Improvement of Rehabilitation Measures Based on the Analysis of Functional Impairments and Activity Limitations in Persons with Disabilities Due to Liver Cirrhosis in the Republic of Dagestan

Liver cirrhosis is a polyetiological disease characterized by a chronic, progressive course, involving damage to the parenchymal and interstitial tissues of the organ against the background of hepatocyte necrosis, followed by nodular regeneration and diffuse proliferation of connective tissue. These processes lead to disruption of the organ architectonics and the development of functional insufficiency [2].

Liver diseases remain a serious public health problem in Russia and worldwide. At present, they occupy one of the leading positions among the causes of population disability and are among the ten most frequent causes of death. In the age group of 20–40 years, mortality from liver cirrhosis exceeds that from ischemic heart disease. Despite modern advances in intensive care and transplantology, mortality rates associated with the development of liver failure remain high, and the World Health Organization predicts that mortality from liver diseases will double over the next 10–20 years. Currently, there are approximately 200 million patients with chronic liver diseases worldwide, about 30% of whom have liver cirrhosis [1].

According to a large international study on the global prevalence of liver cirrhosis across 195 countries from 1990 to 2017, cirrhosis accounted for more than 1.32 million deaths worldwide in 2017 (including 440,000 among women and 883,000 among men), representing 2.4% of all deaths [12,13]. Russia ranks fourth globally in terms of the increase in mortality from liver cirrhosis. Over the past 30 years, an increase in the detection of decompensated cirrhosis has been observed [11,14,15,16,17]. Liver cirrhosis is a progressive pathology leading to persistent activity limitations and mortality among individuals of working age [8]. In the contemporary literature, the assessment of rehabilitation potential and rehabilitation prognosis in patients with liver cirrhosis who have undergone medical and social assessment remains insufficiently studied [3,4,5,6,7,9,10].

Aim of the study. To assess the degree of activity limitations in persons with disabilities due to liver cirrhosis based on clinical and functional impairments.

The largest proportion consisted of individuals with disability group II – 132 persons (44%); the share of individuals with disability group III was 27.3% (82 persons), disability group I – 66 persons (22%), and disability since childhood – 6.7% (20 persons).

Analysis of the etiological factors of liver cirrhosis showed that viral etiology was identified in 234 patients, accounting for 78% of cases, including chronic viral hepatitis C in 161 patients (53%), chronic viral hepatitis B in 84 patients (28%), and chronic viral hepatitis D in 30 patients (10%). Liver cirrhosis of toxic etiology was observed in 31 patients (10%). Liver cirrhosis of unknown and mixed etiology was identified in 15 (5%) and 12 patients (4.0%), respectively.

Figure 1. Dendrogram of clinical symptoms in liver cirrhosis

The dendrogram presents three clusters of clinical symptoms. The first cluster is dominated by complaints associated with the underlying disease: jaundice, pruritus, dyspeptic syndrome, and malabsorption syndrome. The second cluster includes complaints related to cardiovascular disorders: spider angiomas and palmar erythema. The third cluster encompasses the following complaints: coagulation disorders, encephalopathy, esophageal varices, ascites, edema, and portal hypertension syndrome (Figure 1).

The most common clinical and functional indicators used to assess the severity of persistent impairments of body functions in persons with disabilities were analyzed. The main clinical symptoms were represented by portal hypertension syndrome (75%), malabsorption syndrome (49%), dyspeptic syndrome (49%), ascites (46%), encephalopathy (41%), esophageal varices (38%), coagulation disorders (30%), pruritus (19%), edema (16%), spider angiomas (14%), jaundice of the skin and sclera (9.3%), and palmar erythema (4.7%) (Table 1).

Table 1. Main clinical signs in individuals with disabilities due to liver cirrhosis (n; %)

Digestive system dysfunction was moderate in 31% of cases, pronounced in 44%, and severe in 22.0%.

Neuromuscular, skeletal, and statodynamic functions related to movement were moderate in 1.3% of cases, pronounced in 1.3%, and severe in 2.7%.

Cardiovascular system dysfunction was moderate in 3.7% of cases and pronounced in 1.3%.

Hematologic and immune system dysfunction was moderate in 2.0% of cases, pronounced in 4.7%, and severe in 3.3%.

Mental function impairment was moderate in 1.0% of cases and pronounced in 2.0%.

Overall functional impairments were moderate in 33.0% of cases, pronounced in 45.0%, and severe in 22.0% (Table 2).

Table 2. Characteristics of impaired body functions in individuals with disabilities due to liver cirrhosis by severity (n; %)

Table 3. Correlations between cardiovascular system impairments and clinical symptoms (n; %)

The study revealed statistically significant correlations between complaints and cardiovascular system dysfunction. Pruritus was observed in 5 individuals (45.5%) with moderate dysfunction, showing a weak correlation (r = 0.13; p ≤ 0.019). Edema was noted in 4 individuals (36.4%) with moderate cardiovascular dysfunction and in 100% of cases with pronounced dysfunction (r = 0.28; p < 0.001). Dyspeptic syndrome was present in 81.9% of cases (9 individuals) with moderate dysfunction and in 25% of cases with pronounced dysfunction (r = 0.12; p < 0.012) (Table 3).

Table 4. Correlations between digestive system impairments and clinical parameters (n; %)

As shown in Table 4, jaundice was reported in 3.2% of cases with moderate digestive system dysfunction, in 15.2% with pronounced dysfunction, and in 7.5% with severe dysfunction, showing a weak correlation (r = 0.11; p = 0.03). Encephalopathy was observed in 19.1% of cases (18 individuals) with moderate dysfunction, in 45.5% (60 individuals) with pronounced dysfunction, and in 65.7% (44 individuals) with severe dysfunction (r = 0.36; p < 0.001). Esophageal varices were recorded in 44.7% of cases with pronounced digestive dysfunction and in 62.7% with severe dysfunction (r = 0.38; p < 0.001). Ascites was observed in 10.6% of patients with moderate dysfunction, in 49.2% with pronounced dysfunction, and in 92.5% with severe digestive dysfunction (r = 0.53; p < 0.001), indicating a moderate positive correlation. Portal hypertension syndrome was noted in 42.6% of cases (40 individuals) with moderate dysfunction, in 87.9% (116 individuals) with pronounced dysfunction, and in 98.5% (66 individuals) with severe digestive dysfunction, showing a moderate positive correlation (r = 0.51; p < 0.001).

Table 5. Correlations between hematologic and immune system impairments and clinical parameters (n; %)

Table 5 presents the statistical values of correlation indicators between clinical data and dysfunction of the hematologic and immune systems. Encephalopathy was observed in 33.3% of cases (2 individuals) with moderate dysfunction, in 50% with pronounced dysfunction, and in 90% with severe dysfunction, showing a weak positive correlation (r = 0.14; p = 0.008). Ascites was noted in 16.7% of cases with moderate dysfunction, in 64.3% with pronounced dysfunction, and in 90% with severe dysfunction (r = 0.12; p < 0.005). Edema was recorded in 33.3% of cases with moderate dysfunction, in 21.4% with pronounced dysfunction, and in 80% with severe dysfunction of this system, showing a weak positive correlation (r = 0.26; p < 0.001).

Table 6. Correlations between overall functional impairments and clinical parameters (n; %)

Overall functional impairments were pronounced and severe in 14.8% (20 individuals) and 7.5% (5 individuals), respectively, among persons with jaundice. In individuals with encephalopathy, overall functional impairments were pronounced in 44.4% and severe in 64.2% (r = 0.33; p < 0.001). Pronounced overall functional impairments were observed in 44.4% (60 individuals) and 61.2% (41 individuals) of persons with esophageal varices (r = 0.37; p < 0.001). Pronounced and severe overall functional impairments were noted in 49.2% and 91.0%, respectively, among individuals with ascites (r = 0.59; p < 0.001). Among persons with portal hypertension syndrome, pronounced overall functional impairments were recorded in 87.4% and severe in 98.5% (r = 0.51; p < 0.001) (Table 6).

Table 7. Statistically significant correlations between functional impairments in patients with liver cirrhosis and limitations in activities of daily living

A strong positive correlation was observed between digestive system dysfunction and limitations in work-related activities (r = 0.91). A moderate positive correlation was found between digestive system dysfunction and limitations in self-care (r = 0.62) and mobility (r = 0.61). Overall functional impairments in individuals with disabilities showed a moderate positive correlation with self-care and mobility (r = 0.67 and r = 0.63, respectively), and a strong positive correlation with work-related activities (r = 0.92) (Table 7).

Table 8. Characteristics of activity limitations in patients with liver cirrhosis according to severity (n; %)

It was found that among individuals with disabilities due to liver cirrhosis, mobility limitations were of the first degree in 55% of cases, second degree in 27%, and third degree in 7.3%. Limitations in self-care were of the first degree in 60% of cases, second degree in 26%, and third degree in 9.0%. Limitations in work-related activities were of the first degree in 28% of cases, second degree in 44%, and third degree in 22% (Table 8).

Analysis of body function impairments and corresponding limitations in activities of daily living due to liver cirrhosis showed that the most prevalent clinical symptoms in these patients were: portal hypertension syndrome – 75%, malabsorption syndrome – 49%, dyspeptic syndrome – 49%, ascites – 46%, encephalopathy – 41%, and esophageal varices – 38%. Digestive system dysfunction was moderate in 31% of cases, pronounced in 44%, and severe in 22.0%. Neuromuscular, skeletal, and statodynamic functions related to movement were moderate in 1.3% of cases, pronounced in 1.3%, and severe in 2.7%. Overall functional impairments were moderate in 33.0% of cases, pronounced in 45.0%, and severe in 22.0%.

Among the categories of activity limitations, first-degree limitations in mobility and self-care and second-degree limitations in work-related activities were most frequently observed. Conducting an individual assessment of functional impairments in individuals with disabilities due to liver cirrhosis, who have undergone initial and repeated examinations at the Bureau of Medical and Social Expertise, will allow for more effective planning of the scope of examinations, medical care, and rehabilitation services, thereby contributing to improved quality of care for patients with this condition.

Author contributions: Concept development – Zapariy N.S., Mamaev S.N.; statistical data processing – Ramazanov Sh.R.; writing and editing of the manuscript – Ramazanov Sh.R.; selection and review of publications on the research topic – Ramazanov Sh.R.; manuscript review and editing – Ramazanov Sh.R.,

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