**5. Quality of life**

Overall, the quality of life and long-term survival among ALF transplant survivors is good, but some differences have been identified. When ALF patients were compared to a matched control group who had undergone OLT for chronic liver disease, both groups complained of memory difficulties but more ALF patients complained of concentration difficulties and as a group scored lower on neuropsychological tests (Jackson et al., 2002). The King's College group initially sent out questionnaires to small sample of ALF and chronic liver disease OLT recipients about 2-3 years following surgery. The ALF patients tended to be younger (35 vs. 59 years), so age may have influenced results. More ALF patients were employed or were in full-time education (50 vs. 26.5%). The mental health scores were slightly lower for those who had ALF (68 vs. 79; p=0.022), which was attributed to the fact that the ALF recipients did not undergo typical preoperative education and psychological support prior to OLT. There was no significant difference in parasuicide quality of life scores between the two groups (Sargent et al., 2006).

ALF patients scored slightly lower in the physical function and role emotion areas compared to normal values, but the values were similar to those who were transplanted for chronic liver disease (Sargent et al., 2006). When more carefully interviewed, six ALF recipients described significant physical inactivity and fatigue for the first 3-6 months following OLT due to weight loss and loss of muscle tone. They also noted a health transition lasting between 3-6 months, during which time dependence on others was present. Pretransplant lifestyles were changed in order to regain independence. Support groups or role models were deemed extremely helpful in coping with the ordeal. The majority felt that they had been given a "second chance at life" and were willing to reciprocate support to other going through the same process (Sargent et al., 2007).

Following spontaneous recovery, ALF patients with psychiatric illness who had taken a deliberate APAP overdose are at risk of repeated overdoses. Risk of repeated overdose appears to be less common; however, if the patient was transplanted, perhaps due to the intensity of postoperative care. In two series from the United Kingdom, APAP-ALF patients who underwent OLT showed similar long-term survival (median 5 years and 9 years) compared with patients transplanted for chronic liver disease (Cooper et al., 2009; Karvellas et al., 2010). Less than 5% of those transplanted for APAP overdose reattempted overdose. There was worse 30-day mortality for the APAP-ALF patients, and a greater probability of post-OLT medical nonadherence and adverse events in those who had taken APAP for deliberate self-harm compared with both non-APAP-ALF patients and chronic liver disease patients (Cooper et al., 2009).
