Symptom experience, nonadherence and quality of life in adult liver transplant recipients.

Survival outcomes after liver transplantation in adult patients have gradually improved with a five-year survival of about 70% and a ten-year survival of about 60%. The present review focuses on relevant patient-reported outcomes such as self-perceived side effects of immunosuppressive drugs, medication nonadherence and long-term health-related quality of life after liver transplantation. These entities are interrelated but have often been studied separately. Self-perceived symptom experience in liver transplant recipients has not been studied extensively. Symptoms that cause distress differ between men and women, e.g. symptoms related to cosmetic side effects of drugs. Medication nonadherence seems to be infrequent, but if present may have serious consequences. Important risk factors were found to be the costs of drugs, age <40 years, psychiatric disorders, side effects of drugs, beliefs that drugs were harmful, and large influence of the liver transplant on the patient's life. Health-related quality of life is satisfactory, but below the level of the general population. Results, however, must be interpreted with caution as quality-of-life improvements may have been overstated due to variables such as selection bias (e.g. exclusion of severely ill and deceased patients), too many short-term studies, and suboptimal methodology. Presently we lack data on the influence of recurrence of disease, 'de novo' diseases and gender differences on health-related quality of life in liver transplanted patients.

Symptom experience associated with immunosuppressive drugs after liver transplantation in adults: possible relationship with medication non-compliance?

Symptom experience (occurrence and perceived distress) associated with side effects of immunosuppressive medications in organ transplant patients may well be associated with poorer quality of life and medication non-compliance. The aims of this study were: first, to assess symptom experience in clinically stable adult patients during long-term follow-up after liver transplantation; and second, to study the relationship between symptom experience and medication non-compliance. This cross-sectional study included 123 liver transplant patients. Symptom experience was assessed using the "Modified Transplant Symptom Occurrence and Symptom Distress Scale" (29-item version) at the annual evaluation. According to the duration of follow-up, patients were divided into a short-term (1-4 yr) and a long-term (5-18 yr) cohort. Medication non-compliance was measured using electronic monitoring. Results showed that increased hair growth was the most frequent symptom in both sexes. Symptom distress was more serious in women than in men. The most distressing symptom in women was excessive and/or painful periods, while in men this was impotence. Clear differences were revealed at item level between symptom occurrence and symptom distress in relationship with the two time cohorts and between sexes. No relationship was found between symptom experience and prednisolone non-compliance.

Current health status of patients who have survived for more than 15 years after liver transplantation.

BACKGROUND: Liver transplantation was started in our centre as early as 1979. We have studied the clinical outcome of patients surviving longer than 15 years, with special interest for the broad range of comorbidity and the self-perceived quality of life. METHODS: All patients who underwent a liver transplantation at an adult age, between March 1979 and February 1991, and who had survived at least 15 years were eligible for the study. Data were collected from the medical records. Health-related quality of life was assessed using the Six-Dimensional EuroQol test. RESULTS: The five-year survival of patients alive 15 years after transplantation was 78%. Thirty-seven patients are currently alive with a median follow-up of 18.8 years (range 15.0 to 26.8) after transplantation. Comorbidity consists predominantly of overweight (57%), osteoporosis (49%), de novo cancer (38%, mainly skin cancer), hypertension (38%), cardiovascular events (19%), diabetes mellitus (22%), cataract (24%), and renal clearance<50 ml/min (11%). The pattern of comorbidity seems to relate to the type of immunosuppression which consisted mainly of prednisolone and azathioprine. Quality of life was perceived as satisfactory (7 on a scale of 0 to 10). However, about half of the patients reported limitations in the domains mobility, usual activities and pain/discomfort. In addition a minority reported some anxiety or depression. CONCLUSION: The outcome of liver transplantation in this early cohort of patients is fairly good. Improvements may be achieved by adaptations in the immunosuppressive regimen.

Bone loss after liver transplantation is not prevented by cyclical etidronate, calcium and alphacalcidol. The Liver Transplant Group, Groningen.

After orthotopic liver transplantation (OLT) bone mass rapidly declines and vertebral fracture rate increases. We studied bone loss and parameters of bone turnover in 53 consecutive patients. In an attempt to reduce bone loss the patients were prophylactically treated with cyclical etidronate in addition to daily 1 alpha-hydroxyvitamin D3 and calcium. During the first 3 months after transplantation median lumbar spinal bone mineral density (BMD) decreased 4.5%; subsequently no significant changes occurred. Median hip BMD continued to fall during the first post-transplantation year and deteriorated 7% over the whole study period. New vertebral fractures were seen in 25% of the patients, which is not lower than previously reported rates in patients not receiving cyclical etidronate. Parathyroid hormone levels increased after OLT (p = 0.01), but remained within normal ranges. Urinary hydroxyproline levels were increased and normalized in the second half-year after OLT. Elevated fasting calciuria increased further after OLT. 1,25-Dihydroxy-vitamin D3 levels were lowered pre-OLT (25 vs 66 pmol/ 1, p < 0.001) and normalized at 3 months after OLT. Serum osteocalcin concentrations remained unchanged and were reduced compared with levels in healthy controls. In summary, increased bone resorption occurs after OLT with persistent decreased bone formation, leading to vertebral fracture in 25% of patients. Etidronate, 1 alpha-calcidol and calcium treatment did not prevent bone loss.

The covalent and tertiary structure of bovine liver rhodanese.

Bovine liver rhodanese is a single polypeptide of 293 amino acids in which the halves of the molecule assume analogous tertiary structures in the absence of substantial sequence homology. The sulphur atom transferred during catalysis is bound in persulphide linkage to Cys-247. Substrate binding seems to involve Arg-186 and Lys-249.