Cognitive Function, Self-Management, and Health Outcomes among Liver Transplant Recipients: the LivCog Cohort

项目摘要 这项研究将为新的肝移植受者的认知轨迹提供新的见解， 以及认知功能对自我管理、健康行为和患者结局的影响。 在北美，肝硬化和终末期肝病（ESLD）的患病率估计高达1，000%。 10万人口，在过去二十年中，婴儿潮一代（出生于1945-1965年）几乎翻了一番 占案件总数的一半。从2009年到2016年，美国肝硬化死亡率增加了65%。 失代偿期肝硬化的5年生存率仅为34-56%，肝移植（LT）是唯一的生命- 保存选项。到2033年，LT需求将增加23%，每位患者的LT相关成本将从1.4美元上升到1.5美元。 到210万美元，导致10年内与移植相关的医疗费用总计267亿美元 地平线为了最大限度地发挥LT的益处，肝移植受者（LTR）必须具有强大的自我管理能力 技能导航卫生系统，坚持临床监测，并采取复杂的，多种药物方案。所有 这些任务需要强大的认知能力来进行主动学习和解决问题。LTR的风险更高 对于由于移植前认知障碍（肝性脑病）的高患病率而导致的认知较差， 多种慢性疾病、饮酒和年龄增长。随着时间的推移，LTR的认知状态可能会影响 自我管理和移植结果，但这些问题尚未得到彻底调查。 我们提出的队列研究（“LivCog”）将使用NIH纵向表征认知性能 在来自3个不同移植中心的450个新LTR中进行筛选，从移植等待名单开始，然后在 LT后1、4、12和24个月。我们还将连续评估自我管理技能、身体功能、健康 行为、患者报告和临床结局。移植后可能改变的目标将是 调查，包括照顾者的支持，体力活动，睡眠和治疗依从性，以了解因果关系 这些途径可以为未来的卫生系统反应提供信息。我们的具体目标是：1）评估LT前到LT后 认知轨迹，并确定持续性认知障碍的风险因素，2）评估相关性 认知功能与自我管理技能、健康行为、功能性健康状况以及 移植结果，以及3）调查认知功能之间的潜在中介和调节因素 功能和移植后结果。我们提出的LivCog研究将填补理解的关键空白 认知恢复和功能，风险因素和LTR中认知障碍的后果。结果 将直接为未来的干预措施提供信息，以改善移植后的结果。

PROJECT SUMMARY This study will provide novel insights on cognitive trajectories among new liver transplant recipients, and the impact of cognitive function on self-management, health behaviors, and patient outcomes. The prevalence of cirrhosis and end-stage liver disease (ESLD) in North America is estimated at up to 1,000 per 100,000 population and has nearly doubled over the past two decades with baby boomers (born 1945-1965) accounting for half of cases. From 2009 to 2016, there has been a 65% increase in cirrhosis mortality in the U.S. Decompensated cirrhosis has a 5-year survival of only 34-56% with liver transplantation (LT) as the only life- saving option. By 2033, LT demand will increase by 23% and per-patient LT-associated costs will rise from $1.4 to $2.1 million, resulting in a total of $26.7 billion in transplant-related medical expenses over a 10-year time horizon. To maximize the benefits of LT, liver transplant recipients (LTRs) must have strong self-management skills to navigate health systems, adhere to clinical monitoring, and take complex, multi-drug regimens. All of these tasks require formidable cognitive abilities for active learning and problem solving. LTRs are at higher risk for poorer cognition due to high prevalence of pre-transplant cognitive impairment (hepatic encephalopathy), multiple chronic conditions, alcohol use, and increasing age. The cognitive status of LTRs over time could affect self-management and transplant outcomes, yet these issues have not been thoroughly investigated. Our proposed cohort study (`LivCog') will longitudinally characterize cognitive performance using the NIH Toolbox among 450 new LTRs from 3 diverse transplant centers, beginning at transplant waitlisting and then at 1, 4, 12, and 24 months post-LT. We will also serially assess self-management skills, physical function, health behaviors, patient-reported and clinical outcomes. Potentially modifiable post-transplant targets will be investigated, including caregiver support, physical activity, sleep, and treatment adherence to understand causal pathways that could inform future health system responses. Our specific aims are to: 1) assess pre to post-LT cognitive trajectories and identify risk factors for persistent cognitive impairment, 2) evaluate associations between cognitive function and self-management skills, health behaviors, functional health status, and post- transplant outcomes, and 3) investigate potential mediators and moderators of associations between cognitive function and post-transplant outcomes. Our proposed LivCog study will fill critical gaps in understanding cognitive recovery and function, risk factors and consequences of cognitive impairment among LTRs. Findings will directly inform future interventions to improve post-transplant outcomes.