Reintegration into working life after Liver Transplantation: are there predictors of unemployment?

Background

The reintegration of liver transplant (LT) recipients into the workforce remains a key objective, yet specific recommendations to guide this process are still lacking. The BRIC-2022-ID25 project explores how liver disease and transplantation affect employability, analyzing the interplay of clinical, social, and occupational variables before and after LT, with the goal of improving return-to-work outcomes.

Methods

In collaboration with the occupational medicine department, we enrolled all patients who underwent LT at our center between 2018 and 2023, aged 18 to 68 years, who were not retired prior to LT. Participants completed the WHODAS 2.0 (World Health Organization Disability Assessment Schedule) and Work Ability Index (WAI) questionnaires, with results merged with clinical and occupational data from both pre- and post-LT follow-up. Patients were interviewed between January and December 2024. Univariate and multivariate analysis were performed following 3 outcomes: 1) Return to work, 2) Current work ability (WAS) and total WAI, 3) Disability score (WHODAS).

Results

From 2018 to 2023 918 LT were performed; 163/918 (18%) were excluded for age, 77/918 (8%) because they died before the study, 161/918 (17%) already retired before transplant, 55/918 (6%) because never worked before and after LT for personal choice; 181/918 (20%) refused to participate or were excluded for other reasons. 281/918 (31%) agreed to participated. The 83% of partecipants had cirrhosis (viral 40%; alcoholic 15%; 42% with hepatocellular carcinoma – HCC), 11% hepatic/hepatorenal polycistosis, 6.4% other indication to LT. 8% received a combined LT (mostly kidney). The mean age at interview was 55 years (range 24-68), with 65% males and an average of 44 months between LT and the interview. Notably, 55% had a middle-school education, while 25% had a university degree. 90% were Italian; 72% lived in the same region of the transplant center. 66% identified as caregiver his/her partner, 30% another relative/parents. Outcome 1: the overall return-to-work rate was 0.36 (95% CI: 0.30–0.41) at 6 months, reaching a maximum of 0.64 (95% CI: 0.57–0.70) at 36 months. Men return to work more rapidly and in a greater proportion than women (Log-Rank test, p-value < 0.001). Post-LT, 39% were unemployed, with 64% indicating health issues as a barrier to their job search. At univariate analysis, significant correlations were found between unemployment and factors such as age >59 years (p=0.049), having a caregiver outside the household (p=0.01), middle-school education (p=0.04), a longer waiting list time (p=0.02). At multivariate analysis, male sex (OR 3.6, p=0.001), Age > 59 y (OR 0.015, p=0.01), university degree (OR 5.6, P=0.006), caregiver outside the household (OR 0.3, p=0.001) were independent predictor for return-to-work.Outcome 2: low self-assessment of work ability (WAS) correlated with age >59 years old (p=0.01), both active (p=0.01) and previous (p=0.003) smoking, lower education levels (p=0.04). At multivariate analysis, smoking (p=0.005) and educations levels (p=0.047) were confirmed. The total WAI score (applicable only in working patients) was higher in Italian patients (p=0.011) and lower in those with polycistosis (p=0.008). At multivariate analysis, age > 59 years (p=0.01), lower education levels (p=0.036) were identified as independent factors of low WAI score.Outcome 3: Poorer disability scores (WHODAS) were associated with non-Italian nationality (p=0.008), alcohol use disorder (p=0.04), and longer hospital stays after LT (p=0.03). At multivariate analysis, male sex was associated to better WHODAS score (p=0.01), while the other variables were not confirmed.

Conclusions

Our study revealed a 39% unemployment rate following LT, with health status affecting 64% of cases. Factors such as caregiving responsibilities, education level, nationality, age, and complications significantly impact work ability. Enhanced efforts are needed to ensure equitable employment opportunities for transplant recipients.