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INTRODUCTION
The liver is the largest organ in the human body, and it is involved in a variety of bodily tasks ranging from protein synthesis to cholesterol and glucose metabolism. Liver disease is a condition of abnormal liver functioning that causes illness and it can cause damage to the body which is called as hepatic disease. Chronic Liver Disease (CLD) is a continual process of liver parenchyma inflammation, destruction, and regeneration that leads to fibrosis and cirrhosis. Chronic liver disease is one of the frequent causes of death, mainly in the developing world (National Center for Biotechnology Information [NCBI], 2020; Dienstag, 2018; Gutteling et al., 2007). Over the last few decades, monitoring Quality of Life (QoL) of patients with disorders has been mainstream clinical practice, as a consequence of greater survival of patients with chronic conditions. In 1947, the World Health Organisation expanded the definition of health and included an absence of disease in addition, of complete state of physical, mental, and social wellbeing. It has been reported that the presence of CLD reduces HRQoL, and that HRQoL deteriorates as the severity of the disease worsens. HRQoL ranges from negatively valued aspects of life (death) to positively valued aspects of life (happiness) (Gutteling et al., 2007; Sobhonslidsuk et al., 2006; Younossi et al., 2007). HRQoL mainly consists of physical, social and mental components, each of which includes multiple subcomponents. Measurement of HRQoL is done by means of standardised, self-administered questionnaires (Gutteling et al., 2007). However, a recent study found that current mental illness and medical co-morbidities were drivers of HRQoL decline, but not the severity of liver disease (Häuser et al., 2004). In CLD, the impact of socioeconomic determinants and health perception on HRQL remained unknown. One of the most powerful predictors of death is a patient's self-rating of their own health (Wilson and Cleary, 1995). Despite of being severe and revelence of health-related problem associated with liver disease; there is a lack of information about quality of life in CLD patients. The present study enables to assess factor associated with physical and mental health and also overall quality of life.
MATERIALS AND METHODS
This was a cross-sectional observational study conducted in between Jan 2020 to June 2021 at Department of General Medicine, Dhiraj General Hospital, Vadodara. Patient enrolment was started after the approval of Sumandeep Vidyapeeth Institutional Ethics Committee (SVIEC/ON/Phar/BNPG20/21009). Patients diagnosed with CLD was selected from General Medicine. Cases was selected on the basis of inclusion and exclusion criteria. Once the cases suitable for the study, their voluntary consent was taken by PI. Information was collected by PI in a face-to-face interview with subjects and their family members and patient medical records. Patients were assured that all information and records will be kept confidential. Patients with CLD had their Health-Related Quality of Life assessed using the CLDQ consists of 6 domains: Abdominal Symptoms (AS), Fatigue (FA), Systemic Symptoms (SS), Activity (AC), Emotional Function (EF) and Worry (WO) are the many types of symptoms that can occur (WO). All gathered data was transcribed into Microsoft Excel. After the data collection, all the data was exported to statistical software for statistical analysis. p value of ≤ 0.05 was considered as significant.
RESULTS
This study was carried out in the in-patients of general ward, Dhiraj General Hospital, Sumandeep Vidyapeeth Deemed to be University, Vadodara. In our study 50 subjects were included. Out of 50 participants, 41(82%) were Male and 9(18%) were Female. In this study, the age varies from 18 to 70 years with mean age of 42 years. The maximum number of patients were from 31-40 years (n=18, 36%). In this study, 3 main types of CLD patients were included, (1) Viral, (2) Alcoholic and (3) Non-alcoholic. Where maximum number of patients were Alcoholic as mentioned in Table 1.
| Gender | No. of patients (%) | Chi-square value | p-value | ||
|---|---|---|---|---|---|
| Male | 41 (82%) | 20.48 | <0.00001 | ||
| Female | 9 (18%) | ||||
| Age Range | Female (%) | Male (%) | No. of patients (%) | ||
| 18-30 | 0 (0%) | 8 (100%) | 8 (16%) | 7.609 | 0.055 |
| 31-40 | 1 (5.56%) | 17 (94.44%) | 18 (36%) | ||
| 41-50 | 5 (31.25%) | 11 (68.75%) | 16 (32%) | ||
| >50 | 3 (37.5%) | 5 (62.5%) | 8 (16%) | ||
| Types of CLD | No. of patients (%) | ||||
| Viral | 6 (12%) | 14.588 | 0.00068 | ||
| Alcoholic | 29 (58%) | ||||
| Non-Alcoholic | 15 (30%) | ||||
| Total | 50 (100%) | ||||
| Severity of disease | No. of patients (%) | ||||
| Cirrhosis | 29 (58%) | 1.28 | 0.258 | ||
| Non-Cirrhosis | 21 (42%) | ||||
| Total | 50 (100%) |
In this study, 6 viral hepatitis patients were included. Out of 6 patients, 3 patients were developed cirrhosis. The HRQoL (Health Related Quality of Life) decreased significantly with deteriorating disease severity for all dimensions of the CLDQ (Chronic Liver Disease Questionnaire). HRQL scores of CLDQ abdominal symptoms domain (3.61±1.6) and fatigue domain (3.83±0.48) were also more declined in viral hepatitis patients. In this study, 29 alcoholic liver disease patients were included. Out of 29 patients, 17 patients were developed cirrhosis. In this group of patients, HRQoL scores of CLDQ abdominal symptoms domain (3.75±1.5) and activity domain (3.70±1.1) were also more declined. In this study, 15 non-alcoholic liver disease patients were included. Out of 15 patients, 10 patients were diagnosed with cirrhosis. In this group of patients, HRQoL scores of CLDQ fatigue domain (3.75±0.6) and activity domain (3.78±0.9) were also more declined Table 2.
| CLDQ (mean ± SD) | ||||
|---|---|---|---|---|
| AS | 3.61±1.6 | 3.75±1.5 | 4.04±1.3 | 0.759 |
| FA | 3.83±0.48 | 4.01±1.1 | 3.75±0.6 | 0.621 |
| SS | 5.10±0.58 | 4.59±1.2 | 4.83±1.3 | 0.581 |
| AC | 4.17±0.8 | 3.70±1.1 | 3.78±0.9 | 0.569 |
| EF | 4.29±0.8 | 4.50±1.0 | 4.43±0.8 | 0.884 |
| WO | 5.47±0.8 | 5.31±1.0 | 5.68±0.8 | 0.427 |
| Overall CLDQ score | 4.41±0.5 | 4.31±0.9 | 4.42±0.8 | 0.907 |
In CLDQ, abdominal symptoms domain (3.69±1.52) and fatigue domain (3.82±0.95) were relatively more declined in cirrhosis patients compare to non-cirrhosis patients. Overall HRQL score of CLDQ scale had no major difference between cirrhosis and non-cirrhosis patients Table 3.
| Dimension | Severity | N | Mean | Std. Deviation | t-value | p-value |
|---|---|---|---|---|---|---|
| AS | Cirrhosis | 29 | 3.69 | 1.52 | -0.753 | 0.455 |
| Non-Cirrhosis | 21 | 4 | 1.31 | |||
| FA | Cirrhosis | 29 | 3.82 | 0.95 | -0.868 | 0.39 |
| Non-Cirrhosis | 21 | 4.04 | 0.75 | |||
| SS | Cirrhosis | 29 | 4.63 | 1.34 | -0.687 | 0.495 |
| Non-Cirrhosis | 21 | 4.86 | 0.86 | |||
| AC | Cirrhosis | 29 | 3.71 | 1.05 | -0.577 | 0.567 |
| Non-Cirrhosis | 21 | 3.87 | 0.85 | |||
| EF | Cirrhosis | 29 | 4.43 | 1.03 | -0.232 | 0.817 |
| Non-Cirrhosis | 21 | 4.49 | 0.75 | |||
| WO | Cirrhosis | 29 | 5.38 | 0.92 | -0.568 | 0.573 |
| Non-Cirrhosis | 21 | 5.52 | 0.84 | |||
| Overall CLDQ score | Cirrhosis | 29 | 4.28 | 0.98 | -0.793 | 0.432 |
| Non-Cirrhosis | 21 | 4.46 | 0.53 |
Female patients had higher impairment in HRQoL for the abdominal symptoms (2.78±1.09) domain of CLDQ. Male patients had higher impairment in HRQL for the activity (3.83±0.96) domain of CLDQ. In both gender, there were lower impairment in worry (Male-5.57±0.82; Female-4.84±0.96; p= 0.024) domain of CLDQ. There was no major difference in HRQL for overall CLDQ score (p=0.037) between gender group Table 4.
| Dimension | Gender | N | Mean | Std. Deviation | t-value | p-value |
|---|---|---|---|---|---|---|
| AS | Male | 41 | 4.05 | 1.41 | 2.542 | 0.014 |
| Female | 9 | 2.78 | 1.09 | |||
| FA | Male | 41 | 3.97 | 0.87 | 0.93 | 0.357 |
| Female | 9 | 3.67 | 0.89 | |||
| SS | Male | 41 | 4.84 | 1.08 | 1.584 | 0.12 |
| Female | 9 | 4.18 | 1.43 | |||
| AC | Male | 41 | 3.83 | 0.96 | 0.769 | 0.446 |
| Female | 9 | 3.56 | 1 | |||
| EF | Male | 41 | 4.55 | 0.89 | 1.563 | 0.125 |
| Female | 9 | 4.03 | 0.93 | |||
| WO | Male | 41 | 5.57 | 0.82 | 2.338 | 0.024 |
| Female | 9 | 4.84 | 0.96 | |||
| Overall CLDQ score | Male | 41 | 4.47 | 0.8 | 2.144 | 0.037 |
| Female | 9 | 3.84 | 0.77 |
In this study, Patients with all age group had less impaired HRQL for the worry domain of CLDQ scale. In the present data, HRQL for the overall CLDQ score was more impaired with increasing age of patients. Patients with age group of 18-30 years had less impairment in systemic symptoms domain of CLDQ Table 5.
| Dimension | Age group (years) | N | Mean | Std. Deviation | Minimum | Maximum | p-value |
|---|---|---|---|---|---|---|---|
| AS | 18-30 | 8 | 4.54 | 0.89 | 2.67 | 5 | 0.05 |
| 31-40 | 18 | 4.24 | 1.6 | 1.67 | 6.67 | ||
| 41-50 | 16 | 3.19 | 1.36 | 1.33 | 5 | ||
| >50 | 8 | 3.42 | 1.14 | 1.67 | 5 | ||
| Total | 50 | 3.82 | 1.43 | 1.33 | 6.67 | ||
| FA | 18-30 | 8 | 4 | 0.58 | 3.2 | 5 | 0.276 |
| 31-40 | 18 | 4.19 | 0.97 | 2.8 | 6.2 | ||
| 41-50 | 16 | 3.74 | 0.84 | 2.4 | 5.4 | ||
| >50 | 8 | 3.55 | 0.89 | 2.2 | 4.8 | ||
| Total | 50 | 3.91 | 0.87 | 2.2 | 6.2 | ||
| SS | 18-30 | 8 | 5.33 | 0.77 | 4 | 5.8 | 0.394 |
| 31-40 | 18 | 4.74 | 1.14 | 2.6 | 6.2 | ||
| 41-50 | 16 | 4.55 | 1.25 | 2.2 | 6.2 | ||
| >50 | 8 | 4.43 | 1.32 | 1.8 | 5.8 | ||
| Total | 50 | 4.72 | 1.16 | 1.8 | 6.2 | ||
| AC | 18-30 | 8 | 3.79 | 0.5 | 3 | 4.33 | 0.042 |
| 31-40 | 18 | 4.24 | 0.96 | 2.33 | 6 | ||
| 41-50 | 16 | 3.54 | 0.99 | 2 | 5 | ||
| >50 | 8 | 3.21 | 0.92 | 1.67 | 4.33 | ||
| Total | 50 | 3.78 | 0.96 | 1.67 | 6 | ||
| EF | 18-30 | 8 | 4.73 | 0.43 | 3.88 | 5.13 | 0.765 |
| 31-40 | 18 | 4.41 | 1.06 | 2.63 | 6.38 | ||
| 41-50 | 16 | 4.46 | 0.88 | 2.63 | 5.88 | ||
| >50 | 8 | 4.25 | 1.04 | 2.5 | 5.5 | ||
| Total | 50 | 4.45 | 0.91 | 2.5 | 6.38 | ||
| WO | 18-30 | 8 | 5.88 | 0.51 | 4.8 | 6.4 | 0.461 |
| 31-40 | 18 | 5.41 | 0.96 | 3.6 | 6.2 | ||
| 41-50 | 16 | 5.38 | 0.81 | 4 | 6.6 | ||
| >50 | 8 | 5.2 | 1.11 | 3 | 6.2 | ||
| Total | 50 | 5.44 | 0.88 | 3 | 6.6 | ||
| Overall CLDQ score | 18-30 | 8 | 4.71 | 0.48 | 3.86 | 5.09 | 0.178 |
| 31-40 | 18 | 4.54 | 0.87 | 2.79 | 6.17 | ||
| 41-50 | 16 | 4.14 | 0.82 | 2.53 | 5.43 | ||
| >50 | 8 | 4.01 | 0.86 | 2.42 | 5.03 | ||
| Total | 50 | 4.35 | 0.82 | 2.42 | 6.17 |
DISCUSSION
Our study indicates the diverse ways in which Chronic Liver Disease (CLD) affects the lives of the patients. CLD is a progressive deterioration of liver functions for more than six months, which includes synthesis of clotting factors, other proteins, detoxification of harmful products of metabolism and exertion of bile. The scale named the Chronic Liver Disease Questionnaire (CLDQ) was utilized for surveying the patient's Health Related Quality of Life (HRQoL) (Dienstag, 2018). In this study, A total 50 participants were included in this study, out of 50 participants, 41(82%) were male and 9(18%) were female, the age varies from 18 to 70 years with Mean (M) age of 42 years. The maximum numbers of patients were from 31-40 years age group. Many other studies are also having similar results according to our study. Souza NP (2015) led an investigation to assess the HRQL of patients with CLD. In their study, emotional function received higher mean chronic liver diseases questionnaire score, while abdominal symptoms received lower ratings. As the resulted of people had high mean CLDQ scores, inferring poor HRQoL. According to our study we also found same results, the higher mean chronic liver disease questionnaire scores were found as well as less impairment in HRQoL scores were found in our study (Souza et al., 2015). An investigation was performed by gutteling JJ (2010), to evaluate the interrelationships of different mental variables and HRQoL in patients with CLD. As indicated by their discoveries, Depression which is largely determined by low self-efficacy and possibly by use of maladaptive coping strategies influenced HRQoL in three groups of liver patients and HRQoL in CLD patients may be positively influenced by enhancing coping and self-efficacy skills, thus improving levels of depression. In comparison to our study, we discovered no evidence of link between psychological characteristics such as depression and patients we used (Gutteling et al., 2010). An examination was performed by Gutteling JJ (2006), to evaluate the effect of determinants of HRQoL in patients with chronic liver disease. In their investigation, results shows that HRQoL in CLD patients is clearly determined by disease severity, joint pain, depression, decreased appetite, and fatigue. Comparing with our study we found that over all HRQoL score of CLDQ scale had no major difference between cirrhosis and non-cirrhosis patients (Gutteling et al., 2006). Younossi ZM et al. (1999) embraced the investigation to make and assess a disease specific instrument for assessing HRQoL in patients with CLD. The result reveal that patients found CLDQ straightforward and simple to complete in 10 min when presenting, and that CLDQ is brief, easy to administer and produces both a summary score and domain score and correlates with the severity. In comparison with our study, we found that CLDQ is very easy to examine with the patients and severity score is in cirrhotic patients (4.28±0.98) and in non-cirrhotic patients (4.46±0.53), so overall HRQL score of CLDQ scale had no major difference between cirrhotic and non-cirrhotic patients in our study (Younossi et al., 1999). The CLDQ is a disease specific instrument especially designed to assess HRQoL in patients with CLD. In our study, we use this score for determining the all the factors and data of CLD patients. In our study we included all 6 domains of CLDQ scale were correlated to one another. The domains include abdominal symptoms, fatigue, systemic symptoms, activity, emotional function and worry to find out the CLDQ score of all the parameters and factors (Schulz et al., 2008). A study was performed by DAN AA (2007), to develop and assess the relative impact of Non-Alcoholic Fatty Liver Disease (NAFLD) on Healthy Related Quality of Life (HRQoL) compared to other chronic liver disease has not been fully explored and to compare the domain scores of the 29-item CLDQ for patients with NAFLD to those with chronic hepatitis B and chronic hepatitis C. Study was performed using methods as a HRQL questionnaire, CLDQ was routinely administered to patients attending liver clinic and scores for each of the six CLDQ domains were compared using one way ANOVA and multiple regression. The results are noted as complete data available for 237 patients. NAFLD patients scored lowest on multiple CLDQ domains. According to our study we also found the same results as NAFLD patients scored lowest on multiple domains of CLDQ. This study concluded that NAFLD patients had significantly lower quality of life scores compared with patients with hepatitis B and hepatitis C on multiple CLDQ domains (Bondini et al., 2007; Dan et al., 2007; Labenz et al., 2019). A study was performed by Labenz C (2019), to determine differences in HRQOL between patients with compensated and decompensated liver cirrhosis and to identify potentially treatable factors associated with HRQOL. A total 218 patients with liver cirrhosis were enrolled into this study and CLDQ was used to assess HRQOL. The results of this study are found as difference between scores of patients of compensated and decompensated as (CLDQ total score 5.6 vs 4.8, p<0.001) associated with impaired HRQoL (all p<0.05). Comparing with our study we found patients associated with impaired HRQoL (all p<0.05).
CONCLUSION
The study concluded that predictors of impaired HRQoL differ in patients with compensated and decompensated cirrhosis. The study was performed by Bondini S (2007), to compare HRQoL between patients with CH-C, CH-C, primary biliary cirrhosis (PBC) and healthy controls. In this study total 3 HRQoL questionnaire, (CLDQ, SF-36, HUI, Health Utility Index) used and scores were compared using analysis of variance and multiple regression. The study results are obtained as CH-C and PBC patients scores lowest on all CLDQ, SF-36 and HUI domains compared with CH-B patients and healthy controls. Comparing with our study we also found same results as CH-C and PBC patients scored lowest on CLDQ. The study concluded that CH-B patients have better HRQoL than CH-C, PBC and population norms. CH-B patients overall utility scores are lower than population norms.