AGA Clinical Practice Update on Palliative Care Management in Cirrhosis: Expert Review

Tandon, Puneeta; Walling, Anne M.; Patton, Heather; Taddei, Tamar H.

doi:10.1016/j.cgh.2020.11.027

Cited by 37 publications

(37 citation statements)

References 84 publications

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“…( 5 ) Patients with cirrhosis who develop clinically significant ascites and related complications should be considered for referral for liver transplantation (LT) evaluation and, when appropriate, palliative care. ( 6 )…”

Section: Introductionmentioning

confidence: 99%

Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome: 2021 Practice Guidance by the American Association for the Study of Liver Diseases

et al. 2021

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This is a comprehensive guidance on the diagnosis, evaluation, and management of ascites and hepatorenal syndrome in patients with chronic liver disease from the American Association for the Study of Liver Diseases (AASLD). It replaces the prior AASLD guideline on the same topic published in 2012 (1).This AASLD Guidance provides a data-supported approach to the management of ascites and hepatorenal syndrome. It differs from AASLD Guidelines, which are supported by systematic reviews of the literature, formal rating of the quality of the evidence and strength of the recommendations. In contrast, this Guidance was developed by consensus of an expert panel and provides guidance statements based on comprehensive review and analysis of the literature on the topics, with oversight provided by the AASLD Practice Guidelines Committee. The AASLD Practice Guidelines Committee chose to perform a Guidance on this topic because a sufficient number of randomized controlled trials were not available to support meaningful systematic reviews and meta-analyses. A. Introduction Burden of Cirrhotic Ascites and Hepatorenal SyndromeHepatic decompensation, defined by ascites, hepatic encephalopathy, and portal hypertensive gastrointestinal bleeding, is an important landmark in the natural history of cirrhosis (2). Ascites is commonly the first decompensation-defining event, with 5%-10% of patients with compensated cirrhosis developing ascites per year (3). The development of ascites is associated with a reduction in 5-year survival from 80% to 30% (4), which is due in part to patients with ascites being prone to additional complications such as bacterial infections, electrolyte abnormalities, hepatorenal syndrome (HRS) and nutritional imbalances, and consequently, further clinical decline (5). Patients with cirrhosis who develop clinically significant ascites and related complications should be considered for referral for liver transplantation (LT) evaluation and, where appropriate, palliative care (6).HRS is a late complication of cirrhosis that accounted for 3.2% of all hospital discharges related to cirrhosis according to a 2012 study based on a large inpatient health care database of patients representative of community hospitals in the United States (4). Moreover, the number of HRS discharges in the United States has increased significantly in the past 2 decades (7). HRS was also associated with high inpatient mortality (~46%), as well as longer lengths of stay and higher costs of hospitalizations, compared to cirrhosis discharges without HRS.

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Section: Introductionmentioning

confidence: 99%

Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome: 2021 Practice Guidance by the American Association for the Study of Liver Diseases

et al. 2021

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“…Given the high prevalence and heavy burden of impaired HRQoL in cirrhosis, attempts have been made to orchestrate treatment algorithm and care trajectory. For instance, the American Gastroenterological Association recently updated their clinical practice on palliative care management in cirrhosis ( 22 ) and recommended a more comprehensive assessment of data around comorbidities, frailty, functional status, and other issues, as the potential for improvement in addition to etiological therapy. This is the case for population‐based prognostic scores such as MELD and Child‐Pugh classification, embracing recognized limitations when applied to individual patients.…”

Section: Discussionmentioning

confidence: 99%

Health‐Related Quality of Life and Its Contributors According to a Preference‐Based Generic Instrument in Cirrhosis

Hui

et al. 2021

Hepatol Commun

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It is essential to determine contributors around impairment in health-related quality of life (HRQoL) in patients with cirrhosis aiming at improving health care and therapeutic strategy. Studies simultaneously incorporating disease severity based on biochemical parameters and other physical/psychological effects (i.e., sleep disturbance and frailty) are heterogeneous and the subject of the present study. We analyzed and compared HRQoL, using the EuroQol Group 5 Dimension (EQ-5D) questionnaire and the utility index retrieved, in patients with cirrhosis and across groups stratified by sleep disturbance or frailty phenotype. Sleep disturbance and frailty were determined by the Pittsburgh Sleep Quality Index (PSQI) and Frailty Index, respectively. Multiple linear regression was implemented to clarify contributors of poor HRQoL. In this cohort of 227 patients with mean age of 61.7 years and 47.2% male, more than half of the study population represented impairment in HRQoL in at least one domain, according to EQ-5D. Furthermore, sleep disturbance and frailty have proved to be independently associated with poor HRQoL in two separate regression models, whereas conventional scoring systems such as Child-Pugh classification and Model for End-Stage Liver Disease are not closely relevant. Intriguingly, not all health domains within EQ-5D correlated well with PSQI and Frailty Index, with the exception of usual activities. Pain and anxiety/depression were the most frequently affected HRQoL domains even in patients without sleep disturbance or frailty. Conclusion: Impaired HRQoL is prevalent in patients with decompensated cirrhosis. Sleep disturbance and frailty are independently associated with poor HRQoL. It is imperative to timely intervene with these symptoms and deliver tailored health care. (Hepatology Communications 2022;6:610-620).P atients with cirrhosis often experience impairment in health-related quality of life (HRQoL), while this phenotypic perturbation is more profound in decompensated conditions. (1) More recently, a prospective cohort study conducted by Kok et al. also clarified that poor HRQoL is independently related to increased mortality and unplanned hospitalization in patients with cirrhosis. (2) However, most literature in the realm of hepatology has only taken into account ameliorating disease severity or delaying its progression, referring to better biochemical parameters and prolonged survival time. (3) In actuality, it is essential to implement comprehensively holistic evaluation pertaining to HRQoL both in daily practice

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“…Numerous tools are available to assess symptoms such as chronic liver disease questionnaire (CLDQ), liver disease quality of life (LDQOL), short form liver disease quality of life (SF-LDQOL), liver disease symptom index (LDSI), liver cirrhosis patient-reported outcome measure (LC-PROM), sickness impact profile (SIP), Edmonton symptom assessment system (ESAS), and patient health questionnaire (PHQ-9). 7 However, there is significant variability in the domains assessed, leading to a lack of standardisation. A meta-analysis by Peng et al 8 showed a significant symptom burden in ESLD with the most frequent symptoms being pain (30-79%), breathlessness (20-88%), erectile dysfunction (53-93%), anxiety (14-45%) and depression (4.5-64%).…”

Section: Symptom Burden In Esldmentioning

confidence: 99%

Improving end of life care in liver disease

Berry

Kotha

2022

Journal of Hepatology

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AGA Clinical Practice Update on Palliative Care Management in Cirrhosis: Expert Review

Cited by 37 publications

References 84 publications

Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome: 2021 Practice Guidance by the American Association for the Study of Liver Diseases

Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome: 2021 Practice Guidance by the American Association for the Study of Liver Diseases

Health‐Related Quality of Life and Its Contributors According to a Preference‐Based Generic Instrument in Cirrhosis

Improving end of life care in liver disease

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