Quality of life and cognitive function in hepatitis C at different stages of liver disease
Introduction
Hepatitis C is associated with an impairment in health-related quality of life (HRQOL) [1], [2], [3]. Several factors that are common in patients with hepatitis C virus (HCV) infection may determine the decrease in HRQOL, such as low socioeconomic level or intravenous drug abuse [2], medical or psychiatric comorbidities [4], [5] or the labeling effect of establishing the diagnosis of HCV infection [6], [7]. However, the mechanisms underlying the impairment in HRQOL have not been elicited. It has been proposed that hepatitis C may cause some sort of neuropsychological impairment that affects patients’ perceptions of health [8]. In addition, advanced liver disease has been associated with a marked decrease in HRQOL [9], that may be due to minimal hepatic encephalopathy [10]. However, the majority of the studies in patients with HCV have been focused on patients without advanced cirrhosis, which is the group that develops minimal hepatic encephalopathy.
We undertook a study to evaluate HRQOL and cognitive function in patients with hepatitis C at different stages of liver disease. We assessed three groups of patients that covered clinically relevant stages: chronic hepatitis, cirrhosis without prior decompensations and cirrhosis with prior decompensations (ascites, gastrointestinal bleeding or hepatic encephalopathy). Our aim was to investigate the influence of cognitive function on HRQOL and explore possible associations between HRQOL and the clinical characteristics of the patients. For this purpose we controlled for age, gender and years of education, which are variables that are known to influence cognitive function, and we included a healthy control group to avoid local biases in the performance of neuropsychological tests.
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Subjects
Patients with hepatitis C (HCV antibody and RNA-HCV positive) were selected from the outpatient clinic at Hospital Vall d'Hebron before receiving antiviral therapy. We selected middle aged patients, above 45 years (because cirrhosis is uncommon below this age) and below 65 years (to avoid the confounding effect of advanced age). Patients were excluded if they showed one of the following characteristics: marked cognitive disorder (mini-mental test <27), impaired autonomy (Barthel <100%),
Results
Health-related quality of life scores showed deterioration with the severity of the liver disease for most of the domains of the SF-36 (Table 2). The analysis of variance showed that scores were lower (P<0.001) the more severe the liver damage for all the domains, except for role emotional (P=0.4) and mental health (P=0.18). The Beck Depression Inventory and the State-Trait Anxiety Inventory, which are more appropriate than the SF-36 to detect symptoms of depression or anxiety, showed increased
Discussion
The results of this study indicate that patients with hepatitis C have an impairment in quality of life even in the absence of significant cognitive abnormalities. Our results argue against a major role of cognitive function in mediating the decrease in HRQOL, because we observed the characteristic impairment of the SF-36 scores in a group of patients with HCV and chronic hepatitis or compensated cirrhosis that did not exhibit important neuropsychological abnormalities. Recent studies have
Acknowledgements
Montse Flavià, PhD was supported by a grant from Schering-Plough International. Study supported in part by ‘Red Nacional de Investigación en Hepatologı́a y Gastroenterologı́a (RNIHG)’, Instituto de Salud Carlos III, (project C03/02).
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