|Year : 2020 | Volume
| Issue : 1 | Page : 48-52
Quality of life among liver transplantation recipients before and after surgery: A single-center longitudinal study
Alireza Shamsaeefar1, Saman Nikeghbalian1, Kourosh Kazemi1, Sivash Gholami1, Mehrab Sayadi2, Fatemeh Azadian3, Nasrin Motazedian4, Seyed Ali Malekhosseini1
1 Shiraz Organ Transplant Center, Shiraz University of Medical Sciences, Shiraz, Iran
2 Cardiovascular Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
3 Non-Communicable Disease Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
4 Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
|Date of Submission||28-Aug-2019|
|Date of Acceptance||21-Jan-2020|
|Date of Web Publication||31-Mar-2020|
Dr. Nasrin Motazedian
Shiraz Transplant Research Center, Shiraz University of Medical Sciences, 7th Floor, Mohammad Rasulallah Research Tower, Mollasadra St., Khalili Ave., Shiraz
Source of Support: None, Conflict of Interest: None
Background: Liver transplantation has improved patients' survival rates and quality of life (QoL). This study investigated the effect of liver transplantation and model for end-stage liver disease (MELD) score on patients' QoL at Shiraz Organ Transplantation Center. Materials and Methods: This perspective longitudinal study was conducted among 40 liver transplant candidates at Shiraz Organ Transplant Center. Inclusion criteria were patients who were 12 years or older, able to answer the questions and willingness to participate. If they had received multi-organ transplant and had mental or physical disabilities, we excluded them from the study. They were interviewed by the same researcher in the transplant clinic before transplantation, 1 and 6 months after transplantation. The participants completed the data collection form and Short Form-36 questionnaire via face-to-face interview. The data collecting form consist of demographic and medical information. Medical information was collected from Shiraz Organ Transplant Center. Results: Mean age of participants was 41.18 ± 14. By comparing QoL dimensions, a significant difference was found between before and after transplantation (P < 0.001), except in General Health dimension (P = 0.711). There was no statistically significant relationship between MELD score and QoL after liver transplantation (P > 0. 05). Conclusion: Liver transplantation improves patients' quality life with end-stage liver disease. MELD scores do not depict QoL after liver transplantation.
Keywords: Cohort, liver transplantation, quality of life, recipient
|How to cite this article:|
Shamsaeefar A, Nikeghbalian S, Kazemi K, Gholami S, Sayadi M, Azadian F, Motazedian N, Malekhosseini SA. Quality of life among liver transplantation recipients before and after surgery: A single-center longitudinal study. Indian J Transplant 2020;14:48-52
|How to cite this URL:|
Shamsaeefar A, Nikeghbalian S, Kazemi K, Gholami S, Sayadi M, Azadian F, Motazedian N, Malekhosseini SA. Quality of life among liver transplantation recipients before and after surgery: A single-center longitudinal study. Indian J Transplant [serial online] 2020 [cited 2020 Jul 6];14:48-52. Available from: http://www.ijtonline.in/text.asp?2020/14/1/48/281765
| Introduction|| |
Chronic and end-stage liver diseases affect patients' health in many aspects. Patients encounter reduced kidney function, ascites, recurrent hemorrhage, peritonitis, encephalopathy, and reduced quality of life (health-related QoL). Liver transplantation is a life-saving method for most patients with end-stage liver disease and has been shown to improve patients' survival and QoL. However, due to the shortage of organ pool and liver disease complications, the perioperative mortality rate is around 8%–10%. Hence, all liver transplant recipients require social support as well as monitoring by health-care providers.,
Even though there have been advances in surgical techniques and improvement in patient and graft survival, the major challenge still remains to be health-related QoL. Clinical outcome of transplantation appears shortly after operation, and health-care providers evaluate liver transplant recipients' health-related QoL to assess the transplant outcome in long term. Assessing QoL after liver transplantation is important, since health-related QoL in patients has diminished due to clinical symptoms, reduced social activity, and increased economic problems.,
The model for end-stage liver disease (MELD) score is used to distinguish patients with high-risk mortality, which is related to end-stage liver disease with a purpose to rank these patients for liver transplantation. This objective score is based on a mathematical formula using logarithmic values of serum bilirubin, serum creatinine, and institutional normalized ratio.,
Some clinical and laboratory factors before transplantation might influence the Health-related QoL after transplantation, one of these factors is the MELD score. The relationship between MELD and Health-related QoL after transplantation is not clear yet.,
This study investigated the effect of liver transplantation and MELD score on health-related QoL of patients at Shiraz Organ Transplant Center.
| Materials and Methods|| |
This perspective longitudinal study was conducted among 40 liver transplant candidates at Shiraz Organ Transplant Center. The objectives of this study were explained to liver transplant candidates. Inclusion criteria were patients 12 years or older, candidate for liver transplant, able to answer the questions, and willingness to participate. If they were to receive multi-organ transplant, and had physical or mental disabilities, they were excluded. They were interviewed by the same researcher in the transplant clinic before transplantation (the first interview: about 30 days before transplantation) and 1 and 6 months after transplantation in the outpatient clinic (second and third interview). The participants completed the data collection form and Short Form-36 (SF-36) questionnaire via face-to-face interview. The data collection form consists of demographic and medical information. Medical information was collected from Shiraz Organ Transplant Center database. Ethical approval was obtained from the Local Ethics Committee of Shiraz University of Medical Sciences.
The patient consent has been taken for participation in the study and for publication of clinical details and images. Patients understand that the names, initials would not be published, and all standard protocols will be followed to conceal their identity. The study has been approved by Institutional ethics committee of IR.SUMS.REC.1394.S807.
Short Form-36 questionnaire
The SF-36 serves as an assessment tool for health-related QoL. Eight dimensions of health-related QoL were evaluated. These eight dimensions are summarized in two main sections, the physical component summary (PCS) and mental component summary (MCS). These eight dimensions include: physical functioning (PF, 10 items), role-physical (RP, 4 items), bodily pain (BP, 2 items), general health perceptions (GH, 6 items), vitality (VIT, 4 items), social functioning (2 items), role-emotional (RE, 3 items), and mental health (MH, 5 items). In each dimension, the range of possible scores is between 0 and 100 points.
Data are presented as mean standard deviation (SD) for continuous and n (%) for categorical variables. We used repeated measures analysis of variance (RMANOVA) and Bonferroni post hoc test with two-sided tests at the 5% level of statistical significance. All analyses were performed using the Statistical Package for the Social Sciences version 16 (SPSS Inc., Chicago, IL, USA).
| Results|| |
Demographic and clinical characteristic
We enrolled 40 patients with end-stage liver disease who were in liver transplantation waiting list. The mean age of the participants was 41.18 ± 14.96 (range 12–65) years. Among the participants, there were 23 (57.5%) men, and 31 (77.5%) were married, respectively [Table 1]. Mean days of hospital stay was 10.28 ± 2.8 (range 5–15 days). The most common reason (12 patients, 30%) for liver failure was viral hepatitis [Table 2].
Quality of life
The health-related QoL of patients was evaluated via SF36 questionnaire in three times. To compare changes, we used RMANOVA and Bonferroni post hoc test [Table 3]. A significant difference was not observed in GH dimension, while in two-dimensions of PF and RP the scores had increased (P < 0.001), which was due to the differences between Phase 1 and 2 (P < 0.001) and between Phase 2 and 3 (P < 0.001). RE dimension difference between Phase 1 and 2 was statistically significant (P < 0.001), but the difference between Phase 2 and 3 was not statistically significant (P = 0.4). In the BP dimension, differences between Phase 1 and 2 (P < 0.001) and also between Phase 2 and 3 (P < 0.001) were significant. VT dimension showed significant difference between Phase 1 and 2 (P < 0.001), but between phase 2 and 3, (P = 0.093) this was not statistically significant. There was a significant difference between Phase 1 and 2 (P < 0.001), but not statistically significant between Phase 2 and 3 (P = 0.902) in MH dimension. PCS and MCS dimension scores had increased from Phase 1 to 3, and the difference between Phase 1 and 2 and Phase 2 and 3 was statistically significant (P < 0.001).
|Table 3: Comparison of health-related quality of life data at three time points|
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Analysis of the MELD score among our participants before liver transplantation showed a mean ± SD (19.33 ± 5.56) (range: 10–37). A total of 27 (67.5%) patients had a MELD score equal or lower than 16, and 13 (32.5%) patients had MELD score >16. There was no significant relationship between MELD score and health-related QoL after liver transplantation (P > 0. 05) [Table 4].
|Table 4: Relationship between quality of life domains six months after liver transplantation and model for end-stage liver disease scores|
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| Discussion|| |
Health-care workers assess liver transplantation outcome, effect of comorbidities and immunosuppressive medication, using health-related QoL instruments. Powerful tools evaluate health-related QoL in patients with chronic liver disease in different domains. Clinicians should integrate clinical parameters and Health-related QoL instruments to measure the outcome of liver transplantation.
In our study, the health-related QoL of liver transplant recipients improved significantly in various domains, 6 months after liver transplantation. In this study, there was no significant relationship between MELD score and health-related QoL after liver transplantation.
Yang et al. performed a systematic review on 23 studies, including 5402 liver transplant recipient health-related QoL. The comparison of health-related QoL before and after transplantation showed significant improvement after liver transplantation. The highest improvement was reported in BP, PF, MH and functional status domains. According to our results, the highest increases belonged to RE and RP domains. The GH perceptions score did not change after transplantation. The perception of health by an individual deepened on his/her personality, education background, and economic status. The report of health-related QoL by health professionals, and patients' relatives had poor correlation with patients' report themselves. Therefore, subjective and objective tools are necessary to evaluate the treatment outcome. These differences could be attributed to the mentioned factors.
Another review also reported a significant rise in health-related QoL (both in physical and mental domains) 1 year after liver transplantation. Analysis of physical health-related QoL showed a moderate and steady rise. A study in Turkey compared health-related QoL before and 3 months after liver transplantation. Their result showed a significant difference based on gender and disease severity. Their result of health-related QoL after liver transplantation was consistent with our findings.
Different parameters such as physical condition, psychological parameters, sociodemographic elements, influence health-related QoL. Lankarani pointed out the role of culture, values, concerns, and expectations from life in different cultures and even different stages of life when measuring health-related QoL. By evaluating health-related QoL, health-care workers should pay attention to all these parameters and elements.
Repeated-measure analysis of variance showed a statistically significant difference in health related QoL at 1- and 6-month posttransplant when compared with QoL scores of pretransplant. Although the scores increased over time in all domain, for MH, VIT, RE domain the difference between Phase 1 and 2 was significant, between Phase 2 and 3 was not significant.
A similar study investigated health-related QoL pretransplant and 1 and 2 years posttransplant in the same liver transplant recipients. Mean health-related QoL scores at Self-Perception (boring/interesting, enjoyable/miserable, useless/worthwhile, and discouraging/hopeful) domain after 1 year were higher than 5 years, suggesting a reduction in well-being as time passed.
The organ allocation system based on the MELD score has reduced mortality among waiting list patients.,
Different studies have found the different influence of MELD score on recipients' health-related QoL and mortality.
Patients with a higher MELD score had higher improvement in health-related QoL after liver transplantation. There are reports of the MELD score as a predictor of health-related QoL and mortality after liver transplantation.,
However, results from other studies showed that the MELD score could not be used as a parameter to forecast survival or health-related QoL after liver transplantation.,,,,, Patients on waiting list with lower health-related QoL scores and higher MELD scores showed improvement on physical and mental score during the 1st year after living donor liver transplantation. The study did not find any effect of MELD scores on health-related QoL after liver transplantation. MELD score is the representative of liver disease that resolves after liver transplantation.
To the best of our knowledge, this is the first prospective cohort study that has compare health-related QoL of liver transplantation candidate before and 1 and 6 months after liver transplantation in Iran, but due to low number of participants and short time follow-up the results should be interpreted with cautious. The reason for short follow-up and low number of participants is that most patients who receive liver transplantation in Shiraz Transplant Center come from different cities.
| Conclusion|| |
Liver transplantation can improve QoL of patients with end-stage liver disease. Patients on waiting list with low and high MELD scores will benefit from liver transplantation, but MELD scores of liver transplant candida cannot for sure forecast health-related QoL after liver transplantation.
The authors would like to thank Mr. H. Argasi at the Research Consultation Center of Shiraz University of Medical Sciences for his invaluable assistance in editing this manuscript.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]