**Conflict of interest**

transplantation among recipients, employment, age, and depression predicted physical aspects, whereas anxiety and depression predicted mental dimensions of quality of life. Transplantrelated factors such as rejection of the transplant, the number and length of hospital stays, effectiveness of the medication and complications did not predict anxiety symptoms. However, more patients suffering from anxiety and/or depression went through re-transplantation.

Studies have shown that the experience of feelings including ambivalence about donation, hesitation and uncertainty are important predictors of poor adjustment and quality of life at post-donation period among donors [76, 86]. Moreover, it was also shown that donors who were concerned about their own health, finances and close relationships at pre-donation period had a history of psychiatric illness or present psychiatric illness and held a graduate degree reported poorer quality of life, although donors' medical complications were unre-

To date, there are numerous studies among candidates or recipients of a liver transplant and their donors on their adjustment. Evidence suggests that ESLF is associated with adjustment difficulties including experience of psychological problems and poor quality of life among candidates or recipients of a liver transplant. However, findings have been contradictory regarding the extent of these difficulties partly due to different approaches that studies have taken to defining and measuring psychological problems and quality of life. Transplantation is associated with less psychological problems and improvement in quality of life, with more improvements in physical functioning and less improvements in psychosocial areas. However, although it can be argued that quality of life improves after transplantation, the ways in which this improvement continues over time are not clear. Some studies show that quality of life remains similar during follow-up, whereas other studies show subsequent deterioration. In studies which examine quality of life across different time points following transplantation, recipients with high mortality rates need to be accounted for to avoid bias. There is also some evidence to suggest that contrary to recipients of a transplant, organ donation surgery is associated with deterioration in quality of life, particularly in physical functioning among donors and experience of psychological problems and poor quality of life among donors. However, findings have also been contradictory regarding the extent of these difficulties partly due to different approaches that studies have taken to defining and measur-

As mentioned above, contradictory or inconsistent findings may be due to methodological problems. More specifically, studies have mainly used generic measures of quality of life [81, 85, 101]. Such measures may not be specific and sensitive enough to understand adjustmentrelated issues among recipients of a transplant or their donors. Moreover, studies which examined the long-term implications of liver transplantation and donation have assessed

Evidence also suggests that high levels of psychological problems such as anxiety and depression negatively influence quality of life directly or as a mediator among recipients of a liver

lated to their quality of life [86].

228 Liver Research and Clinical Management

ing psychological problems and quality of life.

recipients and donors at different times after surgery [19, 84].

**5. Conclusion**

There is no conflict of interest.

## **Author details**

Margörit Rita Krespi Address all correspondence to: margorit.boothby@khas.edu.tr Kadir Has University, Istanbul, Turkey
