Original article
Inadequate social support decreases survival in decompensated liver cirrhosis patientsEl apoyo social inadecuado disminuye la supervivencia en pacientes con cirrosis hepática descompensada

https://doi.org/10.1016/j.gastrohep.2022.04.006Get rights and content

Abstract

Introduction

Inadequate social support is associated with higher mortality both in the general population and in patients with chronic diseases. There are no studies that have described social support in liver cirrhosis and its impact on prognosis.

Objectives

To analyze the impact social support has in the survival of patients with decompensated cirrhosis.

Methods

Prospective multicentric cohort study (2016–2019). Patients with decompensated liver cirrhosis were included. Epidemiological, clinical and social variables were collected, using the validated Medical Outcomes Study Social Support Survey, with a 12-month follow-up.

Results

A total of 127 patients were included, of which 79.5% were men. The most common etiology of cirrhosis was alcohol (74.8%), mean age was 60 years (SD 10.29), mean MELD was 15.6 (SD 6.3) and most of the patients had a Child–Pugh B (53.5%) or C (35.4%). In the assessment of social support, we observed that most of the patients (92.2%) had adequate global support. At the end of the follow-up (median 314 days), 70.1% of the patients survived. The 1-year survival rate in patients with inadequate global social support was 30%, compared to 73.5% in the presence of social support. In multivariate Cox regression analysis, inadequate social support predicted survival with an adjusted HR of 5.5 (95% CI 2,3-13,4) independently of MELD (HR 1.1, 95% CI 1–1.2), age (HR 1, 95% CI 1–1.1) and hepatocarcinoma (HR 10.6, 95% CI 4.1–27.4).

Conclusion

Adequate social support improves survival in liver cirrhosis, independently of clinical variables. Social intervention strategies should be considered for their management.

Resumen

Introducción

El apoyo social se asocia a mortalidad en población general y en pacientes con enfermedades crónicas. No hay estudios que hayan descrito el apoyo social en cirrosis hepática y su impacto sobre el pronóstico.

Objetivo

Analizar el impacto del apoyo social en la supervivencia en cirrosis hepática descompensada.

Material y métodos

Estudio multicéntrico prospectivo de cohortes (2016–2019). Se incluyeron pacientes con cirrosis hepática descompensada. Se recogieron variables epidemiológicas, clínicas y sociales mediante la escala validada Medical Outcomes Study Social Support Survey (MOS), realizando un seguimiento de 12 meses.

Resultados

Se incluyeron 127 pacientes, el 79,5% eran hombres. La causa más común de la cirrosis hepática fue alcohol (74,8%), la edad media 60 años (DE: 10,29), la media de MELD 15,6 (DE: 6,3) y la mayoría tenían Child-Pugh B (53,5%) o C (35,4%). Se observó que la mayoría de pacientes (92,2%) tenían un apoyo social adecuado (MOS global > 56). Al finalizar el seguimiento (mediana 314 días), el 70,1% de los pacientes sobrevivieron. La supervivencia al año en falta de apoyo social fue del 30%, comparado con el 73,5% en los que el apoyo social era adecuado. En el análisis de regresión multivariante el apoyo social predijo la supervivencia con un HR ajustado de 5,5 (IC 95%: 2,3-13,4) independientemente del MELD (HR: 1,1; IC 95%: 1-1,2), edad (HR: 1; IC 95%: 1-1,1) y hepatocarcinoma (HR: 10,6; IC 95%: 4,1-27,4).

Conclusión

El apoyo social inadecuado en pacientes con CH disminuye la supervivencia, independientemente de las variables clínicas. Se deberían plantear estrategias de intervención social para su manejo.

Introduction

Natural history of liver cirrhosis (LC) is characterized by an asymptomatic phase, known as compensated LC followed by the development of complications of portal hypertension and liver dysfunction, designated decompensated LC. These decompensations (ascites, portal hypertensive gastrointestinal bleeding, encephalopathy, or jaundice) strongly interfere in the prognosis of these patients.1 As some studies have demonstrated, medium survival in decompensated liver cirrhosis (LC) is less than 2 years, while in compensated LC is 12 years.2, 3 Other authors have described a statistically significant difference of 1-year mortality rate, being 5.4% in compensated and 20.2% in decompensated patients.4 Several independent predictive survival factors have been described, mainly related to the liver function (Child–Pugh score and Model for End-Stage Liver Disease (MELD) score) and the age.1, 3, 4

Although early intervention in the modifiable factors may improve hospital outcomes and mortality, mortality remains high and prognosis of decompensated LC is poor in the medium-long term.3, 5 According to World Health Organization's data, age-adjusted mortality of liver diseases ranged between 10 and 36 deaths per 100,000 across European countries. Moreover, on average two-thirds of all potential years of life lost were working years of life, therefore, liver diseases, specifically LC, still represent a very important economic burden for European health management systems nowadays.6

Social support (SS) is defined as an interactive process through which the individual obtains emotional, instrumental or economic help from the social network in which he is immersed.7, 8, 9 It has been demonstrated in many publications that the influence of SS on mortality risk is comparable with well-established risk factors in the general population.10 In chronic diseases, such as arterial hypertension or diabetes, patients with lower SS have a higher risk of developing cardiovascular events and die during long-term follow-up.11, 12 In population-based studies, social isolation has been associated with higher rates of mortality, accidents and suicides.13, 14, 15 Due to these facts, the European Association for the Study of the Liver (EASL) has stated that future priorities to reduce the burden of liver diseases in European countries should be focused on education, both of medical professionals and the public, health system changes and social factors.6 In Spain, the national strategic program of intervention in chronic diseases, in which LC is included, specifically states that one of the priority lines in which we must focus our work is the social network's activation, SS of the patient and relatives and his or her cognitive and functional preservation. It also specifies that investigation and innovation in these aspects is urgently needed to improve the quality of life and the prognosis of these patients.16

With regard to LC, on the one hand, SS is an important variable for liver transplant (LT) candidates, providing them with psychological and social well-being, and might be decisive in their admission in the waiting list for an organ.17, 18 On the other hand, LC is usually associated with higher social risk factors, such as alcoholism or drug abuse. However, SS has barely been analyzed in these patients.6, 19, 20, 21, 22 Furthermore, there is no evidence on the impact of SS on decompensated LC prognosis, so we decided to design a prospective non-intervention study to describe the prevalence of inadequate social support in a cohort of patients that required admission due to decompensated liver cirrhosis, as well as its impact on one-year mortality.

Section snippets

Description of the study

This is a multicentric prospective non-intervention longitudinal study that took place in two Spanish hospitals (University Hospital of La Fe, Valencia and University Hospital of Ourense) between 2016 and 2019. We enrolled all consecutive patients older than 18 years of age with decompensated LC after hospital admission secondary to clinical decompensation (ascites, gastrointestinal variceal bleeding, encephalopathy or jaundice) who preserved cognitive function after giving informed consent.

Description

A total of 127 patients were recruited prospectively between 2016 and 2019 (Fig. 1). Medium age was 60 years (SD 10.29) and 79.5% of them were men. The most common etiology of the cirrhosis was alcohol (74.8%), followed by hepatitis C (19.8%), of which 20.8% had previously eradicated the virus. There was a personal history of hepatocellular carcinoma in 23.6% of the patients and 73.3% of these were candidates for LT, surgery or locoregional treatment (radiofrequency or chemoembolization).

Discussion

Inadequate SS is infrequent in patients with decompensated LC who need hospital admission. However, despite being a minority, the lack of adequate SS is independently associated with mortality in the first year of follow-up. To our knowledge, this is the first published investigation that demonstrates and quantifies the influence of the SS in LC mortality. We have assessed the prevalence of impaired SS among patients requiring hospitalization due to decompensated LC as well as the effect on

Conclusion

The importance of SS in the prognosis of chronic diseases is a reality. Specifically in LC patients, adequate SS improves long-term survival, regardless of clinical variables. A correct assessment of SS is necessary in order to modify different social aspects and identify patients at risk in this sense, since it could improve the prognosis, thus enhancing their quality of life and reducing healthcare costs. Information about the social status is necessary to develop policies and homogeneous

Ethical considerations

This study has the approval of the local Research Ethics Committee (registration number 2017/0620 and 2016/465). All participants signed the informed consent.

Funding

This investigation did not receive any financial support.

Conflict of interest

The authors declare no conflicts of interest for this investigation.

Acknowledgements

We would like to thank Dr. Carlos Menéndez for his help in developing the idea of the investigation, his wise advise and his supervision in the drafting of the manuscript.

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