**12. Conclusion**

178 Liver Transplantation – Basic Issues

Our Liver Transplant Unit started the liver transplant program in 1984. In 1987 we began to study QOL using the generic test NHP (Figueras, 1989). Interestingly, this test allowed us to confirm that after one year of having received transplant, alcoholic patients showed a recovery in all questions related to their daily life. Their recuperation was similar to that of female patients transplanted for primary biliary cirrhosis. Our explanation was that exalcoholics, recipients of transplantation, not only resolved their medical problems while abstaining from alcohol but also experienced a global improvement and had better selfesteem. In our experience patients are offered a new outlook on life post-transplant. Even patients who are suffering from self-inflicted damage (ex-alcoholics or ex-drug users) perceive the donation as proof of solidarity, which sometimes results in them strengthening their relationships with family and friends and in some cases, renewing past relationships. Congress of Spanish Liver Transplantation Groups (1992 Murcia), lecture's main focus was to discuss the "QOL after liver transplant" and whether the etiology of alcohol could affect in the results. It is interesting that we have detected some ex-alcoholics who are riskier cases. They have to attend regular visits with the psychiatric team. After liver transplant some patients may relapse and return to alcohol use. Rehabilitation in these cases is also possible. In our experience, severe cases are the exception; younger males (under 50 years old) who have shown a strong tendency to relapse and who have presented severe cases of

After 2000, due to the relevance of the use of a specific disease questionnaire for QOL assessment in clinical liver diseases and liver transplantation settings, we started using the LDQOL questionnaire, which was translated and adapted to the Spanish population by our

We then made correlations with clinical and analytical data pre and post-transplant, and with validation and outcome studies (Casanovas, 2010a). The administration of this long questionnaire is time consuming. We are therefore currently planning to administer the SF-LDQOL questionnaire, which has already been validated by its authors ( Kanwal, 2008). Recently, some research on QOL in patients with chronic liver disease, with or without HCC, awaiting liver transplantation and the sensitivity to change of the LDQOL questionnaire to determination of the quality of life of liver transplanted patients

The LDQOL 1.0 has proven to be a useful and valid tool for measuring QOL crosssectionally in patients with liver disease. However, its sensitivity to change, or capacity to reflect actual changes in QOL after an intervention of assumed effectiveness, has not been studied to date. Studies on sensibility to change assessed using a prospective follow up from baseline, before transplant to 2 years after transplant, were presented at the AASLD meeting

Areas of future research related to QOL might help to settle long term problems associated with liver transplantation. There are a number of reliable and valid instruments, however none of them can be considered as the gold standard outcome to be used in all situations.

**11. Recommendations for future QOL after liver transplant studies** 

**10. Experiences in our unit** 

recidivism, with small likelihood of rehabilitation.

prospectively followed for twoyears, has been presented.

group (Casanovas, 2003; 2007).

(Casanovas, 2010 b).

In the last few years, it has been recognized that incorporating the patient's perspective on the outcomes of interventions is highly important. While the impact of a health condition on an individual is reflected by symptoms and altered functions, these reflect only part of the total impact of a disease, hence the need to capture the effects on perceptions of his/her self well-being. Moreover, the ratings of physicians on the presence or absence and severity of symptoms or functional limitations can differ from patients' ratings and even from person to person.

Among the measures representing the health effects from the perspective of the patient, are validated questionnaires of HRQL and QOL. Three content areas are crucial, symptoms, functions, and well-being. There are well developed psychometrically generic and disease specific indices suitable for particular areas of research or practice. Chronic liver disease patients perceived a lower measured HRQOL, compared to other chronic disease patients, especially those with advanced or decompensated liver disease.

The results of QOL studies help the physicians to have a better understanding of chronic liver disease patients, some of them candidates to transplantation others post-transplant, thus enabling them to provide their patients with better support. Recognizing the goal of restoration of maximal QOL is essential to create appropriate interventions and to have the required information in order to improve treatment adherence and provide more overall satisfaction with QOL after liver transplantation.

In clinical trials, evaluating new drugs or new treatment schedules, quality-of-life questionnaires should always be added to the usual criteria of toxicity, efficacy or other evaluations. Liver transplant outcomes have to be considered as both a life-saving intervention and also as an opportunity to improve QOL. Patient interests –reported QOLshould suggest opportunities for ongoing development and research in this area. Therefore, we conclude that psychological care should be offered in all health centers and included in the comprehensive care of patients with liver disease.

More research into the predictive and ethical aspects of psychosocial evaluation for liver transplant is needed. Further studies are necessary that include a complete evaluation of the effects of gender, age, socioeconomic status, education, and ethnicity in order to understand modifiable factors on HRQOL especially after HCV recurrence in transplanted patients that could greatly improve patient's QOL with specific interventions.
