To our knowledge, this is the first study reporting the QoL of LT recipients during the pandemic and exploring other important features of the patient's everyday life such as lifestyle patterns, physical activity, employment and eating habits. This multicentre study demonstrates that female gender, sedentary lifestyle and low adherence to a Mediterranean diet were independently associated with impaired QoL in both PCS-12 and MCS-12. Moreover, inactive status (vs. active work) and low (vs. medium-high) physical activity were significantly related to lower PCS-12. Interestingly, MCS-12 did not differ by place of residence, educational level, occupation, time from transplantation, level of physical activity or alcohol habit.
We found that female patients had significantly lower scores than males in both PCS-12 and MCS-12. Of note, females experience numerous challenges in the post-transplant period, which may include greater risk for osteoporosis upon post-menopause metabolic changes. Desai et al. demonstrated that after LT, female gender was associated with a worse QoL (in PCS-12) than males. Notably, women show lower levels of QoL than men also in other contexts such as older adults or patients with cardiovascular disease. Thus, our data and those of previous studies indicate that clinical practitioners should pay special attention to LT female recipients seeking treatment and offer specialized medical and psychosocial resources to address their unique needs.
Our data about the positive impact of physical activity on QoL are coherent with data reported in other studies. Post-transplant physical activity, self-care, mobility and total energy expenditure were all associated with improved QoL in LT recipients. Interestingly, involvement in group sport activities was associated with improved physical function and QoL.[43,44] According to our data, a sedentary lifestyle independently correlated with both MCS-12 and PCS-12 and patients reporting low physical activity had lower PCS-12 than subjects with medium and high activity. Along these lines, we also provide evidence that inactive or retired patients experienced lower PCS-12 than active workers, independently of the type of occupation (blue- or white-collar). Both physical activity and occupation maintained a significant positive correlation to QoL in the multivariate model, indicating that patients on a medium/high activity or an active working status are less likely to report impaired PCS-12 than unemployed/retired or low activity patients.
An original finding of the present study is that adherence to a Mediterranean diet is a significant and independent predictor of better QoL in LT. These data are in line with those recently reported in a large cohort study in the Italian general population, demonstrating that adherence to a Mediterranean diet was related to an enhanced perceived QoL. A positive association between Mediterranean diet and QoL was also reported by Galilea-Zabalza et al. who analysed data from Spanish patients affected by metabolic syndrome. To explain the link between diet and QoL, we should also consider that there are indirect connections between diet and lifestyle and mental disorders, including socioeconomic conditions, obesity and existence of patterns related to chronic diseases. Additional support to our findings is provided by recent data from two retrospective Italian cohorts, showing that psychological distress from the COVID-19 quarantine was directly related to unhealthy diet variations.
The present study can be particularly important also because data on LT recipients' QoL from studies conducted before the COVID-19 pandemic are controversial. Some authors described a significant increase in QoL during the first year after LT in a relevant percentage of cases and a steady state in the subsequent years. However, other authors reported criticisms about the QoL evolution during the years. Masala et al. suggested that LT recipients are more prone to develop psychological and emotional distress and lower physical functioning than the general population. Drent et al. reported that QoL after LT can be satisfactory but below the levels of the general population, and Burra et al. suggested that QoL tends to significantly decline after LT.
The study reported herein is the first analysing the QoL during the COVID-19 pandemic in a multisite investigation that sampled a large cohort of LT patients across many Italian regions. While this is a major strength of our work, some limitations should be acknowledged. First, the present study is based on self-reports, and objective measures of physical or mental well-being (e.g., physical mobility testing or cognitive testing) were not utilized. Future studies should employ objective measures along with self-report to better assess the QoL outcomes. Second, we utilized a cross-sectional study design and thus, causality could not be fully determined based on the current findings. Future longitudinal designs may decipher the distinction and directionality of the described associations. Third, owing to the cross-sectional design, we did not report assessment outside the time-window of the pandemic. In the future, longitudinal studies analysing the modifications from pandemic to post-pandemic period would be useful and interesting. Finally, we decided to include only patients in stable clinical conditions. Recent pathological conditions per se influence not only the QoL but also the other main issues that we analysed (sport, diet, work activity). For example, in the general population, hospitalization induces a reduction of both muscle strength and QoL in adults and elderly. Therefore, the enrollment of unstable subjects would not have allowed us neither to accurately detect the possible modifiable predictors of impaired QoL nor to analyse the other aspects of the everyday life of LT recipients. On the other hand, the present study cannot represent the whole post-LT population.
In conclusion, considering LT recipients, females and patients with sedentary lifestyle or work inactive seem to show lower QoL scores than their counterpart. Sport activities and a Mediterranean diet might help LT recipients to improve their QoL. The transplant community might implement a network of information and support encouraging physical activity and adherence to a healthy Mediterranean-style diet. Further targeted studies should better investigate the gender differences by attempting to eliminate the clinical and social disadvantages of women.
COVID-19, Coronavirus Disease 19; ISTAT, Italian National Institute of Statistics; LT, liver transplantation; QoL, quality of life; SF-12, The Short Form health survey; PCS-12, Physical Component Summary; MCS-12, Mental Component Summary; IPAQ, International Physical Activity Questionnaire; MET, Metabolic Equivalent Task; SD, standard deviation; SA, sedentary activity.
Ethics Approval Statement
The present study was approved by the Local Independent Ethics Committee ("Comitato Etico Area Vasta Centro") (approval number 20659).
Patient Consent Statement
Patients provided informed consent before participating in the study.
A special thanks to "Vite-Volontariato Italiano Trapiantati Epatici" for their continuous effort in support of transplanted patients of our communities, and for collaborating to the present study. A special thanks to "Vita che rinasce-Associazione Trapiantati Modena" for their unvaluable support for the present study. Open Access Funding provided by Universita degli Studi di Firenze within the CRUI-CARE Agreement. [Correction added on 26 May 2022, after first online publication: CRUI funding statement has been added.]
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
Liver International. 2022;42(7):1618-1628. © 2022 Blackwell Publishing