Prospective Cohort Study of Disease and Outcomes in Cirrhosis

INTRODUCTION In Denmark the incidence of liver cirrhosis is increasing. From 1996 to 2005 the number of hospital admissions due to liver cirrhosis rose with 2,500 extra admissions per year. Patients who are readmitted to the hospital have a higher 90 days mortality than those who avoid readmission.

Liver cirrhosis in Denmark is caused by a wide use of alcohol and a population increasing in age and BMI.

The course of cirrhosis depends on etiology, age and nutritional status, as well as social factors such as personal network, employment and economy. Interventional studies on many of these mechanisms are still unexplored.

Cirrhosis is related to decreased quality of life and affects patients and relatives both emotional and socioeconomically.

The Gastro Unit, Amager Hvidovre Hospital has a catchment area of 550,000 citizens in South and West of Copenhagen. The Gastro Unit diagnoses app. 140 people with liver cirrhosis yearly.

Patient education and rehabilitation is implemented as standard health care after significant pulmonary or cardiac disease in all regions of Denmark.

HYPOTHESIS A systematic approach to investigation, treatment and rehabilitation in liver cirrhosis will improve the patient's ability to benefit from medical treatment and health care offers and increase patient involvement and autonomy in disease.

A systematic approach to investigation of liver disease will contribute to identify new risk factors for death, hospital admission and readmission, and decompensation in liver cirrhosis.

Better knowledge on sociodemographic features, use of health care resources and the patient's physical performance and frailty will improve new actions of personalized treatment, interventions focusing on patient needs and patient reported outcomes in cirrhosis.

Primary outcome The primary aim for this prospective cohort study is to improve characterization, treatment and rehabilitation under and after admission of patients with liver cirrhosis, with the purpose of improving survival and reducing risk of readmission.

Secondary outcomes

• To identify 'frail patients' and to improve their access to health care offers.
• To improve the utilization of health care resources by a systematic approach to patient characterization and treatment.
• To identify co-factors with importance for early death and readmission.
• To identify and explore new targets for treatment and symptom-relief in liver cirrhosis.

METHODS The cohort study will apply an observational prospective incidence cohort design in which patients will be followed from diagnosis to death or withdrawal from the cohort. Participants will be enrolled consecutively within six months of diagnosis.

TRIAL FLOW The standardized investigational program includes procedures recommended by National- and European guidelines for complications in liver cirrhosis, applied at the Gastro Unit, Medical Division, Amager Hvidovre Hospital.

The standard investigational program will be initiated within six months of inclusion. To avoid repetition of invasive diagnostic procedures (e.g. upper endoscopy, CT scan or ultrasound), we will accept retrospective inclusion of data, dating back to time of diagnosis (maximum six months).

Standard biochemistry will be performed at inclusion and at follow-up after 1,2,3 and 5 years.

Bio Impedance Assessment will be performed at inclusion and at follow up after 1,2,3 and 5 years.

Assessments of socio demography, loneliness and quality of life will be performed through the following questionnaires:

1. A specific questionnaire assessing socio demography, economic status and use of health care resources is designed for the trial.
2. Three item loneliness scale
3. Alcohol use by Audit C
4. Health related quality of life in cirrhosis by: Chronic Liver Disease Questionnaire (CLDQ).
5. Functional disability in work-, social- and family life by: Sheehan Disability Scale (SDS).

Information will be retrieved from the participant's medical record concerning:

• Dates and length of hospitalization.
• Reason for hospitalization.
• Diagnosis.
• Biochemistry.
• Results from endoscopic procedures.
• Results from ultrasound, CT scan, and if applied, MR scan.
• Results from Dexascan.

BIO BANK FOR FUTURE RESEARCH For this study a research bio bank for future research will be established. The bio bank will contain blood, liver tissue and stool.

The bio bank is registered separately by The Danish Data Protection Agency.

DATA A database in Redcap will be established for the study. Questionnaires will be answered electronically on an Ipad exporting data directly to Redcap. The Redcap database will use study ID numbers and initials for identification of participants. An identification list of all participants will be stored separately.

Investigators aim to publish all results derived from this trial. The investigators support open acces policy, and at the end of the trial, all data will be sought published in anonymous form.

ETHICS The study is approved by the Scientific Ethics Committees of the Capital Region of Denmark and The Danish Data Protection Agency before initiation.

A thorough characterization and consecutive inclusion will strengthen our knowledge on the incidence, prevalence and impact of liver disease in the population, and the use of health care resources allocated to liver disease.

The study will contribute to the finding of formerly unidentified risk factors with importance for survival and use of health care services; and thereby form the basis of implementation of changes in health practices, with both economic and medical gain. The study may also identify new areas for interventional research, with clinically relevant endpoints that can be translated into favorable changes in health care practice.