Integrative Review of Co-Occurring Symptoms Across Etiologies of Chronic Liver Disease and Implications for Symptom Management Research and Practice

Key wordsChronic liver disease, symptom clusters, symptom management, symptomsAbstractPurpose: Chronic liver disease affects over 30 million people worldwide, and despite advances in medical management that have increased survival, a majority of these individuals report multiple symptoms that severely impair function and quality of life. The purpose of this integrative review was to examine and summarize the current literature focused on self-reported symptoms in individuals with chronic liver disease in order to inform the development and delivery of symptom management strategies in clinical practice.Design and Methods: Combinations of search terms related to the symptom experience were used to search three electronic databases. Inclusion criteria were empirical studies that measured self-reported symptoms in populations with chronic liver disease published in English between 2003 and 2014. The literature search initially yielded 112 results; 26 quantitative studies met the inclusion criteria.Findings and Conclusions: The symptom of fatigue was commonly reported across chronic liver disease populations and was often found to co-occur with other distressing symptoms, including depression, sleep disturbance, pain, cognitive impairment, and dizziness associated with autonomic dysfunction. Due to the high prevalence and persistence of these "core" symptoms, the use of core symptom measures integrated longitudinally across populations would inform the development and delivery of symptom management interventions as well as enhance the ability of nurses to incorporate population-level symptom management programs.Clinical Relevance: Nurses play an important role in symptom assessment and may use the findings from the integrative review to incorporate core symptom measures across chronic liver disease populations and advance the development and delivery of symptom management interventions.Chronic liver disease (CLD) is a condition characterized by damage to hepatocytes that can alter normal liver function, with advanced stages of disease marked by fibrosis and cirrhosis (Lozano et al., 2012). The trajectory of CLD can originate from a wide range of etiologies, including viral hepatitis, autoimmune hepatitis, nonalcoholic fatty liver disease/nonalcoholic steatohepatitis (NAFLD/NASH), cholestatic diseases (primary biliary cirrhosis [PBC] and primary sclerosing cholangitis [PSC]), alcohol-related liver disease, as well as genetic conditions (hemochromatosis and alpha-1-antitrypsin deficiency). Importantly, NAFLD/NASH is now the number one cause of liver disease in Western countries, whereas the prevalence of other CLD subtypes have remained stable or even decreased (World Gastroenterology Organisation, 2012). Presently CLD is one of the ten leading causes of death worldwide and can affect all ages, genders, and racial and ethnic groups, as well as socioeconomic classes; however, lower socioeconomic groups and disadvantaged individuals are disproportionately affected (National Institutes of Health, 2009).Advances in the medical management of CLD have substantially improved the rate of survival by preventing or delaying disease progression; however, a majority of individuals living with CLD frequently report multiple symptoms that significantly impair quality of life and functional capacity (Elliot, Frith, Pairman, Jones, & Newton, 2011; Patanwala et al., 2010). The impact of these symptoms, which include fatigue and cognitive impairment, was once thought to be directly related to the pathophysiological consequences of cirrhosis and endstage liver disease (Swain, 2006). However, with more people living long-term with CLD, it is now recognized that symptoms can occur throughout the disease course, are frequently unrelated to disease severity, and often do not improve with treatment of the underlying disease process (Newton & Jones, 2012).Nurses play a significant role in the assessment of symptoms and provision of symptom management strategies for individuals with CLD. …