Chapter 37: Quality of Life in Liver Transplantation

INTRODUCTION

The Centers for Disease Control and Prevention (CDC) defines quality of life (QOL) as “an overall sense of wellbeing, including aspects of happiness and satisfaction with life as a whole.”

BACKGROUND

Liver transplantation has moved from an experimental treatment to standard management for end-stage liver disease. Prolongation in survival is accepted, but evaluation of long-term effects on the patient’s quality of life and its enhancement is the new objective.

QUALITY OF LIFE

• Comprehensive measurement of posttransplantation health-related quality of life (HRQL) are important for several reasons:

  • Patients are more concerned about QOL than longevity.

  • Liver transplant recipients may have debilitating fatigue, bone pain, loss of self-esteem, depression, and complications of immunosuppression that are poorly evaluated through traditional clinical outcomes.

  • Provide valuable information to the health professionals to focus their treatment and procedures toward the most affected areas of recipients’ lives.

  • Provide key components of an evaluation of both effectiveness and cost-effectiveness, which are of particular importance given the cost and scarcity of the resources involved in liver transplantation (LT).

• Measuring of QOL helps to address the overall health status of liver transplant recipients.

METHOD FOR MEASURING QUALITY OF LIFE

• Generic instruments (Table 37-1)

• Targeted instruments focused on disease or treatment (Table 37-2)

• Pretransplant predictors of QOL (Table 37-3)

• Employment: interval without work prior to LT and pre-LT diagnosis correlated with the likelihood of employment after LT.

• Sexual functioning: in most cases there isn’t a perceptible improvement; perceptions of sexual health are likely to be psychological rather than endocrine, since endocrine function typically recovers after LT.

• Effect of immunosuppressant medications (Table 37-4)

  • Increased risk of infections

  • Metabolic complications such as hypertension, diabetes mellitus (DM), hyperlipidemia, obesity, and gout

    • Cardiovascular disease and renal failure are the leading nonhepatic causes of morbidity and mortality late after LT

  • De novo cancers, including posttransplant lymphoproliferative disorder

  • Psychological effects associated with steroid therapy aren’t common

Strategies to improve QOL in post-LT patients

• Monitoring of renal function

• Bone mineral density screenings should be done

• Immunization

  • Annual influenza vaccination

  • Avoid live virus vaccines

  • Reimmunization is indicated for the pneumococcal vaccine (every 3 to 5 years)

• Behavioral intervention

  • Psychoeducational counseling

    • Frequent handwashing

    • Avoid unnecessary sun exposure

    • During periods of maximal immunosuppression, avoid crowds

    • Avoid the consumption of water from lakes and rivers, unpasteurized milk products, and raw and undercooked eggs and meats

    • Avoid high-risk pets, which include rodents, reptiles, and birds

    • Reduction of travel-related risks

    • Sustained cessation of smoking

    • Preconception counseling about contraception and the risks and outcomes of pregnancy

    • Exercise and dietary counseling