Background. Cirrhosis may lead to a poor health-related quality of life (HRQOL), which should be taken into consideration when addressing the cirrhotic outpatient. Methods. Prospective cohort study evaluating predictors of HRQOL in outpatients with cirrhosis. Patients with overt hepatic encephalopathy at baseline were excluded. HRQOL was evaluated at baseline using the six point Chronic Liver Disease Questionnaire. Predictors of low quality of life scores (<4 points) and mortality were analyzed using multivariable logistic regression. Results. In total, 92 patients were included (mean age 61 years, 59% male). Nineteen patients died (mean duration of follow-up 20 months). The mean Child-Pugh score was 6.9. Twenty percent had a poor HRQOL judged by the Chronic Liver Disease Questionnaire score and 45% had covert hepatic encephalopathy. The only predictors of poor HRQOL were the Child-Pugh score ( ), nonalcoholic etiology of cirrhosis ( ), and body mass index ( ). The body mass index predicted poor HRQOL independently of the presence of ascites and albumin level. Conclusions. The body mass index was associated with a low HRQOL. This suggests that malnutrition may be an important target in the management of patients with cirrhosis. 1. Introduction The prognosis of cirrhosis has improved following the development of a number of effective interventions [1–3]. The improvements include the management of gastrointestinal bleeding, hepatorenal syndrome, spontaneous bacterial peritonitis, hepatocellular carcinoma, and hepatic encephalopathy (HE) [4–8]. The health-related quality of life (HRQOL) is therefore becoming increasingly important [9–13]. Most quality of life studies have used generic questionnaires, which allow for comparisons between different groups of patients. These questionnaires will provide an overall picture of the wellbeing of participants. Patients with cirrhosis have specific somatic and cognitive symptoms that may affect their HRQOL [12, 14, 15]. These symptoms may not be captured by generic scales [9, 13, 16, 17]. Questionnaires specifically for patients with chronic liver disease have therefore been developed [14, 18]. Identifying factors associated with HRQOL may help improve patient care and guide future research [12]. This is especially the case for long-term care in an outpatient setting. We therefore performed a prospective cohort study aimed at investigating the prognosis and predictors of HRQOL in patients with cirrhosis followed up at an outpatient setting. 2. Materials and Methods 2.1. Included Subjects From February 2008 to May
References
[1]
A. Propst, T. Propst, G. Zangerl, D. Ofner, G. Judmaier, and W. Vogel, “Prognosis and life expectancy in chronic liver disease,” Digestive Diseases and Sciences, vol. 40, no. 8, pp. 1805–1815, 1995.
[2]
H. T. S？rensen, A. M. Thulstrup, L. Mellemkjar et al., “Long-term survival and cause-specific mortality in patients with cirrhosis of the liver: a nationwide cohort study in Denmark,” Journal of Clinical Epidemiology, vol. 56, no. 1, pp. 88–93, 2003.
[3]
G. D'Amico, G. Garcia-Tsao, and L. Pagliaro, “Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies,” Journal of Hepatology, vol. 44, no. 1, pp. 217–231, 2006.
[4]
M. Thiele, A. Krag, U. Rohde, and L. L. Gluud, “Meta-analysis: banding ligation and medical interventions for the prevention of rebleeding from oesophageal varices,” Alimentary Pharmacology and Therapeutics, vol. 35, no. 10, pp. 1155–1165, 2012.
[5]
L. L. Gluud, K. Christensen, E. Christensen, and A. Krag, “Systematic review of randomized trials on vasoconstrictor drugs for hepatorenal syndrome,” Hepatology, vol. 51, no. 2, pp. 576–584, 2010.
[6]
R. Wiest, A. Krag, and A. Gerbes, “Spontaneous bacterial peritonitis: recent guidelines and beyond,” Gut, vol. 61, no. 2, pp. 297–310, 2012.
[7]
EASL-EORTC, “EASL-EORTC Clinical Practice Guidelines: management of hepatocellular carcinoma,” Journal of Hepatology, vol. 56, pp. 908–943, 2012.
[8]
J. S. Bajaj, “Review article: the modern management of hepatic encephalopathy,” Alimentary Pharmacology and Therapeutics, vol. 31, no. 5, pp. 537–547, 2010.
[9]
M. R. Arguedas, T. G. DeLawrence, and B. M. McGuire, “Influence of hepatic encephalopathy on health-related quality of life in patients with cirrhosis,” Digestive Diseases and Sciences, vol. 48, no. 8, pp. 1622–1626, 2003.
[10]
E. Fritz and J. Hammer, “Gastrointestinal symptoms in patients with liver cirrhosis are linked to impaired quality of life and psychological distress,” European Journal of Gastroenterology and Hepatology, vol. 21, no. 4, pp. 460–465, 2009.
[11]
M. Holecek, “Three targets of branched-chain amino acid supplementation in the treatment of liver disease,” Nutrition, vol. 26, no. 5, pp. 482–490, 2010.
[12]
G. Marchesini, G. Bianchi, P. Amodio et al., “Factors associated with poor health-related quality of life of patients with cirrhosis,” Gastroenterology, vol. 120, no. 1, pp. 170–178, 2001.
[13]
I. Les, E. Doval, M. Flavia, et al., “Quality of life in cirrhosis is related to potentially treatable factors,” European Journal of Gastroenterology & Hepatology, vol. 22, pp. 221–227, 2010.
[14]
Z. M. Younossi, N. Boparai, L. L. Price, M. L. Kiwi, M. McCormick, and G. Guyatt, “Health-related quality of life in chronic liver disease: the impact of type and severity of disease,” American Journal of Gastroenterology, vol. 96, no. 7, pp. 2199–2205, 2001.
[15]
E. Kalaitzakis, M. Simrén, R. Olsson et al., “Gastrointestinal symptoms in patients with liver cirrhosis: associations with nutritional status and health-related quality of life,” Scandinavian Journal of Gastroenterology, vol. 41, no. 12, pp. 1464–1472, 2006.
[16]
Z.-J. Bao, D.-K. Qiu, X. Ma et al., “Assessment of health-related quality of life in Chinese patients with minimal hepatic encephalopathy,” World Journal of Gastroenterology, vol. 13, no. 21, pp. 3003–3008, 2007.
[17]
J. S. Bajaj, J. Cordoba, K. D. Mullen et al., “Review article: the design of clinical trials in hepatic encephalopathy—an International Society for Hepatic Encephalopathy and Nitrogen Metabolism (ISHEN) consensus statement,” Alimentary Pharmacology and Therapeutics, vol. 33, no. 7, pp. 739–747, 2011.
[18]
Z. M. Younossi, G. Guyatt, M. Kiwi, N. Boparai, and D. King, “Development of a disease specific questionnaire to measure health related quality of life in patients with chronic liver disease,” Gut, vol. 45, no. 2, pp. 295–300, 1999.
[19]
S.-E. Christensen, P. Elsass, and H. Vilstrup, “Number connection test and continuous reaction times in non-encephalopathic patients: a comparative study,” Journal of Applied Toxicology, vol. 1, no. 5, pp. 262–263, 1981.
[20]
P. Elsass, “Continuous reaction times in cerebral dysfunction,” Acta Neurologica Scandinavica, vol. 73, no. 3, pp. 225–246, 1986.
[21]
P. Elsass, S. E. Christensen, E. L. Mortensen, and H. Vilstrup, “Discrimination between organic and hepatic encephalopathy by means of continuous reaction times,” Liver, vol. 5, no. 1, pp. 29–34, 1985.
[22]
P. Elsass, S. E. Christensen, and L. Ranek, “Continuous reaction time in patients with hepatic encephalopathy. A quantitative measure of changes in consciousness,” Scandinavian Journal of Gastroenterology, vol. 16, no. 3, pp. 441–447, 1981.
[23]
M. M. Lauridsen, H. Gronbaek, E. B. Naeser, et al., “Gender and age effects on the continuous reaction times method in volunteers and patients with cirrhosis,” Metabolic Brain Disease, vol. 27, no. 4, pp. 559–565, 2012.
[24]
M. M. Lauridsen, P. Jepsen, and H. Vilstrup, “Critical flicker frequency and continuous reaction times for the diagnosis of minimal hepatic encephalopathy. A comparative study of 154 patients with liver disease,” Metabolic Brain Disease, vol. 26, no. 2, pp. 135–139, 2011.
[25]
J. C. Hoekstra, J. H. M. Goosen, G. S. de Wolf, and C. C. P. M. Verheyen, “Effectiveness of multidisciplinary nutritional care on nutritional intake, nutritional status and quality of life in patients with hip fractures: a controlled prospective cohort study,” Clinical Nutrition, vol. 30, no. 4, pp. 455–461, 2011.
[26]
A. Nourissat, M. P. Vasson, Y. Merrouche et al., “Relationship between nutritional status and quality of life in patients with cancer,” European Journal of Cancer, vol. 44, no. 9, pp. 1238–1242, 2008.
[27]
P. Amodio, C. Bemeur, R. Butterworth, et al., “The nutritional management of hepatic encephalopathy in patients with cirrhosis: international society for hepatic encephalopathy and nitrogen metabolism consensus,” Hepatology, vol. 58, pp. 325–336, 2013.
[28]
Y. Nakaya, K. Okita, K. Suzuki et al., “BCAA-enriched snack improves nutritional state of cirrhosis,” Nutrition, vol. 23, no. 2, pp. 113–120, 2007.
[29]
G. Marchesini, G. Bianchi, M. Merli et al., “Nutritional supplementation with branched-chain amino acids in advanced cirrhosis: a double-blind, randomized trial,” Gastroenterology, vol. 124, no. 7, pp. 1792–1801, 2003.
[30]
L. D. Plank, E. J. Gane, S. Peng et al., “Nocturnal nutritional supplementation improves total body protein status of patients with liver cirrhosis: a randomized 12-month trial,” Hepatology, vol. 48, no. 2, pp. 557–566, 2008.
[31]
Y. Chen, X. Wang, J. Wang, Z. Yan, and J. Luo, “Excess body weight and the risk of primary liver cancer: an updated meta-analysis of prospective studies,” European Journal of Cancer, vol. 48, no. 14, pp. 2137–2145, 2012.
[32]
S. Naveau, V. Giraud, E. Borotto, A. Aubert, F. Capron, and J.-C. Chaput, “Excess weight risk factor for alcoholic liver disease,” Hepatology, vol. 25, no. 1, pp. 108–111, 1997.
[33]
R. K. Dhiman, R. Kurmi, K. K. Thumburu et al., “Diagnosis and prognostic significance of minimal hepatic encephalopathy in patients with cirrhosis of liver,” Digestive Diseases and Sciences, vol. 55, no. 8, pp. 2381–2390, 2010.
[34]
S. Prasad, R. K. Dhiman, A. Duseja, Y. K. Chawla, A. Sharma, and R. Agarwal, “Lactulose improves cognitive functions and health-related quality of life in patients with cirrhosis who have minimal hepatic encephalopathy,” Hepatology, vol. 45, no. 3, pp. 549–559, 2007.
[35]
J. S. Bajaj, J. B. Wade, D. P. Gibson et al., “The multi-dimensional burden of cirrhosis and hepatic encephalopathy on patients and caregivers,” American Journal of Gastroenterology, vol. 106, no. 9, pp. 1646–1653, 2011.
[36]
F. Moscucci, S. Nardelli, I. Pentassuglio et al., “Previous overt hepatic encephalopathy rather than minimal hepatic encephalopathy impairs health-related quality of life in cirrhotic patients,” Liver International, vol. 31, no. 10, pp. 1505–1510, 2011.
[37]
E. Wunsch, B. Szymanik, M. Post, W. Marlicz, M. Myd？owska, and P. Milkiewicz, “Minimal hepatic encephalopathy does not impair health-related quality of life in patients with cirrhosis: a prospective study,” Liver International, vol. 31, no. 7, pp. 980–984, 2011.
[38]
H.-H. Tan, G. H. Lee, K. T. J. Thia, H. S. Ng, W. C. Chow, and H. F. Lui, “Minimal hepatic encephalopathy runs a fluctuating course: results from a three-year prospective cohort follow-up study,” Singapore Medical Journal, vol. 50, no. 3, pp. 255–260, 2009.
[39]
H. Schomerus and W. Hamster, “Quality of life in cirrhotics with minimal hepatic encephalopathy,” Metabolic Brain Disease, vol. 16, no. 1-2, pp. 37–41, 2001.
[40]
V. Arvaniti, G. D'Amico, G. Fede et al., “Infections in patients with cirrhosis increase mortality four-fold and should be used in determining prognosis,” Gastroenterology, vol. 139, no. 4, pp. 1246.e5–1256.e5, 2010.
[41]
J. S. Bajaj, J. G. O'Leary, F. Wong, et al., “Bacterial infections in end-stage liver disease: current challenges and future directions,” Gut, vol. 61, pp. 1219–1225, 2012.
[42]
A. Tripodi and P. M. Mannucci, “The coagulopathy of chronic liver disease,” The New England Journal of Medicine, vol. 365, no. 2, pp. 147–156, 2011.
