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