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I.М. Drapchak Features of Life Quality Evaluation in People with Chronic Liver Diseases Department of Internal Medicine No 2 and Nursing Ivano-Frankivsk National Medical University, Ivano-Frankivsk, Ukraine Abstract. Nowadays, numerous forms and questionnaires including those for patients with chronic liver disease are developed and successfully tested for almost every common nosology. The most widely used questionnaire is the 36Item Short Form Health Survey (SF-36). However, the disadvantage of the SF-36 includes insufficiently sensitive reduction in scales during deterioration in the patient’s condition. The Chronic Liver Disease Questionnaire (CLDQ) used in our study is better in this regard. The analysis of the results of interviewing showed significant differences among different groups. The average amount of received points was the largest in the control group, and the smallest in the experimental subgroup II (patients with cirrhosis). A significant difference was also noted in individual scales of the questionnaire. The signs of fatigue were almost identical in the control group and the experimental subgroup I, however, in the group with cirrhosis they were two times less. In this group people complaining of abdominal symptoms including bloating, abdominal pain and discomfort, and decrease in overall activity prevailed. The same group of patients reported the symptoms of anxiety, temper tantrum and sleep disturbances more often. People with chronic diffuse inflammation of the liver (the experimental subgroup I) differed significantly from healthy patients of the control group by characteristics reflecting anxiety levels, dietary habits, overall capacity, and abdominal symptoms to a somewhat lesser extent. Keywords: life quality evaluation; chronic liver diseases; life quality evaluation questionnaire Problem statement and analysis of the recent research ` During study of chronic liver diseases and treatment of patients with chronic liver diseases it is necessary to evaluate the life quality of this group of patients objectively. The life quality is a main index of subjective experience of physical, emotional and mental well-being by a person [13]. Its study provides important information not only about actual self-esteem of health by the person himself or herself, but allows us to predict to some extent outcomes of the disease as well as to evaluate person’s daily and social activity [3]. Nowadays, numerous forms and questionnaires including those for patients with chronic liver disease are developed and successfully tested for almost every common nosology [9, 10, 11]. The most widely used questionnaire is the 36Item Short Form Health Survey (SF-36) developed by Ware JE, et al. in 1988 [12]. However, the disadvantage of the SF-36 includes insufficiently sensitive reduction in scales during deterioration in the patient’s condition especially those related to mental aspects. During continuous observation it also demonstrates insufficient reproducibility of the results [4]. The Chronic Liver Disease Questionnaire (CLDQ) used in our study is better in this regard. Materials and methods The CLDQ (Appendix 1) was developed at the Department of Gastroenterology (The Cleveland Clinic Foundation, USA) by Younossi et al. in 1999 as a specific instrument for examination of patients with chronic liver diseases [4]. It consists of 29 items which are grouped into 6 subscales: “Abdominal Symptoms” (AS) – questions No 1, 5, 17; “Fatigue” (FA) – questions No 2, 4, 8, 11, 13; “Systemic Symptoms” (SS) – questions No 3, 6, 21, 23, 27; “Activity” (AC) – questions No 7, 9, 14; “Emotional Functioning” (EF) – questions No 10, 12, 15, 16, 19, 20, 24, 26; “Worries” (WO) – questions No 18, 22, 25, 28, 29. Each question can be rated on a 7-point scale with endpoints the most pronounced and the least pronounced. The minimum number of points is 29, the maximal one is 203. According to the results the questionnaire gives an opportunity to evaluate a range of indices of physical, mental and emotional spheres of the patient. The CLDQ is thoroughly validated in clinical practice and represented in foreign publications [1, 2, 6, 7]. Considering
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features of eating behavior, life and working conditions, social activity and emotional behavior we determined necessity of additional validation of the questionnaire. At first, the questionnaire was translated from English into Ukrainian by a professional translator. Then, the validation of the questionnaire was performed involving 50 practically healthy persons of young and middle age (the control group) and 120 persons of middle and old age with chronic liver diseases (the experimental group). The experimental group was additionally divided into 2 subgroups: subgroup I included patients with chronic diffuse inflammatory liver diseases (70 patients); subgroup II included patients with hepatic cirrhosis of different stages of compensation (50 patients). About 68% of patients of subgroup I suffered from nonalcoholic fatty liver disease, 22.9% of them suffered from chronic cholecystitis. The rest of patients suffered from chronic cholangitis (3.7%) and steatohepatitis (5.5%). The final mathematical and statistical data processing was performed using statistical software package “Statistica 7.0” and “Microsoft Excel, 2010”. An unpaired two sample Student’s t-test with probability р±0.05 was performed. All groups were similar in gender characteristics: there were 42.0% of women in the control group and 41.4%, 38.0% in subgroups I and II, respectively. In the control group the average age of examined patients was 28.5 years, in subgroup I it was 44.5 years, in subgroup II it was 49.5 years. Liver diseases were diagnosed by clinical, laboratory and functional signs according to National Recommendations and standard approaches. Patients with hepatic cirrhosis were additionally evaluated according to the Child-Pugh score. 64% (32 patients) were included into class А (the lowest mortality risk within a year), 22% (11 patients) were included into class В (the mortality risk within a year is moderate constituting about 20%), and 14% (7 patients) were included into class С (the mortality risk is the highest constituting about 50-60%) (Fig. 1.1).
Fig. 1.1. Patients of subgroup II according to the Child-Pugh scale Results and discussion The analysis of the results of interviewing showed significant differences among different groups (Table 1). Table 1 Distribution of patients of the control and experimental subgroups according to subscales of the CLDQ in patients with chronic liver diseases Control Experimental Experimental group Subscales group I group II (n=50) (n=70) (n=50) “Abdominal Symptoms” (AS) 17.5±2.5 14.4±2.1 8.4±1.6* “Fatigue” (FA) 27.2±1.8 25.2±1.9 12.6±1.5*¶ “Systemic Symptoms” (SS) 30.8±2.7 29.4±2.5 13.5±2.0*¶ “Activity” (AC) 17.5±2.6 10.6±2.4* 8.6±1.9* “Emotional Functioning” (EF) 35.4±3.6 33.8±3.4 28.6±2.9 “Worries” (WO) 31.2±3.1 24.6±2.9* 15.8±2.1* Total 164.5±11.6 122.8±8.4 91.4±7.5*¶ Notes: 1. average number of collected points in subscales is indicated; 2. * - standard deviation of the data between control and experimental groups, р±0.05. 3. ¶ - standard deviation of the data between subgroups I and II, р±0.05.
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The average amount of received points was the largest in the control group, and the smallest in the experimental subgroup II (patients with hepatic cirrhosis). In the control group this index was 164.5±11.6 points while in the experimental subgroup II it was practically twice less: 91.4±7.5 points. In the experimental subgroup I the average value was 122.8±8.4. A significant difference was also noted in individual scales of the questionnaire. The signs of fatigue were almost identical in the control group and the experimental subgroup I (27.2±1.8 and 25.2±1.9, respectively), however, in the group with cirrhosis they were twice lower (12.6±1.5 points). In this group people complaining of abdominal symptoms including bloating, abdominal pain and discomfort, and decrease in overall activity prevailed. The same group of patients reported the symptoms of anxiety, temper tantrum and sleep disturbances more often. Patients with chronic diffuse inflammation of the liver (the experimental subgroup I) differed significantly from healthy patients of the control group by characteristics reflecting anxiety levels, dietary habits, overall capacity, and abdominal symptoms to a somewhat lesser extent. Patients of the control group scored in average 31.2±3.1 points when rating the subscale “Worries” while patients of the experimental subgroup I scored only 24.6±2.9 points. It is necessary to note that patients of the experimental subgroup II scored only 15.8±2.1 points. There was practically no difference between the control and experimental subgroup I in rating the subscales “Fatigue”, “Systemic Symptoms” and “Emotional Functioning”. Patients of both experimental subgroups were also similar in rating the subscale “Emotional Functioning”, 33.8±3.4 points and 28.6±2.9 points respectively. Conclusions Thus, the results of our research confirmed high value of Chronic Liver Disease Questionnaire for grading patients with different degrees of severity of end-stage liver disease in patients with cirrhosis, as well as diagnostics of its early damages, such as hepatic steatosis. The fact that the results of the questionnaire do not depend on the age of examined patients is an additional advantage. The disadvantage includes not always unambiguous characteristics of emotional sphere that can be associated with different psychological status of this group of patients and high levels of depression in patients with hepatic encephalopathy, and requires an additional evaluation by specialists. References Younossi ZM, Boparai N, McCormick M, et al. Assessment of utilities and health-related quality of life in patients with chronic liver disease.Am J Gastroenterol. 2001;96:579-583. 2. Bader FZ. Correlation of quality of life in patients of cirrhosis of liver with etiology and disease severity using disease-specific quality questionnaire. Ayub Med Coll Abbottabad. 2007;19(2):7-12. 3. Borgaonkar MR, Irvine EJ. Quality of life measurement in gastrointestinal. Gut. 2000;47:444-454. 4. Younossi ZM, Guyatt G, Kiwi M, et al. Development of a disease specific questionnaire to measure health related quality of life in patients with chronic liver disease. Gut. 1999;45:295-300. 5. Gozhenko AI, Susla AB, Sidorenko OL, et al. The effect of arginine glutamate and meldonium combination on chronic inflammation and the endothelial function in patients cardiac valve calcification on the predialysis stage of chronic kidney disease. Bukovynskyi medychnyi visnyk. 2012;16(3):83-88. 6. Hauser W, Holtmann G, Grandt D. Determinants of health-related quality of life in patients with chronic liver diseases. Clin Gastroenterol Hepatol. 2004;2:157-163. 7. Kanwal F, Hays RD, Kilbourne AM, et al Are physician-derived disease severity indices associated with healthrelated quality of life in patients with end-stage liver disease? Am J Gastroenterol. 2004;99:1726-1732. 8. Novik АА, Ionova TI. Guide to the study of quality of life in medicine. OLMA Media Grupp. Moscow. 2007;320. 9. Serenko KА, Abdurakhmanov DT, Alekseeva VM. Analysis of studies of quality of life in patients with chronic hepatitis C. Zdravookhranenie segodnya. 2010;1:67-79. 10. Solomenchuk ТМ, Semehen-Bodak KhV. Modern myocardial cytoprotection in ischemic heart disease: a rational choice of drug.Mystetstvo likuvannia. 2011;4:56-61. 11. Stepanov YuМ, Zyhalo EV. Analysis of studies of quality of life in patients with chronic diffuse inflammatory liver diseases. Zhurfond. Dnipropetrovsk. 2012;46:502. 12. Stewart AL, Greenfield S, Hays RD, et al. Functional status and well-being of patients with chronic conditions. JAMA. 1989;262:907-913. 13. The World Health Organization Quality of Life Assessment. Field Trial Version for Adults. Administration Manual. Geneva. WHO.1995; Available from: http://www.sciencedirect.com/science/article/pii/027795369500112K 1.
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Child-Pugh classification of severity of liver disease Index 1 point 2 points 3 points * Total bilirubin <34 34-50 >50 Serum albumin >35 28-35 <28 МНС <1.7 1.7-2.2 >2.2 Ascites none is corrected refractory Hepatic none І-ІІ (is corrected) III-IV (refractory) encephalopathy * – 3 points: the most severe damage
Units mcmol/L g/L - - -
Appendix 2 Child-Pugh classes of chronic liver disease Survival Points* Class within 1 year 5-6 А 100% 7-9 В 81% 10-15 С 45% * – calculated from the sum collected in the subscale
Survival within 2 years 85% 57% 35%
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