Systematic Review and Meta-analysis of Factors related to Functional Status of People with Liver Cirrhosis

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Surachai Maninet
Yupin Aungsuroch
Chanokporn Jitpanya


                 Functional status decline is a frequent problem reported by people with liver cirrhosis. This causes difficulty maintaining defined tasks in terms of physical, psychological, social, and role functioning. Previous studies reported that several factors related to the functional status of people with liver cirrhosis. However, research results remain inconsistent, and the magnitude of relationships of each factor and functional status among people with liver cirrhosis is less likely to share information. Therefore, this study aimed to explore the pooled effect size of factors related to functional status of people with liver cirrhosis across studies. A systematic review and meta-analysis were conducted in 2021 utilizing PRISMA guidelines to report the study. Databases including Ovid, MEDLINE, CINAHL, Embase, PubMed, PsycINFO, Scopus, Science Direct, ProQuest, and Google Scholar were searched. The studies published from the establishment of each database to February 2021 were reviewed. The quality of the selected articles was evaluated utilizing the Newcastle-Ottawa Scale.

                 Ten studies met the inclusion criteria, involving a total of 1,189 participants. Existing variables were categorized into nonmodifiable and potentially modifiable factors. Age, severity of disease, and hemoglobin levels were the nonmodifiable factors that had moderate relation with functional status. For modifiable factors, illness perception and fatigue, were found to have a moderate association with functional status. The findings indicate that healthcare personnel should emphasize minimizing fatigue and negative illness perception to improve functional status among people with liver cirrhosis. Those with older age, severe disease, and a low level of hemoglobin are more vulnerable to functional status decline.

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Maninet S, Aungsuroch Y, Jitpanya C. Systematic Review and Meta-analysis of Factors related to Functional Status of People with Liver Cirrhosis. PRIJNR [Internet]. 2021Sep.3 [cited 2021Oct.20];25(4):639-52. Available from:
Original paper


1. Low, J. T., Rohde, G., Pittordou, K., Candy, B., Davis, S., Marshall, A., & Stone, P. (2018). Supportive and palliative care in people with cirrhosis: international systematic review of the perspective of patients, family members and health
professionals. J Hepatol. 2018, 69(6):1260-73. doi:

2. Tapper EB, Kanwal F, Asrani SK, Ho C, Ovchinsky N, Poterucha J, et al. Patient‐reported outcomes in cirrhosis: a scoping review of the literature. Hepatology. 2018, 67(6):2375-83. doi:

3. de Lima DC, Ribeiro HS, Cristina R, Oliveira M, de Vasconcelos Generoso S, Lima AS, et al. Functional status and heart rate variability in end-stage liver disease patients: association with nutritional status. Nutrition. 2015, 31(7-8):
971-4. doi:

4. Dhar P, Greenslade L, Westbrooke RH, Jackson CD, Marshall A, Morgan MY. Relationship between nutritional status, disease severity and indices of functional decline in patients with cirrhosis. Clin Nutr ESPEN. 2019, 29:248 –83. doi:

5. Orman E, Ghabril M, Chalasani N. Poor performance status is associated with increased mortality in patients with cirrhosis. Clin Gastroenterol Hepatol. 2016, 14(8):1189-95. doi:10.1016/j.cgh.2016.03.036.

6. Zenith L, Meena N, Ramadi A, Yavari M, Harvey A, Carbonneau M, et al. Eight weeks of exercise training tncreases aerobic capacity and muscle mass and reduces fatigue in patients with cirrhosis. Clin Gastroenterol Hepatol. 2014, 12(11):
1920-6 .e2. doi: 10.1016/j.cgh.2014. 04.016.

7. Wu LJ, Wu MS, Lien GS, Chen FC, Tsai JC. Fatigue and physical activity levels in patients with liver cirrhosis. J Clin Nurs. 2011, 21(2):129-38. doi: 10.1111/j.1365-2702. 2011.03900.

8. Fagerström C, Frisman GH. Living with liver cirrhosis: a vulnerable life. Gastroenterol Nurs. 2017, 40(1):38-46.doi:10.1097/SGA.0000000000000158.

9. Jijomon P, Lobo J, Castelino F. Correlates of quality of life patients with cirrhosis of liver admitted in selected hospitals of Udupi Taluk, Karnataka. Indian J Public Health. 2017, 8(4):362-6. doi:10.5958/0976-5506.2017.00370.9.

10. McCabe P, Wong RJ. More severe deficits in functional status associated with higher mortality among adults awaiting liver transplantation. Clin Transplant. 2018, 32(9):1-10. doi: 10.1111/ctr.13346.

11. Bajaj J, Wade J, Gibson D, Heuman D, Thacker L, Sterling R, et al. The multi-dimensional burden of cirrhosis and hepatic encephalopathy on patients and caregivers. Am J Gastroenterol. 2011, 106(9):1646-53. doi: 10.1038/ajg.2011.157.

12. Lai JC, Dodge JL, Sen S, Covinsky K, Feng S. Functional decline in patients with cirrhosis awaiting liver transplantation: results from the functional assessment in liver transplantation (FrAILT) study. Hepatology 2016, 63(2):574-80. doi:10.1002/hep.28316.

13. Chirapongsathorn S, Talwalkar JA, Kamath PS. Readmission in cirrhosis: a growing problem. Curr Treat Options Gastroenterol. 2016, 14(2):236-346. doi: 10.1007/s11938-016-0091-1.

14. Serper M, Bittermann T, Rossi M, Goldberg DS, Thomasson AM, Olthoff KM, et al. Functional status, healthcare utilization, and the costs of liver transplantation. Am J Transplant. 2018, 18(5):1187-96. doi: 10.1111/ajt.14576.

15. Nishikawa H, Kita R, Kimura T, Ohara Y, Sakamoto A, Saito S, et al. Clinical implication of performance status in patients with hepatocellular carcinoma complicating with cirrhosis. J Cancer. 2015, 6(4):394-402. doi:10.7150/jca.11212.

16. Park YH, Lee EN. A study of fatigue and daily living activity in patients with chronic liver disease. Korean J Rehabil Nurs. 2005, 8(2):110-8.

17. Alameri HF, Sanai FM, Al Dukhayil M, Azzam NA, Al-Swat KA, Hersi AS, et al. Six -minute walk test to assess functional capacity in chronic liver disease patients. World J Gastroenterol. 2007,13(29):3996-4001. doi:10.3748/wjg.v13. i29.3996.

18. Loria A, Doyle K, Weinstein AA, Winter P, Escheik C, Price J, et al. Multiple factors predict physical performance in people with chronic liver disease. Am J Phys Med Rehabil. 2014, 93(6):470-6. doi:10.1097/PHM.0000000000000050.

29. Dela Cruz AC, Vilchez V, Kim S, Barnes B, Ravinuthala A, Zanni A, et al. A prospective analysis of factors associated with decreased physical activity in patients with cirrhosis undergoing transplant evaluation. Clin Transplant. 2015, 29(11): 958-64. doi:

20. Weinstein AA, Diao G, Baghi H, Escheik C, Gerber LH, Younossi ZM. Demonstration of two types of fatigue in subjects with chronic liver disease using factor analysis. Qual Life Res. 2017, 26(7):1777-84. doi:10.1007/s11136-017-1516-6.

21. Elliott C, Frith J, Day CP, Jones DE, Newton JL. Functional impairment in alcoholic liver disease and non-alcoholic fatty liver disease is significant and persists over 3 years of follow-up. Dig Dis Sci. 2013, 58(8):2383-91. doi:10.1007/s10620-013-2657-2.

22. Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & the PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Annals Int Med. 2009, 151:264–9.

23. Wells GA, Shea B, O’Connell D, Peterson J, Welch V, Losos M, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses 2000. Available from:

24. Moskalewicz A, & Oremus M. No clear choice between Newcastle–Ottawa Scale and Appraisal Tool for Cross-Sectional Studies to assess methodological quality in cross-sectional studies of health-related quality of life and breast cancer.
J Clin Epidemiol. 2020, 120: 94-103. doi: https://doi. org/10.1016/j.jclinepi.2019.12.013

25. Field AP. Meta-analysis of correlation coefficients: a Monte Carlo comparison of fixed-and random-effects methods. Psycho Methods. 2001, 6(2):161-212. doi:

26. Higgins JP, Thompson SG. Quantifying heterogeneity in a meta‐analysis. Stat Med. 2002;21(11):1539-58. doi:

27. Portney LG, Watkins MP. Foundations of clinical research: applications to practice. 3rd ed. New York: Pearson; 2009.

28. Egger M, Davey-Smith G, Altman D. Systematic reviews in health care: meta-analysis in context: John Wiley & Sons; 2008.

29. Galant L, Junior F, Luiz A, Dias AS, Marroni CA. Functional status, respiratory muscle strength, and quality of life in patients with cirrhosis. Braz J Phys Ther. 2012, 16(1):30-4.

30. Kotarska K, Wunsch E, Kempińska-Podhorodecka A, Raszeja-Wyszomirska J, Bogdanos DP, Wójcicki M, et al. Factors affecting health-related quality of life and physical activity after liver transplantation for autoimmune and nonautoimmune
liver diseases: a prospective, single centre study. J Immunol Res. 2014, 14(2):1-10. doi:

31. Langston S, Edwards MS, Lyvers M. Illness perceptions, coping, benefit finding, and adjustment in individuals with hepatitis C. Aust Psychol. 2018, 53(1):87-96. doi:10.1111/ap.12255.

32. Fan SY, Eiser C, Ho M C., & Lin CY. Health‐related quality of life in patients with hepatocellular carcinoma: the mediation effects of illness perceptions and coping. Psycho‐Oncology. 2013, 22(6):1353-60.

33. Sobhonslidsuk A, Silpakit C, Kongsakon R, Satitpornkul P, Sripetch C, Khanthavit A. Factors influencing health-related quality of life in chronic liver disease. World J Gastroenterol. 2006, 12(48):7786-91. doi: 10.3748/wjg.v12.i48.7786.

34. de Valle MB, Rahman M, Lindkvist B, Björnsson E, Chapman R, Kalaitzakis E. Factors that reduce health-related quality of life in patients with primary sclerosing cholangitis. Clin Gastroenterol Hepatol. 2012;10(7):769-75. doi:

35. Nardelli S, Pentassuglio I, Pasquale C, Ridola L, Moscucci F, Merli M, et al. Depression, anxiety and alexithymia symptoms are major determinants of health-related quality of life (HRQoL) in cirrhotic patients. Metab Brain Dis. 2013;28(2):239-43. doi:10.1007/s11011-012-9364-0.

36. Kim, Seo S. Factors influencing on quality of life in patients with liver cirrhosis: convergence on the theory of unpleasant symptoms. J Digit Converg. 2015,13(4): 271-81.

37. Yadav A, Chang YH, Carpenter S, Silva AC, Rakela J, Aqel BA, et al. Relationship between sarcopenia, six‐minute walk distance and health‐related quality of life in liver transplant candidates. Clin Transplant. 2015, 29(2):134-41. doi:

38. Carey EJ, Steidley DE, Aqel BA, Byrne TJ, Mekeel KL, Rakela J, et al. Six‐minute walk distance predicts mortality in liver transplant candidates. Liver Transpl. 2010, 16(12):1373-8. doi:

39. Les I, Doval E, Flavia M, Jacas C, Cardenas G, Esteban R, et al. Quality of life in cirrhosis is related to potentially treatable factors. Eur J Gastroenterol Hepatol. 2010, 22(2):221-7. doi: 10.1097/MEG.0b013e3283319975.

40. Aadahl M, Hansen BA, Kirkegaard P, Groenvold M. Fatigue and physical function after orthotopic liver transplantation. Liver Transpl. 2002, 8(3):251-9. doi:

41. Patidar KR, Thacker LR, Wade JB, White MB, Gavis EA, Fagan A, et al. Symptom domain groups of the patient-reported outcomes measurement information system tools independently predict hospitalizations and re-hospitalizations in cirrhosis.
Dig Dis Sci. 2017, 62(5):1173-9. doi:10.1007/s10620-017-4509-y.

42. Untas A, Boujut E, Corpechot C, Zenasni F, Chazouillères O, Jaury P, et al. Quality of life and illness perception in primary biliary cirrhosis: a controlled cross-sectional study. Clin Res Hepatol Gastroenterol. 2015, 39(1):52-58. doi:https://