Fatigue a lasting problem after liver transplantation

A new study on fatigue experienced by patients after undergoing liver transplantation found that it is a major problem that does not tend to improve with the passage of time. Liver transplant patients experience physical fatigue and reduced activity rather than mental fatigue and reduced motivation.

The results of this study appear in the June 2006 issue of Liver Transplantation, the official journal of the American Association for the Study of Liver Diseases (AASLD) and the International Liver Transplantation Society (ILTS). The journal is published on behalf of the societies by John Wiley & Sons, Inc. and is available online via Wiley InterScience at http://www.interscience.wiley.com/journal/livertransplantation.

Although fatigue is common in end-stage liver disease and can even contribute to the need for a liver transplant, few studies have been conducted on fatigue after liver transplants take place. In the current study, researchers led by Rita van den Berg-Emons, Ph.D. of the Department of Rehabilitation Medicine at the Erasmus Medical Center in Rotterdam, The Netherlands, assessed 96 liver transplant patients who visited the hospital's outpatient clinic between February and June 2003. The patients were given a series of self-administered questionnaires: the Fatigue Severity Scale (FSS) measured fatigue severity; the Multidimensional Fatigue Inventory (MFI-20) measured the nature of fatigue; two additional questionnaires measured the patients' disability level and their health-related quality of life (HRQoL). In addition, the researchers assessed patients' age, gender, reason for having the transplant, time since the transplant took place, and the number of immunosuppressive agents they were taking.

The results showed that 66 percent of the patients were fatigued, 44 percent were severely fatigued, and there was no indication that fatigue lessened over time. "This is the first study to provide information on both the severity and nature of fatigue after liver transplantation, and on factors associated with the severity of fatigue," the authors note. As with a previous study, the patients experienced physical fatigue and reduced activity rather than mental fatigue and reduced motivation. "These findings imply that fatigue after liver transplantation might be reduced with rehabilitation programs focusing on improving activity patterns and physical fitness," the authors state. They found a weak relationship between severity of fatigue and gender and age (women experienced more fatigue) and a stronger relationship between self-assessed disabilities and HRQoL. This may be because fatigue may lead to an inactive lifestyle which in turn may lead to an impaired quality of life. Neither the condition necessitating the transplant nor the number of immunosuppressive agents was associated with the severity of fatigue, the study found.

The authors conclude: "These findings imply that rehabilitation programs, focusing on improving activity patterns and physical fitness, may reduce complaints of fatigue after liver transplantation. However, the effect of rehabilitation on fatigue has to be established in future research."

In an accompanying editorial in the same issue, Jayant A. Talwalkar, M.D., M.P.H. of the Division of Gastroenterology & Hepatology at the Mayo Clinic College of Medicine in Rochester, MN notes that while many symptoms of liver disease resolve following transplant, fatigue is one that remains, for reasons as yet unclear. The strengths of the current study, according to the author, are that it used valid instruments to measure fatigue, it confirmed the role of physical function in fatigue, and it described the strong relationship between fatigue and lower HRQoL. However, the findings conflicted with an earlier study in which fatigue was less common in patients four to five years post-transplant. This may be due to response shift, where patients experienced a positive change in attitude after the traumatic experience of surviving the transplant, or it may be due to the lack of a psychological assessment and the role of anxiety/depression in causing fatigue in the current study. Regarding the link between fatigue and reduced physical activity, the author notes that two recent studies on the effects of physical rehabilitation showed positive results on physical fitness and quality of life. However, no studies have been performed so far on effects of physical rehabilitation on complaints of fatigue. The author concludes that "the time has come to shift gears by identifying efficacious interventions which improve physical function, fatigue, and HRQL in this population," and suggests that in cases where exercise is ineffective, novel drug therapies may need to be tested and impaired cognitive function may also need to be examined as a possible cause of fatigue.

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Article: "Fatigue Is a Major Problem After Liver Transplantation," Rita van den Berg-Emons, Berbke van Ginneken, Markus Wijffels, Hugo Tilanus, Herold Metselaar, Henk Stam, Geert Kazemier, Liver Transplantation; June 2006 (DOI: 10.1002/lt.20684).

Editorial: "Determining the Nature and Impact of Fatigue After Liver Transplantation," Jayant A. Talwalkar, Liver Transplantation; June 2006 (DOI: 10.1002/lt.20781).


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