the experience of lay-caregivers for adult organ transplant patients. In this report, we summarize the Organ Transplant Caregiver Initiative and meeting findings, providing a preliminary action plan to improve education, research, and advocacy for organ transplant caregivers.

Unmet Care Needs and Related Factors of Spouses of Liver or Kidney Transplant Recipients

This study aimed to (1) explore the unmet care needs of spouses of liver or kidney transplant recipients, (2) compare the unmet care needs, depression, and anxiety levels of transplant recipients and their spouses, and (3) identify factors related to spouses' unmet care needs. A cross-sectional study was conducted using purposive sampling from transplant outpatient departments at a medical center. Ninety-one liver or kidney transplant recipient-spouse dyads were recruited. Most unmet needs for dyads were involved in the psychological needs and health system and service needs domains. Spouses had significantly higher unmet needs, anxiety, and depression than recipients did. The significant factors related to the spouses' unmet needs included being male, having higher anxiety, and whose partners had higher unmet needs. Health care professionals must attend to the needs of both recipients and spouses. Providing disease-specific information and resources to spouses who potentially had higher unmet needs is strongly suggested.

Symptom Experience and Related Predictors in Liver Transplantation Recipients

PURPOSE

Symptom experience after liver transplantation (LT) provides healthcare professionals with important information about the benefits and limitations of LT from patients' perspective. This study aims to explore the multidimensional symptom experience and analyze related predictive factors in LT recipients.

METHODS

This cross-sectional study evaluated the occurrence, frequency, intensity, and level of distress of 40 symptoms in 265 LT recipients. Stepwise multiple regression analysis was performed to analyze the influencing factors of symptom experience.

RESULTS

The analysis of patient-reported data indicated that the ten most common symptoms were fatigue (42.3%), frequent sleep interruptions (38.9%), difficulty falling asleep (35.9%), decreased memory (34.0%), dreaminess (29.8%), itch (28.7%), muscular weakness (26.4%), shortness of breath (25.3%), anxiety (24.5%), and hand tremor (21.9%). Patients were classified into four groups according to survival time (1-month, 2-6-month, 7-12-month, and >1-year groups) after LT, and the most common symptom was fatigue in the one-month and 2-6-month groups, difficulty falling asleep in the 7-12-month group, and decreased memory in the >1-year group. Type of the primary caregiver, complications, concerns about the decreased ability to perform household and outdoor activities, and concerns about being a burden to the family were predictors of symptoms burden.

CONCLUSION

LT recipients experienced complicated symptoms. In clinical practice, it is critical to integrate physicians, nurses, and social workers as a medical team to help LT recipients develop suitable coping strategies that can potentially address patients' concerns, increase the sense of confidence, and improve symptom outcomes.

Quality of life after liver transplantation

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

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

Background.

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

Methods.

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

Results.

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

Conclusions.

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

Should Lack of Social Support Prevent Access to Organ Transplantation?

Transplantation programs commonly rely on clinicians' judgments about patients' social support (care from friends or family) when deciding whether to list them for organ transplantation. We examine whether using social support to make listing decisions for adults seeking transplantation is morally legitimate, drawing on recent data about the evidence-base, implementation, and potential impacts of the criterion on underserved and diverse populations. We demonstrate that the rationale for the social support criterion, based in the principle of utility, is undermined by its reliance on tenuous evidence. Moreover, social support requirements may reinforce transplant inequities, interfere in patients' personal relationships, and contribute to biased and inconsistent listing procedures. As such, accommodating the needs of patients with limited social support would better balance ethical commitments to equity, utility, and respect for persons in transplantation. We suggest steps for researchers, transplantation programs, and policymakers to improve fair use of social support in transplantation.

Palliative care in end-stage liver disease: Time to do better?

Optimal involvement of palliative care (PC) services in the management of patients with decompensated cirrhosis and end-stage liver disease (ESLD) is limited. This may result from both ignorance and the failure to recognize the spectrum and unpredictability of the underlying liver condition. Palliative care is a branch of medicine that focuses on quality of life (QoL) by optimizing symptom management and providing psychosocial, spiritual, and practical support for both patients and their caregivers. Historically, palliative care has been underutilized for patients with decompensated liver disease. This review provides an evidence-based analysis of the benefits of the integration of palliative care into the management of patients with ESLD. Liver Transplantation 24 961-968 2018 AASLD.

Social support for patients undergoing liver transplantation in a Public University Hospital

Background

Several diseases may lead to the need for liver transplantation due to progressive organ damage until the onset of cirrhosis, resulting in changes in interpersonal relationships. Social Support for transplant candidates is an important variable, providing them with psychological and social well-being. This study aims to assess social support in chronic hepatic patients, waiting for liver transplantation.

Methods

A cross-sectional study was conducted with 119 patients, for convenience sampling, from the liver transplant waiting list at a Brazilian University Hospital Outpatients. The information was collected through semistructured questionnaires, in four stages: 1) socioeconomic and demographic information 2) clinical aspects 3) feelings 4) Social Support Network Inventory (SSNI), to Brazilian Portuguese. The statistical analysis was conducted using ANOVA and multivariate linear regression analysis to evaluate the relationship between the scales of social support and the collected co-variables.

Results

Average age was 50.2 ± 11.6, and 87 (73.1%) were men. Patients with alcohol and virus liver disease etiology had the same frequency of 28%. The MELD, without extrapoints, was 16.7 ± 4.9. Global social support family score was 3.72 ± 0.39, and Cronbach’s alpha = 0.79. The multivariate analysis presented the following associations, age = [− 0.010 (95% CI = − 0.010 - -0.010); P = 0.001], etiology of hepatic disease = [− 0.212 (95% CI = − 0.37 - -0.05); P = 0.009], happiness = [− 0.214(95% CI = − 0.33 - -0.09) P = 0.001) and aggressiveness = [0.172 (95% CI = 0.040–0.030); P = 0.010).

Conclusions

The social support was greater when the patients were younger (18 to 30 years). Patients with alcoholic cirrhosis, regardless of whether or not they were associated with virus, had less social support. As for feelings, the absence of happiness and the presence of aggressiveness showed a negative effect on social support.

Decellularized bovine cotyledons may serve as biological scaffolds with preserved vascular arrangement

Technically produced scaffolds are common to establish transplantable tissues for regenerative medicine, but also biological ones that are closer to the natural condition become of interest. Placentas are promising, because they represented available, complete organs with rich extracellular matrix (ECM) and well-developed vasculature that easily could build anastomoses to a host's organ. Only placentas from larger animal models such as the bovine meet the dimensions large enough for most organs but are not adequately described yet. We here studied the nature of the ECM in 27 natural and decellularized bovine cotyledons, that is, the fetal part of the placentomes, by means of histology, immunohistochemistry, and electron microscopy. Successful decellularization was done by perfusion with 0.01%, 0.1%, and 0.5% sodium dodecyl sulfate each and subsequent immersion in 1% Triton X-100, resulting in a removal of cells and DNA, whereas the structure of the allantochorionic surface and villi was preserved. Although some fibres disappeared, also the arrangement of the main ECM proteins was largely similar before and after decellularization: Along the larger vessels, a densely packed network of thick fibres occurred, organized in layers without cells or spaces in between. Collagen IV, fibronectin, and laminin contributed to those areas. In contrast, collagen I and III characterized the meshwork of medium-sized and thin fibres in the mesenchyme, respectively. In conclusion, decellularized bovine cotyledons indeed had characteristics of a biological scaffold and provide an interesting alternative to develop large-scale scaffolds with complex vascular architecture for tissue engineering purposes.

Post-traumatic growth and its relationship to quality of life up to 9 years after liver transplantation: a cross-sectional study in Spain

OBJECTIVE

Little is known concerning post-traumatic growth (PTG) after liver transplantation. Against this backdrop the current study analysed the relationship between PTG and time since transplantation on quality of life. Furthermore, it compared PTG between liver transplant recipients and their caregivers.

DESIGN

Cross-sectional case-control study.

SETTING

University Hospital in Spain.

PARTICIPANTS

240 adult liver transplant recipients who had undergone only one transplantation, with no severe mental disease, were the participants of the study. Specific additional analyses were conducted on the subset of 216 participants for whom caregiver data were available. Moreover, results were compared with a previously recruited general population sample.

OUTCOME MEASURES

All participants completed the Posttraumatic Growth Inventory, and recipients also filled in the 12-Item Short-Form Health Survey. Relevant sociodemographic and clinical parameters were also assessed.

RESULTS

In the sample of 240 recipients, longer time since transplantation (>9 years) was associated with more pain symptoms (p=0.026). Regardless of duration, recipients showed lower scores on most quality of life dimensions than the general population. However, high PTG was associated with a significantly higher score on the vitality quality of life dimension (p=0.021). In recipients with high PTG, specific quality of life dimensions, such as bodily pain (p=0.307), vitality (p=0.890) and mental health (p=0.353), even equalled scores in the general population, whereas scores on general health surpassed them (p=0.006). Furthermore, liver transplant recipients (n=216) compared with their caregivers showed higher total PTG (p<0.001) and higher scores on the subscales relating to others (p<0.001), new possibilities (p<0.001) and appreciation of life (p<0.001).

CONCLUSIONS

Our findings highlight the protective role of PTG in the long-term outcome of liver transplant recipients. Future studies should analyse and develop psychosocial interventions to strengthen PTG in transplant recipients and their caregivers.