1
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Mehtani R, Rathi S. Recurrence of Primary Disease After Adult Liver Transplant - Risk Factors, Early Diagnosis, Management, and Prevention. J Clin Exp Hepatol 2024; 14:101432. [PMID: 38975605 PMCID: PMC11222954 DOI: 10.1016/j.jceh.2024.101432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 04/14/2024] [Indexed: 07/09/2024] Open
Abstract
Liver transplantation offers a new lease of life to patients with end-stage liver disease and hepatocellular carcinoma. However, the implantation of an exogenous allograft and the accompanying immunosuppression bring their own challenges. Moreover, the persistence of risk factors for the initial liver insult place the new graft at a higher risk of damage. With the increasing number of liver transplants along with the improvement in survival posttransplant, the recurrence of primary disease in liver grafts has become more common. Pre-2015, the most common disease to recur after transplant was hepatitis C. However, directly acting antivirals have nearly eliminated this problem. The greatest challenge of disease recurrence we now face are those of nonalcoholic steatohepatitis, alcohol-related liver disease, and primary sclerosing cholangitis. We focus on the epidemiology and pathophysiology of the recurrence of primary disease after transplant. We also discuss means of early identification, risk stratification, prevention, and management of recurrent primary disease after liver transplantation.
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Affiliation(s)
- Rohit Mehtani
- Department of Hepatology, Amrita Institute of Medical Sciences and Research, Faridabad, Haryana, India
| | - Sahaj Rathi
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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2
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Zhou S, Li J, Liu J, Dong S, Chen N, Ran Y, Liu H, Wang X, Yang H, Liu M, Chu H, Wang B, Li Y, Guo L, Zhou L. Depressive symptom as a risk factor for cirrhosis in patients with primary biliary cholangitis: Analysis based on Lasso-logistic regression and decision tree models. Brain Behav 2024; 14:e3639. [PMID: 39099389 PMCID: PMC11298689 DOI: 10.1002/brb3.3639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 05/06/2024] [Accepted: 07/09/2024] [Indexed: 08/06/2024] Open
Abstract
BACKGROUND Depressive symptoms are frequently observed in patients with primary biliary cholangitis (PBC). The role of depressive symptoms on cirrhosis has not been fully noticed in PBC. We aimed to establish a risk model for cirrhosis that took depressive symptoms into account. METHODS Depressive symptoms were assessed by the 17-item Hamilton Depression Rating Scale (HAMD-17). HAMD-17 score was analyzed in relation to clinical parameters. Least absolute shrinkage and selection operator (Lasso)-logistic regression and decision tree models were used to explore the effect of depressive symptoms on cirrhosis. RESULTS The rate of depressive symptom in patients with PBC (n = 162) was higher than in healthy controls (n = 180) (52.5% vs. 16.1%; p < .001). HAMD-17 score was negatively associated with C4 levels and positively associated with levels of alkaline phosphatase (ALP), γ-glutamyl transpeptidase (GGT), total bilirubin (TB), Immunoglobulin (Ig) G, and IgM (r = -0.162, 0.197, 0.355, 0.203, 0.182, 0.314, p < .05). In Lasso-logistic regression analysis, HAMD-17 score, human leukocyte antigen (HLA)-DRB1*03:01 allele, age, ALP levels, and IgM levels (odds ratio [OR] = 1.087, 7.353, 1.075, 1.009, 1.005; p < 0.05) were independent risk factors for cirrhosis. Elevated HAMD-17 score was also a discriminating factor for high risk of cirrhosis in patients with PBC in decision tree model. CONCLUSIONS Depressive symptoms were associated with disease severity. Elevated HAMD-17 score was a risk factor for cirrhosis in patients with PBC.
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Affiliation(s)
- Simin Zhou
- Department of Gastroenterology and Hepatology, General HospitalTianjin Medical UniversityTianjinChina
| | - Jiwen Li
- Department of Gastroenterology and Hepatology, General HospitalTianjin Medical UniversityTianjinChina
| | - Jiangpeng Liu
- Department of Gastroenterology and Hepatology, General HospitalTianjin Medical UniversityTianjinChina
| | - Shijing Dong
- Department of Gastroenterology and Hepatology, General HospitalTianjin Medical UniversityTianjinChina
| | - Nian Chen
- Department of Gastroenterology and Hepatology, General HospitalTianjin Medical UniversityTianjinChina
| | - Ying Ran
- Department of Gastroenterology and Hepatology, General HospitalTianjin Medical UniversityTianjinChina
| | - Haifeng Liu
- Department of Gastroenterology and Hepatology, General HospitalTianjin Medical UniversityTianjinChina
| | - Xiaoyi Wang
- Department of Gastroenterology and Hepatology, General HospitalTianjin Medical UniversityTianjinChina
| | - Hui Yang
- Department of Gastroenterology and Hepatology, General HospitalTianjin Medical UniversityTianjinChina
| | - Man Liu
- Department of Gastroenterology and Hepatology, General HospitalTianjin Medical UniversityTianjinChina
| | - Hongyu Chu
- Department of Gastroenterology and Hepatology, General HospitalTianjin Medical UniversityTianjinChina
| | - Bangmao Wang
- Department of Gastroenterology and Hepatology, General HospitalTianjin Medical UniversityTianjinChina
| | - Yanni Li
- Department of Gastroenterology and Hepatology, General HospitalTianjin Medical UniversityTianjinChina
| | - Liping Guo
- Department of Gastroenterology and Hepatology, General HospitalTianjin Medical UniversityTianjinChina
| | - Lu Zhou
- Department of Gastroenterology and Hepatology, General HospitalTianjin Medical UniversityTianjinChina
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3
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Im GY, Goel A, Asrani S, Singal AK, Wall A, Sherman CB. Transplant selection simulation: Liver transplantation for alcohol-associated hepatitis. Liver Transpl 2024; 30:826-834. [PMID: 38009866 DOI: 10.1097/lvt.0000000000000305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 11/09/2023] [Indexed: 11/29/2023]
Abstract
Liver transplantation (LT) for alcohol-associated hepatitis (AH) remains controversial due to concerns about candidate selection subjectivity, post-LT alcohol relapse, and the potential exacerbation of LT disparities. Our aim was to design, perform, and examine the results of a simulated selection of candidates for LT for AH. Medical histories, psychosocial profiles and scores, and outcomes of 4 simulation candidates were presented and discussed at 2 multidisciplinary societal conferences with real-time polling of participant responses. Candidate psychosocial profiles represented a wide spectrum of alcohol relapse risk. The predictive accuracy of four psychosocial scores, Dallas consensus criteria, sustained alcohol use post-LT, Stanford Integrated Psychosocial Assessment for Transplant, and QuickTrans, were assessed. Overall, 68 providers, mostly academic transplant hepatologists, participated in the simulation. Using a democratic process of selection, a significant majority from both simulations voted to accept the lowest psychosocial risk candidate for LT (72% and 85%) and decline the highest risk candidate (78% and 90%). For the 2 borderline-risk candidates, a narrower majority voted to decline (56% and 65%; 64% and 82%). Two out of 4 patients had post-LT relapse. Predictive accuracies of Dallas, Stanford Integrated Psychosocial Assessment for Transplant, and Quicktrans scores were 50%, while sustained alcohol use post-LT was 25%. The majority of voting outcomes were concordant with post-LT relapse in 3 out of 4 patients. When defining "success" in LT for AH, providers prioritized allograft health and quality of life rather than strict abstinence. In this simulation of LT for AH using a democratic process of selection, we demonstrate its potential as a learning model to evaluate the accuracy of psychosocial scores in predicting post-LT relapse and the concordance of majority voting with post-LT outcomes. Provider definitions of "success" in LT for AH have shifted toward patient-centered outcomes.
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Affiliation(s)
- Gene Y Im
- Icahn School of Medicine at Mount Sinai, Division of Liver Diseases, Recanati/Miller Transplantation Institute, New York, New York, USA
| | - Aparna Goel
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Sumeet Asrani
- Baylor University Medical Center, Baylor Scott and White, Dallas, Texas, USA
| | - Ashwani K Singal
- University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Anji Wall
- Baylor University Medical Center, Baylor Scott and White, Dallas, Texas, USA
| | - Courtney B Sherman
- Division of Gastroenterology and Hepatology, University of California, San Francisco, California, USA
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4
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Sharma P, Shenoy A, Shroff H, Kwong A, Lim N, Pillai A, Devuni D, Haque LY, Balliet W, Serper M. Management of alcohol-associated liver disease and alcohol use disorder in liver transplant candidates and recipients: Challenges and opportunities. Liver Transpl 2024; 30:848-861. [PMID: 38471008 DOI: 10.1097/lvt.0000000000000362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 03/01/2024] [Indexed: 03/14/2024]
Abstract
Alcohol-associated liver disease poses a significant global health burden, with rising alcohol consumption and prevalence of alcohol use disorder (AUD) contributing to increased morbidity and mortality. This review examines the challenges and opportunities in the care of candidates and recipients of liver transplant (LT) with AUD. Despite advancements in posttransplant patient survival, the risk of disease recurrence and alcohol relapse remains substantial. Several challenges have been identified, including (1) rising disease burden of alcohol-associated liver disease, variable transplant practices, and systemic barriers; (2) disparities in mental health therapy access and the impact on transplant; (3) variable definitions, underdiagnosis, and stigma affecting access to care; and (4) post-LT relapse, its risk factors, and consequential harm. The review focuses on the opportunities to improve AUD care for candidates and recipients of LT through effective biochemical monitoring, behavioral and pharmacologic approaches, creating Centers of Excellence for post-LT AUD care, advocating for policy reforms, and ensuring insurance coverage for necessary services as essential steps toward improving patient outcomes. The review also highlights unmet needs, such as the scarcity of addiction specialists, and calls for further research on personalized behavioral treatments, digital health, and value-based care models to optimize AUD care in the LT setting.
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Affiliation(s)
- Pratima Sharma
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Akhil Shenoy
- Department of Psychiatry, Columbia University Medical Center, New York, New York, USA
| | - Hersh Shroff
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Allison Kwong
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Stanford University, Stanford, California, USA
| | - Nicholas Lim
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Anjana Pillai
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, University of Chicago, Chicago, Illinois, USA
| | - Deepika Devuni
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, UMass Chan Medical School, Worcester, Massachusetts, USA
| | - Lamia Y Haque
- Department of Internal Medicine, Section of Digestive Diseases and Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Wendy Balliet
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Marina Serper
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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5
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Musto JA, Palmer G, Nemer M, Schell T, Waclawik G, Glover Q, Lucey MR, Osman F, Rice JP. Early Liver Transplant for Alcohol-associated Liver Disease Has Excellent Survival but Higher Rates of Harmful Alcohol Use. Clin Gastroenterol Hepatol 2024; 22:1646-1656.e2. [PMID: 38729395 DOI: 10.1016/j.cgh.2024.04.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 04/09/2024] [Accepted: 04/09/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND & AIMS Early liver transplantation (LT) for alcohol-associated liver disease (ALD) has increased worldwide. Short-term outcomes have been favorable, but data on longer-term outcomes are lacking. METHODS Single-center retrospective study of primary LT recipients between 2010 and 2020, with follow-up through July 1, 2022. Survival analysis was performed using log rank, Cox models, and Kaplan-Meier method. Cox models were created to identify variables associated with mortality; logistic regression to identify variables associated with post-LT alcohol use. RESULTS Of 708 patients who underwent LT, 110 (15.5%) had ALD and abstinence <6 months prior to LT (ELT), 234 (33.1%) had ALD and alcohol abstinence >6 months (SLT), and 364 (51.4%) had non-ALD diagnoses. Median follow-up was 4.6 years (interquartile range, 2.6-7.3 years). ELT recipients were younger (P = .001) with median abstinence pre-LT of 61.5 days. On adjusted Cox model, post-LT survival was similar in ELT and SLT (hazard ratio [HR], 1.31; P = .30) and superior to non-ALD (HR, 1.68; P = .04). Alcohol use (40.9% vs 21.8%; P < .001) and harmful alcohol use (31.2% vs 16.0%; P = .002) were more common in ELT recipients. Harmful alcohol use was associated with post-LT mortality on univariate (HR, 1.69; P = .03), but not multivariable regression (HR, 1.54; P = .10). Recurrence of decompensated ALD trended toward more common in ELT (9.1% vs 4.4%; P = .09). Greater than 6 months pre-LT abstinence was associated with a decreased risk of harmful alcohol use (odds ratio, 0.42; P = .001), but not in a multivariable model (odds ratio, 0.71; P = .33). CONCLUSIONS Patients who undergo ELT for ALD have similar or better survival than other diagnoses in the first 10 years after LT despite a higher incidence of post-LT alcohol use.
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Affiliation(s)
- Jessica A Musto
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
| | - Geralyn Palmer
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Mary Nemer
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Trevor Schell
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Gabrielle Waclawik
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Quarshie Glover
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Michael R Lucey
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Fay Osman
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - John P Rice
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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6
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Lee BP. Current Management of Patients With Alcohol-Associated Hepatitis. Gastroenterol Hepatol (N Y) 2024; 20:401-403. [PMID: 39206025 PMCID: PMC11348548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Affiliation(s)
- Brian P Lee
- Associate Professor of Clinical Medicine Keck School of Medicine University of Southern California Los Angeles, California
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7
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Goswami A, Weinberg E, Coraluzzi L, Bittermann T, Nahas J, Addis S, Weinrieb R, Serper M. A Tailored Virtual Program for Alcohol Use Disorder Treatment Among Liver Transplant Candidates and Recipients Is Feasible and Associated With Lower Post-Transplant Relapse. Clin Transplant 2024; 38:e15381. [PMID: 38940230 PMCID: PMC11273277 DOI: 10.1111/ctr.15381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 05/05/2024] [Accepted: 06/02/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Alcohol-associated liver disease (ALD) is a leading indication for liver transplant (LT) in the United States. Rates of early liver transplant (ELT) with less than 6 months of sobriety have increased substantially. Patients who receive ELT commonly have alcohol-associated hepatitis (AH) and are often too ill to complete an intensive outpatient program (IOP) for alcohol use disorder (AUD) prior to LT. ELT recipients feel alienated from traditional IOPs. METHODS We implemented Total Recovery-LT, a tailored virtual outpatient IOP specific for patients under evaluation or waitlisted for LT who were too ill to attend community-based alcohol treatment programs. The 12-week program consisted of weekly group and individual counseling delivered by a master's level Certified Addiction Counselor trained in the basics of LT. Treatment consisted of 12-Step Facilitation, Motivational Interviewing, and Cognitive Behavioral Therapy. We report on program design, implementation, feasibility and early outcomes. RESULTS From March 2021 to September 2022, 42 patients (36% female, 23 in LT evaluation, 19 post-transplant) enrolled across five cohorts with 76% (32/42) completing the program. Alcohol relapse was more common among noncompleters versus those who completed the program (8/10, 80% vs. 7/32, 22%, p = 0.002). History of trauma or post-traumatic stress symptoms were associated with lower likelihood of completion. Patients' desire for continued engagement after completion led to the creation of a monthly alumni group. CONCLUSIONS Our integrated IOP model for patients with high-risk AUD in LT evaluation or post-transplant is well-received by patients and could be considered a model for LT programs.
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Affiliation(s)
- Arpita Goswami
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia PA
| | - Ethan Weinberg
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia PA
| | | | - Therese Bittermann
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia PA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia PA
| | - Jonathan Nahas
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia PA
| | - Senayish Addis
- Penn Transplant Institute, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Robert Weinrieb
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia PA
| | - Marina Serper
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia PA
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8
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Haque LY, Leggio L. Integrated and collaborative care across the spectrum of alcohol-associated liver disease and alcohol use disorder. Hepatology 2024:01515467-990000000-00939. [PMID: 38935926 DOI: 10.1097/hep.0000000000000996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Accepted: 06/08/2024] [Indexed: 06/29/2024]
Abstract
The public health impact of alcohol-associated liver disease (ALD), a serious consequence of problematic alcohol use, and alcohol use disorder (AUD) is growing, with ALD becoming a major cause of alcohol-associated death overall and the leading indication for liver transplantation in the United States. Comprehensive care for ALD often requires treatment of AUD. Although there is a growing body of evidence showing that AUD treatment is associated with reductions in liver-related morbidity and mortality, only a minority of patients with ALD and AUD receive this care. Integrated and collaborative models that streamline both ALD and AUD care for patients with ALD and AUD are promising approaches to bridge this treatment gap and rely on multidisciplinary and interprofessional teams and partnerships. Here, we review the role of AUD care in ALD treatment, the effects of AUD treatment on liver-related outcomes, the impact of comorbid conditions such as other substance use disorders, obesity, and metabolic syndrome, and the current landscape of integrated and collaborative care for ALD and AUD in various treatment settings. We further review knowledge gaps and unmet needs that remain, including the role of precision medicine, the application of harm reduction approaches, the impact of health disparities, and the need for additional AUD treatment options, as well as further efforts to support implementation and dissemination.
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Affiliation(s)
- Lamia Y Haque
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Lorenzo Leggio
- Clinical Psychoneuroendocrinology and Neuropsychopharmacology Section, Translational Addiction Medicine Branch, National Institute on Drug Abuse and National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Baltimore and Bethesda, Maryland, USA
- Department of Behavioral and Social Sciences, Center for Alcohol and Addiction Studies, School of Public Health, Brown University, Providence, Rhode Island, USA
- Division of Addiction Medicine, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Neuroscience, Georgetown University Medical Center, Washington, District of Columbia, USA
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9
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Ramirez-Cadiz C, Blaney H, Kubanek N, Díaz LA, Loomba R, Skladany L, Arab JP. Review article: Current indications and selection criteria for early liver transplantation in severe alcohol-associated hepatitis. Aliment Pharmacol Ther 2024; 59:1049-1061. [PMID: 38475893 DOI: 10.1111/apt.17948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 10/17/2023] [Accepted: 03/03/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND Alcohol-associated hepatitis (AH) is a severe inflammatory form of alcohol-associated liver disease (ALD) that carries a high mortality rate. Early liver transplantation for severe AH is increasingly available. However, specific criteria for referral and selection remain a subject of debate. AIMS To provide a narrative review of the natural history, diagnostic criteria and indications for referral for early liver transplantation for severe AH. METHODS We searched PubMed for articles published through August 2023. Key search terms were 'alcoholic hepatitis,' 'alcohol-associated hepatitis,' 'abstinence,' 'alcohol relapse,' and 'liver transplantation.' RESULTS Previously, a six-month period of alcohol abstinence was required before patients with ALD were considered for liver transplantation. However, studies in recent years have demonstrated that, among carefully selected patients, patients who received early transplants have much higher survival rates than patients with similarly severe disease who did not undergo transplants (77% vs. 23%). Despite these successes, early liver transplantation remains controversial, as these patients have typically not undergone treatment for alcohol use disorder, with the ensuing risk of returning to alcohol use. CONCLUSIONS While early liver transplantation for AH has survival benefits, many patients would not have received treatment for alcohol use disorder. An integrated approach to evaluating candidacy for early liver transplantation is needed.
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Affiliation(s)
- Carolina Ramirez-Cadiz
- Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada
| | - Hanna Blaney
- Division of Gastroenterology and Hepatology, University of Maryland, College Park, Maryland, USA
| | - Natalia Kubanek
- Division of Hepatology, Gastroenterology and Liver Transplantation, Department of Internal Medicine II, Slovak Medical University Faculty of Medicine, F. D. Roosevelt University Hospital, Banska Bystrica, Slovak Republic
| | - Luis Antonio Díaz
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Rohit Loomba
- Division of Gastroenterology, University of California at San Diego, San Diego, California, USA
| | - Lubomir Skladany
- Division of Hepatology, Gastroenterology and Liver Transplantation, Department of Internal Medicine II, Slovak Medical University Faculty of Medicine, F. D. Roosevelt University Hospital, Banska Bystrica, Slovak Republic
| | - Juan Pablo Arab
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine, Western University, London, Ontario, Canada
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10
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Shaji Mathew J, Shingina A, Khan MQ, Wilson E, Syn N, Rammohan A, Alconchel F, Hakeem AR, Shankar S, Patel D, Keskin O, Liu J, Nasralla D, Mazzola A, Patel MS, Tanaka T, Victor D, Yoon U, Yoon YI, Vinaixa C, Kirchner V, De Martin E, Ghobrial RM, Chadha R. Proceedings of the 28th Annual Congress of the International Liver Transplantation Society. Liver Transpl 2024; 30:544-554. [PMID: 38240602 DOI: 10.1097/lvt.0000000000000330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 12/09/2023] [Indexed: 02/16/2024]
Abstract
The 2023 Joint International Congress of the International Liver Transplantation Society (ILTS), the European Liver and Intestine Transplant Association (ELITA), and the Liver Intensive Care Group of Europe (LICAGE) held in Rotterdam, the Netherlands, marked a significant recovery milestone for the liver transplant community after COVID-19. With 1159 participants and a surge in abstract submissions, the event focused on "Liver Disorders and Transplantation: Innovations and Evolving Indications." This conference report provides a comprehensive overview of the key themes discussed during the event, encompassing Hepatology, Anesthesia and Critical Care, Acute Liver Failure, Infectious Disease, Immunosuppression, Pediatric Liver Transplantation, Living Donor Liver Transplantation, Transplant Oncology, Surgical Approaches, and Machine Perfusion. The congress provided a platform for extensive discussions on a wide range of topics, reflecting the continuous advancements and collaborative efforts within the liver transplant community.
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Affiliation(s)
- Johns Shaji Mathew
- Department of GI, HPB & Multi-Organ Transplant Surgery, Rajagiri Hospital, Kochi, Kerala, India
| | - Alexandra Shingina
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Mohammad Qasim Khan
- Division of Gastroenterology, Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - Elizabeth Wilson
- Department of Anesthesiology, Emory University Hospital, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Nicholas Syn
- Division of Biomedical Informatics, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ashwin Rammohan
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Bharath Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | | | - Abdul Rahman Hakeem
- Department of Hepatobiliary and Liver Transplant Surgery, St James's University Hospital NHS Trust, Leeds, UK
| | - Sadhana Shankar
- Institute of Liver Studies, King's College Hospital, London, UK
| | | | - Onur Keskin
- Department of Gastroenterology, Hacettepe University Medical School, Ankara, Turkey
| | - Jiang Liu
- Hepato-Pancreato-Biliary Center, Department of Medicine, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - David Nasralla
- Department of HPB and Liver Transplant Surgery, The Royal Free Hospital, London, UK
| | - Alessandra Mazzola
- Sorbonne Université, Unité médicale de transplantation hépatique, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Madhukar S Patel
- Division of Surgical Transplantation, Department of Surgery, University of Texas, Southwestern Medical Center, Dallas, Texas, USA
| | - Tomohiro Tanaka
- Department of Internal Medicine, Gastroenterology and Hepatology, University of Iowa, Iowa City, Iowa, USA
| | - David Victor
- Sherrie and Alan Conover Center for Liver Disease and Transplantation. Houston Methodist Hospital, Houston, Texas, USA
| | - Uzung Yoon
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | | | - Carmen Vinaixa
- Hepatology Unit, Digestive Diseases Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Varvara Kirchner
- Department of Surgery, Division of Abdominal Transplantation, Stanford University, Stanford, California, USA
| | - Eleonora De Martin
- AP-HP, Hôpital Paul-Brousse, Centre Hépato- Biliaire, Unité INSERM 1193, Villejuif, France
| | - R Mark Ghobrial
- J.C. Walter Jr, Transplant Center, Department of Surgery, Weill Cornell Medical College, Houston Methodist Institute for Academic Medicine, Houston, Texas, USA
| | - Ryan Chadha
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida, USA
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11
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Kim DS, Yoon YI, Kim BK, Choudhury A, Kulkarni A, Park JY, Kim J, Sinn DH, Joo DJ, Choi Y, Lee JH, Choi HJ, Yoon KT, Yim SY, Park CS, Kim DG, Lee HW, Choi WM, Chon YE, Kang WH, Rhu J, Lee JG, Cho Y, Sung PS, Lee HA, Kim JH, Bae SH, Yang JM, Suh KS, Al Mahtab M, Tan SS, Abbas Z, Shresta A, Alam S, Arora A, Kumar A, Rathi P, Bhavani R, Panackel C, Lee KC, Li J, Yu ML, George J, Tanwandee T, Hsieh SY, Yong CC, Rela M, Lin HC, Omata M, Sarin SK. Asian Pacific Association for the Study of the Liver clinical practice guidelines on liver transplantation. Hepatol Int 2024; 18:299-383. [PMID: 38416312 DOI: 10.1007/s12072-023-10629-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 12/18/2023] [Indexed: 02/29/2024]
Abstract
Liver transplantation is a highly complex and challenging field of clinical practice. Although it was originally developed in western countries, it has been further advanced in Asian countries through the use of living donor liver transplantation. This method of transplantation is the only available option in many countries in the Asia-Pacific region due to the lack of deceased organ donation. As a result of this clinical situation, there is a growing need for guidelines that are specific to the Asia-Pacific region. These guidelines provide comprehensive recommendations for evidence-based management throughout the entire process of liver transplantation, covering both deceased and living donor liver transplantation. In addition, the development of these guidelines has been a collaborative effort between medical professionals from various countries in the region. This has allowed for the inclusion of diverse perspectives and experiences, leading to a more comprehensive and effective set of guidelines.
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Affiliation(s)
- Dong-Sik Kim
- Department of Surgery, Korea University College of Medicine, Seoul, Republic of Korea
| | - Young-In Yoon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Beom Kyung Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Jun Yong Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jongman Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dong Hyun Sinn
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dong Jin Joo
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - YoungRok Choi
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jeong-Hoon Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ho Joong Choi
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ki Tae Yoon
- Department of Internal Medicine, Pusan National University College of Medicine, Yangsan, Republic of Korea
| | - Sun Young Yim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Cheon-Soo Park
- Department of Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Deok-Gie Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hae Won Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Won-Mook Choi
- Department of Gastroenterology, Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Young Eun Chon
- Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Woo-Hyoung Kang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jinsoo Rhu
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jae Geun Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yuri Cho
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Ilsan, Republic of Korea
| | - Pil Soo Sung
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Han Ah Lee
- Department of Internal Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Ji Hoon Kim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Si Hyun Bae
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jin Mo Yang
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Mamun Al Mahtab
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Soek Siam Tan
- Department of Medicine, Hospital Selayang, Batu Caves, Selangor, Malaysia
| | - Zaigham Abbas
- Sindh Institute of Urology and Transplantation, Karachi, Pakistan
| | - Ananta Shresta
- Department of Hepatology, Alka Hospital, Lalitpur, Nepal
| | - Shahinul Alam
- Crescent Gastroliver and General Hospital, Dhaka, Bangladesh
| | - Anil Arora
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital New Delhi, New Delhi, India
| | - Ashish Kumar
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital New Delhi, New Delhi, India
| | - Pravin Rathi
- TN Medical College and BYL Nair Hospital, Mumbai, India
| | - Ruveena Bhavani
- University of Malaya Medical Centre, Petaling Jaya, Selangor, Malaysia
| | | | - Kuei Chuan Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jun Li
- College of Medicine, Zhejiang University, Hangzhou, China
| | - Ming-Lung Yu
- Department of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | | | | | | | | | | | - H C Lin
- Endoscopy Center for Diagnosis and Treatment, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Masao Omata
- Department of Gastroenterology, Yamanashi Central Hospital, Yamanashi, Japan
- University of Tokyo, Bunkyo City, Japan
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12
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Sedki M, Kwong A, Bhargava M, Ahmed A, Daugherty T, Kwo P, Dronamraju D, Kumari R, Kim WR, Esquivel C, Melcher M, Bonham CA, Gallo A, Nelson A, Norwood A, Hussain F, Goel A. Alcohol Use in Liver Transplant Recipients With Alcohol-related Liver Disease: A Comparative Assessment of Relapse Prediction Models. Transplantation 2024; 108:742-749. [PMID: 37899485 DOI: 10.1097/tp.0000000000004800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
BACKGROUND The selection of liver transplant (LT) candidates with alcohol-related liver disease (ALD) is influenced by the risk of alcohol relapse (AR), yet the ability to predict AR is limited. We evaluate psychosocial factors associated with post-LT AR and compare the performance of high-risk alcoholism risk (HRAR), sustained alcohol use post-LT (SALT), and the Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) scores in predicting relapse. METHODS A retrospective analysis of ALD patients undergoing LT from 2015 to 2021 at a single US transplant center was performed. Risk factors associated with post-LT AR were evaluated and test characteristics of 3 prediction models were compared. RESULTS Of 219 ALD LT recipients, 23 (11%) had AR during a median study follow-up of 37.5 mo. On multivariate analysis, comorbid psychiatric illness (odds ratio 5.22) and continued alcohol use after advice from a health care provider (odds ratio 3.8) were found to be significantly associated with post-LT AR. On sensitivity analysis, SIPAT of 30 was optimal on discriminating between ALD LT recipients with and without post-LT AR. SIPAT outperformed both the HRAR and SALT scores (c-statistic 0.67 versus 0.59 and 0.62, respectively) in identifying post-LT AR. However, all scores had poor positive predictive value (<25%). CONCLUSIONS AR after LT is associated with comorbid psychiatric illness and lack of heeding health care provider advice to abstain from alcohol. Although SIPAT outperformed the HRAR and SALT scores in predicting AR, all are poor predictors. The current tools to predict post-LT AR should not be used to exclude LT candidacy.
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Affiliation(s)
- Mai Sedki
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, CA
| | - Allison Kwong
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, CA
| | - Meera Bhargava
- Department of Medicine, Stanford Center for Clinical Research, Palo Alto, CA
| | - Aijaz Ahmed
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, CA
| | - Tami Daugherty
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, CA
| | - Paul Kwo
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, CA
| | - Deepti Dronamraju
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, CA
| | - Radhika Kumari
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, CA
| | - W Ray Kim
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, CA
| | - Carlos Esquivel
- Department of Surgery, Abdominal Transplantation, Stanford University, Palo Alto, CA
| | - Marc Melcher
- Department of Surgery, Abdominal Transplantation, Stanford University, Palo Alto, CA
| | - C Andrew Bonham
- Department of Surgery, Abdominal Transplantation, Stanford University, Palo Alto, CA
| | - Amy Gallo
- Department of Surgery, Abdominal Transplantation, Stanford University, Palo Alto, CA
| | - Ashly Nelson
- Department of Social Work, Stanford Health Care, Palo Alto, CA
| | - Amanda Norwood
- Department of Social Work, Stanford Health Care, Palo Alto, CA
| | - Filza Hussain
- Department of Psychiatry, Stanford University, Palo Alto, CA
| | - Aparna Goel
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, CA
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13
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Branagan WT, Norvell JP. Assessment and Evaluation of Alcohol Use Disorder in Liver Transplant. Transplantation 2024; 108:654-661. [PMID: 37408098 DOI: 10.1097/tp.0000000000004722] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
Alcohol-related liver disease is the most common indication for liver transplantation. It is essential for providers in transplantation to be informed of the state of the science in evaluation of alcohol use disorder (AUD). This review examines the broad range of approaches to the evaluation of AUD ranging from traditional interview approaches to recent literature on artificial intelligence models. The empirical support for methods of evaluation is examined. The authors discuss the use of each method in the context of patients seeking a liver transplant for alcohol-related liver disease. This review emphasizes the importance of using objective assessments so that transplant centers make evidence-based decisions and reduce cognitive bias. The review concludes with a proposed assessment battery for evaluation and bridges to future directions in the field of AUD assessment in liver transplantation.
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Affiliation(s)
- William T Branagan
- Department of Psychiatry, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO
| | - J P Norvell
- Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO
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14
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Tarli C, Mannucci S, Vecchione M, Antonelli M, Sestito L, Mancarella FA, Tosoni A, Dionisi T, Maccauro V, Sario GD, Burra P, Germani G, Gasbarrini A, Addolorato G. Prothrombin time predicts steroid response in severe alcohol-related hepatitis. Liver Int 2024; 44:823-830. [PMID: 38238897 DOI: 10.1111/liv.15835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 12/19/2023] [Accepted: 12/25/2023] [Indexed: 03/01/2024]
Abstract
BACKGROUND AND AIMS Alcohol-related hepatitis (AH) is the most severe form of acute alcohol-related liver disease. Maddrey's discriminant function ≥32 defines the severe form of AH, which is associated with a high mortality. Steroid therapy represents the main medical treatment that may reduce short-term mortality. Lille score at day 7 assesses the therapeutic response to steroid therapy. At present, no parameters able to predict the response to steroid therapy have been highlighted. The aim of the present study was to evaluate if baseline prothrombin time (BPT) could predict the response to steroid in severe AH (sAH). METHODS Patients consecutively admitted in two Italian Liver Units, from 2017 to 2022, suffering from sAH were included. Data were collected prospectively. In order to evaluate if BPT could predict steroid response, we assessed the correlation between BPT using the Lille score at day 7. RESULTS A total of 52 patients received steroid treatment were enrolled in the study. The response to therapy was assessed by Lille score at day 7. Responders were 34 patients (65%), non-responders 18 patients (34%). BPT significantly predicted the steroid response (p < .001). The likelihood of not responding to the steroid therapy was significantly higher in patients with higher BPT (OR = 2.954). CONCLUSIONS BPT value predicted steroid response in patients with sAH. BPT could quickly identify non-responder patients to steroid therapy, reducing the risk of infections and it could allow the early evaluation for liver transplantation.
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Affiliation(s)
- Claudia Tarli
- Internal Medicine and Alcohol Related Disease Unit, Department of Medical and Surgical Sciences, Columbus-Gemelli Hospital, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Sergio Mannucci
- Internal Medicine and Alcohol Related Disease Unit, Department of Medical and Surgical Sciences, Columbus-Gemelli Hospital, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Michele Vecchione
- Department of Social and Developmental Psychology Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
| | - Mariangela Antonelli
- Internal Medicine and Alcohol Related Disease Unit, Department of Medical and Surgical Sciences, Columbus-Gemelli Hospital, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luisa Sestito
- Internal Medicine and Alcohol Related Disease Unit, Department of Medical and Surgical Sciences, Columbus-Gemelli Hospital, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesco Antonio Mancarella
- Internal Medicine and Alcohol Related Disease Unit, Department of Medical and Surgical Sciences, Columbus-Gemelli Hospital, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Alberto Tosoni
- Internal Medicine and Alcohol Related Disease Unit, Department of Medical and Surgical Sciences, Columbus-Gemelli Hospital, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Tommaso Dionisi
- Internal Medicine and Alcohol Related Disease Unit, Department of Medical and Surgical Sciences, Columbus-Gemelli Hospital, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Valeria Maccauro
- Internal Medicine and Alcohol Related Disease Unit, Department of Medical and Surgical Sciences, Columbus-Gemelli Hospital, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giovanna Di Sario
- Internal Medicine and Alcohol Related Disease Unit, Department of Medical and Surgical Sciences, Columbus-Gemelli Hospital, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Giacomo Germani
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Antonio Gasbarrini
- Internal Medicine Unit, Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- CEMAD Digestive Disease Center, Department of Medical and Surgical Sciences, Hepatology and Gastroenterology Unit, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanni Addolorato
- Internal Medicine and Alcohol Related Disease Unit, Department of Medical and Surgical Sciences, Columbus-Gemelli Hospital, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- CEMAD Digestive Disease Center, Department of Medical and Surgical Sciences, Hepatology and Gastroenterology Unit, Università Cattolica del Sacro Cuore, Rome, Italy
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15
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Germani G, Degré D, Moreno C, Burra P. Workup and management of liver transplantation in alcohol-related liver disease. United European Gastroenterol J 2024; 12:203-209. [PMID: 38456339 PMCID: PMC10954425 DOI: 10.1002/ueg2.12548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 12/26/2023] [Indexed: 03/09/2024] Open
Abstract
Alcohol-related liver disease (ALD) represents the most common indication for liver transplantation (LT) worldwide. Outcomes of LT for ALD are comparable with those of LT for other etiologies; however, ALD is still considered a controversial indication for LT, mainly because it is considered a self-inflicted disease with a high risk of return to alcohol use after LT. Pre-LT evaluation criteria have changed over time, with a progressive re-evaluation of the required pre-transplant duration of abstinence. Despite the fact that some transplant programs still require 6 months of abstinence in order to consider a patient suitable for LT, there is increasing evidence that a pre-transplant abstinence period of <6 months can be considered for well-selected patients. Early LT for severe alcohol-related hepatitis that has not responded to medical therapy has been shown to be an effective therapeutic option with high survival benefit when performed within strict and well-recognized criteria. However, high variability in LT access exists for these patients due to the presence of social and medical stigma. A psycho-social assessment, together with an evaluation by an addiction specialist, should be mandatory in patients with ALD who are potential candidates for LT in order to assess the risk of post-transplant return to alcohol use and to ensure good long-term outcomes. Finally, before LT, attention should be paid to the presence of other potential comorbidities (i.e., cardiovascular and neurological diseases), which could represent a potential contraindication to LT. Similarly, after LT, patients should be adequately monitored for the development of cardiovascular events and screened for "de novo" tumors, although standardized protocols for this monitoring do not exist at this time.
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Affiliation(s)
- Giacomo Germani
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Delphine Degré
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Christophe Moreno
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
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16
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Singal AK, Leggio L, DiMartini A. Alcohol use disorder in alcohol-associated liver disease: Two sides of the same coin. Liver Transpl 2024; 30:200-212. [PMID: 37934047 DOI: 10.1097/lvt.0000000000000296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 10/16/2023] [Indexed: 11/08/2023]
Abstract
Alcohol-associated liver disease (ALD) has emerged as the leading indication for liver transplantation (LT) worldwide, with 40% of LTs in the United States performed for ALD in 2019. The ALD-related health care burden accelerated during the COVID-19 pandemic, especially in young individuals. Alcohol use disorder (AUD), which focuses on the negative effects of alcohol on psychosocial, physical, and mental health, is present in the majority of patients with ALD, with moderate to severe AUD in 75%-80%. During the last decade, early liver transplantation (eLT) has emerged as a lifesaving treatment for selected patients with alcohol-associated hepatitis; these patients may have a higher risk of using alcohol after LT. The risk of alcohol use recurrence may be reduced during the pretransplant or post-transplant period with AUD treatment using behavioral and/or pharmacological therapies and with regular monitoring for alcohol use (self-reported and complemented with biomarkers like phosphatidylethanol). However, AUD treatment in patients with ALD is challenging due to patient, clinician, and system barriers. An integrated model to provide AUD and ALD care by hepatologists and addiction experts in a colocated clinic starting from LT evaluation and selection to monitoring listed candidates and then to following up on recipients of LT should be promoted. However, the integration of addiction and hepatology teams in an LT program in the real world is often present only during evaluation and candidate selection for LT. Data are emerging to show that a multidisciplinary integrated AUD treatment within an LT program reduces recurrent alcohol use after LT. If we want to continue using early liver transplantation for patients with severe alcohol-associated hepatitis, LT programs should focus on building integrated multidisciplinary care teams for the integrated treatment of both AUD and ALD.
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Affiliation(s)
- Ashwani K Singal
- Department of Medicine, University of South Dakota, Vermillion, South Dakota, USA
- Department of Gastroenterology and Hepatology, Avera McKennan University Hospital, Sioux Falls, South Dakota, USA
- Department of Transplant Hepatology, Avera Transplant Institute, Sioux Falls, South Dakota, USA
- Department of Medicine, VA Medical Center, Sioux Falls, South Dakota, USA
| | - Lorenzo Leggio
- Department of Neuropsychopharmacology Clinical Psychoneuroendocrinology and Neuropsychopharmacology Section, Translational Addiction Medicine Branch, Division of Intramural Clinical and Biological Research, National Institute on Drug Abuse Intramural Research Program and National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland, USA
- Department of Behavioral and Social Sciences, Center for Alcohol and Addiction Studies, Brown University, Providence, Rhode Island, USA
- Department of Medicine, Division of Addiction Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Neuroscience, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Andrea DiMartini
- Departments of Psychiatry and Transplant Surgery, and the Clinical and Translational Science Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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17
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Ivkovic A, Nisavic M, Yang AH, Punko D, Aaron AE, Keegan E, Bethea ED, Yeh H. Single-center experience with early liver transplantation for acute alcohol-related hepatitis-Limitations of the SALT score and directions for future study. Clin Transplant 2024; 38:e15194. [PMID: 37964668 DOI: 10.1111/ctr.15194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 10/18/2023] [Accepted: 10/28/2023] [Indexed: 11/16/2023]
Abstract
Alcohol-related liver disease (ALD) is the leading indication for liver transplantation worldwide. Since Mathurin et al. described their experience in providing early liver transplantation for patients with ALD in 2011, other centers have followed suit with generally favorable survival outcomes. This patient population poses a unique clinical challenge given the expedited nature of the evaluation and the lack of any significant sobriety period prior to transplantation. The SALT (Sustained Alcohol Use Post-Liver Transplant) score is a standardized psychometric tool increasingly used to help stratify the risk of relapse and guide listing decisions for these challenging clinical situations. In 2018, our center introduced a protocol for early liver transplantation for acute alcohol-related hepatitis (AAH). In this article, we offer a retrospective review of 26 patients transplanted between May 2018 and May 2021, including at least 1-year follow-up, and compare outcomes to initial SALT scores; we further identify additional factors that may impact post-transplant success. As transplant committees continue to weigh the ethical dilemma of denying lifesaving treatment against the obligation to remain stewards of a limited resource, we aim to contribute to a more nuanced understanding of risk regarding early transplantation for ALD.
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Affiliation(s)
- Ana Ivkovic
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
- Center for Transplantation, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Mladen Nisavic
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
- Center for Transplantation, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Alexander H Yang
- Center for Transplantation, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Division of Gastroenterology and Hepatology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Diana Punko
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
- Center for Transplantation, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Ashley Elizabeth Aaron
- Department of Surgery, Division of Surgical Immunology and Transplantation, Eastern Carolina University, Greenville, South Carolina, USA
| | - Eileen Keegan
- Center for Transplantation, Massachusetts General Hospital, Boston, Massachusetts, USA
- Social Service Department, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Emily D Bethea
- Center for Transplantation, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Division of Gastroenterology and Hepatology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Heidi Yeh
- Center for Transplantation, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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18
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Jophlin LL, Singal AK, Bataller R, Wong RJ, Sauer BG, Terrault NA, Shah VH. ACG Clinical Guideline: Alcohol-Associated Liver Disease. Am J Gastroenterol 2024; 119:30-54. [PMID: 38174913 PMCID: PMC11040545 DOI: 10.14309/ajg.0000000000002572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 10/04/2023] [Indexed: 01/05/2024]
Abstract
ABSTRACT Alcohol-associated liver disease (ALD) is the most common cause of advanced hepatic disease and frequent indication for liver transplantation worldwide. With harmful alcohol use as the primary risk factor, increasing alcohol use over the past decade has resulted in rapid growth of the ALD-related healthcare burden. The spectrum of ALD ranges from early asymptomatic liver injury to advanced disease with decompensation and portal hypertension. Compared with those with other etiologies of liver disease, patients with ALD progress faster and more often present at an advanced stage. A unique phenotype of advanced disease is alcohol-associated hepatitis (AH) presenting with rapid onset or worsening of jaundice, and acute on chronic liver failure in severe forms conveying a 1-month mortality risk of 20%-50%. The model for end stage disease score is the most accurate score to stratify AH severity (>20 defined as severe disease). Corticosteroids are currently the only available therapeutic with proven efficacy for patients with severe AH, providing survival benefit at 1 month in 50%-60% of patients. Abstinence of alcohol use, a crucial determinant of long-term outcomes, is challenging to achieve in ALD patients with concurrent alcohol use disorder (AUD). As patients with ALD are rarely treated for AUD, strategies are needed to overcome barriers to AUD treatment in patients with ALD and to promote a multidisciplinary integrated care model with hepatology, addiction medicine providers, and social workers to comprehensively manage the dual pathologies of liver disease and of AUD. Liver transplantation, a definitive treatment option in patients with advanced cirrhosis, should be considered in selected patients with AH, who are unresponsive to medical therapy and have a low risk of relapse to posttransplant alcohol use. Level of evidence and strength of recommendations were evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations system. This guideline was developed under the American College of Gastroenterology Practice Parameters Committee.
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Affiliation(s)
- Loretta L. Jophlin
- Division of Gastroenterology, Hepatology and Nutrition, University of Louisville Health, Louisville, Kentucky, USA
| | - Ashwani K. Singal
- Division of Gastroenterology and Hepatology, University of South Dakota, Sioux Falls, South Dakota, USA
| | - Ramon Bataller
- Liver Unit, Department of Digestive and Metabolic Diseases, Hospital Clinic, Barcelona, Spain
| | - Robert J. Wong
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California, USA
| | - Bryan G. Sauer
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, USA
| | - Norah A. Terrault
- Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles, California, USA
| | - Vijay H. Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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19
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Ali H, Shahzad M, Sarfraz S, Sewell KB, Alqalyoobi S, Mohan BP. Application and impact of Lasso regression in gastroenterology: A systematic review. Indian J Gastroenterol 2023; 42:780-790. [PMID: 37594652 DOI: 10.1007/s12664-023-01426-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 07/05/2023] [Indexed: 08/19/2023]
Abstract
Least absolute shrinkage and selection operator (Lasso) regression is a statistical technique that can be used to study the effects of clinical variables in outcome prediction. In this study, we aimed at systematically reviewing the application of Lasso regression in gastroenterology for developing predictive models and providing a method of performing Lasso regression. A comprehensive search strategy was conducted in PubMed, Embase and Cochrane CENTRAL databases (Keywords: lasso regression; gastrointestinal tract/diseases) following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were screened for eligibility based on pre-defined selection criteria and the data was extracted using a standardized form. Total 16 studies were included, comprising a diverse range of gastroenterological disease-related outcomes. Sample sizes ranged from 134 to 8861 subjects. Eleven studies reported liver disease-related prediction models, while five focused on non-hepatic etiology models. Lasso regression was applied for variable selection, risk prediction and model development, with various validation methods and performance metrics used. Model performance metrics included Area Under the Receiver Operating Characteristics (AUROC), C-index and calibration plots. In gastroenterology, Lasso regression has been used in various diseases such as inflammatory bowel disease, liver disease and esophageal cancer. It is valuable for complex scenarios with many predictors. However, its effectiveness depends on high-quality and complete data. While it identifies important variables, it doesn't provide causal interpretations. Therefore, cautious interpretation is necessary considering the study design and data quality.
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Affiliation(s)
- Hassam Ali
- Department of Gastroenterology and Hepatology, East Carolina University, Greenville, NC, USA
| | - Maria Shahzad
- Department of Internal Medicine, University of Health Sciences, Lahore, Punjab, Pakistan
| | - Shiza Sarfraz
- Department of Internal Medicine, University of Health Sciences, Lahore, Punjab, Pakistan
| | - Kerry B Sewell
- Laupus Health Sciences Library, East Carolina University, Greenville, NC, USA
| | - Shehabaldin Alqalyoobi
- Department of Pulmonary and Critical Care Medicine, East Carolina University, Greenville, NC, USA
- Department of Bioinformatics and Biostatistics, School of Public Health and Information Sciences, University of Louisville, Louisville, KY, USA
| | - Babu P Mohan
- Gastroenterology and Hepatology, Orlando Gastroenterology PA, 1507 S Hiawassee Road, Ste 105, Orlando, FL, 32835, USA.
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20
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Musto JA, Lucey MR. Prognostic models in alcohol-related liver disease and alcohol-related hepatitis. Best Pract Res Clin Gastroenterol 2023; 67:101867. [PMID: 38103931 DOI: 10.1016/j.bpg.2023.101867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 08/18/2023] [Indexed: 12/19/2023]
Abstract
Alcohol-associated liver disease (ALD) and alcohol-associated hepatitis (AH) are dynamic disorders whose prognosis can be challenging to determine. A number of prognostic models have been developed to determine likelihood of death, when to refer for liver transplant (LT) and the role for glucocorticoids. Often these models were created with a specific application in mind but were found to have additional applications with further study. Those prognostic models that have stood the test of time are easy to use, have clear interpretations and employ objective parameters. These parameters most often include total bilirubin, INR and creatinine among other data points. Ideally, these models could be utilized at all phases of disease but in most, it is important for clinicians to consider drinking history and how it might alter the determined scores. Herein we provide a brief review of prognostic models in ALD and AH and provide practical tips and considerations to successfully make use of these tools in a clinical setting.
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Affiliation(s)
- Jessica Ann Musto
- Department of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
| | - Michael Ronan Lucey
- Department of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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21
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Torre A, Cisneros-Garza LE, Castillo-Barradas M, Navarro-Alvarez N, Sandoval-Salas R, González-Huezo MS, Pérez-Hernández JL, Méndez-Guerrero O, Ruiz-Manríquez JA, Trejo-Estrada R, Chavez-Tapia NC, Solís-Gasca LC, Moctezuma-Velázquez C, Aguirre-Valádez J, Flores-Calderón J, Higuera-de-la-Tijera F, García-Juárez I, Canedo-Castillo NA, Malé-Velázquez R, Montalvo-Gordon I, Vilatobá M, Márquez-Guillén E, Córdova-Gallardo J, Flores-García NC, Miranda-Zazueta G, Martínez-Saldívar BI, Páez-Zayas VM, Muñoz-Espinosa LE, Solís-Galindo FA. Consensus document on acute-on-chronic liver failure (ACLF) established by the Mexican Association of Hepatology. Ann Hepatol 2023; 28:101140. [PMID: 37482299 DOI: 10.1016/j.aohep.2023.101140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 05/26/2023] [Accepted: 05/31/2023] [Indexed: 07/25/2023]
Abstract
Acute-on chronic liver failure (ACLF) has been an intensively debated topic mainly due to the lack of a unified definition and diagnostic criteria. The growing number of publications describing the mechanisms of ACLF development, the progression of the disease, outcomes and treatment has contributed to a better understanding of the disease, however, it has also sparked the debate about this condition. As an attempt to provide medical professionals with a more uniform definition that could be applied to our population, the first Mexican consensus was performed by a panel of experts in the area of hepatology in Mexico. We used the most relevant and impactful publications along with the clinical and research experience of the consensus participants. The consensus was led by 4 coordinators who provided the most relevant bibliography by doing an exhaustive search on the topic. The entire bibliography was made available to the members of the consensus for consultation at any time during the process and six working groups were formed to develop the following sections: 1.- Generalities, definitions, and criteria, 2.- Pathophysiology of cirrhosis, 3.- Genetics in ACLF, 4.- Clinical manifestations, 5.- Liver transplantation in ACLF, 6.- Other treatments.
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Affiliation(s)
- Aldo Torre
- Metabolic Unit, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
| | - Laura Esthela Cisneros-Garza
- Gastroenterology and Hepatology Department, Hospital Christus Muguerza Alta Especialidad, Monterrey, Nuevo León, Mexico
| | | | - Nalu Navarro-Alvarez
- Gastroenterology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | | | | | - Osvely Méndez-Guerrero
- Gastroenterology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | | | | | - Luis Carlos Solís-Gasca
- Gastroenterology Department, Hospital General de Zona #12 Benito Juárez del Instituto Mexicano del Seguro Social, Mérida, Yucatán, Mexico
| | - Carlos Moctezuma-Velázquez
- Gastroenterology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico; Department of Medicine - Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Alberta, Canada
| | | | - Judith Flores-Calderón
- Pediatrics Department, Hospital de Pediatría, Centro Médico Nacional Siglo XXI, Mexico City, Mexico
| | | | - Ignacio García-Juárez
- Gastroenterology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | | | - Iaarah Montalvo-Gordon
- Clinic of Gastrointestinal and Hepatic Specialties, Hospital Faro del Mayab, Mérida, Yucatán, Mexico
| | - Mario Vilatobá
- Transplant Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Ernesto Márquez-Guillén
- Gastroenterology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico; Hospital Ángeles del Pedregal, Mexico City, Mexico
| | - Jacqueline Córdova-Gallardo
- Hepatology Department - General Surgery Service, Hospital General Dr. Manuel Gea González, Mexico City, Mexico
| | - Nayeli Cointa Flores-García
- Gastroenterology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Godolfino Miranda-Zazueta
- Gastroenterology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | | | - Linda Elsa Muñoz-Espinosa
- Universidad Autónoma de Nuevo León. Liver Unit, Department of Internal Medicine, University Hospital 'Dr. José E. González', Monterrey, Nuevo León, Mexico
| | - Francisco Alfonso Solís-Galindo
- Gastroenterology Department, Unidad Médica de Alta Especialidad # 71 Instituto Mexicano del Seguro Social, Torreón, Coahuila, Mexico
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22
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Prince DS, Nash E, Liu K. Alcohol-Associated Liver Disease: Evolving Concepts and Treatments. Drugs 2023; 83:1459-1474. [PMID: 37747685 PMCID: PMC10624727 DOI: 10.1007/s40265-023-01939-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2023] [Indexed: 09/26/2023]
Abstract
Alcohol is a prominent cause of liver disease worldwide with higher prevalence in developed nations. The spectrum of alcohol-associated liver disease (ALD) encompasses a diverse range of clinical entities, from asymptomatic isolated steatosis to decompensated cirrhosis, and in some cases, acute or chronic liver failure. Consequently, it is important for healthcare practitioners to maintain awareness and systematically screen for ALD. The optimal evaluation and management of ALD necessitates a collaborative approach, incorporating a multidisciplinary team and accounting for concurrent medical conditions. A repertoire of therapeutic interventions exists to support patients in achieving alcohol cessation and sustaining remission, with complete abstinence being the ultimate objective. This review explores the existing therapeutic options for ALD acknowledging geographical discrepancies in accessibility. Recent innovations, including the inclusion of alcohol consumption biomarkers into clinical protocols and the expansion of liver transplantation eligibility to encompass severe alcohol-associated hepatitis, are explored.
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Affiliation(s)
- David Stephen Prince
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia.
- Department of Gastroenterology and Liver, Liverpool Hospital, Sydney, NSW, Australia.
- Liver Injury and Cancer Program, Centenary Institute, Sydney, NSW, Australia.
- The Ingham Institute for Applied Medical Research, Sydney, NSW, Australia.
- Faculty of Medicine and Health, The University of New South Wales, Sydney, NSW, Australia.
| | - Emily Nash
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Ken Liu
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Liver Injury and Cancer Program, Centenary Institute, Sydney, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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23
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Puri P, Malik S. Liver Transplantation: Contraindication and Ineligibility. J Clin Exp Hepatol 2023; 13:1116-1129. [PMID: 37975058 PMCID: PMC10643298 DOI: 10.1016/j.jceh.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 04/14/2023] [Indexed: 11/19/2023] Open
Abstract
Liver transplantation (LT) is a life-saving therapeutic modality for patients with various advanced liver diseases. It is crucial to identify that the patient's illness is sufficiently advanced and unlikely to improve with medical management to justify the need for transplantation. At the same time, it is crucial to identify patients with comorbidities and far advanced disease that would result in an unacceptable outcome after LT. Specific care also is required before deciding on LT in the elderly, acute on chronic liver disease, patients with comorbidities, and hepatocellular carcinoma. Transplantation needs to be timed appropriately to avoid unnecessary LT and ensure that the decision is not left too late to avoid losing the patient without a transplant. Also, important is the decision as to when not to transplant. The current review explores some of these issues of contraindications and ineligibility for LT.
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Affiliation(s)
- Pankaj Puri
- Fortis Escorts Liver and Digestive Diseases Institute, Fortis Escorts Hospital, New Delhi 110025, India
| | - Sarthak Malik
- Department of Gastroenterology, Manipal Hospital, Dwarka, New Delhi 110075, India
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24
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Chálim Rebelo C, Félix C, Cardoso FS, Bagulho L, Sousa M, Mendes M, Glória H, Mateus É, Mega I, Jara M, Pinto Marques H, Nolasco F, Martins A, Perdigoto R. Alcohol Consumption Post-Liver Transplantation: A Cross-Sectional Study. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2023; 30:343-349. [PMID: 37868639 PMCID: PMC10586211 DOI: 10.1159/000525808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 02/16/2022] [Indexed: 10/24/2023]
Abstract
Background Listing patients with alcohol-associated liver disease (ALD) for liver transplant (LT) remains challenging especially due to the risk of alcohol resumption post-LT. We aimed to evaluate post-LT alcohol consumption at a Portuguese transplant center. Methods We conducted a cross-sectional study including LT recipients from 2019 at Curry Cabral Hospital, Lisbon, Portugal. A pretested survey and a validated Portuguese translation of the Alcohol Use Disorder Identification Test (AUDIT) were applied via a telephone call. Alcohol consumption was defined by patients' self-reports or a positive AUDIT. Results In 2019, 122 patients underwent LT, and 99 patients answered the survey (June 2021). The mean (SD) age was 57 (10) years, 70 patients (70.7%) were males, and 49 (49.5%) underwent ALD-related LT. During a median (IQR) follow-up of 24 (20-26) months post-index LT, 22 (22.2%) recipients consumed any amount of alcohol: 14 had a drink monthly or less and 8 drank 2-4 times/month. On drinking days, 18 patients usually consumed 1-2 drinks and the remainder no more than 3-4 drinks. One patient reported having drunk ≥6 drinks on one occasion. All post-LT drinking recipients were considered low risk (score <8) as per the AUDIT score (median [IQR] of 1 [1-2]). No patient reported alcohol-related problems, whether self-inflicted or toward others. Drinking recipients were younger (53 vs. 59 years, p = 0.020), had more non-ALD-related LT (72.7 vs. 44.2%, p = 0.018) and active smoking (31.8 vs. 10.4%, p = 0.037) than abstinent ones. Conclusion In our cohort, about a quarter of LT recipients consumed alcohol early posttransplant, all with a low-risk pattern according to the AUDIT score.
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Affiliation(s)
| | - Catarina Félix
- Gastroenterology Division, Western Lisbon Hospital Center, Lisbon, Portugal
| | - Filipe S. Cardoso
- Transplant Unit, Curry Cabral Hospital, Central Lisbon University Hospital Center, Nova Medical School, Nova University, Lisbon, Portugal
| | - Luis Bagulho
- Transplant Unit, Curry Cabral Hospital, Central Lisbon University Hospital Center, Nova Medical School, Nova University, Lisbon, Portugal
| | - Monica Sousa
- Transplant Unit, Curry Cabral Hospital, Central Lisbon University Hospital Center, Nova Medical School, Nova University, Lisbon, Portugal
| | - Milena Mendes
- Transplant Unit, Curry Cabral Hospital, Central Lisbon University Hospital Center, Nova Medical School, Nova University, Lisbon, Portugal
| | - Helena Glória
- Transplant Unit, Curry Cabral Hospital, Central Lisbon University Hospital Center, Nova Medical School, Nova University, Lisbon, Portugal
| | - Élia Mateus
- Transplant Unit, Curry Cabral Hospital, Central Lisbon University Hospital Center, Nova Medical School, Nova University, Lisbon, Portugal
| | - Inês Mega
- Transplant Unit, Curry Cabral Hospital, Central Lisbon University Hospital Center, Nova Medical School, Nova University, Lisbon, Portugal
| | - Miguel Jara
- Transplant Unit, Curry Cabral Hospital, Central Lisbon University Hospital Center, Nova Medical School, Nova University, Lisbon, Portugal
| | - Hugo Pinto Marques
- Transplant Unit, Curry Cabral Hospital, Central Lisbon University Hospital Center, Nova Medical School, Nova University, Lisbon, Portugal
| | - Fernando Nolasco
- Transplant Unit, Curry Cabral Hospital, Central Lisbon University Hospital Center, Nova Medical School, Nova University, Lisbon, Portugal
| | - Américo Martins
- Transplant Unit, Curry Cabral Hospital, Central Lisbon University Hospital Center, Nova Medical School, Nova University, Lisbon, Portugal
| | - Rui Perdigoto
- Transplant Unit, Curry Cabral Hospital, Central Lisbon University Hospital Center, Nova Medical School, Nova University, Lisbon, Portugal
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25
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Ali H. Letter Regarding "Predictive Model for Positive Video Capsule Endoscopy in Iron Deficiency Anemia". Dig Dis Sci 2023; 68:4060-4061. [PMID: 37620714 DOI: 10.1007/s10620-023-08039-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 07/07/2023] [Indexed: 08/26/2023]
Affiliation(s)
- Hassam Ali
- Department of Internal Medicine, ECU Health Medical Center, Greenville, NC, 27834, USA.
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26
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Odenwald MA, Roth HF, Reticker A, Segovia M, Pillai A. Evolving challenges with long-term care of liver transplant recipients. Clin Transplant 2023; 37:e15085. [PMID: 37545440 DOI: 10.1111/ctr.15085] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/17/2023] [Accepted: 07/23/2023] [Indexed: 08/08/2023]
Abstract
The number of liver transplants (LT) performed worldwide continues to rise, and LT recipients are living longer post-transplant. This has led to an increasing number of LT recipients requiring lifelong care. Optimal care post-LT requires careful attention to both the allograft and systemic issues that are more common after organ transplantation. Common causes of allograft dysfunction include rejection, biliary complications, and primary disease recurrence. While immunosuppression prevents rejection and reduces incidences of some primary disease recurrence, it has detrimental systemic effects. Most commonly, these include increased incidences of metabolic syndrome, various malignancies, and infections. Therefore, it is of utmost importance to optimize immunosuppression regimens to prevent allograft dysfunction while also decreasing the risk of systemic complications. Institutional protocols to screen for systemic disease and heightened clinical suspicion also play an important role in providing optimal long-term post-LT care. In this review, we discuss these common complications of LT as well as unique considerations when caring for LT recipients in the years after transplant.
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Affiliation(s)
- Matthew A Odenwald
- Department of Medicine, Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago Medicine, Chicago, USA
| | - Hannah F Roth
- Department of Medicine, Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago Medicine, Chicago, USA
| | - Anesia Reticker
- Department of Pharmacy, University of Chicago Medicine, Chicago, USA
| | - Maria Segovia
- Department of Medicine, Section of Gastroenterology, Duke University School of Medicine, Durham, USA
| | - Anjana Pillai
- Department of Medicine, Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago Medicine, Chicago, USA
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27
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Mitchell J, Herrick-Reynolds K, Motter JD, Teles M, Kates O, Sung H, Chen PH, King E, Cameron A. Transplant Center Attitudes Toward Early Liver Transplant for Alcohol-associated Liver Disease. Transplant Direct 2023; 9:e1532. [PMID: 37649789 PMCID: PMC10465102 DOI: 10.1097/txd.0000000000001532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/29/2023] [Accepted: 07/14/2023] [Indexed: 09/01/2023] Open
Abstract
Background Many centers have removed 6-mo pretransplant alcohol abstinence requirements to provide early liver transplant (ELT) for individuals with severe alcohol-associated liver disease (ALD), but the practice remains controversial. Using data collected from a nationally distributed survey, this study examines the practices and attitudes of transplant centers in the United States regarding ELT. Methods A 20-item survey designed to assess center practices and provider attitudes was distributed to 225 medical and surgical directors from 143 liver transplant centers via email. Results Surveys were completed by 28.9% (n = 65) of directors and 39% (n = 56) of transplant centers. All responding centers reported evaluating patients for ELT. Circumstances for considering ELT included <6 mo of survival without a transplant (96.4%) and inability to participate in alcohol addiction therapy pretransplant (75%). Most (66%) directors indicated their center had established criteria for listing candidates with severe ALD for ELT. Regarding important factors for ELT candidate listing, 57.1% indicated patient survival, 37.5% indicated graft survival, and 55.4% indicated having a low risk of relapse. Only 12.7% of directors affirmed the statement, "Six months of pretransplant abstinence decreases the risk of relapse." Conclusions More centers are providing ELT for severe ALD. Inability to participate in alcohol addiction therapy and <6 mo of survival are commonly reported circumstances for considering ELT. Continued investigation of posttransplant outcomes in patients receiving ELT is essential to establishing a national consensus for distributing this valuable resource.
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Affiliation(s)
- Jonathan Mitchell
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Jennifer D. Motter
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Mayan Teles
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Olivia Kates
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Hannah Sung
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Po-Hung Chen
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Elizabeth King
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andrew Cameron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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28
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Germani G, D’Arcangelo F, Grasso M, Burra P. Advances and Controversies in Acute Alcohol-Related Hepatitis: From Medical Therapy to Liver Transplantation. Life (Basel) 2023; 13:1802. [PMID: 37763206 PMCID: PMC10532507 DOI: 10.3390/life13091802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/10/2023] [Accepted: 08/18/2023] [Indexed: 09/29/2023] Open
Abstract
Alcohol-related hepatitis (AH) is a clinical syndrome characterized by recent-onset jaundice in the context of alcohol consumption. In patients with severe AH "unresponsive" to steroid therapy, mortality rates exceed 70% within six months. According to European and American guidelines, liver transplantation (LT) may be considered in highly selected patients who do not respond to medical therapy. The aim of this narrative review is to summarize current knowledge from medical therapy to liver transplantation in acute alcohol-related hepatitis. Due to the impossibility to guarantee six-month abstinence, LT for AH is controversial. Principal concerns are related to organ scarcity in the subset of stigma of "alcohol use disorder" (AUD) and the risk of relapse to alcohol use after LT. Return to alcohol use after LT is a complex issue that cannot be assessed as a yes/no variable with heterogeneous results among studies. In conclusion, present data indicate that well-selected patients have excellent outcomes, with survival rates of up to 100% at 24 and 36 months after LT. Behavioral therapy, ongoing psychological support, and strong family support seem essential to improve long-term outcomes after LT and reduce the risk in relapse of alcohol use.
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Affiliation(s)
- Giacomo Germani
- Multivisceral Transplant Unit, Azienda Ospedale—Università Padova, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35122 Padova, Italy
| | - Francesca D’Arcangelo
- Gastroenterology and Multivisceral Transplant Unit, Azienda Ospedale—Università Padova, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35122 Padova, Italy; (F.D.); (M.G.); (P.B.)
| | - Marco Grasso
- Gastroenterology and Multivisceral Transplant Unit, Azienda Ospedale—Università Padova, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35122 Padova, Italy; (F.D.); (M.G.); (P.B.)
| | - Patrizia Burra
- Gastroenterology and Multivisceral Transplant Unit, Azienda Ospedale—Università Padova, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35122 Padova, Italy; (F.D.); (M.G.); (P.B.)
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29
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Lee BP, Terrault NA. Liver transplantation for alcohol-associated liver disease: A call for national standards of best practices to monitor and bridge disparities in access and outcomes. Am J Transplant 2023; 23:1097-1101. [PMID: 37023857 PMCID: PMC10524758 DOI: 10.1016/j.ajt.2023.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 03/17/2023] [Accepted: 03/29/2023] [Indexed: 04/08/2023]
Abstract
Early (ie, without a mandated abstinence period) liver transplantation for alcohol-associated liver disease is the fastest-growing indication for liver transplantation in the United States. Despite widespread adoption, there is no standardization of practice or policies across transplant centers, nor are there any quality metrics from regulatory organizations specific to alcohol, all of which have likely contributed to confirmed disparities in transplant access and patient outcomes. In this article, we propose new mandates and best practices that could be put forth by the organ procurement and transplantation network regarding processes related to candidate selection, monitoring of alcohol use, and services to prevent and treat harmful alcohol use among early transplant candidates and recipients. We hope that this article stimulates discussion and leads to policy changes to maximize equity and quality of transplant care.
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Affiliation(s)
- Brian P Lee
- Division of Gastroenterology and Liver Diseases, University of Southern California, Los Angeles, California, USA.
| | - Norah A Terrault
- Division of Gastroenterology and Liver Diseases, University of Southern California, Los Angeles, California, USA
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30
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Yoon EL, Kim W. Current and future treatment for alcoholic-related liver diseases. J Gastroenterol Hepatol 2023; 38:1218-1226. [PMID: 37300449 DOI: 10.1111/jgh.16257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 05/29/2023] [Indexed: 06/12/2023]
Abstract
The socioeconomic burden of alcohol-related liver disease has been increasing worldwide. Its prevalence is underestimated, and patients with alcohol-related liver disease are rarely diagnosed in the earlier phase of the disease spectrum. Alcoholic hepatitis is a distinct syndrome with life-threatening signs of systemic inflammation. In severe alcoholic hepatitis, prednisolone is indicated as the first-line treatment even with the possibility of various complications. Early liver transplantation can be another option for highly selected patients with a null response to prednisolone. Most importantly, abstinence is the mainstay of long-term care, but relapse is frequent among patients. Recent findings on the pathogenesis of alcoholic hepatitis have enabled us to discover new therapeutic targets. Preventing hepatic inflammation, reducing oxidative stress, improving gut dysbiosis, and enhancing liver regeneration are the main targets of emerging therapies. Herein, we review the pathogenesis, current treatment, and barriers to successful clinical trials of alcoholic hepatitis. Additionally, clinical trials for alcoholic hepatitis, either ongoing or recently completed, will be briefly introduced.
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Affiliation(s)
- Eileen L Yoon
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea
- Hanyang Institute of Bioscience and Biotechnology, Hanyang University, Seoul, Republic of Korea
| | - Won Kim
- Department of Internal Medicine, Seoul National University College of Medicine and Seoul Metropolitan Government Boramae Medical Center, Seoul, Republic of Korea
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Terrault NA, Francoz C, Berenguer M, Charlton M, Heimbach J. Liver Transplantation 2023: Status Report, Current and Future Challenges. Clin Gastroenterol Hepatol 2023; 21:2150-2166. [PMID: 37084928 DOI: 10.1016/j.cgh.2023.04.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 03/29/2023] [Accepted: 04/04/2023] [Indexed: 04/23/2023]
Abstract
Liver transplantation offers live-saving therapy for patients with complications of cirrhosis and stage T2 hepatocellular carcinoma. The demand for organs far outstrips the supply, and innovations aimed at increasing the number of usable deceased donors as well as alternative donor sources are a major focus. The etiologies of cirrhosis are shifting over time, with more need for transplantation among patients with alcohol-associated liver disease and nonalcoholic/metabolic fatty liver disease and less for viral hepatitis, although hepatitis B remains an important indication for transplant in countries with high endemicity. The rise in transplantation for alcohol-associated liver disease and nonalcoholic/metabolic fatty liver disease has brought attention to how patients are selected for transplantation and the strategies needed to prevent recurrent disease. In this review, we present a status report on the most pressing topics in liver transplantation and future challenges.
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Affiliation(s)
- Norah A Terrault
- Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles, California.
| | - Claire Francoz
- Liver Intensive Care and Liver Transplantation Unit, Hepatology, Hospital Beaujon, Clichy, France
| | - Marina Berenguer
- Hepatology and Liver Transplantation Unit, Hospital Universitario la Fe - IIS La Fe Valencia; CiberEHD and University of Valencia, Valencia, Spain
| | - Michael Charlton
- Transplantation Institute, University of Chicago, Chicago, Illinois
| | - Julie Heimbach
- William von Liebig Center for Transplantation, Mayo Clinic Rochester, Minnesota
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Varshney M, Dhingra K, Choudhury A. Psychosocial Assessment and Management-related Issues Among Liver Transplant Recipients. J Clin Exp Hepatol 2023. [DOI: 10.1016/j.jceh.2023.07.414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
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Winder GS, Clifton EG, Fernandez AC, MacEachern M, Andrews S, Perumalswami P, DiMartini AF, Mellinger JL. Definition and measurement of alcohol-associated insight in early liver transplantation for acute alcohol-associated hepatitis: A systematic review. Liver Transpl 2023; 29:757-767. [PMID: 37016758 DOI: 10.1097/lvt.0000000000000144] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 03/27/2023] [Indexed: 04/06/2023]
Abstract
BACKGROUND Alcohol accounts for a large disease burden in hepatology and liver transplantation (LT) and across the globe. Clinical evaluations and decisions about LT candidacy are challenging because they rely on detailed psychosocial assessments and interpretations of psychiatric and substance use disorder data, which often must occur rapidly according to the acuity of end-stage liver disease. Such difficulties commonly occur during the process of candidate selection and liver allocation, particularly during early LT (eLT) in patients with acute alcohol-associated hepatitis (AAH). Patients with AAH commonly have very recent or active substance use, high short-term mortality, psychiatric comorbidities, and compressed evaluation and treatment timetables. LT clinicians report that patients' alcohol-associated insight (AAI) is among the most relevant psychosocial data in this population, yet no studies exist examining how LT teams define and use AAI in eLT or its effect on clinical outcomes. In April 2022, we searched Ovid MEDLINE, Elsevier Embase, EBSCOhost PsycInfo and CINAHL, and Wiley Cochrane Central Register of Controlled Trials for reports describing AAH populations who underwent eLT, which also described psychosocial evaluation parameters. The searches retrieved 1603 unique reports. After eligibility screening, 8 were included in the qualitative analysis. This systematic review reveals that AAI is a poorly defined construct that is not measured in a standardized way. Yet it is a commonly cited parameter in articles that describe the psychosocial evaluation and decision-making of patients undergoing eLT for AAH. This article also discusses the general challenges of assessing AAI during eLT for AAH, existing AAI definitions and rating scales, how AAI has been used to date in the broader hepatology and LT literature, and future areas for clinical and research progress.
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Affiliation(s)
- Gerald Scott Winder
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
| | - Erin G Clifton
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Anne C Fernandez
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Mark MacEachern
- Taubman Health Sciences Library, University of Michigan, Ann Arbor, Michigan, USA
| | - Sarah Andrews
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ponni Perumalswami
- Gastroenterology Section, Veterans Affairs, Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Andrea F DiMartini
- Departments of Psychiatry, Surgery, and Translational Science, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jessica L Mellinger
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Germani G, Mathurin P, Lucey MR, Trotter J. Early liver transplantation for severe acute alcohol-related hepatitis after more than a decade of experience. J Hepatol 2023; 78:1130-1136. [PMID: 37208100 DOI: 10.1016/j.jhep.2023.03.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 03/01/2023] [Accepted: 03/06/2023] [Indexed: 05/21/2023]
Abstract
In patients with severe acute alcohol-related hepatitis not responding to medical therapy, early liver transplantation (LT) represents the only effective therapy and, when performed within strict and well-defined protocols, it is associated with a clear survival benefit and acceptable rates of return to alcohol use after transplantation. However, there is still high variability in access to LT for patients with severe alcohol-related hepatitis, mainly due to a persistent overemphasis in the pre-LT evaluation on duration of pre-transplant abstinence and the stigma that patients with alcohol-related liver disease often experience, leading to marked inequity of access to this potentially lifesaving procedure and negative health outcomes. Therefore, there is an increasing need for prospective multicentre studies focusing on pre-transplant selection practices and on better interventions to treat alcohol use disorder after LT.
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Affiliation(s)
- Giacomo Germani
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University Hospital Padua, University of Padua, Padua, Italy.
| | - Philippe Mathurin
- Service des Maladies de l'appareil Digestif, Hôpital Huriez, CHU Lille, France
| | - Michael R Lucey
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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Schroeder M, Pedersen M, Petrasek J, Grant L. Outcomes following liver transplant for alcohol-associated liver disease: comparing alcohol-associated hepatitis and cirrhosis. Hepatol Commun 2023; 7:02009842-202305010-00026. [PMID: 37141503 PMCID: PMC10162787 DOI: 10.1097/hc9.0000000000000132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 02/22/2023] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND Liver transplant (LT) is a highly effective therapy for refractory severe alcohol-associated hepatitis (SAH), but optimal selection criteria remain unknown. We aim to evaluate the outcomes of patients who received LT for alcohol-associated liver disease at our center following the introduction of updated selection criteria, including the removal of the minimum sobriety requirement. METHODS Data were collected on all patients who underwent LT for alcohol-associated liver disease from January 1, 2018, to September 30, 2020. Patients were divided into SAH and cirrhosis cohorts based on disease phenotype. RESULTS One hundred twenty-three patients underwent LT for alcohol-associated liver disease, including 89 (72.4%) for cirrhosis and 34 (27.6%) for SAH. There was no difference in 1- (97.1 ± 2.9% vs. 97.7 ± 1.6%, p = 0.97) and 3-year (97.1 ± 2.9% vs. 92.4 ± 3.4%, p = 0.97) survival between SAH and cirrhosis cohorts. Return to alcohol use was more frequent in the SAH cohort at 1 year (29.4 ± 7.8% vs. 11.4 ± 3.4%, p = 0.005) and 3 years (45.1 ± 8.7% vs. 21.0 ± 6.2%, p = 0.005) including higher frequencies of both slips and problematic drinking. Unsuccessful alcohol use counseling (HR 3.42, 95% CI 1.12-10.5) and prior alcohol support meetings (HR 3.01, 95% CI 1.03-8.83) predicted a return to harmful alcohol use patterns in early LT recipients. Both duration of sobriety (c-statistic 0.32 (95% CI 0.34-0.43) and SALT score (c-statistic 0.47, 95% CI 0.34-0.60) were independently poor predictors of return to harmful drinking. CONCLUSION Survival following LT was excellent in both SAH and cirrhosis cohorts. Higher rates of return to alcohol use highlight the importance of further individualized refinement of selection criteria and improved support following LT.
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Affiliation(s)
- Matthew Schroeder
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Mark Pedersen
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical, Dallas, Texas, USA
| | - Jan Petrasek
- Division of Digestive Disease, University of Mississippi, Mississippi, USA
| | - Lafaine Grant
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical, Dallas, Texas, USA
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Durkin C, Bittermann T. Liver transplantation for alcohol-associated hepatitis. Curr Opin Organ Transplant 2023; 28:85-94. [PMID: 36512482 PMCID: PMC9992110 DOI: 10.1097/mot.0000000000001044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Early liver transplantation is emerging as a treatment option for severe alcohol-associated hepatitis refractory to pharmacotherapies. This review outlines the current status of transplantation for alcohol-associated hepatitis and the treatment of alcohol use disorder after liver transplantation. RECENT FINDINGS Rates of early liver transplantation for alcohol-associated hepatitis are increasing with significant heterogeneity in practices across the Unites States. Recent studies have demonstrated a substantial survival benefit in patients transplanted for alcohol-associated hepatitis with improved outcomes in early vs. late transplantation, first vs. prior hepatic decompensation, and posttransplant abstinence/delayed relapse vs. early return to alcohol use. Several prediction algorithms have been developed to ascertain patients' risk of alcohol relapse and aid in candidate selection, though data on treatment of alcohol use disorders in transplant recipients remains limited. SUMMARY Although controversial, early liver transplantation for severe alcohol-associated hepatitis has shown to be a lifesaving intervention. Additional research is needed to evaluate its long-term outcomes, optimize candidate selection, and understand treatment of alcohol use disorder posttransplant.
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Affiliation(s)
- Claire Durkin
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Therese Bittermann
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
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Liver transplantation in alcohol-associated liver disease: ensuring equity through new processes. Liver Transpl 2023; 29:539-547. [PMID: 36738082 DOI: 10.1097/lvt.0000000000000088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 12/14/2022] [Indexed: 02/05/2023]
Abstract
Worsened by the COVID-19 pandemic, alcohol use is one of the leading causes of preventable death in the US, in large part due to alcohol-associated liver disease. Throughout history, liver transplantation for this population has been controversial, and many policies and regulations have existed to limit access to lifesaving transplant for patients who use alcohol. In recent years, the rates of liver transplantation for patients with alcohol-associated liver disease have increased dramatically; however, disparities persist. For instance, many criteria used in evaluation for transplant listing, such as social support and prior knowledge of the harms of alcohol use, are not evidence based and may selectively disadvantage patients with alcohol use disorder. In addition, few transplant providers have adequate training in the treatment of alcohol use disorder, and few transplant centers offer specialized addiction treatment. Finally, current approaches to liver transplantation would benefit from adopting principles of harm reduction, which have demonstrated efficacy in the realm of addiction medicine for years. As we look toward the future, we must emphasize the use of evidence-based measures in selecting patients for listing, ensure access to high-quality addiction care for all patients pretransplant and posttransplant, and adopt harm reduction beliefs to better address relapse when it inevitably occurs. We believe that only by addressing each of these issues will we be able to ensure a more equitable distribution of resources in liver transplantation for all patients.
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Ntandja Wandji LC, Ningarhari M, Lassailly G, Dharancy S, Boleslawski E, Mathurin P, Louvet A. Liver Transplantation in Alcohol-related Liver Disease and Alcohol-related Hepatitis. J Clin Exp Hepatol 2023; 13:127-138. [PMID: 36647412 PMCID: PMC9840078 DOI: 10.1016/j.jceh.2022.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 06/25/2022] [Indexed: 02/07/2023] Open
Abstract
Alcohol-related liver disease (ARLD) remains one of the leading causes of chronic liver disease and the prevalence of alcohol-related cirrhosis is still increasing worldwide. Thus, ARLD is one of the leading indications for liver transplantation (LT) worldwide especially after the arrival of direct-acting antivirals for chronic hepatitis C infection. Despite the risk of alcohol relapse, the outcomes of LT for ARLD are as good as for other indications such as hepatocellular carcinoma (HCC), with 1-, 5-, and 10- year survival rates of 85%, 74%, and 59%, respectively. Despite these good results, certain questions concerning LT for ARLD remain unanswered, in particular because of persistent organ shortages. As a result, too many transplantation centers continue to require 6 months of abstinence from alcohol for patients with ARLD before LT to reduce the risk of alcohol relapse even though compelling data show the poor prognostic value of this criterion. A recent pilot study even observed a lower alcohol relapse rate in patients receiving LT after less than 6 months of abstinence as long as addictological follow-up is reinforced. Thus, the question should not be whether LT should be offered to patients with ARLD but how to select patients who will benefit from this treatment.
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Key Words
- AH, alcohol-related hepatitis
- ARLD, Alcohol-related liver disease
- AUDIT, Alcohol Use Disorders Identification Test
- CLD, chronic liver disease
- ELTR, European Liver Transplant Registry
- HCC, hepatocellular carcinoma
- HCV, hepatitis C virus
- LT, liver transplantation
- NASH, non-alcoholic steatohepatitis
- NIAAA, National Institute on Alcohol Abuse and Alcoholism
- UNOS, United Network for Organ Sharing
- alcohol
- alcohol-related hepatitis
- alcohol-related liver disease
- liver transplantation
- survival
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Affiliation(s)
- Line Carolle Ntandja Wandji
- University of Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, Lille, F-59000 France
| | - Massih Ningarhari
- University of Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, Lille, F-59000 France
| | - Guillaume Lassailly
- University of Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, Lille, F-59000 France
| | - Sébastien Dharancy
- University of Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, Lille, F-59000 France
| | - Emmanuel Boleslawski
- University of Lille, Inserm, CHU Lille, U1189 - ONCO-THAI - Image Assisted Laser Therapy for Oncology, Lille, F-59000 France
| | - Philippe Mathurin
- University of Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, Lille, F-59000 France
| | - Alexandre Louvet
- University of Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, Lille, F-59000 France
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Affiliation(s)
- Ramon Bataller
- From the Liver Unit, Hospital Clínic de Barcelona, Barcelona (R.B.); Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago (J.P.A.); the Division of Gastroenterology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, and London Health Sciences Centre, London, ON, Canada (J.P.A.); and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (V.H.S.)
| | - Juan Pablo Arab
- From the Liver Unit, Hospital Clínic de Barcelona, Barcelona (R.B.); Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago (J.P.A.); the Division of Gastroenterology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, and London Health Sciences Centre, London, ON, Canada (J.P.A.); and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (V.H.S.)
| | - Vijay H Shah
- From the Liver Unit, Hospital Clínic de Barcelona, Barcelona (R.B.); Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago (J.P.A.); the Division of Gastroenterology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, and London Health Sciences Centre, London, ON, Canada (J.P.A.); and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (V.H.S.)
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40
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Early Liver Transplantation for Severe Alcohol-Associated Hepatitis and a History of Prior Liver Decompensation. Am J Gastroenterol 2022; 117:1990-1998. [PMID: 35853462 PMCID: PMC10361649 DOI: 10.14309/ajg.0000000000001901] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 06/08/2022] [Indexed: 02/08/2023]
Abstract
INTRODUCTION In the published studies of early liver transplantation (LT) for alcohol-associated hepatitis (AH), patients with a prior liver decompensation are excluded. The appropriateness of this criteria is unknown. METHODS Among 6 American Consortium of Early Liver Transplantation for Alcohol-Associated Hepatitis sites, we included consecutive early LT for clinically diagnosed AH between 2007 and 2020. Patients were stratified as first vs prior history of liver decompensation, with the latter defined as a diagnosis of ascites, hepatic encephalopathy, variceal bleeding, or jaundice, and evidence of alcohol use after this event. Adjusted Cox regression assessed the association of first (vs prior) decompensation with post-LT mortality and harmful (i.e., any binge and/or frequent) alcohol use. RESULTS A total of 241 LT recipients (210 first vs 31 prior decompensation) were included: median age 43 vs 38 years ( P = 0.23), Model for End-Stage Liver Disease Sodium score of 39 vs 39 ( P = 0.98), and follow-up after LT 2.3 vs 1.7 years ( P = 0.08). Unadjusted 1- and 3-year survival among first vs prior decompensation was 93% (95% confidence interval [CI] 89%-96%) vs 86% (95% CI 66%-94%) and 85% (95% CI 79%-90%) vs 78% (95% CI 57%-89%). Prior (vs first) decompensation was associated with higher adjusted post-LT mortality (adjusted hazard ratio 2.72, 95% CI 1.61-4.59) and harmful alcohol use (adjusted hazard ratio 1.77, 95% CI 1.07-2.94). DISCUSSION Prior liver decompensation was associated with higher risk of post-LT mortality and harmful alcohol use. These results are a preliminary safety signal and validate first decompensation as a criterion for consideration in early LT for AH patients. However, the high 3-year survival suggests a survival benefit for early LT and the need for larger studies to refine this criterion. These results suggest that prior liver decompensation is a risk factor, but not an absolute contraindication to early LT.
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41
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Horwich BH, Leven E, Winters AC, Pourmand K. The evolving paradigm of alcohol‐associated hepatitis and liver transplantation. Clin Liver Dis (Hoboken) 2022; 21:80-83. [PMID: 37095774 PMCID: PMC10121440 DOI: 10.1002/cld.1259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 07/18/2022] [Accepted: 08/04/2022] [Indexed: 12/03/2022] Open
Abstract
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Affiliation(s)
- Brian H. Horwich
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Emily Leven
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Adam C. Winters
- Division of Liver Diseases, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kamron Pourmand
- Division of Liver Diseases, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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42
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Zanowski SC, Price JS, Selim MA, Schumann V, Durazo F, Hong JC. Effect of an Integrated Transplantation Mental Health Program on Alcohol Relapse After Liver Transplantation for Severe Alcoholic Hepatitis: A Single-Center Prospective Study. Transplant Proc 2022; 54:2627-2633. [DOI: 10.1016/j.transproceed.2022.09.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 09/19/2022] [Accepted: 09/20/2022] [Indexed: 11/21/2022]
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Bajaj JS, Nagy LE. Natural History of Alcohol-Associated Liver Disease: Understanding the Changing Landscape of Pathophysiology and Patient Care. Gastroenterology 2022; 163:840-851. [PMID: 35598629 PMCID: PMC9509416 DOI: 10.1053/j.gastro.2022.05.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 05/12/2022] [Accepted: 05/14/2022] [Indexed: 12/02/2022]
Abstract
Alcohol use and consequent liver disease are major burdens that have worsened during the COVID-19 pandemic. There are several facets to the pathophysiology and clinical consequences of alcohol-use disorder (AUD) and progression to alcohol-associated liver disease (ALD) that require a concerted effort by clinicians and translational and basic science investigators. Several recent advances from bedside to bench and bench to bedside have been made in ALD. We focused this review on a case-based approach that provides a human context to these important advances across the spectrum of ALD.
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Affiliation(s)
- Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University, Richmond, Virginia; Central Virginia Veterans Healthcare System, Richmond, Virginia.
| | - Laura E Nagy
- Center for Liver Disease Research, Departments of Inflammation and Immunity and Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio; Department of Molecular Medicine, Case Western Reserve University, Cleveland, Ohio
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44
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Lee BP, Terrault NA. Advocacy for Equity in Transplantation Access for Alcohol-Associated Liver Disease: How Research Changed Medi-Cal Policy. Gastroenterology 2022; 163:539-542. [PMID: 35577123 PMCID: PMC10361648 DOI: 10.1053/j.gastro.2022.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 05/06/2022] [Accepted: 05/10/2022] [Indexed: 02/08/2023]
Affiliation(s)
- Brian P Lee
- Department of Gastroenterology and Liver Diseases, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Norah A Terrault
- Department of Gastroenterology and Liver Diseases, University of Southern California Keck School of Medicine, Los Angeles, California
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Shenoy A, Salajegheh A, Shen NT. Multimodal multidisciplinary management of alcohol use disorder in liver transplant candidates and recipients. Transl Gastroenterol Hepatol 2022; 7:28. [PMID: 35892051 PMCID: PMC9257538 DOI: 10.21037/tgh.2020.02.22] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 12/06/2019] [Indexed: 08/01/2023] Open
Abstract
Alcohol-related liver disease (ALD) is the most common indication for liver transplantation (LT) in the United States. The judicious allocation of organs and improvement in outcomes requires identification and monitoring of patients with ALD at high-risk for relapse post-transplantation. The controversial movement toward early LT for severe alcohol-related hepatitis (SAH) has also raised concern for alcohol relapse. While LT cures ALD, treatment of alcohol use disorder (AUD) must be included in the care plan to prevent a return to drinking and subsequent graft ALD. Patients with underlying AUD must be recognized, offered brief interventions and referred for multimodal multidisciplinary treatment that includes medications and psychotherapies along with sober support groups, family engagement, and a new dedication to healthy living in order to help sustain remission. Such comprehensive care will increase LT candidacy in patients with ALD while optimizing clinical outcomes of patients transplanted with AUD.
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Affiliation(s)
- Akhil Shenoy
- Director of Transplant Psychiatry, Assistant Professor, Columbia University Medical Center, Psychiatric Liaison to the Center for Liver Disease and Transplantation, New York-Presbyterian Hospital-Columbia, New York, NY, USA
| | - Anna Salajegheh
- Assistant Professor, Weill Cornell Psychiatry, Psychiatric Liaison to the Center for Liver Disease and Transplantation, New York-Presbyterian Hospital-Cornell, New York, NY, USA
| | - Nicole T. Shen
- Weill Cornell Medicine, Division of Clinical Epidemiology and Evaluative Sciences Research, Fellow, Transplant Hepatology, New York-Presbyterian Hospitals-Columbia and Cornell, New York, NY, USA
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46
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Sedki M, Ahmed A, Goel A. Ethical and allocation issues in liver transplant candidates with alcohol related liver disease. Transl Gastroenterol Hepatol 2022; 7:26. [PMID: 35892052 PMCID: PMC9257533 DOI: 10.21037/tgh-2020-13] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 09/17/2020] [Indexed: 09/01/2024] Open
Abstract
In the past decade, alcohol-related liver disease (ALD) has become the leading indication for liver transplantation (LT) in the United States. Despite this major development, there still remains some controversy in a distinct subset of this patient population, those presenting with alcoholic hepatitis (AH). There is significant debate within the transplant community regarding acceptance criteria for patients with AH requiring LT, especially those with less than 6 months of sobriety. With that being said, LT in the setting of ALD and AH has shown an improvement in survival rates; additionally, many studies have reported that careful selection of patients with ALD has produced excellent post-transplant outcomes even if transplant occurred with less than 6 months of sobriety. In this review, we aim to discuss the ethical and allocation-associated issues that arise when considering ALD and/or AH for LT; furthermore, we delve into the history, controversies, current guidelines, and future directions of LT in this subgroup.
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Affiliation(s)
- Mai Sedki
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Aijaz Ahmed
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Aparna Goel
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
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Gotlieb N, Azhie A, Sharma D, Spann A, Suo NJ, Tran J, Orchanian-Cheff A, Wang B, Goldenberg A, Chassé M, Cardinal H, Cohen JP, Lodi A, Dieude M, Bhat M. The promise of machine learning applications in solid organ transplantation. NPJ Digit Med 2022; 5:89. [PMID: 35817953 PMCID: PMC9273640 DOI: 10.1038/s41746-022-00637-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 06/24/2022] [Indexed: 11/16/2022] Open
Abstract
Solid-organ transplantation is a life-saving treatment for end-stage organ disease in highly selected patients. Alongside the tremendous progress in the last several decades, new challenges have emerged. The growing disparity between organ demand and supply requires optimal patient/donor selection and matching. Improvements in long-term graft and patient survival require data-driven diagnosis and management of post-transplant complications. The growing abundance of clinical, genetic, radiologic, and metabolic data in transplantation has led to increasing interest in applying machine-learning (ML) tools that can uncover hidden patterns in large datasets. ML algorithms have been applied in predictive modeling of waitlist mortality, donor–recipient matching, survival prediction, post-transplant complications diagnosis, and prediction, aiming to optimize immunosuppression and management. In this review, we provide insight into the various applications of ML in transplant medicine, why these were used to evaluate a specific clinical question, and the potential of ML to transform the care of transplant recipients. 36 articles were selected after a comprehensive search of the following databases: Ovid MEDLINE; Ovid MEDLINE Epub Ahead of Print and In-Process & Other Non-Indexed Citations; Ovid Embase; Cochrane Database of Systematic Reviews (Ovid); and Cochrane Central Register of Controlled Trials (Ovid). In summary, these studies showed that ML techniques hold great potential to improve the outcome of transplant recipients. Future work is required to improve the interpretability of these algorithms, ensure generalizability through larger-scale external validation, and establishment of infrastructure to permit clinical integration.
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Affiliation(s)
- Neta Gotlieb
- Ajmera Transplant Program, University Health Network, Toronto, ON, Canada.,Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Amirhossein Azhie
- Ajmera Transplant Program, University Health Network, Toronto, ON, Canada
| | - Divya Sharma
- Department of Gastroenterology, Toronto General Hospital Research Institute, Toronto, ON, Canada
| | - Ashley Spann
- Division of Gastroenterology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nan-Ji Suo
- Department of Cell and Systems Biology, University of Toronto, Toronto, ON, Canada
| | - Jason Tran
- Ajmera Transplant Program, University Health Network, Toronto, ON, Canada
| | - Ani Orchanian-Cheff
- Library and Information Services, University Health Network, Toronto, ON, Canada
| | - Bo Wang
- Vector Institute for Artificial Intelligence, Toronto, ON, Canada
| | - Anna Goldenberg
- Vector Institute for Artificial Intelligence, Toronto, ON, Canada
| | - Michael Chassé
- Department of Medicine (Critical Care), University of Montreal Hospital, Montréal, QC, Canada.,Canadian Donation and Transplantation Research Program, Data and Innovation Expert Group, Toronto, ON, Canada
| | - Heloise Cardinal
- Canadian Donation and Transplantation Research Program, Data and Innovation Expert Group, Toronto, ON, Canada.,Centre hospitalier de l'Université de Montréal Research Center, Université de Montréal, Montréal, QC, Canada
| | - Joseph Paul Cohen
- Canadian Donation and Transplantation Research Program, Data and Innovation Expert Group, Toronto, ON, Canada.,Center for Artificial Intelligence in Medicine & Imaging, Stanford University, Stanford, CA, USA.,Mila, Quebec Artificial Intelligence Institute, Montréal, QC, Canada
| | - Andrea Lodi
- Canadian Donation and Transplantation Research Program, Data and Innovation Expert Group, Toronto, ON, Canada.,Canada Excellence Research Chair, Polytechnique Montréal, Montréal, QC, Canada
| | - Melanie Dieude
- Canadian Donation and Transplantation Research Program, Data and Innovation Expert Group, Toronto, ON, Canada.,Centre hospitalier de l'Université de Montréal Research Center, Université de Montréal, Montréal, QC, Canada.,Department Microbiology, Infectiology and Immunology, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada.,Héma-Québec, Montréal, QC, Canada
| | - Mamatha Bhat
- Ajmera Transplant Program, University Health Network, Toronto, ON, Canada. .,Canadian Donation and Transplantation Research Program, Data and Innovation Expert Group, Toronto, ON, Canada. .,Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, ON, Canada.
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Lee BP, Roth N, Rao P, Im GY, Vogel AS, Hasbun J, Roth Y, Shenoy A, Arvelakis A, Ford L, Dawe I, Schiano TD, Davis JP, Rice JP, Eswaran S, Weinberg E, Han H, Hsu C, Fix OK, Maddur H, Ghobrial RM, Therapondos G, Dilkina B, Terrault NA. Artificial intelligence to identify harmful alcohol use after early liver transplant for alcohol-associated hepatitis. Am J Transplant 2022; 22:1834-1841. [PMID: 35416409 PMCID: PMC9541176 DOI: 10.1111/ajt.17059] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 03/13/2022] [Accepted: 04/10/2022] [Indexed: 01/25/2023]
Abstract
Early liver transplantation (LT) for alcohol-associated hepatitis (AH) is the fastest growing indication for LT, but prediction of harmful alcohol use post-LT remains limited. Among 10 ACCELERATE-AH centers, we examined psychosocial evaluations from consecutive LT recipients for AH from 2006 to 2017. A multidisciplinary panel used content analysis to develop a maximal list of psychosocial variables. We developed an artificial intelligence model to predict post-LT harmful alcohol use. The cohort included training (N = 91 among 8 centers) and external validation (N = 25 among 2 centers) sets, with median follow-up of 4.4 (IQR 3.0-6.0) years post-LT. In the training set, AUC was 0.930 (95%CI 0.862-0.998) with positive predictive value of 0.891 (95%CI 0.620-1.000), internally validated through fivefold cross-validation. In the external validation set, AUC was 0.692 (95%CI 0.666-0.718) with positive predictive value of 0.82 (95%CI 0.625-1.000). The model identified specific variables related to social support and substance use as highly important to predict post-LT harmful alcohol use. We retrospectively developed and validated a model that identified psychosocial profiles at LT predicting harmful alcohol use post-LT for AH. This preliminary model may inform selection and post-LT management for AH and warrants prospective evaluation in larger studies among all alcohol-associated liver disease being considered for early LT.
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Affiliation(s)
- Brian P. Lee
- University of Southern California Keck School of MedicineLos AngelesCaliforniaUSA
| | | | - Prathik Rao
- University of Southern California Keck School of MedicineLos AngelesCaliforniaUSA
| | - Gene Y. Im
- Mount Sinai Icahn School of MedicineNew York CityNew YorkUSA
| | | | - Johann Hasbun
- New York University Grossman School of MedicineNew York CityNew YorkUSA
| | - Yoel Roth
- Twitter IncSan FranciscoCaliforniaUSA
| | - Akhil Shenoy
- Columbia University Vagelos College of Physicians and SurgeonsNew York CityNew YorkUSA
| | | | - Laura Ford
- Mount Sinai Icahn School of MedicineNew York CityNew YorkUSA
| | - Inga Dawe
- Mount Sinai Icahn School of MedicineNew York CityNew YorkUSA
| | | | - Jordan P. Davis
- University of Southern California Keck School of MedicineLos AngelesCaliforniaUSA
| | | | | | - Ethan Weinberg
- University of Pennsylvania Perelman School of MedicinePhiladelphiaPennsylvaniaUSA
| | - Hyosun Han
- University of Southern California Keck School of MedicineLos AngelesCaliforniaUSA
| | - Christine Hsu
- Georgetown School of MedicineWashingtonDistrict of ColumbiaUSA
| | - Oren K. Fix
- University of North Carolina at Chapel Hill School of MedicineChapel HillNorth CarolinaUSA
| | - Haripriya Maddur
- Northwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | | | | | - Bistra Dilkina
- University of Southern California Keck School of MedicineLos AngelesCaliforniaUSA
| | - Norah A. Terrault
- University of Southern California Keck School of MedicineLos AngelesCaliforniaUSA
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49
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Tran J, Sharma D, Gotlieb N, Xu W, Bhat M. Application of machine learning in liver transplantation: a review. Hepatol Int 2022; 16:495-508. [PMID: 35020154 DOI: 10.1007/s12072-021-10291-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 12/15/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Machine learning (ML) has been increasingly applied in the health-care and liver transplant setting. The demand for liver transplantation continues to expand on an international scale, and with advanced aging and complex comorbidities, many challenges throughout the transplantation decision-making process must be better addressed. There exist massive datasets with hidden, non-linear relationships between demographic, clinical, laboratory, genetic, and imaging parameters that conventional methods fail to capitalize on when reviewing their predictive potential. Pre-transplant challenges include addressing efficacies of liver segmentation, hepatic steatosis assessment, and graft allocation. Post-transplant applications include predicting patient survival, graft rejection and failure, and post-operative morbidity risk. AIM In this review, we describe a comprehensive summary of ML applications in liver transplantation including the clinical context and how to overcome challenges for clinical implementation. METHODS Twenty-nine articles were identified from Ovid MEDLINE, MEDLINE Epub Ahead of Print and In-Process and Other Non-Indexed Citations, Embase, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials. CONCLUSION ML is vastly interrogated in liver transplantation with promising applications in pre- and post-transplant settings. Although challenges exist including site-specific training requirements, the demand for more multi-center studies, and optimization hurdles for clinical interpretability, the powerful potential of ML merits further exploration to enhance patient care.
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Affiliation(s)
- Jason Tran
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Divya Sharma
- Department of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of Biostatistics, Princess Margaret Cancer Center, University Health Network, Toronto, ON, Canada
| | - Neta Gotlieb
- Ajmera Transplant Program, University Health Network, Toronto, ON, Canada
| | - Wei Xu
- Department of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of Biostatistics, Princess Margaret Cancer Center, University Health Network, Toronto, ON, Canada
| | - Mamatha Bhat
- Ajmera Transplant Program, University Health Network, Toronto, ON, Canada.
- Division of Gastroenterology, Department of Medicine, University of Toronto, 585 University Avenue, Toronto, ON, M5G 2N2, Canada.
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50
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Louvet A, Labreuche J, Moreno C, Vanlemmens C, Moirand R, Féray C, Dumortier J, Pageaux GP, Bureau C, Chermak F, Duvoux C, Thabut D, Leroy V, Carbonell N, Rolland B, Salamé E, Anty R, Gournay J, Delwaide J, Silvain C, Lucidi V, Lassailly G, Dharancy S, Nguyen-Khac E, Samuel D, Duhamel A, Mathurin P, Berthot C, Claudet S, Doussot A, Gérardin C, Muel E, Hiriart JB, Degré D, Gustot T, Bonadona A, Bordy L, Hilleret MN, Detry O, Honoré P, Meurisse N, Boleslawski E, Deplanque D, El Amrani M, Lebuffe G, Millet G, Soret D, Truant S, Erard-Poinsot D, Radenne S, Faure S, Gelsi E, Truchi R, Rudler M, Rouleau L, Brenner A, Larrue H, Péron JM, Robic MA, Antonini T, Duclos-Vallée JC. Early liver transplantation for severe alcohol-related hepatitis not responding to medical treatment: a prospective controlled study. Lancet Gastroenterol Hepatol 2022; 7:416-425. [DOI: 10.1016/s2468-1253(21)00430-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 10/29/2021] [Accepted: 11/03/2021] [Indexed: 02/07/2023]
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