**7. Studying QOL after liver transplant. Results in HCV, liver transplantation and QOL**

A review of quality of life instruments used in liver transplantation (Jay, 2009) has been recently published. Factors influencing the QOL of an individual patient include pretransplant disease severity, complications during the perioperative period, long-term adverse effects of immunosuppressive drugs, the etiology and recurrence of the underlying liver disease and the information received from the medical team throughout the process (Paterson, 2000).

Nowadays, liver transplantation is a common therapeutical option. However transplantation teams have to deal with strict selection of candidates, due to the relative shortage of donors. Moreover we have to take into consideration the present available information on the natural history regarding the risks of "de novo" diseases, or malignancy or the primary disease recurrence in the long term (Telles-Correia, 2011; Estraviz, 2007). Other goals may be more widely accepted, for example, describing functional health and HRQOL before and after transplantation; comparing contrast outcomes and exploring whether physiological performance, demographics, and other clinical variables are predictors of posttransplantation QOL (Bravata& Keeffe, 2001; Ho, 2006; Aberg, 2009).

In particular, HCV-infected patients generally report a worse QOL before transplant and a lesser increase in QOL after transplant than patients transplanted for other reasons (Feurer, 2002).

The major predictors of poor adherence to medication gives an idea of how we can intervene early in treatment (Bernstein, 2002). There are few studies addressing QOL in relation with anti-HCV treatment after liver transplant (Alsatie, 2007; Neri, 2010). Patient and treatment factors to be aware of are treatment of asymptomatic disease; the presence of psychological problems, particularly depression; a patient's lack of belief in the benefit of treatment; the complexity of the treatment; and adverse events (Schiano, 2006). Other factors that perhaps are harder to quantify are a poor provider-patient relationship, inadequate follow-up or discharge planning, missed appointments, and the cost of medication, copayment, or both. (Ghobrial, 2001).

Liver transplant recipients do not, however, achieve the same QOL scores as healthy controls, and the prevalence of psychiatric comorbidities including depression is higher than controls (Dew, 1997). Patients experience more acute anxiety and depression, especially exalcoholics and hepatitis C patients (Paterson, 2000).

Despite few physical manifestations of disease at the time of HCV recurrence, patients report an impaired quality of life and functional status compared with other recipients without recurrence (Feurer, 2002). This suggests that patient knowledge of the diagnosis of recurrent HCV alone can negatively impact HRQOL (Hauser, 2004). They perceive themselves as unwell and have significant changes in their mental and physical health despite the absence of disease-related complications. However, only a limited number of studies have investigated the influence of gender, HCV genotype, or HCV antiviral treatment on the HRQOL of liver transplanted patients with HCV recurrence (Feurer, 2002; Saab, 2010).

Complexity of the treatment requires an extra effort by the transplant team, for example before patients leave the hospital after transplant. Adverse events of medication have to be taken into account, possibly in the long-term, due to poorer physical functioning, depression, and greater rates of fatigue some patients can miss some doses. More than 50% of liver transplants recipients survive more than 20 years, achieve important selfachievements, and report quality of life superior to patients with liver disease or other chronic conditions (Ruppert, 2010).
