Objectives: Continuous innovations in liver transplant technology have significantly improved surgical success and patient survival rates, leading to substantial gains in patient quality of life. Although numerous publica-tions address quality of life after liver transplant, a comprehensive statistical analysis of this literature is lacking. This study aimed to identify and analyze emerging trends and collaborative networks in postoperative liver transplant quality of life research.
Materials and Methods: We extracted research publica-tions on postoperative liver transplant quality of life published for the period 1992-2025 from the Web of Science Core Collection. After deduplication and screening, bibliometric data (titles, abstracts, keywords, authors, affiliations, countries/regions, publication year, journal names, and references) were collected. We used Microsoft Office Excel, VOSviewer, and Biblioshiny software to examine bibliometric parameters, leading contributors, high-impact keywords, and research trends.
Results: A total of 3682 publications met the inclusion criteria. Annual publication volume increased consis-tently over the study period. The United States was the top-producing country (n = 1157). The University of Zurich emerged as the core institution, and Liver Transplantation was the most prolific journal. Author Alonso EM was identified as a core member of the collaboration network. Keyword analysis revealed major topics, including quality of life, liver transplant, disease, outcomes, recipients, cirrhosis, children, survival, impact, and hepatocellular carcinoma.
Conclusions: This bibliometric analysis underscores the growing significance of postoperative liver transplant quality of life research, offering insights to clinicians, researchers, and policymakers for prioritization of future investigations toward development of comprehensive, patient-centered strategies. Future research should focus on interventions that enhance survival outcomes, effectively manage specific symptoms, and assess the effect of novel treatments on quality of life.

Key words : Bibliometric analysis, Liver transplantation

Introduction

Liver transplant (LT) remains the gold standard for management of end-stage liver diseases.¹ With advances in surgical techniques and standardized postoperative care, survival rates for LT recipients have improved substantially.² Current 1-year and 5-year survival rates approach 90% and 70%, respectively, with even better outcomes for specific indications such as chronic cholestatic liver diseases.³ As surgical success rates continue to rise, clinical focus has shifted from short-term survival to the long-term medical management of transplant survivors.⁴
In contemporary health care, quality of life (QOL) and patient-reported outcomes are essential for evaluation of medical interventions.⁵ Unlike sole reliance on disease-specific metrics, QOL offers a holistic assessment of illness and treatment effects on physical function and well-being. The European Association for the Study of the Liver explicitly recommends QOL as an outcome measure for post-LT evaluation.⁶ Thus, comprehensive understanding of QOL is crucial for optimization of therapies and enhancement of patient outcomes.
The rapid expansion of scholarly research on QOL after LT poses challenges for systematic literature synthesis. The field of bibliometrics employs quan-titative methods (such as citation networks, keyword co-occurrence analysis, and author/institutional impact assessment) to analyze macro-level literature characteristics. Bibliometrics uses visual tools (eg, clustering maps, temporal trend diagrams) to illustrate disciplinary evolution with an aim to uncover research dynamics, collaborative patterns, and knowledge structure shifts in specific fields.⁷ By providing empirical frameworks to prioritize research agendas, foster interdisciplinary collaboration, and inform scientific funding strategies, these bibliometric evalua-tions establish evidence bases for strategic knowledge management.⁸ Thus, systematic exploration of post-LT QOL offers multifaceted insights that are crucial for identification of research gaps, assessment of intervention efficacy, and guidance of future inquiry.

Materials and Methods

Search strategy
We conducted an electronic literature search in March 2025 with the Web of Science Core Collection (WoSCC), a large database of important bibliometric information for each record; this system served as the data source due to its status as a globally recognized, high-quality digital repository that is ideally suited for bibliometric analysis. We selected the Science Citation Index Expanded option (SCI-EXPANDED, 1900-present) to ensure comprehensive and accurate data coverage.
Our primary search terms included the following items: (TS1 = “liver” OR “hepatic”) AND (TS2 = “transplant” OR “transplantation”) AND (TS3 = “Quality of Life” OR “Life Quality” OR “Health Related Quality Of Life” OR “HRQOL”). The document types searched for were Article and Review, with English as the language.

Data extraction
We exported full records and cited references of included publications as tab-delimited text files, and we extracted the following bibliometric parameters: titles, abstracts, keywords, authors, affiliations, count-ries or regions, year of publication, journal title, and references. We double-checked data for accuracy and resolved discrepancies through the reexamination of the original publication. Word derivatives were unified from the thesaurus files. Data obtained by the WoSCC functions of “analyze results” were also collected.

Data analysis
We used the Bibliometrix package in R software (version 4.4.3) and VOSviewer (version 1.6.20) for bibliometric analysis and creation of scientific know-ledge maps.⁹ We used the Bibliometrix package to analyze annual publication output, country-level productivity, authors’ contributions over time, source journal impact factors (based on H index), and trending topics.¹⁰ We used VOSviewer, a powerful bibliometric visualization tool, to generate knowledge maps from bibliometric data and facilitate our exploration of these data.¹¹ In the VOSviewer network visualizations, consistent colors denote cluster membership, whereas node size reflects co-occurrence frequency. Total link strength (TLS) quantifies cumulative connection weights, visually represented by link width to highlight collaboration intensity. We use the VOSviewer tool for clustering analyses of countries, institutions, journals, authors, citations, and keywords, leveraging its superior performance in intuitive clustering.

Results

Retrieval overview
We retrieved 3682 documents (Figure 1) from the Web of Science platform. The publication period of the retrieved documents spanned the period from 1992 to 2025. The retrieval results included 856 journals, with an annual article growth rate of 4.81%, an average citation frequency of 44.51 per document, and a total of 17160 authors (Table 1).

Distribution of publication volume by decade
Figure 2 depicts the distribution of the number of articles published in the field of QOL research in LT across different years. In the initial period (1992-2001), there were 305 publications, with an average of fewer than 40 articles per year. In the subsequent period (2002-2011), the cumulative number of publications rose to 903, indicating a significant growth in publication volume. In the final period (2012-2022), the total number of publications reached 1989 articles, with a peak of 218 articles in 2021.

Contribution of publications volume and collabo-ration in countries and regions
The national publication output analysis showed that 58 countries/regions published articles in relevant fields. The distribution of publications by country is shown in Table 2 and Figure 3. The United States (n = 1157) was the most productive country, accounting for 31.4% of the total publications, followed by the United Kingdom (n = 282; 7.7%), China (n = 255; 6.9%), Italy (n = 239; 6.5%), Germany (n = 215; 5.8%), and Japan (n = 166; 4.5%).
To present the international collaborative network, we used the VOSviewer co-authorship-country mo-dule (Figure 4). A total of 42 prolific countries/regions (with at least 10 publications) formed a cooperative network. Among these, the United States, the United Kingdom, Italy, Germany, and China were large nodes with thicker connecting lines.
The United States had the highest TLS (score of 664) in international cooperation, collaborating with 38 prolific countries. Among these partners, the United Kingdom (TLS = 560) and Italy (TLS = 454) main-tained closer academic ties with the United States.

Publishing by institution
Among the top 10 institutions with the highest number of publications (Table 3), the University of Pittsburgh (USA) was the leader with 114 contri-butions, closely followed by the University of California, San Francisco (USA) with 102 publications and the University of Toronto (Canada) with 98 publications. Notably, 8 of these top 10 institutions are based in the United States. Furthermore, in terms of scholarly impact, the University of Zurich (Switzerland) was the most cited institution, with a total of 17091 citations.

Top journals and co-cited journals
This study included 3682 articles published in 856 journals. Table 4 list the top 10 journals ranked by publication quantity and the respective 2024 impact factors (IF). These include Transplantation Proceedings (n = 241; IF = 0.8), Liver Transplantation (n = 206; IF = 5.1), Pediatric Transplantation (n = 134; IF = 1.2), Transplantation (n = 117; IF = 5.5), and Clinical Transplantation (n = 89; IF = 1.9). The Journal of Liver Transplantation had the highest H index (Figure 5A). The publication trend over the years is shown in
Figure 5B. The source titles of the co-citation analysis were analyzed using VOSviewer, and journals with at least 500 citations were included. We identified 38 journals on the basis of TLS (Figure 5C). The top 3 journals with the highest TLS scores were Hepatology (TLS = 544094), Transplantation (TLS = 414048), and Journal of Hepatology (TLS = 389000).

Authors and co-cited authors
Globally, 17160 authors have published articles in this field. The top 25 authors, ranked by publication quantity, were defined as core authors in this analysis. As detailed in Table 5, metrics such as the H index, G index, and M index, along with other relevant indicators, were calculated over the past 33 years. Although author Alonso EM and author Burra P had the highest number of publications, author Younossi ZM achieved the highest total citation count in the field. The author Alonso EM also held the highest H index and G index.
Figure 6A illustrates close collaborative relati-onships among these cited authors. Furthermore, Figure 6B shows authors with more than 100 co-citations, with the top 3 being Younossi ZM (598 citations), Starzl TE (442 citations), and Dew MA (425 citations), indicating the important contributions of these authors in the relevant research fields.

Keywords and hotspots
To count the number of keyword occurrences more accurately, a thesaurus (Table 6) was used to merge keywords with similar meanings. A total of 17160 author keywords were included in the present study. Figure 7 (A and B) shows 274 keywords with a threshold of over 20 in the co-occurrence network.
The top 10 keywords were as follows: quality of life (n = 1725), liver transplantation (n = 1593), disease (n = 396), outcomes (n = 384), recipients (n = 355), cirrhosis (n = 351), children (n = 350), survival (n = 316), impact (n = 292), and hepatocellular carcinoma (n = 276). Regarding research trends and foci, prominent themes in this field (Figure 7C) include sarcopenia, progression, insulin resistance, hepatic, encephalopathy, associations, mortality, diagnosis, cirrhosis, management, and outcomes, among others.

Discussion

This bibliometric analysis summarizes key insights into research of post-LT QOL over a period of 33 years. Research attention and publications on post-LT QOL grew steadily, which reflects a rising clinical focus on improvement of recipients’ physical/mental health and QOL.
Geographically, the United States, the United Kingdom, China, Italy, Germany, and Japan are major hubs. Institutions located in the United States contributed nearly one-third of global publications, with 8 of the top 10 most productive institutions; Canada and the United Kingdom each had 1. Researchers tend to collaborate with peers from culturally similar regions, and US institutions show intensive, extensive collaboration. The University of Zurich, the Mayo Clinic, and the University of Pittsburgh were the leaders in citations, highlighting their influence.
Journal analysis showed that Transplantation Proceedings had the highest publication volume and growth, but few top journals (by volume) were in Q1 (only 2 of top 5), indicating untapped potential in high-IF journals. Top co-cited journals included Hepatology, Transplantation, and the Journal of Hepatology (mostly Q1), providing high-quality foundational literature. Scholars should prioritize these journals for latest advances.

Analysis of keywords and research frontiers
Analysis of keyword frequencies efficiently reveals core research directions. The predominant terms include disease, outcomes, recipients, cirrhosis, children, survival, and impact. This indicates that current trends in post-LT QOL research focus on areas detailed below.

Profile of quality of life after liver transplant
Advancements in LT have shifted the focus from survival prolongation to prevention of complications and enhancement of QOL. Studies demonstrate significant improvements in patients’ physical, psychological, and social functioning within 1 to 2 years after LT.¹²

Physical recovery
Previous studies have shown that LT markedly improves liver function and physical performance, alleviating symptoms such as jaundice, ascites, and hepatic encephalopathy.¹³ Prospective studies confirm significant improvements in liver function markers (eg, albumin, prothrombin time) and increased physical activity,¹⁴ enabling greater engagement in daily life.

Psychological improvement
Depression and anxiety often decrease following LT, whereas self-confidence and happiness increase.¹⁵ This correlates with symptom relief and improved health outlook. However, persistent challenges such as fear of rejection and concerns regarding long-term medication may necessitate ongoing psychological support.¹⁶

Social function recovery
Patients typically exhibit positive social changes, including better participation in activities, improved family/friend relationships, and higher return-to-work rates,¹⁷ facilitated by physical/psychological recovery and social support.

Factors that influence quality of life after liver transplant
Despite improved liver function, multiple factors affect QOL. Postoperative complications such as rejection, infection, and biliary complications (~10%-30% incidence)¹⁸ cause significantly higher morbidity (eg, recurrent pain, jaundice requiring intervention), higher rates of debilitation, and lower QOL scores versus complication-free cases.¹⁹ With regard to immunosuppression regimens, long-term use is essential but induces adverse reactions (renal dysfunction, hypertension, diabetes).²⁰ Appearance-altering effects (tremors, hirsutism) also affect self-image and QOL. Poor medication adherence correlates strongly with lower QOL scores.²¹
Psychological factors include anxiety and depression, which are prevalent among recipients and have been shown to negatively affect QOL.²² Negative effects arise from fear of disease recurrence, outcome uncertainty, medication requirements, and financial stress.²³ Abdominal scarring, body changes, and ongoing treatment needs can further degrade self-perception.²⁴
For social support, patient support systems are negatively affected by increased caregiver demands and temporary role incapacitation. Family rela-tionship disruptions due to financial pressures are common. Support is vital for alleviation of stress and improvement of coping ability and QOL.²⁵
Employment aspects include factors such as follow-up needs and infection risk that can restrict social activities and employment. An estimated 30% to 50% of LT recipients may experience disruption in their plans to return to work,²⁶ with negative effects on finances and social integration. Economic status is affected by factors such as financial hardship that can impede access to health care and essential resources, with detrimental effects on QOL. Liver transplant recipients from lower-income families report lower QOL scores and may experience greater economic and psychological pressures.²⁷

Intervention strategies for quality of life
Multiple approaches show promise for improving post-LT outcomes.
The first approach is complication management. Prompt identification and treatment of complications (infection, rejection, biliary issues, hepatic artery thrombosis)²⁸ and long-term risks such as de novo malignancies are crucial for preserving QOL.
The second approach is immunosuppression opti-mization. Tailoring immunosuppression regimens minimizes negative side effects. Calcineurin inhibitors increase risk of metabolic syndrome; protocol optimization reduces long-term complications. Novel agents (eg, extended-release tacrolimus) show lower adverse events and superior QOL outcomes.²⁹ Adjustment of dosing frequency in pediatric recipients also enhances QOL.³⁰
The third approach is psychological intervention. Methods such as cognitive-behavioral therapy, support groups, and counseling improve psychoso-cial adjust-ment and resilience.³¹ Continuous perioperative psychological support focusing on adaptability and emotional regulation is essential.
The fourth approach is nutritional support. Tailored nutrition based on metabolic status improves nutritional state, immunity, wound healing, and complication management,³² thereby supporting QOL.
The fifth approach is rehabilitation training. Indi-vidualized programs (aerobic, strength, flexibility training) under professional guidance accelerate physical recovery and enhance endurance, psycholo-gical state, and social functioning.^33,34
Finally, there is the multidisciplinary care approach, which comprises collaboration among transplant surgeons, hepatologists, nurses, psychologists, dieti-tians, and rehabilitation therapists³⁵ and facilitates delivery of comprehensive, personalized care that leads to improved outcomes and improved QOL.

Current research hotspots
Analysis of keyword co-occurrence, frequency, and centrality highlights several active frontiers.

Pediatric liver transplant
Although survival and QOL outcomes have im-proved, with peer-level function often achieved,³⁶ challenges remain. Long-term immunosuppression and surgical trauma contribute to sleep disorders and anxiety. Neuro-functional recovery is critical for children with preexisting impairment.³⁷ Research focuses on improvement of long-term QOL and survival, expansion of donor sources (reducing wait list mortality), development of individualized immunosuppression protocols, and establishment of optimal LT timing for children with end-stage liver disease.

Sarcopenia
Prevalent in candidates due to underlying disease, malnutrition, and inflammation, sarcopenia has been reported to predict lower pre-LT QOL and lower post-LT QOL, higher mortality (44% higher risk),^38,39 longer hospitalization, higher infection rates, and greater financial costs. Current management involves addressing the primary disease and lifestyle modifi-cation to mitigate muscle loss.⁴⁰ Investigating targeted interventions based on pathogenesis is key.

Frailty
Frailty affects 21% to 47% of recipients with regard to pre-LT QOL^41,42 and correlates with higher mortality, longer hospitalization, higher rates of complications, and diminished QOL.⁴³ Inter-ventions include exercise, dietary management, prehabilitation, and cognitive therapies.⁴⁴ Addressing frailty requires individualized strategies that integrate comorbidity management with dietary, exercise, psychological, and social support.

Liver transplant metabolic syndrome
Liver transplant metabolic syndrome (LTMS) is charac-terized by hypertension, insulin resistance, obesity, and dyslipidemia,⁴⁵ and incidence of LTMS is rising, driven by factors such as immunosuppressants (steroids, calcineurin inhibitors), obesity, pretransplant glycemic control, older age, and liver disease etiology. Previous reports have established that LTMS significantly affects long-term survival, QOL, and family resources.⁴⁶ Management of LTMS requires multidisciplinary care focused on proactive pre-vention and risk mitigation, with emphasis on smoke-free, alcohol-free, and healthy lifestyles.⁴⁷

Limitations
This study had several limitations. First, reliance on a single database (WoSCC) may introduce selection bias, potentially missing relevant studies from other sources such as Scopus. Second, limiting the analysis to English language publications risks overlooking valuable contributions from non-English-speaking regions. Third, although synonymous keywords were merged carefully by 2 independent authors, some residual errors or omissions may persist.

Conclusions

This bibliometric analysis highlights the growing importance of QOL research in the field of LT, which can inform clinicians, researchers, and policymakers to prioritize areas for future investigation in order to develop comprehensive, patient-centered strategies. Future research should focus on interventions and strategies to improve survival outcomes, effective management of specific symptoms, and the effect of new treatment methods on the QOL.

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