Joint International Congress of ILTS, ELITA and LICAGE 2014: Making the most of a new liver

by Professor John O’Grady, Kings College Hospital, London – Liver transplantation is highly successful from the technical perspective, returning the majority of patients to a level of health compatible with a ‘normal’ existence. The challenges of immunosuppression and its consequences are diminishing and the prospects for managing recurrent disease are improving. Quality of life evaluations are encouraging, although some domains reflect a short-fall compared to the normal population. However, translating these data to a vision of how liver transplant recipients live their lives requires imagination. Some of these issues were addressed at a symposium at the recent International Liver Transplant Society meeting hosted in London.

Participation in employment or education is one of the more transparent insights into normality after liver transplantation. The liver transplant population is relatively young and the health profile after surgery should allow a high return rate to gainful employment. Less than 40% returned to work despite 87% reporting improved working and functional capacity (1). In 15 studies the median employment rate was 36% with a range of 22-55% (Aberg F, personal communication). An US study of 21,942 patients reported an employment rate of 24% within 2 years of transplantation (2). There is also an extremely low transition from receiving benefits to employment, around 1% in most countries but higher at 7% in the UK. Liver transplant recipients (38%) were less likely to return to work than kidney (59%) and heart (44%) recipients in a Belgian study and were unlikely to do so unless it occurred within the first post-transplant year (3).

The reasons behind the low employment rate are likely to be multifactorial. For some, the transplant experience may trigger a re-evaluation of life-priorities that no longer rates employment highly. Others may not feel able to do their previous work for physical reasons or their previous job was no longer considered suitable e.g. working outdoors, in construction or with animals (4). However, there is a possibility that some may take a short-term view of their regained good health and not have the confidence to seriously plan for the future. Dr. Aberg advocated a shift in focus from recovery to re-engagement 2-3 months after liver transplantation by actively addressing fears and perceived barriers to rehabilitation.

Expression of sexuality is another important metric of normality. Liver disease interferes with sexual function with loss of libido, sexual dysfunction and reduced fertility being common. Hormonal imbalance is corrected by successful liver transplantation resulting in demonstrable improvement in sexual function. Erectile dysfunction can resolve within days and menstruation resumes within 3-6 months in most women in the appropriate age group, even in the context of extended amenorrhoea prior to transplantation. Libido and sexual satisfaction are less tangible manifestations of sexuality. One study identified decreased libido in 33% of men and 26% of women and difficulty reaching orgasm in 33% of men and 26% of women (5).  Another study reported a decrease in the frequency of sexual intercourse in 40% of patients and some degree of erectile dysfunction in 34% of men (6). Sexual dysfunction was more frequent in older patients and in those with depression (7)

Fertility improves after liver transplantation and a meta-analysis involving 450 pregnancies in 306 patients suggested a lower miscarriage rate (15.6%) and a higher live birth rate (76.9%) than in the US general population (8). However, the rates of pre-eclampsia (21.9%), prematurity (39.4%) and delivery by caesarean section (44.6%) were higher than in the normal population. These figures support the ambition to have children after liver transplantation but point to a need for more intensive multidisciplinary support.

A significant minority of the population smoke tobacco as part of their ‘normal’ existence. Policy with respect to smoking and candidacy for liver transplantation is variable and ranges from prohibition to non-intrusive. The former attitude has been justified on the basis of the link between smoking and the serious complication of hepatic artery thrombosis. There are also strong data indicating that cessation of smoking for at least 3 weeks before surgery results in enhanced post-operative recovery.

Smoking habits after liver transplantation are monitored less rigorously even though the health consequences may be more severe than in the immediate post-transplant period. The frequency of tobacco smoking was reported in the range of 15-22%, rising to 40% in the patients with alcohol-related liver disease (Leithead J, personal communication). Cardio-vascular disease, for which tobacco is a prominent risk factor, features prominently in the causes of premature mortality in liver transplant recipients. It seems reasonable to assume that tobacco consumption is synergistic with the profile of diabetes mellitus, hypertension, dyslipidemia and raised body mass index that is over-represented in the liver transplant population. The link between tobacco smoking and malignant disease is particularly apparent in patients who received transplants for alcohol-related liver disease. These patients have an increased risk of cancers of the airways and the upper digestive system. The data are less conclusive for lung cancer and tobacco smoking in the overall transplant population.

A consideration of normal life would be incomplete without addressing the issue of the cost of living. The measurable impact varies in different health care systems depending on policy with respect to payment and re-imbursement. Affordability is linked to adherence to prescribed medication. In extreme examples the choice of immunosuppression may have to be modified if patients are responsible for the costs. Less obvious are the costs of activities related to the status of being a transplant recipient e.g. travel and meals when attending hospital appointments. These issues may not feature prominently in a macro-economic evaluation of liver transplantation but can be very impactful in individual cases struggling to cope financially.

References

1. Aberg F, Rissanen AM, Sintonen H, Roine RP, Hockerstedt K, Isoniemi H. Health-related quality of life and employment status of liver transplant patients. Liver Transpl 2009;15:64-72.
2. Huda A, Newcomer R, Harrington C, Blegen MG, Keeffe EB. High rate of unemployment after liver transplantation: analysis of the United Network for Organ Sharing database. Liver Transpl 2012;18:89-99.
3. De Baere C, Delva D, Kloeck A, et al. Return to work and social participation: does type of organ transplantation matter? Transplantation 2010;89:1009-15.
4. Avery RK, Michaels MG. Strategies for safe living after solid organ transplantation. Am J Transpl 2013;13:304-10.
5. Ho JK, Ko HH, Schaeffer DF, et al. Sexual health after orthotopic liver transplantation. Liver Transpl 2006;12:1478-84.
6. Sorrell JH, Brown JR. Sexual functioning in patients with end-stage liver disease before and after transplantation. Liver Transpl 2006;12:1473-7.
7. Burra P. Sexual dysfunction after liver transplantation. Liver Transpl 2009;15:S50-56.
8. Deshpande NA, James NT, Kucirka LM, et al. Pregnancy outcomes of liver transplant recipients: a systematic review and meta-analysis. Liver Transpl 2012;18:621-9.