Introduction

Liver disease is a major cause of mortality and morbidity worldwide and the 12th leading cause of death in the USA [1]. In the USA and worldwide, the main causes of advanced liver disease or cirrhosis are alcohol-related liver disease, non-alcoholic steatohepatitis (NASH), and viral hepatitis [1].

Cirrhosis has had a tremendous clinical impact as a result of its complications including ascites, esophageal varices, liver failure, hepatic encephalopathy, hepatocellular carcinoma, and liver-related death. However, cirrhosis also has a negative impact on patient-reported outcomes (PROs) and on the resource utilization (the economic impact) [2••].

Measurement Tools for Quality of Life (Table 1)

In our previous work, we outlined the effect of cirrhosis and its associated complications on patients’ health-related quality of life (HRQL) as well as discussing the different measurement tools used to measure HRQL [10]. Briefly, HRQL is defined as a “broad multidimensional concept that includes subjective evaluations of both positive and negative aspects of life” and are reports that come directly from the patient about the status of their health condition without amendment or interpretation by a clinician or anyone else [11].

Table 1 Measurement tools used to measure patient-reported outcomes in patients with cirrhosis [3•, 4, 5••, 6••, 7,8,••–9]
Full size table

There has been substantial investigation of HRQL assessment in patients with chronic liver disease. In this context, HRQL is influenced by the type and severity of liver disease [3•, 11,12,13,14,15]. In fact, patients with chronic hepatitis C have the most profound HRQL impairment while those with chronic hepatitis B have less impairment. Furthermore, patients with advanced cirrhosis experience severe impairment of HRQL impairments. The net overall effect is significant impairment of HRQL, whether due to mental impairment or limitations affecting patients’ ability to perform an activity of daily living such as HCV associated fatigue, cirrhosis associated muscle cramps and pruritus as well as the complications of cirrhosis, namely hepatic encephalopathy and ascites, which have their own unique impact on HRQL. In fact, ascites, hepatic encephalopathy, and hyponatremia have been found to be an independent predictor of severe impairment of HRQL possibly as a result of patients’ acknowledgement of their liver disease progression [16,14,15,16,20, 21•, 22]. However, treatment of these complications leads to a positive impact on a patient’s HRQL. In fact, the ultimate treatment of cirrhosis is liver transplantation which dramatically improves HRQL [19]. In this context, improvement in HRQL post liver transplantation is so profound that it can easily be captured with both a generic and a disease-specific HRQL instrument [19, 21•, 22].

As previously discussed, it is important to understand the different HRQL measurement tools and their properties that have been used for patients with liver disease [10]. The most commonly used tools to assess HRQL in patients with liver disease and cirrhosis include disease-specific tools: The Chronic Liver Disease Questionnaire (CLDQ) or the Liver Disease Quality of Life tool (LDQOL), and generic tools which include the widely used HRQL tool, the SF-36 and Sickness Impact Profile (SIP) [3•, 4, 23, 24].

As our understanding of the impact of different causes of liver disease on HRQL has deepened, more disease-specific instruments for types of CLD are being developed. In this context, recognizing that chronic hepatitis C (CH-C) is the most common cause of cirrhosis in the USA and the western world [1], a validated HCV-specific HRQL instrument (CLDQ-HCV) was developed and validated to measure the specific impact of HCV on patients’ quality of life [5••]. In addition, due to the growing prevalence of NAFLD and NASH (global prevalence rate is 25%), NASH-NAFLD-specific CLDQ (CLDQ NASH-NAFLD) was also developed and validated [6••, 25]. Furthermore, clinical trials of new treatment regimens for Primary Sclerosing Cholangitis (PSC) have necessitated the development and validation of PSC PRO [7••].

Cirrhosis and Quality of Life for Associated Liver Diseases

A number of these instruments have been extensively used to assess HRQL in patients with HCV, HBV, and NASH as well as complication of cirrhosis (ascites, hepatic encephalopathy, and liver transplantation) [26•]. In this context, the recent approval of interferon-free and ribavirin free regimens has provided patients with a shorter time of treatment with very highly efficacious, safe, and cost-effective therapies but also significant increase in their health-related quality of life [27•, 28••, 29••]. In addition, the new treatments have been shown to improve patients HRQL and other Patient Reported Outcomes (PROs) as early as 4 weeks into treatment [27•, 28••, 30]. In fact, these PRO improvements were also reported in patients with compensated and decompensated cirrhosis [27•]. Baseline HRQL (measured by the generic SF-36 and the disease-specific CLDQ-HCV) impairment has been found to be profound in patients with cirrhosis especially decompensated cirrhosis in the areas of activity, energy, vitality, and fatigue (measured with the FACIT-F). These noted decreases were present even after adjustment for baseline demographic disparities of the cirrhotic cohort. However, on average, cirrhotic patients PRO’s increased about 10% across the majority of domains especially those that were most affected prior to treatment [27•]. In fact, patients with decompensated cirrhosis had the most significant gains after treatment though it is important to note that all patients who reached SVR had significant HRQL improvement as well but also that the gains obtained by patients with cirrhosis were similar or better than those gained by non-cirrhotics [30, 31].

In addition to HCV, there are HRQL studies of patients with NAFLD and NASH [32••, 33]. In fact, NAFLD patients show decrements in their HRQL when compared to the general population but is especially evident for patients with NAFLD associated cirrhosis. In one particular study which used the SF-36 to measure HRQL, investigators found that the domains most affected included role performance, vitality, role emotional, and the physical composite score, suggesting physical functioning in patients with NAFLD cirrhosis is profoundly affected [33]. Other studies have had similar findings [32••, 34]. There are no FDA approved treatments for NAFLD and NASH at this time; however, there are new medical treatments currently in development, and as they come to market, attention must be paid to how the treatments affect the patients’ quality of life when judging the true effectiveness of the therapy [35].

Chronic hepatitis B virus (CH-B), primary biliary cholangitis (PBC), and primary sclerosing cholangitis (PSC) also lead to cirrhosis and cause significant decrements in HRQL. CH-B patients seem to have better HRQL than patients with CH-C and PBC. However, CH-B patients’ overall utility scores are lower than population norms, whereas those with CH-C or PBC/PSC reported significantly lower HRQL scores than population norms while having cirrhosis was a predictive for decreased HRQL scores regardless of etiology of liver disease [36, 37•, 38•].

Importance to Clinicians

The most important lesson that clinicians should take away from HRQL studies of patients with chronic liver disease is that these patients not only face poor prognosis and survival but suffer from severe impairment of their HRQL. In this context, symptoms of cirrhosis (fatigue, muscle cramps, hepatic encephalopathy, ascites) can drive the impairment in HRQL and can cause tremendous negative impact on patients’ functioning. Knowing this, treatment of cirrhosis should not just focus on clinical outcomes but also should include interventions that will improve patients’ PROs. It is only with this comprehensive approach to patients with cirrhosis that we can capture the full impact of their disease and the impact of its treatment on PROs. Furthermore, focusing on HRQL as an outcome can build a bridge between disciplines as well as developing relationships between social, mental, and medical services, all health care entities which can help improve PRO’s while at the same time meeting the Healthy People 2020 central public health campaign of improving people’s quality of life (https://www.cdc.gov/hrqol/concept.htm).

Conclusion

Healthcare practitioners understanding of the impact of liver disease, cirrhosis, and treatment on patients’ health-related quality of life has increased due to the development of liver disease-specific quality of life tools. Specifically, we now know that regardless of the cause of cirrhosis, cirrhosis is associated with a significant decline in quality of life especially for those that develop decompensated cirrhosis. However, treatment of the underlying cause of cirrhosis leads to substantial increase in the patients’ health-related quality of life especially for those with decompensated cirrhosis. As such, assessment of quality of life should be a routine part of the clinical trials, as well as findings used in the clinical environment when treating patients with cirrhosis.