Social support and risk of mortality in cirrhosis: A cohort study

Gro Askgaard; Lone Galmstrup Madsen; Natasja von Wowern; Matilde Winther-Jensen; Cathrine Juel Lau; Anne Illemann Christensen; Colin Crooks; Joe West; Peter Jepsen

doi:10.1016/j.jhepr.2022.100600

Social support and risk of mortality in cirrhosis: A cohort study

JHEP Rep. 2022 Oct 3;5(1):100600. doi: 10.1016/j.jhepr.2022.100600. eCollection 2023 Jan.

Authors

Gro Askgaard^{1

2

3}, Lone Galmstrup Madsen², Natasja von Wowern², Matilde Winther-Jensen³, Cathrine Juel Lau³, Anne Illemann Christensen⁴, Colin Crooks^{5

6}, Joe West^{5

7

8}, Peter Jepsen^{1

8}

Affiliations

¹ Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.
² Section of Gastroenterology and Hepatology, Medical Department, Zealand University Hospital, Køge, Denmark.
³ Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Frederiksberg, The Capital Region, Denmark.
⁴ National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark.
⁵ Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, UK.
⁶ NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK.
⁷ Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK.
⁸ Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.

Abstract

Background & aims: The function and structure of social relationships influence mortality in individuals within the general population. We compared aspects of social relationships in individuals with cirrhosis and a matched comparison cohort and studied their association with health-related quality of life (HRQoL) and mortality in cirrhosis.

Methods: Individuals with cirrhosis and comparators were identified among participants of the Danish National Health Surveys 2010-2017. The surveys included questions on functional (social support and loneliness) and structural (living alone/cohabitating and frequency of contacts with relatives and friends) aspects of social relationships and HRQoL (Short Form-12). We estimated associations of aspects of social relationships with HRQoL and all-cause mortality in individuals with cirrhosis through 2020.

Results: Of 541 individuals with cirrhosis and 2,157 comparators, low social support (22% in cirrhosis vs. 13% in comparators), loneliness (35% vs. 20%), and living alone (48% vs. 22%) were more frequent in individuals with cirrhosis than comparators, whereas the frequency of contacts with relatives and friends was similar. Except for living alone, weak functional and structural social relationships were associated with lower mental HRQoL in those with cirrhosis. Physical HRQoL was only marginally associated with social relationships. During 2,795 person-years of follow-up, 269 individuals with cirrhosis died. Functional and not structural aspects of social relationships were associated with risk of mortality in cirrhosis. Specifically, the adjusted hazard ratio was 1.4 (95% CI 1.1-1.9), p = 0.011, for low vs. moderate-to-high social support (functional aspect), and 1.0 (95% CI 0.8-1.3), p = 0.85 for living alone vs. cohabitating (structural aspect).

Conclusions: Individuals with cirrhosis have weaker functional and structural social relationships than matched comparators. Weak functional relationships are associated with lower mental HRQoL and increased risk of mortality in individuals with cirrhosis.

Impact and implications: This study investigated the prevalence of weak social relationships in individuals with cirrhosis and their influence on health-related quality of life and risk of mortality. Individuals with cirrhosis were nearly twice as likely to report low social support, loneliness, and to live alone than a matched comparison cohort. Low social support and loneliness (functional measures of social relationships) were associated with lower mental health-related quality of life and increased risk of mortality risk in cirrhosis, when adjusting for known confounders. We hope that these results will make healthcare providers aware of the functional aspects of the social relationships of individuals with cirrhosis, in addition to the traditional clinical management, and motivate further research of interventions to strengthen the social support of individuals with cirrhosis.

Keywords: Alcohol-related liver disease; CCI, Charlson Comorbidity Index; Cirrhosis; Cohort study; DNHS, Danish National Health Surveys; HR, Hazard Ratio; HRQoL, Health-Related Quality of Life; ICD-10, International Classification of Diseases, Tenth Revision; ISCED, International Standard Classification of Education; Mortality; SF-12, Short Form-12; Social relationships; Social support.