Health-related quality of life after liver transplantation

 Corresponding author: Gantugs Yundendorj Copyright © 2025 Author(s) retain the copyright of this article. This article is published under the terms of the Creative Commons Attribution Liscense 4.0. Health-related quality of life after liver transplantation Amarjargal Tsengel 1, 3, Sergelen Orgoi 2 and Gantugs Yundendorj 3, * 1 First Central Hospital of Mongolia, Ulaanbaatar, Mongolia. 2 First Central Hospital of Mongolia, Organ Transplantation Center, Ulaanbaatar, Mongolia. 3 Department of Health Policy, School of Public Health, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia. World Journal of Biology Pharmacy and Health Sciences, 2025, 21(01), 088-094 Publication history: Received on 26 November 2024; revised on 03 January 2025; accepted on 05 January 2025 Article DOI: https://doi.org/10.30574/wjbphs.2025.21.1.0006 Abstract Background: Mongolian citizens in need of liver transplant treatment have been receiving the treatment abroad since 2004, and in Mongolia since 2011. As the number of years of life after liver transplantation increases, it is important to better understand the factors that influence patient’s quality of life during those years, and what can be done to modify them. (1) Quality of life reflects how the interaction between socio-economic and environmental factors influences social and human development. (2) Studies on work capacity have shown that 6% of people after liver transplantation are classified as unable to work based on functional and international disability assessments, (3) while 23-61% are fully employed after liver transplantation. (4)(5) There is a lack of research examining the physical, psychological, and social well-being of patients after liver transplant treatment in Mongolia. Methods: Data were collected from 144 liver transplant cases using descriptive research design and questionnaire method. The study used the SF-36 Health Assessment Questionnaire, which was grouped into 8 groups and the scores were averaged according to the scale. The results of the study were analyzed using SPSS 25.0 software using Pearson’s Chi-square test for differences between groups. Results: Of the total 144 cases included in the study, 81 (56.3%), were male and 63 (43.8%) were female. By age group, 120 (83.3%) are between the ages of 19-60, or working age, and 24 (16.7%) are over 60. Employment after liver transplantation was 41 (28.5%) full-time, 19 (13.2%) part-time, 84 (58.3%) unemployed or there was no statistically significant difference between groups (P=0.024), of which 62 (43%) were willing to work, 17 (12%) were unwilling to work, and 65 (45%) were unknown (0.173) with no statistically significant difference. When assessing health-related quality of life, physical activity was 65.7±27.1, health-related limitations 38.5±40.1, psychological limitations 41.9±43.0, pain 65.5±27.2, psychological average 71.7±19.2, physical energy average 57.8±21.2, moderate, social participation average 68.1±20.6, and health change 85±22.2, indicating that citizens who underwent liver transplant treatment had good health-related quality of life and health change indicators. Conclusion: People who have undergone liver transplant treatment have good health-related quality of life and healthrelated changes. Keywords: Liver transplant; Health; Quality of life; SF-36 1. Introduction Mongolia first began performing liver transplants in 2011, the country is economically limited, but over the past 10 years, cell, tissue, and organ transplants have been developed in the healthcare sector, and this treatment has been World Journal of Biology Pharmacy and Health Sciences, 2025, 21(01), 088-094 89 provided in developed countries around the world. (6) One measure of this that, on average, over 90% of people worldwide survive for 1 year and over 75% survive for 5 years for 5 years after liver transplantation. (7) In Mongolia, the 1year survival rate after liver transplantation is 93.7%, the 3 year survival rate is 92.3%, and the 5 year survival rate is 91.2%. (8) The World Health Organization defines health as “a state of complete physical, mental, and social wellbeing”.(9) The research outlook for organ transplant therapy is focused on long-term survival and health-related quality of life (HrQoL).(10) Quality of life assessments have shown that although quality of life after liver transplantation is higher than before, physical function is lower than in the healthy population.(4) The fail phenotype in patient with cirrhosis is thought to be primarily due to malnutrition, muscle weakness, and neuromotor dysregulation.(11)(12) The above factors are considered in the 3 tests of the Liver Weakness Phenotypic Index. These include physical function assessments such as grip strength, balance, and muscle function (13), and the Frailty Phenotype Index (LFI) is defined as one of three groups of physical function assessments in the SF36 test. There is no study in Mongolia that examines the physical, psychological, and social well-being of patient after liver transplant treatment. 2. Material and methods 2.1. Study design Data were collected using a descriptive research design and questionnaire method. 2.2. Study population The sample size of clients required for the study was calculated using the formula of Krejce and Morgan (14) when the original population size is known. The required sample size was estimated to be 144 patients, which was distributed proportionally according to whether they received liver transplant treatment at the National Institute of Health and abroad, resulting in a sample size of 69 patients treated at the National Institute of Health and 75 patients treated abroad. Eligibility criteria for the survey - Citizens who have undergone liver transplant treatment at the First State Hospital and abroad, included in the target sample. Exclusion criteria -Refusal to participate in the study 2.3. Variables The survey questionnaire, the SF-36 Health Assessment Questionnaire, was grouped as follows. We converted the scores for these groups of questions into a score from 0 to 100 and averaged the scores according to the eight groups above. • Physical activity • Physical pain • Physical activity limitations • Psychological activity limitations • Personal psychological state • Social participation • General health status • Health changes 2.4. Statistical analysis The SF-36 (Short Form Survey) questionnaire, developed by the American Rand Corporation, was used to assess quality of life, and consisted of eight categories: physical health, psychological health, level of independence, social relationships, environment, personal values, and beliefs. The assessment was calculated in two stages. First, each question was converted to a score from 0 to 100, with higher scores indicating better health. Second, the scores were averaged across eight groups according to the scale. The results of the study were analyzed using SPSS25. Pearson’s Chi-square test was used to calculate the mean, standard deviation, and mean difference between groups for life assessment after liver transplantation. World Journal of Biology Pharmacy and Health Sciences, 2025, 21(01), 088-094 90 3. Results Of the 144 cases included in the study, 69 (47.9%) received liver transplant treatment in Mongolia and 75 (52.1%) abroad, and 81 (56.2%) were male and 63 (43.8%) were female. By age group, 0 (0%) were 0-9 years old, 1 (0.7%) were 20-29 years old, 15 (10.4%) Were 30-39 years old, 47 (32.6%) were 40-49 years old, 50-59 years old, and 24 (16.7%) were over 60 years old. By educational level, 3(2.1%) had primary education, 39(27.1%) had secondary education, and 102 (70.8%) had tertiary education. In terms of employment, 24 (16.7%) workers, 16 (11.1%) employees, 59 (41.0%) in the group, and 35 (24.3%) pensioners (P=0.002) showed a statistically significant difference. (Table 1) Table 1 Demographic characteristics of study participants Indicat or Sum Country where liver transplant treatment was performed Mongolia Foreign country Р value N % Num ber Percentage (along the line) Percentage (By column) Num ber Percentage (along the line) Percentage (By column) Gender 0.69 Male 81 56.2 40 49.4 58 41 50.6 54.7 Female 63 43.8 29 46 42 34 54 45.3 Age group 0-9 0 0 0 0 0 0 0 0 10-19 1 0.7 1 100 1.5 0 0 0 20-29 1 0.7 1 100 1.5 0 0 0 30-39 15 10.4 8 53.3 11.5 7 46.7 9.3 40 - 49 47 32.6 24 51.1 34.8 23 48.9 30.7 50 - 59 56 38.9 30 53.6 43.5 26 46.4 34.7 Over 60+ 24 16.7 5 20.8 7.2 19 79.2 25.3 Education level 0.768 Low 3 2.1 2 66 2.8 1 50 1.3 Mediu m 39 27.1 18 46.2 26.1 21 53.8 28 High 102 70.8 49 48 71 53 52 70.7 Employment 0.002 Employ ee 24 16.7 7 29.2 10.1 17 70.8 22.7 Officer 16 11.1 8 50 11.6 8 50 10.7 Pensio n 35 24.3 10 28.6 14.5 25 71.4 33.3 Disabili ty 59 41 39 66.1 56.5 20 33.9 26.7 Other 10 6.9 5 50 7.2 5 50 6.7 144 100 69 47.9 100 75 52.1 100 World Journal of Biology Pharmacy and Health Sciences, 2025, 21(01), 088-094 91 When viewed in relation to physical health, psychological state, level of independence, social relationships, personal beliefs, and environmental characteristics, there were no differences in general health and health change indicators among people who underwent liver transplants treatment. Physical activity Mongolian 65.3±26.9, foreign 65.9±27.3 (P=0.900), health-related limitations Mongolia 35.1±37.7, foreign 41.6±42.1 (P=0.329), psychological limitations Mongolian 40.1±43.3, foreign 43.5±42.7 (P=0.631), physical energy Mongolian 59.4±22.2, foreign 56.3±20.3 (P=0.386), psychological Mongolian 72.2±18.7, foreign 71.2±19.6 (P=0.761), social participation Mongolian 69.2±20.0, foreign 67.1±21.2 (P=0.556), pain Mongolian 63.7±26.7, foreign 67.2±27.7 (P=0.438), general health Mongolian 52.9±13.0, foreign 49.2±16.0 (P=0.133), health change Mongolian 88.4±19.4, foreign 82.3±24.2 (P=0.098) there was o statistically significant difference. (Table 2) Table 2 Quality of life assessment Indicator Country where liver transplant treatment was performed P value Mongolia Foreign country Mean St.D Mean St.D Physical functioning 65.3 26.9 65.9 27.3 0.900 Role limitations due to physical health 35.1 37.7 41.6 42.1 0.329 Role limitations due to emotional problems 40.1 43.3 43.5 42.7 0.631 Energy fatigue 59.4 22.2 56.3 20.3 0.386 Emotional well being 72.2 18.7 71.2 19.6 0.761 Social functioning 69.2 20.0 67.1 21.2 0.556 Pain 63.7 26.7 67.2 27.7 0.438 General health 52.9 13.0 49.2 16.0 0.133 Health change 88.4 19.4 82.3 24.2 0.098 P value is Independent 2 sample T test When comparing the health related quality of life by employment after liver transplantation, there were statistically significant differences in physical activity working 76.42±22.50, not working 59.40±27.61 (P<0.001), health related limitations working 54.72±41.04, not working 55.35±42.84, not working 34.07±41.27 (P=0.004), pain working 75.00±21.61, not working 60.03±28.69 (P=0.001), and general health working 54.62±13.83, not working 48.96±14.97 (P=0.026). However, there were no statistically significant differences in physical energy when working, 60.47±18.53, and when not working, 56.26±22.63 (P=0.253), psychological energy when working, 71.70±16.71, and when not working, 71.74±20.60 (P=0.991), social participation when working, 68.40±16.91, and when not working, 67.99±22.61 (P=0.904), and health changes when working, 85.38±21.05, and when not working, 85.16±22.97 (P=0.956). The average physical activity scores of the above groups were 63.52±25.32, when working and 52.90±25.75, when not working (P=0.018), and the psychological scores were 64.94±14.53, when working and 53.63±17.87 when not working (P<0.001), with statistically significant differences. Health related quality of life is higher in people who are employed after liver transplantation. (Table 3) World Journal of Biology Pharmacy and Health Sciences, 2025, 21(01), 088-094 92 Table 3 Quality of life assessment (By employment) Indicator Employment after liver transplant treatment P value Yes No Mean St.D Mean St.D Physical functioning 76.42 22.50 59.40 27.61 <0.001 Role limitations due to physical health 54.72 41.04 29.12 36.56 <0.001 Role limitations due to emotional problems 55.35 42.84 34.07 41.27 0.004 Energy fatigue 60.47 18.53 56.26 22.63 0.253 Emotional well being 71.70 16.71 71.74 20.60 0.991 Social functioning 68.40 16.91 67.99 22.61 0.904 Pain 75.00 21.61 60.03 28.69 0.001 General health 54.62 13.83 48.96 14.97 0.026 Health change 85.38 21.05 85.16 22.97 0.956 Physical functioning 63.52 25.32 52.90 25.75 0.018 Role limitations due to physical health 64.94 14.53 53.63 17.87 <0.001 P value is Independent 2 sample T test Compared with the overall health related quality of life assessment, general physical functioning indicators and general psychological indictors improved with increasing years after treatment. Figure 1 Quality of life liver transplantation (years) In Figure1, when the above eight indicators are grouped, the overall quality of life indicator of physical activity was the highest in people who received treatment in 2010 (93±7.0), 80±0.0 in 2011, 75.3±29.2 in 2013, 81.4±17.3 in 2014, and 85±15.5 in 2017, while the lowest was 48.5±24.7 in 2023 and 52.3±26.8 in 2022 (P=0.046), with a statistically significant difference. When assessing the general indicators related to psychological health, the highest was 80±2.9 in 2010, 73.3±2.9 in 2013, 70.5±12.6 in 2014, and 76.2±0.0 in 2017, and the lowest was 48.8±17.5 in 2023, 52.6±11.9 in 2024, and 54.0±15.7 in 2022 (P=0.008), with statistically significant differences. 4. Discussion Our study found that the health improvement after liver transplantation was 88.4% and the psychological state was 72.2% which is good. A study assessing quality of life using the SF-36 method, conducted by Kristin Pazekas (2024) in World Journal of Biology Pharmacy and Health Sciences, 2025, 21(01), 088-094 93 the study “Health related quality of life and work ability of patients after liver transplantation”, found that general health was 69.7%, (10) according to a study by Isabel Roldo Noguera (2020) and colleagues, “Quality of life after living donor liver transplantation” general health was 73.2%, and psychological well-being was 66.4%,(15) according to study by Hillary Monick (2009) on “Health related quality of life after liver transplantation in adults”, general health was 58%, and psychological well-being was 73%, (16) Jennifer S.Lai (2023) “Association of Frailty With Health-Related Quality of Life in Liver Transplant Recipients”, (1) Louis Onghena (2016) “Quality of life after liver transplantation: State of the art”, (17) Santiago Tome (2008) “Quality of life after liver transplantation. A systematic review” (18) as a result, the quality of life after liver transplantation has improved compared to previous periods. In a study by Maria Ann Simpsin (2023) “Health-related Quality of Life After Liver Transplantation—An Important Goal, but One Definition (or Size) Does Not Fit All” health related quality of life after liver transplantation is influenced by drug choice, side effects, treatment waiting time, basic health khowledge, physical condition, and individual characteristics. These factors are thought to play an important role in the overall well-being of liver transplant recipients. (19) Nakao et.al (2016) conducted a health survey in 8 hospitals in Ulaanbaatar, Mongolia, in 2012-2013, using the SF36 assessment method to assess the health status of adults in Ulaanbaatar, a city with high air pollution. The results of the study showed that the quality of life questionnaire scores were high, and Cronbach’s alpha was above 0.7 in most subgroups, indicating that the questionnaire was reliable. (20) Our study did not compare the quality of life before liver transplantation with that of healthy controls, and this is important to investigate further. 5. Conclusion Compared with the overall health related quality of life assessment after liver transplantation, general physical function and general psychological indicators improved with increasing years after treatment. Compliance with ethical standards Disclosure of conflict of interest No conflict of interest to be disclosed. Statement of ethical approval The research methodology was discussed and approved by the Academic Council of the School of Public Health, Mongolian National University of Medical Sciences on May 31, 2022 (meeting no. 22/15). 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