**5.2 Hepatocellular Carcinoma (HCC)**

170 Liver Transplantation – Basic Issues

**5. Does etiology of the liver disease appear to influence individual's HRQOL?** 

Pretransplantation HRQOL scores are affected by the etiology of liver cirrhosis, therefore it is important the knowledge of the impact of a particular disease. Patients with hepatocellular and cholestatic etiologies have higher HRQOL scores than alcohol or viral hepatitis patients (Bianchi, 2003; Steel, 2007). Although the individual's perception of his/her state of health is crucial, different etiologies may identify some of the characteristics of the components of QOL in liver diseases (Krasnoff,2005). In general terms, younger and male people perceive a better QOL compared to older and women

In early stages, liver disease patients show few or non-specific symptoms, therefore reporting insignificant effects on HRQOL. As the disease progresses to cirrhosis and complications arise (ascites, muscle cramps, fatigue etc.) individuals report noteworthy effects on HRQOL (Gutteling, 2006; Björnsson, 2009). In patients with advanced disease the etiology of the liver disease does not seem to influence patients' ratings. Although in earlier cases of chronic cholestatic liver disease significant pruritus and fatigue may have a significant impairment of HRQOL (Poupon, 2004). These symptoms that may also be observed in chronic hepatitis C may not be present in those with other forms of chronic liver

We will explore the most important issues that have been developed in the last few years (Jay, 2009). Some determinants of HRQOL are derived from specific symptoms and concerns of liver diseases, but a generic HRQOL test is unable to measure them (Gutteling, 2007; Kotlyar, 2008). Examples of some specific problems observed in advanced liver disease are: sleep related problems, sleep pattern changes, stigma of liver disease, symptoms and effects

Patients with chronic hepatitis C assessed by the SF-36 show diverse and non specific symptoms (fatigue, anorexia, weight loss, abdominal distress…) and usually have significant reductions in their SF-36 scores for all of the scales (both mental and physical

Patients with chronic hepatitis B virus (HBV) infection show a reduction in the SF-36 scores that assessed mental functions, but they have no reduction in the scores that measured physical symptoms, indicating that the symptoms associated with chronic HCV infection are qualitatively different to those associated with chronic HBV infection (Curry, 2004; Spiegel,

Patients with chronic HCV infection who had used intravenous drugs in the past had the greatest impairment in QOL scores, but the reduction in QOL scores was still found in patients who had never used drugs (Weissman, 1980; Fowler 1980). The reduction in QOL could not be attributed to the degree of liver inflammation or to the mode of acquisition of the infection. Recent studies have demonstrated through cerebral magnetic resonance images of abnormal cerebral metabolism and cognitive impairments in patients with chronic

**Issues concerning Acute Liver Disease vs. Chronic Liver Disease** 

disease such as chronic hepatitis B or iron overload (Lam, 2009).

**5.1 Issues related to HRQOL in hepatitis C and hepatitis B** 

of liver disease and their treatments (Holzner, 2001).

components) (Dwigt, 1998; Foster, 2000; Strauss, 2006) .

hepatitis C ( Hilsabeck, 2002; Forton, 2008; Bokemeyer, 2011)

patients (Painter, 2001).

2005; Lam, 2009).

Development of a malignant tumour might occur in a cirrhotic liver that can have a preserved liver function. For this reason, clinical guidelines recommend screening surveillance programs in every cirrhotic patient in order to detect possible tumours in early stages to assure treatment efficacy (Ruppert, 2010). Owing to recent advances in early stage liver tumour diagnosis, presumably, these patients do not have specific symptoms and their perceived HRQOL is perhaps stable, but due to the little research available in this area the result for the moment remains uncertain (Kotlyar, 2006; Steel, 2007).

Indications for orthotopic liver transplantation according to the European Liver Transplant Registry (2008), are the following. Virus related indication in 38%; Alcoholic liver disease (ALD) related indication in 33%, and 4% had combined aetiology of ALD and hepatitis C and B. (Varma, 2010)

We could assume that at the time of diagnosis of the HCC, patients may suffer distress and be disturbed by the prospect of a therapeutical intervention such as a possible liver transplant. If the HCC is diagnosed at an early stage the prognosis is good but the patient is not adapted to the disease as is the case in a chronic patient (Gangeri, 2007; Castaldo, 2009; Crone, 2010). After transplant they might have recurrent viral hepatitis which worsens the clinical situation and even the prognosis (Bownik, 2010). New approaches for the prophylaxis of recurrent hepatitis C are under evaluation but whether this treatment will influence the severity of liver disease or the outcome of recurrence is still unknown.
