Factors affecting health-related quality of life and physical activity after liver transplantation for autoimmune and nonautoimmune liver diseases: a prospective, single centre study

Quality of life, anxiety, and depression improve at one-year after liver transplantation in patients with advanced liver disease

Background

Liver transplantation (LT) improves survival in end-stage liver disease. Several reports have addressed the impact of LT on patients' lives, beyond purely medical outcomes. Although the quality of life and mental health have been demonstrated to improve with this procedure, such studies are still missing in Latin America.

Methods

Patients who received LT at the Fundación Santa Fe de Bogotá between 2017 and 2019 were assessed for quality of life (QoL), anxiety, and depression and they were followed up for one year after the procedure. Pre-transplant data were gathered at inclusion on the waiting list, while post-transplant data at 3- and 12 months after LT. European Quality of Life-5 Dimensions (EQ-5D) and European Quality of Life-Visual Analog Scale (EQ-VAS) instruments were used to evaluate QoL. The Hospital Anxiety and Depression Scale (HADS) was used for evaluating anxious and depressive symptoms.

Results

115 recipients met the inclusion criteria. Mean pre-transplant EQ-VAS was 70.78, rising to 87.16 and 92.56 at 3- and 12-months, respectively. Improvements in all EQ-5D dimensions were found in response to LT. According to the HADS questionnaire, anxiety was reduced by 2.35 points and depression by 1.63 points after LT.

Conclusion

in the short term, LT is a successful strategy for enhancing QoL, anxiety, and depression in patients with liver disease. Long-term benefits must be assessed.

Low socioeconomic status exacerbates unmet health-related needs in patients with autoimmune hepatitis

BACKGROUND AND AIMS

Diminished quality of life has been well characterized in patients with autoimmune hepatitis (AIH); however, the full spectrum of unmet needs is unclear. We hypothesized that there is a high burden of health-related unmet needs in patients with AIH, and this burden differs by socioeconomic status (SES).

METHODS

Members of the Autoimmune Hepatitis Association were invited online and by email to complete a modified version of the Systemic Lupus Erythematosus Patient Needs Questionnaire. Demographic and clinical data were also captured. Low SES was defined as annual household income <30 k, education level below high school, or moderate-high concern for transportation, food or housing. Multivariable logistic regression assessed the association between unmet health-related needs and SES.

RESULTS

There were 433 participants; 89.8% identified as women, 16.2% lived outside the US, and 25.6% were classified as low SES. Over 70% of respondents reported at least one moderate-high need in the health-related unmet need domains. In multivariable logistic regression, patients in the low-SES group reported significantly higher odds of unmet needs compared to the moderate-high-SES group: for adequate information about side effects (OR 1.64, 95% CI 1.06-2.53, p = 0.026), opportunity to speak with others with AIH (OR 2.34, 95% CI 1.50-3.66, p < 0.001), healthcare professionals acknowledging patient emotions (OR 2.41, 95% CI 1.56-3.74, p < 0.001) and being taken seriously by medical providers (OR 2.09, 95% CI 1.34-3.28, p = 0.001).

CONCLUSION

There is a high burden of health-related unmet needs in all patients with AIH that is exacerbated by low SES.

Physical Activity Levels in Transplant Recipients

BACKGROUND Physical activity is a key factor in improvement of quality of life. This study aimed to assess the extent of physical activity in solid-organ transplant recipients. MATERIAL AND METHODS The study involved 106 patients, mostly kidney (64.15%) and liver (28.30%) recipients, observed in a Warsaw transplant center. The study group was dominated by women (56.6%), mean age 49.25±14.09 years, the time since transplantation ranged from 1 month to 28 years, with a mean of 93.9±71.83 months. Recipients were educated about physical activity in the immediate post-transplant period and during follow-up visits. The study was conducted in early 2021 and used the long form of the International Physical Activity Questionnaire (IPAQ) validated for Polish patients, consisting of the of 5 parts - physical activity, professional work, travel, housework, recreation, and time spent sitting - containing a total of 27 questions in the main part of the questionnaire and 7 questions in the introductory part determining the typicality of the last 7 days. RESULTS More than half (57.5%) of the transplant recipients reported high levels of physical activity. Patients reported the highest mean physical activity in job-related physical activity (P<0.001). Patients also had high scores for walking and moderate-intensity physical activity, while the lowest mean scores were for leisure-time physical activity, total vigorous-intensity physical activity, and housework-related activity. CONCLUSIONS When undertaking physical activity, patients turn to activities that do not involve intense effort, are less physically demanding, and do not result in high energy expenditure. Employed patients had higher PA levels in all domains.

Unsupervised Exercise Intervention vs. Adherence to a Mediterranean Diet Alone: The Role of Bioelectrical Impedance Vector Analysis and Cardiovascular Performance in Liver-Transplanted Recipients

(1) Background: Cardiovascular disease is one of the leading causes of mortality after liver transplantation. Body composition and cardiovascular performance assessment represent a potential approach for modulating lifestyle correction and proper follow-up in chronic disease patients. This study aimed to verify the additional role of an unsupervised physical activity program in a sample of male liver transplant recipients who follow the Mediterranean diet. (2) Methods: Thirty-three male liver transplant recipients were enrolled. Sixteen subjects followed a moderate-intensity home exercise program in addition to nutritional support, and seventeen received advice on the Mediterranean diet. After six months, bioelectrical vector impedance analysis (BIVA) and cardiopulmonary exercise testing (CPET) were performed. (3) Results: No differences in CPET (VO2 peak: exercise 21.4 ± 4.1 vs. diet 23.5 ± 6.5 mL/kg/min; p = 0.283) and BIVA (Z/H: exercise 288.3 ± 33.9 vs. diet 310.5 ± 34.2 Ω/m; p = 0.071) were found. Furthermore, the BIVA values of resistance correlate with the submaximal performance of the Ve/VCO2 slope (R = 0.509; p < 0.05) and phase angle with the maximal effort of the VO2 peak (R = 0.557; p < 0.05). (4) Conclusions: Unsupervised physical exercise alone for six months does not substantially modify liver transplant recipients' cardiovascular performance and hydration status, despite their adherence to a Mediterranean diet. The body composition analysis is useful to stratify the risk profile, and it is potentially associated with better outcomes in transplanted subjects.

Validation of the LPA-SQUASH in post-liver-transplant patients

AIM

This study aimed to validate the revised Short Questionnaire to Assess Health-Enhancing Physical Activity (SQUASH) to measure sedentary activity in post-liver-transplant patients. The proposed scale could be useful for transplantation nurses to assess and modify sedentary lifestyles and increase physical activity.

METHODS

The SQUASH was modified to include items on sitting time and light-intensity physical activity (LPA-SQUASH). A pilot study was conducted with 20 liver transplant patients, and an expert panel validated the scale contents. Then, post-liver-transplant outpatients at a Japanese university hospital participated in the main study (September-October 2020), in which questionnaires were mailed twice to assess test-retest reliability, and accelerometers used to establish criterion validity. Intra-class correlation coefficients (ICC) were calculated for test-retest reliability. Spearman correlations and Bland-Altman plots were used to assess validity and measurement error.

RESULTS

In total, 173 participants returned the questionnaires, and 106 and 71 completed the reliability and validation studies, respectively. The range of LPA-SQUASH correlation coefficients for test-retest was .49-.58. ICCs ranged from .72 to .80 for items other than leisure. Accelerometer data and the LPA-SQUASH total physical activity amount and light-intensity physical activity correlated moderately.

CONCLUSION

We modified the SQUASH, which was developed to measure physical activity in healthy adults, to assess light-intensity physical activity in post-liver-transplant patients. The LPA-SQUASH showed acceptable validity and reliability. The questionnaire may be used by transplantation nurses to examine light-intensity physical activity content/duration, deliver patient education considering patients' sedentary lifestyle, and facilitate goal setting for physical activity interventions to prevent metabolic syndrome.

Health-related quality of life and symptoms in autoimmune liver diseases

Assessment of Health-Related Quality of Life (HRQoL) has emerged as an important tool in the evaluation of both the well-being of patients and the results of their clinical management. Over the years, a large number of questionnaires focusing on various aspects of quality of life have been developed. They are frequently divided into generic questionnaires, which can be used under various conditions, disease-specific and symptom-specific questionnaires. Autoimmune liver diseases, such as autoimmune hepatitis, primary sclerosing cholangitis, or primary biliary cirrhosis, comprise a group of rare liver conditions (i.e. affecting fewer than 5 in 10,000 people in the general population). Unfortunately, HRQoL has not been well-studied in this group of patients. In this review, we comprehensively summarize the data available in the literature on HRQoL in these conditions, emphasizing the important role that quality of life plays in the successful management of such patients.

Self-reported physical activity and lack of association with health-related quality of life in a pediatric solid-organ transplant population

BACKGROUND

Physical activity (PA) has been shown to have benefits, including improving health-related quality of life (HRQOL). However, there are few and conflicting studies assessing PA and its relationship with HRQOL in a pediatric solid-organ transplant (SOT) population. The aim of this study was to assess whether overall HRQOL was associated with PA and to determine whether that association was independent of other baseline and contemporaneous clinical and demographic indicators.

METHODS

A retrospective cross-sectional review was performed on 55 pediatric transplant patients (13 heart, 27 kidney, and 15 liver transplant). PA was measured by PAQ-C/PAQ-A, and HRQOL was measured using PedsQL. Demographics, baseline, and contemporaneous data were collected.

RESULTS

There were no significant differences in baseline and contemporaneous characteristics between heart, kidney, and liver transplant recipients. SOT recipients were 15.0 (11.0-18.0) years old at completion of surveys. Median PAQ score was 2.3 (1.6-3.2), PedsQL total score was 77 (65-91), and PedsQL physical functioning score was 88 (72-97). The PedsQL total score was not significantly associated with PAQ score. The PAQ score was significantly associated with physical functioning subscore of the PedsQL (r = 0.37, p < 0.01). Higher physical functioning score was associated with time since transplant (r = 0.29, p = 0.031).

CONCLUSION

Our SOT cohort has a HRQOL similar to other chronic conditions and higher than previous reported HRQOL in pediatric SOT populations. Higher levels of PA and longer time since transplant are associated with higher physical functioning scores.

Effects of Progressive Relaxation Exercises on Vital Signs and Fatigue in Liver Transplant Patients: A Randomized Controlled Trial

This randomized controlled study was conducted to evaluate the effects of progressive relaxation exercises on vital signs and fatigue level. Ninety patients with liver transplantation (experimental group = 45, control group = 45) were included in the study. The patients in the experimental group performed progressive relaxation exercises for 25 to 30 minutes every day for 4 weeks. Before the progressive relaxation exercises, the vital signs and fatigue level of the patients were recorded. Vital signs were recorded again immediately after the progressive relaxation exercises and at the end of the second week. At the end of the fourth week, the final measurement of vital signs was performed along with the second fatigue level assessment. In the experimental group, pulse and respiratory rates, systolic and diastolic blood pressure values, and fatigue severity mean scores were found to be lower and oxygen saturation level was higher than those of the control group. The improvement in vital signs in the experimental group was evident at week 3 (p < .05).

Chronic Fatigue Persists in a Significant Proportion of Female Patients After Transplantation for Primary Sclerosing Cholangitis

Chronic fatigue and an impairment of general health-related quality of life (HRQoL) are frequently reported by patients with primary sclerosing cholangitis (PSC). Studies on patients with primary biliary cholangitis (PBC) suggest that, unlike pruritus, fatigue may not be ameliorated by liver transplantation (LT). However, there are few data regarding the assessment of fatigue before and after transplantation in PSC. To investigate the effect of LT on fatigue and HRQoL in patients with PSC, 81 patients with PSC (median age 33 years; 69% men) were prospectively enrolled in this study. The PBC-40 and Short Form 36 (SF-36) questionnaires were used for assessment before and twice after LT. A total of 26 patients who received a transplant for PBC were included as controls. The potential impact of the clinical and laboratory parameters was evaluated by univariate and multivariate analyses. Although in addition to other well-being indexes the median fatigue score improved after LT (P < 0.001), a detailed analysis demonstrated that fatigue persists in one-third of patients. A significant fatigue reduction was seen in men (P < 0.001) but not women (P = 0.25). Posttransplant fatigue did not depend on concomitant inflammatory bowel disease, laboratory indexes of cholestasis, or disease recurrence. In the multivariate regression model, female sex was the only independent covariate associated with persistent fatigue. In terms of other measures of HRQoL, LT caused a substantial improvement in the majority of SF-36 and PBC-40 domains. Recurrent PSC and unemployment negatively affected the well-being of patients. Patients who received a transplant for PSC had significantly better HRQoL than those patients with PBC. LT improves various measures of HRQoL, but it does not ameliorate fatigue in female patients with PSC.

Relationships of accelerometer-determined physical activity with obesity, hypertension, diabetes, dyslipidemia, and health-related quality of life in patients after liver transplantation

The contribution of physical activity (PA) to the prevention of metabolic abnormalities following liver transplantation (LT) has not been well documented. We aimed to assess PA in post-LT patients and to quantify its relationships with the development of postoperative metabolic abnormalities and health-related quality of life (HRQOL). We recruited 111 patients who had undergone LT ≥ 6 months previously. PA was measured by accelerometry, and HRQOL was evaluated using SF-8. PA was quantified as the number of steps per day, and the time spent performing moderate-to-vigorous PA and light PA per week. The prevalence of hypertension, diabetes, and dyslipidemia increased more than twofold following LT. The proportion of the participants with a sedentary lifestyle (<5000 steps/day) was 36%. Logistic regression analysis showed that postoperative hypertension and obesity were associated with preoperative body mass index and the number of steps taken (in 2000 steps/day increments). Preoperative diabetes was associated with obesity, and PA was associated with physical function-related HRQOL scores. Thus, increasing the number of steps taken per day has the potential to reduce hypertension and obesity, and PA could improve physical function-related HRQOL in patients following LT.

Prospective study of objective physical activity and quality of life in living donor liver transplant recipients

AIM

The aims of this study were to: (a) describe the physical activity (PA) and quality of life (QOL) in living donor liver transplant (LDLT) recipients pre-operatively and at 3 months and 6 months post-operatively; (b) compare PA and QOL at 6 months post-operatively with a healthy control group; and (c) explore pre-operative factors that predict PA changes.

METHODS

Patients over 20 years of age who were undergoing LDLT were recruited. PA was measured based on the number of steps/day and time spent performing moderate-to-vigorous PA (MVPA) during 1 week using an accelerometer. QOL was assessed based on a physical (PCS) and mental (MCS) component summary of the eight-item Short-Form Health Survey. The LDLT and healthy control groups were matched for age (±3 years) and gender. Pre-operative factors predicting a change in PA were calculated using a generalized linear mixed model.

RESULTS

Twenty-four patients completed the study. By 6 months post-LDLT, the MCS and PCS were comparable to those in the control group. The number of steps (3,887 steps/day) and MVPA (29.3 min/week) showed significant improvement by 6 months post-operatively, but remained much lower compared with those in the control group. The multivariate analysis showed that younger age (p < .01, p = .04) and higher skeletal muscle mass (SMM; p < .01, p = .03) were predictors of improvement in number of steps and MVPA.

CONCLUSION

This study suggests the need for pre-operative interventions by healthcare professionals that focus on outcomes such as improving low SMM to facilitate post-operative PA recovery.

Vitamin-D Receptor-Gene Polymorphisms Affect Quality of Life in Patients with Autoimmune Liver Diseases

Vitamin D deficiency has been associated with depressive symptoms and reduced physical functioning. The aim of the study was to characterize the relationship between polymorphisms of the vitamin D receptor (VDR) gene and the quality of life in patients with autoimmune hepatitis (AIH) and primary biliary cholangitis (PBC). Three polymorphisms of the VDR gene (TaqI-rs731236, BsmI-rs1544410, and ApaI-rs7975232) were analyzed in patients with AIH (n = 142) and PBC (n = 230) and in healthy individuals (n = 376). Patient quality of life was assessed by validated questionnaires such as Medical Outcomes Study Short-Form 36 (SF-36), State Trait Anxiety Inventory (STAI), Modified Fatigue-Impact Scale (MFIS), Patient-Health Questionnaire 9 (PHQ-9), and PBC-40. The TaqI C and ApaI A alleles are risk alleles in both AIH and PBC, and a significant dominance of the A allele in BsmI was observed in AIH patients. In terms of quality of life, the presence of the CC or CT TaqI genotype was associated with emotional reactions, including the fatigue and the cognitive skills of patients with PBC, whereas in the group of AIH patients, homozygotes CC of TaqI, AA of BsmI, and AA of ApaI had worse physical, social, emotional, and mental function. The genetic variations of VDR gene can influence individual susceptibility to develop chronic autoimmune liver diseases such as AIH and PBC and affect quality of life.

Long-Term Health-Related Quality of Life in Living Liver Donors

BACKGROUND In living donor liver transplantation (LDLT), 2 patients undergo surgery, and the advantages and disadvantages for both patients should be considered. This study evaluated the long-term quality of life in living liver donors, and its impact on their activities of daily living focusing on mood and mental health. MATERIAL AND METHODS In total, 101 living liver donors (69 female and 32 male patients, median age of 36.8 years) were surveyed at a median time of 61.8 months after liver donation (range 7-169 months). The generic Short Form Health Survey (SF-36), the Patient Health Questionnaire 9 (PHQ-9), and the Questionnaire of Physical Activity (IPAQ) were used. The results of SF-36 were compared to a matched control group (n=72) using the Wilcoxon test; the SF-36, the PHQ-9, and the IPAQ scores were analyzed using Spearman's rank correlation. Linear regression model was used to check for dependencies between variables of interest. The IPAQ results were compared between the study group and the general Polish population. RESULTS There were no significant differences in the SF-36 domains between the study group and control group except body pain, which was higher in the living liver donor group (P<0.05). In 30.6% of patients, the PHQ-9 survey revealed mood disturbances. The PHQ-9 scores were higher in female-donors (P<0.05). Both summary scores of the SF-36 correlated to the PHQ-9 (P<0.001). In 89.1% of patients, physical activity was below the population norm and was lower in female donors than in male donors (P<0.01). CONCLUSIONS LDLT had no impact on donors' physical and mental health. Physical activity of living liver donors was lower than that of the general population. The SF-36 and the IPAQ measures seem to be reliable in the care of living liver donors. The PHQ-9 survey results and the inclination to depression of female living liver donors requires further study.

Autoimmune hepatitis exerts a profound, negative effect on health-related quality of life: A prospective, single-centre study

BACKGROUND AND AIMS

Autoimmune hepatitis is a progressive chronic liver disease. Health-related quality of life in autoimmune hepatitis has not attracted much attention so far. We prospectively assessed various aspects of health-related quality of life in a well characterized group of patients with autoimmune hepatitis.

METHODS

In total, 140 patients with autoimmune hepatitis (mean age 40 ± 17 years) and 170 controls (mean age 36 ± 14 years) were included. Health-related quality of life was evaluated with following questionnaires: The Short Form (36) Health Survey, Modified Fatigue Impact Score, State-Trait Anxiety Inventory and Patient Health Questionnaire-9 assessing depression.

RESULTS

Patients with autoimmune hepatitis showed a significant impairment of health-related quality of life in all, but one, domains of The Short Form (36) Health Survey. Autoimmune hepatitis was associated with pronounced physical fatigue (P < 0.001), anxiety (P < 0.001) and depression (P < 0.001). As compared to males, female patients demonstrated greater impairment of physical aspects of The Short Form (36) Health Survey and Modified Fatigue Impact Score. Twenty-seven patients (19%) had moderate (Patient Health Questionnaire-9 >10) and 14 (10%) moderately severe depression (Patient Health Questionnaire-9 >15). Depression showed a very strong correlation with chronic fatigue (R = 0.68; P < 0.001); physical and mental components of The Short Form (36) Health Survey (R = 0.52/0.68 respectively; P < 0.001) and anxiety (R = 0.47; P < 0.001). There was a trend towards better life's quality in patients treated with budesonide in some aspects of their health-related quality of life. Duration of the disease, age at diagnosis, liver fibrosis and the presence of cirrhosis were not associated with health-related quality of life.

CONCLUSIONS

Health-related quality of life is significantly impaired in patients with autoimmune hepatitis. Depression seems to be a dominant symptom affecting their well-being, not associated with clinical and biochemical features of the disease.

Factors Affecting Exercise Test Performance in Patients After Liver Transplantation

BACKGROUND

Cardiovascular diseases are a leading cause of morbidity and mortality in solid organ transplant recipients. In addition, low physical activity is a risk factor for cardiac and cerebrovascular complications.

OBJECTIVES

This study examined potential relationships between physical activity, health-related quality of life (HRQoL), risk factors for cardiovascular disease, and an exercise test in liver-graft recipients.

PATIENTS AND METHODS

A total of 107 participants (62 men/45 women) who had received a liver transplantation (LT) at least 6 months previously were evaluated. Physical activity was assessed using three different questionnaires, while HRQoL was assessed using the medical outcomes study short form (SF)-36 questionnaire, and health behaviors were evaluated using the health behavior inventory (HBI). The exercise test was performed in a standard manner.

RESULTS

Seven participants (6.5%) had a positive exercise test, and these individuals were older than those who had a negative exercise test (P = 0.04). A significant association between a negative exercise test and a higher level of physical activity was shown by the Seven-day physical activity recall questionnaire. In addition, HRQoL was improved in various domains of the SF-36 in participants who had a negative exercise test. No correlations between physical activity, the exercise test and healthy behaviors, as assessed via the HBI were observed.

CONCLUSIONS

Exercise test performance was affected by lower quality of life and lower physical activity after LT. With the exception of hypertension, well known factors that affect the risk of coronary artery disease had no effect on the exercise test results.

Leisure time physical activity and health-related behaviours after liver transplantation: a prospective, single-centre study

INTRODUCTION

Leisure time physical activity is of proven significance in surveys of fitness levels in various patient groups. Low physical functioning may affect recovery after liver transplantation (LTx).

AIM

To assess patients' leisure time activity and health-related habits after transplantation.

MATERIAL AND METHODS

One hundred and seven patients after LTx were included. They were divided into groups depending on aetiology of liver problem and the period after LTx. Minnesota Leisure Time Physical Activity Questionnaire (MILTPAQ) and Health Behaviour Inventory (HBI) were applied.

RESULTS

Neither the primary indication for the procedure nor the period after surgery had a significant relationship with physical activity assessed with MILTPAQ; however, activity was lower in females than males (1804.3 ±1848.9 vs. 2619.9 ±2067; p = 0.03). Age at survey/surgery was inversely associated with higher activity (p = 0.02 and p = 0.03, respectively). Health Behaviour Inventory analysis showed a correlation between all four of its domains and age at transplantation/survey (p < 0.001 for both). There was a negative correlation between positive mental attitude and body mass index (BMI).

CONCLUSIONS

The primary indications for grafting and, surprisingly, the period after surgery did not seem to be related to the patients' physical activity in leisure time. Younger and leaner patients appeared to understand the standards of healthy behaviour better and implement them in their daily activities. As higher BMI are associated with a negative mental attitude in patients after LTx, a particular emphasis should be placed on proper counselling in this subgroup of patients.