Liver Recipients Are Not Sick But Tired

ROTTERDAM, The Netherlands, June 2 ? Two-thirds of liver transplant recipients complain of constant physical fatigue, and nearly half say they are severely fatigued, researchers here reported.

The feeling of physical exhaustion persisted up to 15 years after transplantation, and did not appear to lessen over time, wrote Rita van den Berg-Emons, Ph.D., of Erasmus Medical Center here, and colleagues.

"Liver transplant recipients experience physical fatigue and reduced activity rather than mental fatigue and reduced motivation," the investigators wrote in the June issue of Liver Transplantation. "These findings imply that rehabilitation programs, focusing on improving activity patterns and physical fitness, may reduce complaints of fatigue after liver transplantation."

They conducted a cross-sectional looking at the severity of fatigue in 96 patients who had undergone liver transplantation an average of 4.5 years previously (range 52 days to 15.4 years).

They also assessed the nature of the fatigue itself ? physical or mental ? and tried to determine its source.

To measure and evaluate exhaustion, the investigators used two validated instruments: the Fatigue Severity Scale and the Multidimensional Fatigue Inventory. They also considered variables such as age, gender, indication for transplantation, time since transplantation, immunosuppressive medication, patient-reported disability, and health-related quality-of-life measures.

They found that 66% of patients were fatigued, as measured by a Fatigue Severity Scale score of 4.0 or more, and 44% were rated as being severely fatigued, with a score of 5.1 or more.

When the authors looked at the nature of the fatigue as assessed by the Multidimensional Fatigue Inventory, a 20-item self-reported scale, they found that the patients had significantly higher scores (indicating more fatigue) on the physical fatigue and reduced activity subscales of the inventory than on either the reduced motivation or mental fatigue subscales.

Among the variables that significantly correlated with Fatigue Severity Scale score were age and gender, with women having more fatigue than men, and, not surprisingly, older liver graft recipients having more fatigue than younger recipients. The mean age of recipients was 51.8 (+ 12.7) years.

"Without adjustment for gender and age, time since transplantation, self-experienced disabilities, and health-related quality of life were significantly correlated with the severity of fatigue," the authors wrote.

But when they adjusted for both gender and age, they found that the relationship between time since transplantation and severity of fatigue was no longer significant. They did not find any associations between indication for liver transplantation or immunosuppressive medication and severity of fatigue.

"A previous study by our group using an activity monitor demonstrated that fatigued liver transplant recipients have a sedentary lifestyle," the investigators wrote. "These findings imply that fatigue after liver transplantation might be reduced with rehabilitation programs focusing on improving activity patterns and physical fitness."

In an accompanying editorial, Jayant A. Talwalkar, M.D., M.P.H. of the Mayo Clinic in Rochester, Minn., noted that the Dutch investigators did not look at psychological assessments of the patients or consider the roles that anxiety and depression might play in causing fatigue in transplant recipients.

"Depression is common in patients with chronic liver disease and confounds the relationship between fatigue and health-related quality of life," he wrote. "Similar interactions can occur in liver transplant recipients yet data on the frequency of psychiatric disturbance after liver transplant are scant."

Dr. van den Berg-Emons and colleagues are investigating relationships between severity of fatigue and depression, anxiety, sleep quality, complications after transplantation, and physical fitness of the recipient, they reported.