Distinct Longitudinal Trajectories of Symptom Burden Predict Clinical Outcomes in End-Stage Liver Disease

Abstract

Objectives: Little has been reported about the clinical relevance and trajectories of symptoms in end-stage liver disease (ESLD). The purpose of this prospective study was to identify trajectories of change in symptom burden over the course of 12 months in adults with ESLD. Methods: Patients were recruited from hepatology clinics at two health care systems. Validated measures were used to assess physical and psychological symptoms. Latent growth mixture modeling and survival and growth modeling were used to analyze the survey data. Results: Data were available for 192 patients (mean age 56.5±11.1 years, 64.1% male, mean MELD-3.0 19.2±5.1, ETOH as primary etiology 33.9%, ascites 88.5%, encephalopathy 70.8%); there were 38 deaths and 39 liver transplantations over 12 months. Two symptom trajectories were identified: 62 patients (32.3%) had high and unmitigated symptoms, and 130 (67.7%) had lower and improving symptoms. Patients with high and unmitigated symptoms had twice the hazard of all-cause mortality (sHR 2.53, 95% CI: 1.32-4.83), and had worse physical (p<0.001) and mental quality of life (p=0.012) compared with patients with lower and improving symptoms. Symptom trajectories were not associated with MELD 3.0 scores (p=0.395). Female gender, social support, and level of religiosity were significant predictors of symptom trajectories (p<0.05 for all). Conclusions: There appears to be two distinct phenotypes of symptom experience in patients with ESLD that is independent of disease severity and associated with gender, social support, religiosity, and mortality. Identifying patients with high symptom burden can help optimize their care.