The Complex Relationship Between Pain, Mental Health, and Quality-Of-Life in Cirrhosis Patients Awaiting Liver Transplant

Introduction: Patients awaiting liver transplant have high rates of pain and anxiety/depression, both of which impair health-related quality-of-life (HRQL). We sought to explore the association between pain, anxiety/depression, and HRQL in cirrhosis patients undergoing liver transplant evaluation. Methods: Among 62 cirrhosis patients enrolled in an ongoing prospective cohort study (FrAILT), we performed 4 validated assessments to better characterize: pain (Brief Pain Inventory-Short Form, [BPI-SF]), anxiety (Generalize Anxiety Disorder-7, GAD-7), depression (Patient Health Questionnaire-8, PHQ-8), and liver-specific HRQL (Chronic Liver Disease Questionnaire, CLDQ). The BPI-SF is a well-validated survey that measures both severity of pain (severity subscale, PS) and the impact of pain on daily functions (interference subscale, PI). “Clinically significant pain” was a non-zero average of either PS or PI subscale. We used linear regression to identify demographic/clinical factors predictive of PS and PI, and to evaluate the association between pain, anxiety/depression, and HRQL. Results: Median age of our cohort was 54 (IQR 45-63); 44% were female and 82% were White. 45% had alcohol-related cirrhosis, 23% had HCC, 65% had ascites, and 53% had HE. 79% of patients had clinically significant pain; among whom median PS was 4/10 (IQR 3-6) and PI was 3/10 (IQR 1-6). 26% were clinically depressed (PHQ-8≥10) and 24% reported moderate-severe anxiety (GAD-7≥10). Demographic factors associated with increased pain (higher PS, PI, or both) included: younger age (bPS=-0.07, bPI=-0.8 per yr), high school education or less (bPS=1.5, bPI=2.2), and lack of a committed relationship (bPS = 1.83). Clinical factors associated with PI included frailty (bPI=1.3) and alcohol (vs-HCV)-related cirrhosis (bPI = 3.4); none were associated with PS. Depression/anxiety were correlated with pain (PI: r=0.7, PS: r=0.5). Neither liver disease severity (i.e. MELD-Na) nor its complications (i.e. HE, ascites) were associated with PS or PI. On multivariable regression, only depression—but not PS or any other covariate—was significantly associated with lower HRQL (badj=-0.23). Conclusion: Pain is present in nearly 80% of cirrhosis patients undergoing liver transplant evaluation. Depression occurs in 1/4 of cirrhosis patients: it is highly correlated with pain and appears to be a key driver of diminished HRQL in this population. Thus, mental health interventions should be explored as strategies for improving HRQL in cirrhosis patients with pain.