**1. Introduction**

Diseases of the liver are becoming increasingly recognized due to their elevated prevalence and their impact on patients' daily life (Younossi,1998; Armstrong, 2000). Besides, in recent years enormous progress in diagnosis and therapeutics has been made. Currently, liver transplantation is the treatment of choice in selected patients for acute and chronic liver failure (Tomé, 2008; Desai, 2008). Liver transplantation has shown that it improves both survival and perceived changes of quality of life (Tomé, 2008; Duffy, 2010). Survival after liver transplantation is excellent, both in the short and long term. Patient survival rates of approximately 85% after the first year and 75% five years after transplantation have been reported in the European Liver Transplant Registry (www.eltr.org).

Quality of life (QOL) is a broad concept which includes all aspects of life such as where and how one lives and the role he/she plays in society (Bergner, 1989). We have to consider that QOL will also be affected by factors such as interactions with the environment, previous experiences, cultural background, life expectancy, family life, social interactions, present circumstances; financial situation, housing and job satisfaction, which are difficult to incorporate in research ( Sanders, 2008; Flamme, 2008).

QOL is a complex concept involving patient's perception of his/her ability to perform functions such as work, but also comprises the physical effects of the illness and concomitant psychological conditions, anxiety, depression, stigma and feeling of hopelessness (Gutteling, 2007; Cordoba, 2003). Other related issues are studied such as sexual problems, relationships with his/her family, friends and the healthcare team (Ware, 1992; Carver, 2005; Day, 2009).

The present review focuses on relevant patient-reported outcomes such as self-perceived symptoms (some are related to immunosuppressor drugs), medication adherence and long term HRQOL (Health Related Quality of Life) after liver transplant (Osterberg, 2005). In our opinion, although these are interrelated issues we will consider here the most recent development of HRQOL in advanced liver disease and transplantation (Unal, 2001).

There is some doubt as to what differentiates HRQOL and QOL. Some concepts that can be encapsulated under the term QOL include social functioning, emotional well-being, role functioning, cognitive functioning, sleep problems, sexual functioning, vitality/energy, pain, life satisfaction, body image and general perceptions of health (Table 1) (Borgaonkar, 2000; van den Plas, 2003). In this chapter we will discuss HRQOL because in clinical practice both concepts HRQOL and QOL are used as equivalents, especially for patients with severe disease.

Due to the multidimensionality of HRQOL, it is not possible to measure every dimension simultaneously, therefore a more limited and focused assessment should be undertaken. In patients with chronic diseases such as advanced liver disease, QOL is based on health parameters, and not on more general factors such as socioeconomic status or housing conditions since these are often considered as not having any relevance to their medical concerns. However, some problems related to finances, corporal image or specific architectural needs are contemplated in relation to some medical conditions as it is done for the study of QOL in oncological patients using specific tools (Roila & Cortesi, 2001; Gangeri, 2007).

**Leisure and recreation**, **Mobility and self-care,** Travel, Walking, Food/drink, Running, Visit friends' homes, Climbing, Vacation, Eating, Nearnes sto toilet facilities, Grooming, Hobbies and sports, Physical endurance, Relationships, **Emotional,** Intimacy and sexual function, Anger, Body image, Embarrassment, Understanding from others, Anxiety, Coping and support, Irritability, Relations with children and extended family, Happiness, Friendships, Worries or fears, Pain and discomfort, Ability to relax, Chest pain, Frustration, Abdominal pain, Depression/sadness, Abdominal cramps, Satisfaction, Abdominal discomfort, **Job-education,** Rectal pain, Satisfaction, Back pain, Attendance, Headaches, Concentration, Extra intestinal pain, Task completion, Joint pain, Achievement/promotion, **Well being**, Financial reward, Energy, **Treatment,** Fatigue, Efficacy, Sleep, Adverse effects, Self-control

Table 1. Problems, issues and domains of health related quality of ife (HRQOL) studied by questionnaires (Borgaonkar, 2000*.*)
