Quality of life after liver transplantation

The results of liver transplantation arc now well established in tenns of graft and patient survival, but there is surprisingly little Jara on the qual1tyoflife attained. The authors mailed questionnaires to 32 consecutive adult liver recipients to assess their quality of life. Thirty-one patients ( 14 males, 17 females) with a mean age of 37 years (range 16 to 55), responded (97%). The mean time smce transplantation was 19 months (range three to 50). Eighty per cent, lhe respondents functioned at no rmal or near normal levels as measured by the Karnofsky Performance Index. Sixty-five per cent (20 patients) indicated they were currently able to live and function as they did before they became ill wuh liver disease. The responJents' scores were similar to normative scores on all of the following measures: life satisfaction, well being, and general affect (Campbell); and material well being, personal growth, marital re lations, family relations and friendships (Evans). It is concluded that liver transplantation rc,tores physical, mental and social well being in most patients with endMage hvcr<lisease. CanJ Gastroenterol 1990;4(2):49-52

significant progress in liver Lransplantatio n .One year patient survival rates have increased to 70% o r more as a result of improved selection of transplant candidates, better immunosuppression with cyclosporine, and careful perioperative patient management (1,2).Moreover, patients who survive the first year after liver Lransplantation have an excellent ch ance of laving for ma ny years.Reports from Pittsburgh indicate that annual lo ng term morrality rates in patients who survive the first yea r after transplantation arc now less than 3% (3).
The improved results with liver grafting have stim ulated a dramatic growth in the number of transplants performed througho ut Lhe world.The proliferation of liver trarn,plant programs and the associated ethical, social a nd finan cial implicatio ns have led to legitimate concerns about the costs and benefits of this procedure.To date, however, most evaluatiom of liver transplantation have focused on graft and patient ~urvival rates.There arc surprisingly few data o n the health of liver recipients (4)(5)(6)(7)(8).The present study was therefore underta ken to mem,urc the degree of reh abilitacaon and the q uality of life after li ver grafting at the authors' 1mt1t ucaon.atteints de malad ie hepatique.Les scores obtenus etaient similaires a la norme pour routes Jes mesures suivantes: satisfaction envers la vie, bien-etre, et etat affectif general (Campbell); bien-etre materiel, croissance personnelle, relations maritales, relations de famille et amities (Evans).Nous concluons que la transplantation hepatique permet a la plupart des patients atteints de maladie hepatique permet a la plupart des patients atteints de maladie hepacique cerminale de retrouver le bien-etre physique, mental et social.2).Ninety per cent (28 patients) had returned to their previous activities as wage earners (20 patients}, household managers (six patients) or students ( two patients).Sixty-five per cent (20 patients) indicated they were currently able to live and function as they did before they became ill with liver disease.Q uality of life: When asked how satisfied they were with their lives as a whole, 77.5% (24 patients) were very Unlversi!}'.degree 17%(5) 12% • Based upon census data tor age 15 years ()( greater satisfied, 6.5% were marg inally satisfied (two patients), and 16% (five patients) were dissatisfied.There were no significant d ifferences between the responses of the liver recipients and the normative samples as shown in Table 3.
The liver recipients' responses were no more contaminated than the normative samples with socially desirable responses.
Further statistical analysis demonstrated significant intcrcorrelations between the quality of life measures, indicating multidimensional relationships between the respective variables (data not shown).The structure matrix of two factors derived by factor analysis is shown in Table 4

DISCUSSION
An .. nalysis of results beyond mere survival is required now that liver graftmg has passed from the experimental stage to become a genuine therapeutic modality.The benefits of this procedure need to be assessed carefully in relation co the costs (2,14).At the authors' centre, one year patient survival rates are currently 78%.A liver transplant costs approximately CON $80,000 (more than twice the cost of a renal transplant).In the United States, rhe cost of a Liver transplant is closer to US $150,000 (2).Additional burdens for the patients include the requirement of regular monitoring of graft function, the need for lifelong immunosuppression and the risk of transplant failure.
In the present study, data are presented on the quality of life attained in31 consecutive adult liver recipients.Over 80% reported satisfactory rehabilitation as measured by t he Karnofsky Performance Index, and the ability co return to work ( (Table 3).In brief, they were healthy, with a sense of "physical, mental and social well being, not merely the absence of disease or infirmity" (15).Quality of life is a multidimensional construct that includes behavioural and cognitive abilities, emotional well being and psychosocial adjustment (6).Assessment is complex {16).Factor analysis of these data revealed two principal areas contributing to the quality of life after liver transplantation: the quality of extrafamilial and extended family relationships; and the ability to carry out normal activities (Table 4).Boch of these factors were associated with a sense of personal and general well being.These data support the clinical impression that liver recipients often have a renewe<l appreciation for friends, family, and daily routine.
Liver transplantation was not always successful.Twenty per cent of the respondents in this survey were not fully rehabilitated and/or reported a poor quality of life.Thirty-five per cent of the respondents were unable to Live and function as they did before they had liver disease.These patients present a major challenge for planners and providers of liver transplantation.
Q uality of life may continue co improve for years after liver transplantation.The mean follow-up in the present study was only 19 .3months.Longitudinal studies with diseasespecific quality of life measures would help to identify more accurately factors affecting patient health after liver transplantation (17,18)

TABLE 1 Demographic
RESULTSRespondents: Thirty-one patients (97%) completed the questionnaire, including 14 males and 17 females with a mean age of37.9 years (range 16 to 55).The distribution of the participants' demographic profile was similar to the Canadian population (Table1).

TABLE 3
Scores of liver transplant patients on the quality of life scales

Table 2 )
. Most had a sense of personal well being and general satisfaction with life . Issues that merit further study include the effect of CAN J GASTROENTEROL VOL 4 No 2 MARCH/APRIL 1990 Quality of life after liver transplantation

TABLE 4
Factor analysis of the quality of life measures In liver recipients