1
|
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.
Collapse
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
| |
Collapse
|
2
|
Hill GS, Cohen SM, Weimer MB. Treatment of alcohol use disorder in patients with liver disease. Clin Liver Dis (Hoboken) 2024; 23:e0217. [PMID: 38841192 PMCID: PMC11152780 DOI: 10.1097/cld.0000000000000217] [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: 03/15/2024] [Accepted: 04/15/2024] [Indexed: 06/07/2024] Open
|
3
|
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] [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.
Collapse
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
| |
Collapse
|
4
|
Shroff H, Gallagher H. Multidisciplinary Care of Alcohol-related Liver Disease and Alcohol Use Disorder: A Narrative Review for Hepatology and Addiction Clinicians. Clin Ther 2023; 45:1177-1188. [PMID: 37813775 DOI: 10.1016/j.clinthera.2023.09.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 09/14/2023] [Accepted: 09/19/2023] [Indexed: 10/11/2023]
Abstract
PURPOSE Models of integrated, multidisciplinary care are optimal in the setting of complex, chronic diseases and in the overlap of medical and mental health disease, both of which apply to alcohol-related liver disease (ALD). Alcohol use disorder (AUD) drives nearly all cases of ALD, and coexisting mental health disease is common. ALD is a complex condition with severe clinical manifestations and high mortality that can occasionally lead to liver transplantation. As a result, integrated care for ALD is an attractive proposition. The aim of this narrative review was to: (1) review the overlapping and concerning trends in the epidemiology of AUD and ALD; (2) use a theoretical framework for integrated care known as the "five-component model" as a basis to highlight the need for integrated care and the overlapping clinical manifestations and management of the 2 conditions; and (3) review the existing applications of integrated care in this area. METHODS We performed a narrative review of epidemiology, clinical manifestations, and management strategies in AUD and ALD, with a particular focus on areas of overlap that are pertinent to clinicians who manage each disease. Previously published models were reviewed for integrating care in AUD and ALD, both in the general ALD population and in the setting of liver transplantation. FINDINGS The incidences of AUD and ALD are rising, with a pronounced acceleration driven by the Coronavirus Disease 2019 pandemic. Hepatologists are underprepared to diagnose and treat AUD despite its high prevalence in patients with liver disease. A patient who presents with overlapping clinical manifestations of both AUD and ALD may not fit neatly into typical treatment paradigms for each individual disease but rather will require new management strategies that are appropriately adapted. As a result, the dimensions of integrated care, including collective ownership of shared goals, interdependence among providers, flexibility of roles, and newly created professional activities, are highly pertinent to the holistic management of both diseases. IMPLICATIONS Integrated care models have proliferated as recognition grows of the dual pathology of AUD and ALD. Ongoing coordination across disciplines and research in the fields of hepatology and addiction medicine are needed to further elucidate optimal mechanisms for collaboration and improved quality of care.
Collapse
Affiliation(s)
- Hersh Shroff
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.
| | - Heather Gallagher
- Substance Treatment and Recovery Program, University of North Carolina Hospital, Chapel Hill, North Carolina, USA
| |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Mellinger JL, Medley S, Kidwell KM, Asefah H, Winder GS, Fernandez AC, Lok ASF, Blow F. Improving alcohol treatment engagement using integrated behavioral interventions in alcohol-associated liver disease: A randomized pilot trial. Hepatol Commun 2023; 7:e0181. [PMID: 37708435 PMCID: PMC10503679 DOI: 10.1097/hc9.0000000000000181] [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: 03/06/2023] [Accepted: 04/24/2023] [Indexed: 09/16/2023] Open
Abstract
INTRODUCTION Alcohol cessation improves mortality in alcohol-associated liver disease (ALD), but few ALD patients will engage in treatment. We aimed to demonstrate the feasibility and acceptability of a mobile health intervention to increase alcohol use disorder (AUD) treatment among ALD patients. METHODS We conducted a pilot randomized controlled trial (September 2020 to June 2022) at a single tertiary care center in adults with any stage of ALD, past 6-month drinking, and no past-month AUD treatment. Sixty participants were randomized 1:1 to a mobile health application designed to increase AUD treatment engagement through preference elicitation and matching to treatment and misconception correction. Controls received enhanced usual care. The primary outcomes were feasibility (recruitment and retention rates) and acceptability. Exploratory outcomes were AUD treatment engagement and alcohol use, measured by Timeline Followback. Outcomes were measured at 3 and 6 months. RESULTS Baseline characteristics were balanced. The recruitment rate was 46%. Retention was 65% at 6 months. The intervention was highly acceptable to participants (91% were mostly/very satisfied; 95% felt that the intervention matched them well to AUD treatment). Secondary outcomes showed increased AUD treatment at 6 months in the intervention group (intent-to-treat: 27.3% vs. 13.3%, OR 2.3, 95% CI, 0.61-8.76). There was a trend toward a 1-level or greater reduction in World Health Organization (WHO) drinking risk levels in the intervention group (OR 2.25, 95% CI, 0.51-9.97). CONCLUSIONS A mobile health intervention for AUD treatment engagement was highly feasible, acceptable, and produced promising early outcomes, with improved AUD treatment engagement and alcohol reduction in ALD patients.
Collapse
Affiliation(s)
- Jessica L. Mellinger
- Michigan Medicine, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Ann Arbor, Michigan, United States
- Michigan Medicine, Department of Psychiatry, Ann Arbor, Michigan, United States
| | - Sarah Medley
- Department of Biostatistics, University of Michigan, School of Public Health, Ann Arbor, Michigan, United States
| | - Kelley M. Kidwell
- Department of Biostatistics, University of Michigan, School of Public Health, Ann Arbor, Michigan, United States
| | - Haila Asefah
- Michigan Medicine, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Ann Arbor, Michigan, United States
| | - G. Scott Winder
- Michigan Medicine, Department of Psychiatry, Ann Arbor, Michigan, United States
- Department of Surgery Michigan Medicine, Ann Arbor, Michigan, United States
- Department of Neurology Michigan Medicine, Ann Arbor, Michigan, United States
| | - Anne C. Fernandez
- Michigan Medicine, Department of Psychiatry, Ann Arbor, Michigan, United States
| | - Anna S. F. Lok
- Michigan Medicine, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Ann Arbor, Michigan, United States
| | - Fred Blow
- Michigan Medicine, Department of Psychiatry, Ann Arbor, Michigan, United States
| |
Collapse
|
7
|
Oldroyd C, Greenham O, Martin G, Allison M, Notley C. Systematic review: Interventions for alcohol use disorder in patients with cirrhosis or alcohol-associated hepatitis. Aliment Pharmacol Ther 2023; 58:763-773. [PMID: 37602505 DOI: 10.1111/apt.17665] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/12/2023] [Accepted: 07/29/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND Alcohol use is the most important factor in determining the prognosis of patients with alcohol-related cirrhosis and alcohol-associated hepatitis. AIM To conduct a systematic review of interventions for alcohol use disorder specific to patients with cirrhosis or alcohol-associated hepatitis. METHODS We searched five databases between inception and November 2022. The primary outcomes were abstinence, hepatic decompensation and mortality. We included randomised and non-randomised studies. Risk of bias was assessed using validated tools. Where possible, meta-analysis was performed. RESULTS Twenty-three studies met the inclusion criteria including six randomised trials and 17 non-randomised studies of interventions. These included 104,298 patients with a mean/median age range from 44 to 65, of whom 75% were male. Interventions included psychological therapy, pharmacological therapies, specialist clinics, patient education and low alcohol drinks. Baclofen was the only intervention to demonstrate a statistically significant impact on the primary outcomes in a randomised trial (abstinence OR: 6.3, 95% CI: 2.4-16.1). Three non-randomised studies reported reductions in episodes of hepatic decompensation that were significant in multivariate models. This was in response to psychological therapy, use of any pharmacotherapy, and use of any treatment. A meta-analysis of non-randomised studies that examined the impact of psychological therapies revealed statistically non-significant improvements in abstinence (4 studies, OR: 1.87, 95% CI: 0.38-9.23) and mortality (4 studies, OR: 0.47, 95% CI: 0.12-1.77). CONCLUSIONS Baclofen is the only intervention with randomised trial evidence for significant benefit in patients with cirrhosis. Non-randomised studies also point to non-pharmaceutical interventions possibly improving clinical outcomes.
Collapse
Affiliation(s)
- Christopher Oldroyd
- Cambridge NIHR Biomedical Research Centre, Cambridge, UK
- Cambridge Liver Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Olivia Greenham
- Cambridge Liver Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Graham Martin
- The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge, UK
| | - Michael Allison
- Cambridge NIHR Biomedical Research Centre, Cambridge, UK
- Cambridge Liver Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Caitlin Notley
- Addiction Research Group, University of East Anglia, Norwich, UK
| |
Collapse
|
8
|
Hemrage S, Brobbin E, Deluca P, Drummond C. Efficacy of psychosocial interventions to reduce alcohol use in comorbid alcohol use disorder and alcohol-related liver disease: a systematic review of randomized controlled trials. Alcohol Alcohol 2023; 58:478-484. [PMID: 37530582 PMCID: PMC10493519 DOI: 10.1093/alcalc/agad051] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 06/10/2023] [Accepted: 07/12/2023] [Indexed: 08/03/2023] Open
Abstract
This systematic review (PROSPERO CRD42021234598) fills a gap in the literature by assessing the efficacy of psychosocial interventions in patients with alcohol use disorder and alcohol-related liver disease (ARLD), focusing on drinking reduction and abstinence as intervention goals. A systematic search for randomized controlled trials (RCTs) was conducted across various databases. Study screening and data extraction were conducted independently by two reviewers. The data were presented through narrative synthesis. Primary outcomes were alcohol reduction and abstinence at the longest follow-up. Ten RCTs were included, evaluating interventions such as cognitive behavioral therapy (CBT), motivational enhancement therapy (MET), motivational interviewing, or peer support. The total population included 1519 participants. Four studies included a combination of more than one intervention, and two trialed an integrated approach, including medical and psychosocial management. A significant reduction was observed with MET, while abstinence was observed with peer support, MET, and CBT/MET within integrated treatment. The overall certainty of the evidence was moderate. Six studies presented a low risk of bias, one had some concerns, and three were high risk. The findings highlight the potential of psychosocial interventions, with MET being repeatedly associated with improved outcomes. Integrated treatment also demonstrated a promising role in ARLD. Future research should head toward improving the robustness and quality of the evidence. It should also aim to further tailor and trial new psychosocial interventions on this specific clinical population. This will enhance the translation of the evidence into real-world settings.
Collapse
Affiliation(s)
- Sofia Hemrage
- Department of Addictions, National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, 4 Windsor Walk, London SE5 8AF, United Kingdom
| | - Eileen Brobbin
- Department of Addictions, National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, 4 Windsor Walk, London SE5 8AF, United Kingdom
| | - Paolo Deluca
- Department of Addictions, National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, 4 Windsor Walk, London SE5 8AF, United Kingdom
| | - Colin Drummond
- Department of Addictions, National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, 4 Windsor Walk, London SE5 8AF, United Kingdom
| |
Collapse
|
9
|
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
|
10
|
Vannier AGL, Przybyszewski EM, Shay J, Patel SJ, Schaefer E, Goodman RP, Luther J. Psychotherapy for Alcohol Use Disorder Is Associated With Reduced Risk of Incident Alcohol-Associated Liver Disease. Clin Gastroenterol Hepatol 2023; 21:1571-1580.e7. [PMID: 35964893 PMCID: PMC9918606 DOI: 10.1016/j.cgh.2022.08.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 08/01/2022] [Accepted: 08/02/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Alcohol-associated liver disease (ALD) is a devastating complication of alcohol use disorder (AUD). Once it develops, ALD is exceedingly difficult to treat; it therefore is critical to identify ways to prevent ALD. By treating the causes of increased alcohol consumption, psychotherapy may offer prophylactic benefit against the development of ALD for patients with AUD. METHODS In this retrospective cohort study, we used International Classification of Diseases, 9th and 10th revision, codes to identify 9635 patients with AUD in the Mass General Brigham Biobank. The mean follow-up period from AUD diagnosis was 9.2 years. We used Cox regression models to generate hazard ratios (HR) for the development of ALD given the receipt or nonreceipt of psychotherapy, adjusting for a range of other contributors including the receipt of medication-assisted treatment. RESULTS In our cohort, 60.4% of patients were men, 83.5% of patients were white, the median age was 57.0 years, and 3544 patients (36.8%) received psychotherapy. ALD developed in 1135 patients (11.8%). In multivariable analysis, psychotherapy was associated with a reduced rate of ALD (HR, 0.59; 95% CI, 0.50-0.71; P < .001). This association held for both individual psychotherapy (HR, 0.70; 95% CI, 0.56-0.86; P < .001) and group psychotherapy (HR, 0.76; 95% CI, 0.61-0.94; P = .01). Among patients with cirrhosis, psychotherapy was associated with a lower rate of hepatic decompensation (HR, 0.68; 95% CI, 0.48-0.95; P = .03). CONCLUSIONS The receipt of psychotherapy in the setting of AUD is associated with reduced incidence and progression of ALD. Given the safety and potential benefit of psychotherapy, clinicians should consider using it to prevent the development of ALD.
Collapse
Affiliation(s)
- Augustin G L Vannier
- Massachusetts General Hospital Alcohol Liver Center, Massachusetts General Hospital, Boston, Massachusetts; Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Jessica Shay
- Massachusetts General Hospital Alcohol Liver Center, Massachusetts General Hospital, Boston, Massachusetts; Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts
| | - Suraj J Patel
- Massachusetts General Hospital Alcohol Liver Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Esperance Schaefer
- Massachusetts General Hospital Alcohol Liver Center, Massachusetts General Hospital, Boston, Massachusetts; Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts
| | - Russell P Goodman
- Massachusetts General Hospital Alcohol Liver Center, Massachusetts General Hospital, Boston, Massachusetts; Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts
| | - Jay Luther
- Massachusetts General Hospital Alcohol Liver Center, Massachusetts General Hospital, Boston, Massachusetts; Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts.
| |
Collapse
|
11
|
Simultaneous Management of Alcohol Use Disorder and Liver Disease: A Systematic Review and Meta-analysis. J Addict Med 2023; 17:e119-e128. [PMID: 36259647 DOI: 10.1097/adm.0000000000001084] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Management of alcohol use disorder (AUD) is rarely used in patients with liver disease. We performed a systematic review to examine the impact of AUD management among patients with liver disease. METHODS Twenty studies fulfilling the inclusion and exclusion criteria on 38,329 patients (7072 receiving AUD intervention) with liver disease (15 with liver disease and 6 liver transplant [LT] recipients) were analyzed. One study was common to both groups. Variable follow-up period across studies was weighted for sample size and converting to person-years. Primary outcome was alcohol use, and secondary outcomes were liver decompensation and patient mortality. RESULTS Abstinence and alcohol relapse rates/person-year with AUD intervention among liver disease patients were 0.41 (0.27-0.55) and 0.42 (0.30-0.755), similar for integrated (colocated liver and addiction clinics) versus concomitant (separate hepatology and addiction clinics) intervention. Compared with standard of care, odds for decompensation with AUD intervention (n = 1), 30-day readmission (n = 1), and patient mortality (n = 2) were lower by 44%, 59%, and 58% respectively. Similar figures were 1.24 (0.86-1.80) for abstinence and 0.52 (0.24-0.14) for relapse. Among LT recipients, odds for alcohol relapse and mortality with follow-up integrated with addiction team versus hepatology alone were 0.48 (0.25-0.72) and 0.29 (0.08-0.99), respectively. CONCLUSIONS Follow-up of LT recipients in an integrated clinic with addiction team is associated with improved outcomes. Simultaneous management of AUD in patients with liver disease improves liver-related outcomes. Large prospective studies are needed to examine benefits of AUD intervention in patients with liver disease.
Collapse
|
12
|
Current and emerging therapies for alcohol-associated hepatitis. LIVER RESEARCH 2023. [DOI: 10.1016/j.livres.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
|
13
|
Adekunle AD, Adejumo A, Singal AK. Therapeutic targets in alcohol-associated liver disease: progress and challenges. Therap Adv Gastroenterol 2023; 16:17562848231170946. [PMID: 37187673 PMCID: PMC10176580 DOI: 10.1177/17562848231170946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 04/04/2023] [Indexed: 05/17/2023] Open
Abstract
Alcohol-associated liver disease (ALD) is a complex disease with rapidly increasing prevalence. Although there are promising therapeutic targets on the horizon, none of the newer targets is currently close to an Food and Drug Administration approval. Strategies are needed to overcome challenges in study designs and conducting clinical trials and provide impetus to the field of drug development in the landscape of ALD and alcoholic hepatitis. Management of ALD is complex and should include therapies to achieve and maintain alcohol abstinence, preferably delivered by a multidisciplinary team. Although associated with clear mortality benefit in select patients, the use of early liver transplantation still requires refinement to create uniformity in selection protocols across transplant centers. There is also a need for reliable noninvasive biomarkers for prognostication. Last but not the least, strategies are urgently needed to implement integrated multidisciplinary care models for treating the dual pathology of alcohol use disorder and of liver disease for improving the long-term outcomes of patients with ALD.
Collapse
Affiliation(s)
- Ayooluwatomiwa Deborah Adekunle
- Department of Internal Medicine, St. Luke’s
Hospital, Chesterfield, Missouri, USA
- Division of Hepatology, University of
Pittsburgh Medical Center, Pittsburgh, PA, USA
- Division of Transplant Hepatology, University
of South Dakota Sanford Medical School, Sioux Falls, SD
| | - Adeyinka Adejumo
- Department of Internal Medicine, St. Luke’s
Hospital, Chesterfield, Missouri, USA
- Division of Hepatology, University of
Pittsburgh Medical Center, Pittsburgh, PA, USA
- Division of Transplant Hepatology, University
of South Dakota Sanford Medical School, Sioux Falls, SD
| | | |
Collapse
|
14
|
Murthy P, Shadakshari D, Mahadevan J, Chand PK. Management of Alcohol Use Disorder in Patients With Alcoholic Liver Disease. J Clin Exp Hepatol 2022; 12:1514-1526. [PMID: 36340303 PMCID: PMC9630026 DOI: 10.1016/j.jceh.2022.04.010] [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: 12/29/2021] [Accepted: 04/10/2022] [Indexed: 12/12/2022] Open
Abstract
Alcohol use disorder (AUD) is a common condition that develops on the background of heavy alcohol use and is characterised by the loss of control over alcohol use and a compulsion to use alcohol, often despite negative consequences. AUD is a leading cause for the resumption of alcohol use in patients with alcoholic liver disease (ALD) after treatment. Hence it is essential to screen all patients with ALD for the presence of AUD. Screening tools such as alcohol use disorders identification test (AUDIT) and AUDIT-C are used, following which the diagnosis and severity of AUD are determined using DSM-5 criteria. The management of AUD in patients with ALD is best carried out using an integrated approach involving psychiatrists and gastroenterologists/hepatologists. The treatment most often involves a combination of pharmacotherapy and psychosocial interventions which try to achieve and maintain abstinence. Although, there is limited evidence, Baclofen is the first line pharmacological agent for long-term management of AUD in patients with ALD. Intensive psychological interventions such as motivation enhancement therapy and cognitive behavioural therapy are also seen to be beneficial. Treatment retention and follow-up are vital and can positively influence outcomes.
Collapse
Key Words
- AA, Alcoholics Anonymous
- ALD, Alcoholic Liver Disease
- AMPA, α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid
- AUD, Alcohol Use Disorder
- AUDIT – C, Alcohol Use Disorder Identification Test – Consumption
- AUDIT, Alcohol Use Disorder Identification Test
- CBT, Cognitive Behavioural Therapy
- CDT, Carbohydrate Deficient Transferrin
- CIWA – Ar, Clinical Institute Withdrawal Assessment for Alcohol Revised
- DALY, Disability Adjusted Life Years
- EtG, Ethyl glucuronide
- EtS, Ethyl Sulphate
- FAEE, Fatty acid ethyl ester
- FDA, Food and Drug Administration
- GABA, Gamma-Aminobutyric acid
- GGT, Gamma glutamyl transferase
- HCV, Hepatitis C Virus
- HE, Hepatic Encephalopathy
- LT, Liver Transplantation
- MCV, Mean corpuscular volume
- MET, Motivation Enhancement Therapy
- MI, Motivational Interviewing
- NMDA, N-Methyl-d-aspartate
- PEth, Phosphatidylethanol
- RCT, Randomised control trial
- SMS, Short Message Service
- alcohol use disorder
- alcoholic liver disease
- diagnosis
- pharmacotherapy
- psychotherapy
Collapse
Affiliation(s)
- Pratima Murthy
- National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Darshan Shadakshari
- Centre for Addiction Medicine, Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Jayant Mahadevan
- Centre for Addiction Medicine, Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Prabhat Kumar Chand
- Centre for Addiction Medicine, Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India
| |
Collapse
|
15
|
Verma M, Winder GS. Treatment of substance use disorders in patients with chronic liver disease. Clin Liver Dis (Hoboken) 2022; 20:66-71. [PMID: 36033425 PMCID: PMC9405498 DOI: 10.1002/cld.1248] [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: 11/02/2021] [Revised: 06/11/2022] [Accepted: 06/19/2022] [Indexed: 02/04/2023] Open
Affiliation(s)
- Manisha Verma
- Department of MedicineEinstein Healthcare NetworkPhiladelphiaPennsylvaniaUSA
| | - Gerald Scott Winder
- Departments of Psychiatry, Surgery, and NeurologyUniversity of MichiganAnn ArborMichiganUSA
| |
Collapse
|
16
|
Nishio T, Ito T, Hata K, Taura K, Hatano E. Current status of liver transplantation for non-B non-C liver cirrhosis and hepatocellular carcinoma. Ann Gastroenterol Surg 2022; 7:42-52. [PMID: 36643372 PMCID: PMC9831911 DOI: 10.1002/ags3.12612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 08/05/2022] [Indexed: 01/18/2023] Open
Abstract
Recently, non-B non-C chronic liver diseases, including alcoholic liver disease (ALD) and nonalcoholic fatty liver disease (NAFLD)/nonalcoholic steatohepatitis (NASH), have markedly increased worldwide. Liver transplantation (LT) is an effective curative therapy for hepatocellular carcinoma (HCC) as well as decompensated liver cirrhosis. In Japan, where the source of liver grafts is strongly dependent on living donors, efforts have been made to unify the indications for eligibility of HCC patients for LT, leading to the development of 5-5-500 criteria. Along with the expansion of eligibility for LT, the current changing trends in underlying liver diseases of LT recipients, which are related to the rising tide of non-B non-C cirrhosis and HCC, are highlighting the importance of peri-transplant management of patients with various comorbidities. The post-LT prognosis of patients with ALD is significantly affected by de novo malignancies and metabolic syndrome-related complications as well as posttransplant alcohol relapse. NAFLD/NASH patients often suffer from obesity, type 2 diabetes mellitus, and other metabolic syndrome-related disorders, and nonneoplastic factors such as cardiovascular events and recurrence of NAFLD/NASH have a significant impact on post-LT outcomes. Patient management in the peri-transplant period as well as risk assessment for LT are key to improving post-LT outcomes in the era of a growing number of cases of LT for non-B non-C liver diseases.
Collapse
Affiliation(s)
- Takahiro Nishio
- Department of Surgery, Graduate School of MedicineKyoto UniversityKyotoJapan
| | - Takashi Ito
- Department of Surgery, Graduate School of MedicineKyoto UniversityKyotoJapan
| | - Koichiro Hata
- Department of Surgery, Graduate School of MedicineKyoto UniversityKyotoJapan
| | - Kojiro Taura
- Department of Surgery, Graduate School of MedicineKyoto UniversityKyotoJapan
| | - Etsuro Hatano
- Department of Surgery, Graduate School of MedicineKyoto UniversityKyotoJapan
| |
Collapse
|
17
|
Tian X, Li YH, Deng LZ, Han WZ, Pu D, Han XL, Du SF, Deng W. Anxiety and depression mediate the relationship between digestive tract conditions and oral health-related quality of life in orthodontic patients. Front Psychol 2022; 13:873983. [PMID: 35967641 PMCID: PMC9373922 DOI: 10.3389/fpsyg.2022.873983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 07/06/2022] [Indexed: 11/13/2022] Open
Abstract
Background Anxiety and depression are common psychological problems in orthodontic patients whose diet habits and oral health status change frequently during treatment. However, relationships between anxiety and depression, digestive tract condition, and impaired oral health-related quality of life remain unknown. Materials and methods In this study, clinical assessments, including anxiety, depression, digestive tract condition, and oral health-related quality of life, were collected from 769 outpatients in the orthodontic department using three self-reported questionnaires. Correlation analysis was used to investigate the relationships among different clinical assessments. A chained mediation analysis model was further conducted to explore the direct and indirect effects of these various clinical factors. Results Changes in digestive tract conditions were positively correlated with the psychological status and oral health-related quality of life. Anxiety and depression partially mediated the relationship between them, and the indirect effect was 0.68 (30%), of which the mediation effect of anxiety accounted for 56%. Conclusion Anxiety and depression mediate the relationship between gastrointestinal conditions and oral health. In particular, anxiety seems to play a significant mediating role. Our findings indicate that psychological status must be paid more attention to in future clinical practices and supervision for digestive tract symptoms of orthodontic patients.
Collapse
Affiliation(s)
- Xue Tian
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Yuan-hong Li
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Lan-zhi Deng
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Wen-ze Han
- School of Stomatology, Shanxi Medical University, Taiyuan, China
| | - Dan Pu
- Department of Orthodontics, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Xiang-long Han
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
- Xiang-long Han,
| | - Shu-fang Du
- Department of Orthodontics, West China Hospital of Stomatology, Sichuan University, Chengdu, China
- Shu-fang Du,
| | - Wei Deng
- Affiliated Mental Health Center, Zhejiang University School of Medicine, Hangzhou, China
- *Correspondence: Wei Deng,
| |
Collapse
|
18
|
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.
Collapse
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
| |
Collapse
|
19
|
DiMartini AF, Leggio L, Singal AK. Barriers to the management of alcohol use disorder and alcohol-associated liver disease: strategies to implement integrated care models. Lancet Gastroenterol Hepatol 2022; 7:186-195. [DOI: 10.1016/s2468-1253(21)00191-6] [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: 03/08/2021] [Revised: 05/20/2021] [Accepted: 05/25/2021] [Indexed: 02/07/2023]
|
20
|
Winder GS, Fernandez AC, Mellinger JL. Integrated Care of Alcohol-Related Liver Disease. J Clin Exp Hepatol 2022; 12:1069-1082. [PMID: 35814517 PMCID: PMC9257883 DOI: 10.1016/j.jceh.2022.01.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 01/22/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND/AIMS Alcohol-related liver disease (ALD) is the medical manifestation of alcohol use disorder, a prevalent psychiatric condition. Acute and chronic manifestations of ALD have risen in recent years especially in young people and ALD is now a leading indication of liver transplantation (LT) worldwide. Such alarming trends raise urgent and unanswered questions about how medical and psychiatric care can be sustainably integrated to better manage ALD patients before and after LT. METHODS Critical evaluation of the interprofessional implications of broad and multifaceted ALD pathophysiology, general principles of and barriers to interprofessional teamwork and care integration, and measures that clinicians and institutions can implement for improved and integrated ALD care. RESULTS The breadth of ALD pathophysiology, and its numerous medical and psychiatric comorbidities, ensures that no single medical or psychiatric discipline is adequately trained and equipped to manage the disease alone. CONCLUSIONS Early models of feasible ALD care integration have emerged in recent years but much more work is needed to develop and study them. The future of ALD care is an integrated approach led jointly by interprofessional medical and psychiatric clinicians.
Collapse
Affiliation(s)
- Gerald S. Winder
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA,Department of Surgery, University of Michigan, Ann Arbor, MI, USA,Department of Neurology, University of Michigan, Ann Arbor, MI, USA,Address for correspondence. Gerald Scott Winder, Clinical Associate Professor, Departments of Psychiatry, Surgery, and Neurology, University of Michigan, F6319 University Hospital South, 1500 E. Medical Center Dr., SPC 5259, Ann Arbor, MI 48109, USA.
| | - Anne C. Fernandez
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | | |
Collapse
|
21
|
Integration of addiction treatment and behavioral therapies in comprehensive liver transplantation care to augment adherence and reduce alcohol relapse. JOURNAL OF LIVER TRANSPLANTATION 2022. [DOI: 10.1016/j.liver.2021.100061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
|
22
|
Management of alcohol use disorder in patients with cirrhosis in the setting of liver transplantation. Nat Rev Gastroenterol Hepatol 2022; 19:45-59. [PMID: 34725498 PMCID: PMC8559139 DOI: 10.1038/s41575-021-00527-0] [Citation(s) in RCA: 53] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/21/2021] [Indexed: 02/07/2023]
Abstract
The prevalence of alcohol use disorder (AUD) has been steadily increasing over the past decade. In parallel, alcohol-associated liver disease (ALD) has been increasing at an alarming rate, especially among young patients. Data suggest that most patients with ALD do not receive AUD therapy. Although liver transplantation is the only curative therapy for end-stage ALD, transplant candidacy is often a matter of debate given concerns about patients being under-treated for AUD and fears of post-transplantation relapse affecting the allograft. In this Review, we discuss diagnosis, predictors and effects of relapse, behavioural therapies and pharmacotherapies, and we also propose an integrative, multidisciplinary and multimodality approach for treating AUD in patients with cirrhosis, especially in the setting of liver transplantation. Notably, this approach takes into account the utility of AUD pharmacotherapy in patients on immunosuppressive medications and those with renal impairment after liver transplantation. We also propose a comprehensive and objective definition of relapse utilizing contemporary biomarkers to guide future clinical trials. Future research using the proposed approach and definition is warranted with the goal of optimizing AUD treatment in patients with cirrhosis, the transplant selection process and post-transplantation care of patients with AUD.
Collapse
|
23
|
Schneekloth TD, Arab JP, Simonetto DA, Petterson TM, Niazi SK, Hall-Flavin DK, Karpyak VM, Kolla BP, Roth JE, Kremers WK, Rosen CB. Factors Having an Impact on Relapse and Survival in Transplant Recipients With Alcohol-Induced Liver Disease. Mayo Clin Proc Innov Qual Outcomes 2021; 5:1153-1164. [PMID: 34938953 PMCID: PMC8666351 DOI: 10.1016/j.mayocpiqo.2021.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Objective To assess the impact of standardized pretransplant alcohol abstinence and treatment guidelines on liver transplant outcomes. Methods This study assessed the posttransplant relapse and survival associated with a pretransplant guideline mandating alcohol abstinence, addiction treatment, and Alcoholics Anonymous (AA) attendance. This retrospective cohort study included liver recipients with alcohol-induced liver disease transplanted between January 1, 2000, and December 31, 2012, at a Midwest transplant center. Cox regression models tested for associations between pretransplant treatment, demographic and clinical characteristics, and outcome measures. Results Of 236 liver recipients (188 [79.7%] male; 210 [89%] white; mean follow-up, 88.6±55.0 months), 212 (90.2%) completed pretransplant treatment and 135 (57.2%) attended AA weekly. At 5 years, 16.3% and 8.2% had relapsed to any alcohol use and to high-dose drinking, respectively. Smoking during the 6 months before transplant was associated with any relapse (P=.0002) and high-dose relapse (P<.0001), and smoking at transplant was associated with death (P=.001). High-dose relapse was associated with death (hazard ratio, 3.5; P<.0001). Conclusion A transplant center with a guideline requiring abstinence, treatment, and AA participation experienced lower posttransplant relapse rates from those previously reported in comparable large US transplant programs. Smoking cessation may further improve posttransplant outcomes.
Collapse
Affiliation(s)
| | - Juan P Arab
- Department of Gastroenterology and Hepatology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.,William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN
| | - Tanya M Petterson
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN
| | - Shehzad K Niazi
- Department of Psychiatry and Psychology, Mayo Clinic, Jacksonville, FL
| | | | - Victor M Karpyak
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN
| | - Bhanu P Kolla
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN
| | | | - Walter K Kremers
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN.,Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN
| | - Charles B Rosen
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN.,Department of Surgery, Mayo Clinic, Rochester, MN
| |
Collapse
|
24
|
Carrique L, Quance J, Tan A, Abbey S, Sales I, Lilly L, Bhat M, Galvin Z, Cattral M, Ghanekar A, McGilvray I, Reichman T, Sapisochin G, Sayed B, Selzner M, Lynch MJ, Selzner N. Results of Early Transplantation for Alcohol-Related Cirrhosis: Integrated Addiction Treatment With Low Rate of Relapse. Gastroenterology 2021; 161:1896-1906.e2. [PMID: 34370999 DOI: 10.1053/j.gastro.2021.08.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 07/28/2021] [Accepted: 08/02/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS In 2018, our team initiated a prospective pilot program to challenge the paradigm of the "6-month rule" of abstinence for patients with alcohol-related liver disease (ALD) requiring transplant. Our pilot involved an in-depth examination of patients' alcohol use, social support, and psychiatric comorbidity, as well as the provision of pre- and post-transplantation addiction treatment. METHODS Patients with ALD were assessed for inclusion in the pilot by a multidisciplinary team. Relapse prevention therapy was provided directly to all patients deemed to meet the program's inclusion criteria. Random biomarker testing for alcohol was used pre and post transplantation. RESULTS We received 703 referrals from May 1, 2018 to October 31, 2020. After fulfilling the program's criteria, 101 patients (14%) were listed for transplantation and 44 (6.2%) received transplants. There were no significant differences in survival rates between those receiving transplants through the pilot program compared with a control group with more than 6 months of abstinence (P = .07). Three patients returned to alcohol use during an average post-transplantation follow-up period of 339 days. In a multivariate analysis, younger age and lower Model for End-Stage Liver Disease scores at listing were associated with an increased likelihood of a return to alcohol use (P < .05); length of abstinence was not a predictor. CONCLUSIONS Our prospective program provided direct monitoring and relapse prevention treatment for patients with ALD and with less than 6 months of abstinence and resulted in a reduction of post-transplantation return to drinking. This pilot study provides a framework for the future of more equitable transplant care.
Collapse
Affiliation(s)
- Lauren Carrique
- Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Jill Quance
- Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Adrienne Tan
- Ajmera Transplant Centre, University Health Network, Toronto, Canada; Department of Psychiatry, University of Toronto, Toronto, Canada; Centre for Mental Health, University Health Network, Toronto, Canada
| | - Susan Abbey
- Ajmera Transplant Centre, University Health Network, Toronto, Canada; Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Isabel Sales
- Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Les Lilly
- Ajmera Transplant Centre, University Health Network, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada
| | - Mamatha Bhat
- Ajmera Transplant Centre, University Health Network, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada
| | - Zita Galvin
- Ajmera Transplant Centre, University Health Network, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada
| | - Mark Cattral
- Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Anand Ghanekar
- Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Ian McGilvray
- Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Trevor Reichman
- Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | | | - Blayne Sayed
- Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Markus Selzner
- Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Marie-Josée Lynch
- Ajmera Transplant Centre, University Health Network, Toronto, Canada; Department of Psychiatry, University of Toronto, Toronto, Canada; Centre for Mental Health, University Health Network, Toronto, Canada
| | - Nazia Selzner
- Ajmera Transplant Centre, University Health Network, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada.
| |
Collapse
|
25
|
Management of Substance Use Disorders in a Patient With Left Ventricular Assist Device. J Acad Consult Liaison Psychiatry 2021; 62:568-576. [PMID: 34391977 DOI: 10.1016/j.jaclp.2021.07.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 07/28/2021] [Accepted: 07/31/2021] [Indexed: 11/23/2022]
Abstract
We present a case of common challenges in assessment and treatment of substance use disorders in patients with advanced heart failure requiring left ventricular assist device (LVAD). Top experts in the field of consultation-liaison psychiatry, cardiology, and cardiac surgery provide guidance for this commonly encountered clinical case based on their experience and review of the available literature. Key teaching topics include the role of LVAD in heart failure management, the impact of substance use disorder on heart failure and LVAD patient outcomes, and recommendations for assessment and management of substance use disorder in a patient with LVAD. Specifically, we highlight the challenges of assessing for substance use disorder in LVAD candidates and the limited literature available to guide treatment in this challenging patient population.
Collapse
|
26
|
Burgette LF, Cabreros I, Han B, Paddock SM. Appropriate analyses of bimodal substance use frequency outcomes: a mixture model approach. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2021; 47:559-568. [PMID: 34372719 DOI: 10.1080/00952990.2021.1946070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background: In addiction research, outcome measures are often characterized by bimodal distributions. One mode can be for individuals with low substance use and the other mode for individuals with high substance use. Applying standard statistical procedures to bimodal data may result in invalid inference. Mixture models are appropriate for bimodal data because they assume that the sampled population is composed of several underlying subpopulations.Objectives: To introduce a novel mixture modeling approach to analyze bimodal substance use frequency data.Methods: We reviewed existing models used to analyze substance use frequency outcomes and developed multiple alternative variants of a finite mixture model. We applied all methods to data from a randomized controlled study in which 30-day alcohol abstinence was the primary outcome. Study data included 73 individuals (38 men and 35 women). Models were implemented in the software packages SAS, Stata, and Stan.Results: Shortcomings of existing approaches include: 1) inability to model outcomes with multiple modes, 2) invalid statistical inferences, including anti-conservative p-values, 3) sensitivity of results to the arbitrary choice to model days of substance use versus days of substance abstention, and 4) generation of predictions outside the range of common substance use frequency outcomes. Our mixture model variants avoided all of these shortcomings.Conclusions: Standard models of substance use frequency outcomes can be problematic, sometimes overstating treatment effectiveness. The mixture models developed improve the analysis of bimodal substance use frequency.
Collapse
Affiliation(s)
| | | | - Bing Han
- Economics, Sociology, and Statistics Department, RAND Corporation, Santa Monica, CA, USA
| | | |
Collapse
|
27
|
Ting PS, Gurakar A, Wheatley J, Chander G, Cameron AM, Chen PH. Approaching Alcohol Use Disorder After Liver Transplantation for Acute Alcoholic Hepatitis. Clin Liver Dis 2021; 25:645-671. [PMID: 34229846 PMCID: PMC8264137 DOI: 10.1016/j.cld.2021.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Severe alcoholic hepatitis portends a high risk of mortality without liver transplantation. Transplant outcomes in patients with severe alcoholic hepatitis exhibit a strong inverse association with post-transplant alcohol relapse. The ingredients most central to ameliorating alcohol relapse risk may include destigmatized post-transplant alcohol monitoring, a nonpunitive clinician-patient partnership, and multimodal therapies to maintain abstinence and mitigate high-risk drinking. We here review the core principles of post-liver transplant management specific to alcohol use disorder.
Collapse
Affiliation(s)
- Peng-Sheng Ting
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 431, Baltimore, MD 21287, USA
| | - Ahmet Gurakar
- Liver Transplant, Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, 720 Rutland Avenue, Ross Research Building, Suite 918, Baltimore, MD 21205, USA.
| | - Jason Wheatley
- Department of Social Work, Johns Hopkins Hospital, 600 North Wolfe Street, Carnegie Suite 100, Baltimore, MD 21287, USA
| | - Geetanjali Chander
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street, Room 8047A, Baltimore, MD 21287, USA
| | - Andrew M Cameron
- Division of Liver Transplant Surgery, Department of Surgery, Johns Hopkins University School of Medicine, 720 Rutland Avenue, Ross 765, Baltimore, MD 21205, USA
| | - Po-Hung Chen
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 429, Baltimore, MD 21287, USA
| |
Collapse
|
28
|
A Young Patient with Brief Alcohol Use and Rapidly Progressive Alcohol-Related Hepatitis: Considerations in Transplant Eligibility. Harv Rev Psychiatry 2021; 28:133-142. [PMID: 32134837 DOI: 10.1097/hrp.0000000000000249] [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: 11/26/2022]
|
29
|
García-Alanís M, Toapanta-Yanchapaxi L, Vilatobá M, Cruz-Martínez R, Contreras AG, López-Yáñez S, Flores-García N, Marquéz-Guillén E, García-Juárez I. Psychosocial evaluation for liver transplantation: A brief guide for gastroenterologists. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2021; 86:172-187. [PMID: 33771379 DOI: 10.1016/j.rgmx.2020.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 12/09/2020] [Accepted: 12/27/2020] [Indexed: 06/12/2023]
Abstract
Liver transplantation is a lifesaving treatment that improves survival and quality of life. The procedure requires adequate transplant candidate selection carried out by a multidisciplinary team. Psychosocial evaluation is a necessary part of recipient selection and its primary aims are to identify problems and psychosocial needs of the patient and his/her family, to improve transplantation outcomes. Different psychosocial conditions are considered risk factors for morbidity and mortality after transplantation. The presence of those factors per se is not an absolute contraindication, thus adequate evaluation promotes equal access to healthcare, improves results, and optimizes resources. The present review provides an overview of and guidelines for the most important psychosocial issues during the pretransplantation phase.
Collapse
Affiliation(s)
- M García-Alanís
- Departamento de Neurología y Psiquiatría, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, CDMX, México.
| | - L Toapanta-Yanchapaxi
- Departamento de Neurología y Psiquiatría, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, CDMX, México
| | - M Vilatobá
- Departamento de Trasplantes, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, CDMX, México
| | - R Cruz-Martínez
- Departamento de Trasplantes, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, CDMX, México
| | - A G Contreras
- Departamento de Trasplantes, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, CDMX, México
| | - S López-Yáñez
- Departamento de Trabajo Social, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, CDMX, México
| | - N Flores-García
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, CDMX, México
| | - E Marquéz-Guillén
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, CDMX, México
| | - I García-Juárez
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, CDMX, México
| |
Collapse
|
30
|
García-Alanís M, Toapanta-Yanchapaxi L, Vilatobá M, Cruz-Martínez R, Contreras A, López-Yáñez S, Flores-García N, Marquéz-Guillén E, García-Juárez I. Psychosocial evaluation for liver transplantation: A brief guide for gastroenterologists. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2021. [DOI: 10.1016/j.rgmxen.2020.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
|
31
|
Ursic-Bedoya J, Dumortier J, Altwegg R, Belkacemi M, Vanlemmens C, Dharancy S, Besch C, Shili-Masmoudi S, Francoz C, Boillot O, Meszaros M, Meunier L, Faure S, Herrero A, Donnadieu-Rigole H, Pageaux GP. Alcohol Consumption the Day of Liver Transplantation for Alcohol-Associated Liver Disease Does Not Affect Long-Term Survival: A Case-Control Study. Liver Transpl 2021; 27:34-42. [PMID: 32978890 DOI: 10.1002/lt.25904] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 07/21/2020] [Accepted: 08/09/2020] [Indexed: 02/07/2023]
Abstract
Alcohol abstinence before liver transplantation (LT) for alcohol-associated liver disease (ALD) is required for every candidate. Some listed patients might relapse, resulting in LT for patients nonabstinent during the pretransplant period. Long-term survival outcomes of these patients have never been studied. We sought to determine whether alcohol consumption on the day of the LT influenced long-term survival after LT. We conducted a retrospective case-control study among French LT centers. Cases were defined as recipients between January 1995 and December 2007 having positive blood and/or urine alcohol levels the day of LT. Each case was paired with 2 controls corresponding to patients transplanted for ALD during the same trimester. Patients were classified into 3 categories per alcohol consumption: abstainers, occasional or transitory excessive consumers, or patients with a sustained excessive consumption (daily consumption >20-30 g/day). During the study period, 3052 LTs for ALD were conducted in France. We identified 42 cases paired with 84 controls. Median blood alcohol level was 0.4 g/L (range 0.1-4.1 g/L) and median urine alcohol level was 0.2 g/L (range 0.1-2.0 g/L). Median follow-up period until death or censoring was 12.9 years (CI95% = [12.3; 13.6]). Long-term survival was not different between the groups. Relapse to any alcohol consumption rate was higher in the case group (59.5%) than in the control group (38.1%, odds ratio 2.44; CI95% = [1.13; 5.27]), but sustained excessive consumption was not significantly different between the groups (33.3% versus 29.8% in case and control groups respectively, χ2 = 0.68). Rates of recurrent cirrhosis and cirrhosis-related deaths were more frequent in the case group. Liver transplantation for nonabstinent patients during the immediate pretransplant period does not result in impaired long-term survival despite higher relapse and recurrent cirrhosis rates.
Collapse
Affiliation(s)
- José Ursic-Bedoya
- Department of Hepatogastroenterology, Hepatology and Liver Transplantation Unit, Saint Eloi Hospital, University of Montpellier, Montpellier, France
| | | | - Romain Altwegg
- Department of Hepatogastroenterology, Hepatology and Liver Transplantation Unit, Saint Eloi Hospital, University of Montpellier, Montpellier, France
| | - Mohamed Belkacemi
- Montpellier University Institute for Clinical Research, Montpellier, France
| | - Claire Vanlemmens
- Jean Minjoz Hospital, Besançon University Hospital, Besançon, France
| | | | - Camille Besch
- Hautepierre Hospital, Strasbourg University Hospital, Strasbourg, France
| | | | | | | | - Magdalena Meszaros
- Department of Hepatogastroenterology, Hepatology and Liver Transplantation Unit, Saint Eloi Hospital, University of Montpellier, Montpellier, France
| | - Lucy Meunier
- Department of Hepatogastroenterology, Hepatology and Liver Transplantation Unit, Saint Eloi Hospital, University of Montpellier, Montpellier, France
| | - Stéphanie Faure
- Department of Hepatogastroenterology, Hepatology and Liver Transplantation Unit, Saint Eloi Hospital, University of Montpellier, Montpellier, France
| | - Astrid Herrero
- Department of General Surgery, Liver Transplantation Unit, Saint Eloi Hospital, University of Montpellier, Montpellier, France
| | - Hélène Donnadieu-Rigole
- Department of Addictology, Saint Eloi Hospital, University of Montpellier, Montpellier, France
| | - Georges-Philippe Pageaux
- Department of Hepatogastroenterology, Hepatology and Liver Transplantation Unit, Saint Eloi Hospital, University of Montpellier, Montpellier, France
| |
Collapse
|
32
|
Kikuchi M, Matsutani N, Ishihara R, Sugihara M, Mizuno Y, Chiba C, Ohta T, Yamada E, Oguro S, Sato Y, Bessho H, Horie Y. Inter-professional and inter-departmental alcoholism rehabilitation program. Clin Mol Hepatol 2020; 26:626-632. [PMID: 33053935 PMCID: PMC7641577 DOI: 10.3350/cmh.2020.0151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 08/07/2020] [Accepted: 08/15/2020] [Indexed: 11/05/2022] Open
Abstract
A 3-month alcoholism rehabilitation program at psychiatric hospitals is common in Japan for patients with alcohol use disorder (AUD). However, many AUD patients are often hospitalized for the treatment of digestive disorders due to alcohol-related liver diseases and pancreatitis. In this sense, AUD patients need to be better supported by professionals and departments in general hospitals. Here we analyzed the problems in alcohol-related medical care in Japan and examined the measures to be taken at general hospitals.
Collapse
Affiliation(s)
- Masahiro Kikuchi
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Naomi Matsutani
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Ryota Ishihara
- Department of Psychiatry, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Masako Sugihara
- Department of Psychiatry, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Yuuki Mizuno
- Department of Medical Welfare, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Chiyo Chiba
- Department of Psychiatry, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Takahiro Ohta
- Department of Pharmacy, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Eri Yamada
- Department of Nutrition, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Sota Oguro
- Department of Radiology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Yasuko Sato
- Department of Nursing, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Hiroki Bessho
- Department of Dentistry, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Yoshinori Horie
- Department of Gastroenterology, Shonan Keiiku Hospital, Kanagawa, Japan
| |
Collapse
|
33
|
Prior Relapse, Ongoing Alcohol Consumption, and Failure to Engage in Treatment Predict Alcohol Relapse After Liver Transplantation. Dig Dis Sci 2020; 65:2089-2103. [PMID: 31707529 DOI: 10.1007/s10620-019-05937-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 11/02/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Alcohol-related liver disease (ALD) is the leading indication for liver transplantation (LT) in the USA. Alcohol relapse post-LT can negatively impact long-term outcomes, and prognostic scoring systems are available for further study. AIMS Our study aims were to: (1) evaluate the relationship between alcohol relapse and rejection and mortality, (2) investigate risk factors for relapse, and (3) assess predictive validity of the SIPAT (Stanford Integrated Psychosocial Assessment for Transplant) and SALT (Sustained Alcohol Use Post-Liver Transplant) scores on post-LT alcohol relapse. METHODS We conducted a retrospective chart review of 155 patients transplanted for chronic ALD at a single transplant center. Cox proportional hazard models assessed the relationship between alcohol relapse and allograft rejection and psychosocial risk factors for relapse. RESULTS 20% of patients met criteria for alcohol relapse. Alcohol relapse was associated with allograft rejection (HR 2.33, 95% CI 1.11-4.91, p = .03). Three variables most strongly associated with alcohol relapse: prior relapse, failure to engage in recommended alcohol treatment, and continued drinking with liver disease, which were combined into a psychosocial model. SIPAT score≥ 21 and SALT score ≥ 7 were associated with alcohol relapse (HR 6.40, 95% CI 1.36-30.18, p = .019 and HR 2.30, 95% CI 1.12-4.75, p = .024). Receiver operator characteristic analysis compared predictive ability of our psychosocial model to SIPAT (C-statistic .83 compared to .71) and SALT (C-statistic = .77 compared to .62). CONCLUSION We identified important psychosocial predictors of post-LT alcohol relapse and validated SIPAT and SALT scores as pre-transplant risk factors for alcohol relapse.
Collapse
|
34
|
Lucey MR, Singal AK. Integrated Treatment of Alcohol Use Disorder in Patients With Alcohol-Associated Liver Disease: An Evolving Story. Hepatology 2020; 71:1891-1893. [PMID: 32171034 DOI: 10.1002/hep.31235] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 02/27/2020] [Accepted: 03/10/2020] [Indexed: 12/26/2022]
Affiliation(s)
- Michael R Lucey
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin, School of Medicine and Public Health, Madison, WI
| | - Ashwani K Singal
- Division of Transplant Hepatology, Avera Transplant Institute, Sioux Falls, SD.,Department of Medicine, Sanford School of Medicine, University of South Dakota, Sioux Falls, SD
| |
Collapse
|
35
|
Rogal S, Youk A, Zhang H, Gellad WF, Fine MJ, Good CB, Chartier M, DiMartini A, Morgan T, Bataller R, Kraemer KL. Impact of Alcohol Use Disorder Treatment on Clinical Outcomes Among Patients With Cirrhosis. Hepatology 2020; 71:2080-2092. [PMID: 31758811 PMCID: PMC8032461 DOI: 10.1002/hep.31042] [Citation(s) in RCA: 104] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 11/07/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIMS Despite the significant medical and economic consequences of coexisting alcohol use disorder (AUD) in patients with cirrhosis, little is known about AUD treatment patterns and their impact on clinical outcomes in this population. We aimed to characterize the use of and outcomes associated with AUD treatment in patients with cirrhosis. APPROACH AND RESULTS This retrospective cohort study included Veterans with cirrhosis who received Veterans Health Administration care and had an index diagnosis of AUD between 2011 and 2015. We assessed the baseline factors associated with AUD treatment (pharmacotherapy or behavioral therapy) and clinical outcomes for 180 days following the first AUD diagnosis code within the study time frame. Among 93,612 Veterans with cirrhosis, we identified 35,682 with AUD, after excluding 2,671 who had prior diagnoses of AUD and recent treatment. Over 180 days following the index diagnosis of AUD, 5,088 (14%) received AUD treatment, including 4,461 (12%) who received behavioral therapy alone, 159 (0.4%) who received pharmacotherapy alone, and 468 (1%) who received both behavioral therapy and pharmacotherapy. In adjusted analyses, behavioral and/or pharmacotherapy-based AUD treatment was associated with a significant reduction in incident hepatic decompensation (6.5% vs. 11.6%, adjusted odds ratio [AOR], 0.63; 95% confidence interval [CI], 0.52, 0.76), a nonsignificant decrease in short-term all-cause mortality (2.6% vs. 3.9%, AOR, 0.79; 95% CI, 0.57, 1.08), and a significant decrease in long-term all-cause mortality (51% vs. 58%, AOR, 0.87; 95% CI, 0.80, 0.96). CONCLUSIONS Most Veterans with cirrhosis and coexisting AUD did not receive behavioral therapy or pharmacotherapy treatment for AUD over a 6-month follow-up. The reductions in hepatic decompensation and mortality suggest that future studies should focus on delivering evidence-based AUD treatments to patients with coexisting AUD and cirrhosis.
Collapse
Affiliation(s)
- Shari Rogal
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA,Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA,Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Ada Youk
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA,Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Hongwei Zhang
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Walid F. Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA,Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Michael J. Fine
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA,Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Chester B. Good
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA,Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA,Center for High Value Pharmacy Initiatives, University of Pittsburgh Medical Center Health Plan, Pittsburgh, PA
| | - Maggie Chartier
- HIV, Hepatitis and Related Conditions Programs, Office of Specialty Care Services, Veterans Health Administration, Washington, DC, USA
| | - Andrea DiMartini
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA,Department of Psychiatry, University of Pittsburgh School of Medicine, Western Psychiatric Institute and Clinic, Pittsburgh, PA 15213, USA
| | - Timothy Morgan
- Gastroenterology Section, VA Long Beach Healthcare System, Long Beach, CA, USA,Division of Gastroenterology, Department of Medicine, University of California, Irvine, California, USA
| | - Ramon Bataller
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Kevin L. Kraemer
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA,Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
36
|
Luchsinger W, Zimbrean P. Systematic Review: Treatment for Addictive Disorder in Transplant Patients. Am J Addict 2020; 29:445-462. [PMID: 32410396 DOI: 10.1111/ajad.13054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 04/04/2020] [Accepted: 04/23/2020] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The number of patients with substance use disorders in need for organ transplantation is expected to increase. Patients with addictive disorders are considered a higher risk of negative outcomes after organ transplantation due to the impact of substance use upon medical status and adherence with treatment. The goal of this systematic review was to assess the current literature on treatment for addiction transplant candidates and recipients. METHODS We conducted a literature search within four databases PubMed, MEDLINE, EMBASE, and PsycINFO for publications dated 1/1/1988 to 12/31/2018. RESULTS Out of 3108 articles identified through database screening, 39 were included in the qualitative synthesis. Sixteen studies described addiction treatment in groups over five patients. All the articles included liver transplant patients, with only two studies including patients who needed a kidney or a heart transplant. Nine articles described treatment of alcohol use disorder exclusively, five focused on treatment of opioid use disorders. Although 9 of 16 studies were prospective, the variability of the treatment intervention, outcome measures, and control group when applicable prohibited a meaningful meta-analysis of the results. Eight articles that described the case reports are analyzed separately. DISCUSSION AND CONCLUSIONS Promising treatment options for alcohol use disorder have been reported but more studies are needed to confirm their effectiveness and their feasibility. Methadone appears effective for opioid disorder in transplant patients. SCIENTIFIC SIGNIFICANCE To the best of our knowledge, this is the first systematic review on the treatment of addictive disorders in transplant patients. (Am J Addict 2020;29:445-462).
Collapse
Affiliation(s)
| | - Paula Zimbrean
- Yale University School of Medicine, New Haven, Connecticut.,Yale New Haven Hospital, New Haven, Connecticut
| |
Collapse
|
37
|
Yoo ER, Cholankeril G, Ahmed A. Treating Alcohol Use Disorder in Chronic Liver Disease. Clin Liver Dis (Hoboken) 2020; 15:77-80. [PMID: 32226621 PMCID: PMC7098671 DOI: 10.1002/cld.881] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 08/25/2019] [Indexed: 02/04/2023] Open
Abstract
http://aasldpubs.onlinelibrary.wiley.com/hub/journal/10.1002/(ISSN)2046-2484/video/15-2-reading-yoo a video presentation of this article http://aasldpubs.onlinelibrary.wiley.com/hub/journal/10.1002/(ISSN)2046-2484/video/15-2-interview-yoo an interview with the author Answer questions and earn https://www.wileyhealthlearning.com/Activity/7036145/disclaimerspopup.aspx.
Collapse
Affiliation(s)
- Eric R. Yoo
- Department of Internal MedicineSanta Clara Valley Medical CenterSan JoseCA
| | - George Cholankeril
- Division of Gastroenterology and HepatologyStanford University School of MedicineStanfordCA
| | - Aijaz Ahmed
- Division of Gastroenterology and HepatologyStanford University School of MedicineStanfordCA
| |
Collapse
|
38
|
Ayyala-Somayajula D, Han H, Terrault NA. Selective use of liver transplantation for severe alcohol-associated hepatitis. Expert Rev Gastroenterol Hepatol 2020; 14:175-184. [PMID: 32077333 DOI: 10.1080/17474124.2020.1733414] [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] [Indexed: 10/25/2022]
Abstract
Introduction: Severe alcohol-associated hepatitis (sAH) portends high morbidity and mortality and there are no effective therapies for those ineligible or unresponsive to corticosteroids. Early liver transplantation (LT) defined as transplantation without a mandated period of sobriety, for sAH, is being increasingly considered as a rescue therapy.Areas covered: PubMed and manual searches were combined and last performed on 28 October 2019. Key search terms were 'alcoholic hepatitis', 'abstinence', 'alcohol relapse', and 'liver transplantation'. Terms were combined within each database. General reviews and references from published trials were also used.Expert opinion: Early LT is indicated in highly selected patients with sAH. While long-term data are sparse, 1 and 3-year survival post-transplantation are excellent and comparable to other liver diseases. Alcohol relapse is uncommon but approaches 10-25% at 3 years and if use is heavy and/or sustained leads to reduced survival. Thus, for continued application of transplantation for this indication, there is a need to further refine selection criteria and to optimize management of alcohol use disorder (AUD) in the transplant setting. Integral to advancing these objectives is the elimination of societal stigmatization and an acknowledgment that AUD is a medical condition that requires long-term management.
Collapse
Affiliation(s)
| | - Hyosun Han
- Department of Medicine, USC Keck School of Medicine, Los Angeles, CA, USA.,Division of Gastrointestinal and Liver Diseases, USC Keck School of Medicine, Los Angeles, CA, USA
| | - Norah A Terrault
- Department of Medicine, USC Keck School of Medicine, Los Angeles, CA, USA.,Division of Gastrointestinal and Liver Diseases, USC Keck School of Medicine, Los Angeles, CA, USA
| |
Collapse
|
39
|
Ting P, Wheatley J, Chen P. Behavioral Treatment for Patients With Alcohol-Related Liver Disease: A Primer for Hepatologists. Clin Liver Dis (Hoboken) 2020; 15:31-35. [PMID: 32104575 PMCID: PMC7041957 DOI: 10.1002/cld.854] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Accepted: 06/07/2019] [Indexed: 02/04/2023] Open
Affiliation(s)
- Peng‐Sheng Ting
- Division of Gastroenterology and HepatologyJohns Hopkins University School of MedicineBaltimoreMD
| | - Jason Wheatley
- Department of Medical Surgical Social WorkJohns Hopkins HospitalBaltimoreMD
| | - Po‐Hung Chen
- Division of Gastroenterology and HepatologyJohns Hopkins University School of MedicineBaltimoreMD
| |
Collapse
|
40
|
Peeraphatdit T(B, Kamath PS, Karpyak VM, Davis B, Desai V, Liangpunsakul S, Sanyal A, Chalasani N, Shah VH, Simonetto DA. Alcohol Rehabilitation Within 30 Days of Hospital Discharge Is Associated With Reduced Readmission, Relapse, and Death in Patients With Alcoholic Hepatitis. Clin Gastroenterol Hepatol 2020; 18:477-485.e5. [PMID: 31042580 PMCID: PMC9764228 DOI: 10.1016/j.cgh.2019.04.048] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 04/16/2019] [Accepted: 04/21/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients admitted to the hospital for alcoholic hepatitis (AH) are at increased risk of readmission and death. We aimed to identify factors associated with readmission, alcohol relapse, and mortality. METHODS We performed a retrospective analysis of consecutive patients admitted with AH to a tertiary care hospital from 1999 through 2016 (test cohort, n = 135). We validated our findings in a prospective analysis of patients in a multi-center AH research consortium from 2013 through 2017 (validation cohort, n = 159). Alcohol relapse was defined as any amount of alcohol consumption within 30 days after hospital discharge. Early alcohol rehabilitation was defined as residential or outpatient addiction treatment or mutual support group participation within 30 days after hospital discharge. RESULTS Thirty-day readmission rates were 30% in both cohorts. Alcohol relapse rates were 37% in the test and 34% in the validation cohort. Following hospital discharge, 27 patients (20%) in the test cohort and 19 patients (16%) in the validation cohort attended early alcohol rehabilitation. There were 53 deaths (39%) in a median follow-up time of 2.8 years and 42 deaths (26%) in a median follow-up time of 1.3 years, respectively. In the test cohort, early alcohol rehabilitation reduced odds for 30-day readmission (adjusted odds ratios [AOR] 0.16; 95% CI, 0.04-0.65; P = .01), 30-day alcohol relapse (AOR, 0.11; 95% CI, 0.02-0.53; P < .001), and death (adjusted hazard ratio [AHR], 0.20; 95% CI, 0.05-0.56; P = .001). In the validation cohort early alcohol rehabilitation reduced odds for 30-day readmission (AOR, 0.30; 95% CI, 0.09-0.98; P = .04), 30-day alcohol relapse (AOR 0.09; 95% CI, 0.01-0.73; P = .02), and death (AHR, 0.20; 95% CI, 0.01-0.94; P = .04). A model combining alcohol rehabilitation and bilirubin identified patients with readmission to the hospital within 30 days with an area under the receiver operating characteristic curve of 0.73. CONCLUSIONS In an analysis from two cohorts of patients admitted with AH, early alcohol rehabilitation can reduce risk of hospital readmission, alcohol relapse, and death and should be considered as a quality indicator in AH hospitalization treatment.
Collapse
Affiliation(s)
| | - Patrick S. Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Victor M. Karpyak
- Department of Psychiatry and Psychology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Brian Davis
- Division of Gastroenterology and Hepatology, Department of Medicine, Virginia Commonwealth University, Richmond
| | - Vivek Desai
- Department of Family Medicine, The Institute for Family Health, New York, NY
| | - Suthat Liangpunsakul
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN,Roudebush Veterans Administration Medical Center, Indianapolis, IN
| | - Arun Sanyal
- Division of Gastroenterology and Hepatology, Department of Medicine, Virginia Commonwealth University, Richmond
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Vijay H. Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Douglas A. Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota
| |
Collapse
|
41
|
Addolorato G, Vassallo GA, Mirijello A, Gasbarrini A. Diagnosis and Management of Alcohol Use Disorder in Patients with Liver Disease: Lights and Shadows. Neurotherapeutics 2020; 17:127-141. [PMID: 31713188 PMCID: PMC7007485 DOI: 10.1007/s13311-019-00802-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Alcohol use disorder is the most common cause of advanced liver disease in the Western world. Diagnosis of alcohol use disorder can be difficult because patients with liver disease tend to deny alcohol intake for the fear of being excluded from treatment and because available biomarkers of alcohol intake have poor specificity in these patients. Alcohol abstinence is the cornerstone of the therapy in these patients. However, pharmacological treatments for alcohol use disorders have not been formally tested in patients with advanced liver disease, except for baclofen. Psychosocial intervention became crucial in these patients considering the limited pharmacological choice. However, psychosocial approach and an appropriate team to manage these patients are not still well defined. In this review, we critically discuss the diagnosis and the management of alcohol use disorder in patients with liver disease.
Collapse
Affiliation(s)
- Giovanni Addolorato
- "Internal Medicine and Alcohol Related Disease" Unit, Department of Internal Medicine and Gastroenterology, Catholic University of Rome, Rome, Italy.
- Fondazione Policlinico Universitario A Gemelli IRCCS Research Hospital, Rome, Italy.
| | - Gabriele A Vassallo
- "Internal Medicine and Alcohol Related Disease" Unit, Department of Internal Medicine and Gastroenterology, Catholic University of Rome, Rome, Italy
- Department of Internal Medicine, Barone Lombardo Hospital, Canicattì, Italy
| | - Antonio Mirijello
- "Internal Medicine and Alcohol Related Disease" Unit, Department of Internal Medicine and Gastroenterology, Catholic University of Rome, Rome, Italy
- Department of Medical Sciences, IRCCS Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, Italy
| | - Antonio Gasbarrini
- Fondazione Policlinico Universitario A Gemelli IRCCS Research Hospital, Rome, Italy
- Department of Internal Medicine and Gastroenterology, Catholic University of Rome, Rome, Italy
| |
Collapse
|
42
|
Crabb DW, Im GY, Szabo G, Mellinger JL, Lucey MR. Diagnosis and Treatment of Alcohol-Associated Liver Diseases: 2019 Practice Guidance From the American Association for the Study of Liver Diseases. Hepatology 2020; 71:306-333. [PMID: 31314133 DOI: 10.1002/hep.30866] [Citation(s) in RCA: 418] [Impact Index Per Article: 104.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 05/31/2019] [Indexed: 12/12/2022]
Affiliation(s)
- David W Crabb
- Indiana University School of Medicine, Indianapolis, IN
| | - Gene Y Im
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - Gyongyi Szabo
- University of Massachusetts Medical School, Worcester, MA
| | | | | |
Collapse
|
43
|
Insights Into the Experience of Liver Transplant Recipients With Alcoholic Liver Disease: A Descriptive Qualitative Study. Transplant Direct 2019; 5:e506. [PMID: 32095501 PMCID: PMC7004591 DOI: 10.1097/txd.0000000000000951] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 09/21/2019] [Indexed: 12/01/2022] Open
Abstract
Background. Alcoholic liver disease (ALD) due to alcohol use disorder (AUD) is the primary cause of liver transplantation (LT) in the United States. Studies have found that LT recipients experience a range of physical and emotional difficulties posttransplantation including return to alcohol use, depression, and anxiety. The aim of this study is to better understand the experiences of LT recipients with ALD because they recovered posttransplant to inform the development of a patient-centered intervention to assist patients during recovery. Methods. Using qualitative methods, researchers conducted semi-structured interviews with 16 ALD LT recipients. The primary topics of the interview were physical recovery, mental health, substance use including alcohol and tobacco use, and financial experiences. Common patient themes were identified and coded. Results. Within the domain of physical health, patients stressed that undergoing LT was a near-death experience, they were helpless, changes in weight influenced their perception of their illness, and they have ongoing medical problems. In the domain of mental health, patients described cognitive impairments during their initial recovery, difficulty in processing the emotions of having a terminal condition, ongoing depression, anxiety, and irritability. The patients also described their perception of having AUD, the last time they used alcohol and their attitude to AUD treatment posttransplant. Patients also described their reliance on one member of their social support network for practical assistance during their recovery and identified one member of their medical team as being of particular importance in providing emotional as well as medical support during recovery. Conclusions. The patient’s description of their lived experience during the months following transplant informed the development of a patient-centered intervention that colocates behavioral health components with medical treatment that helps broaden their social network while addressing topics that emerged from this study.
Collapse
|
44
|
Schlagintweit HE, Lynch MJ, Hendershot CS. A review of behavioral alcohol interventions for transplant candidates and recipients with alcohol-related liver disease. Am J Transplant 2019; 19:2678-2685. [PMID: 31419015 DOI: 10.1111/ajt.15569] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 07/16/2019] [Accepted: 08/06/2019] [Indexed: 01/25/2023]
Abstract
Alcohol-related liver disease (ALD) is a common indication for liver transplantation. Reflecting growing consensus that early transplant (ie, prior to sustained abstinence) can be a viable option for acute alcoholic hepatitis, access to liver transplantation for ALD patients has increased. Prevention of alcohol relapse is critical to pretransplant stabilization and posttransplant survival. Behavioral interventions are a fundamental component of alcohol use disorder treatment, but have rarely been studied in the transplant context. This scoping review summarizes published reports of behavioral and psychosocial alcohol interventions conducted with ALD patients who were liver transplant candidates and/or recipients. A structured review identified 11 eligible reports (3 original research studies, 8 descriptive papers). Intervention characteristics and clinical outcomes were summarized. Interventions varied significantly in orientation, content, delivery format, and timing/duration. Observational findings illustrate the importance of situating alcohol interventions within a multidisciplinary treatment context, and suggest the potential efficacy of cognitive-behavioral and motivational enhancement interventions. However, given extremely limited research evaluating behavioral alcohol interventions among ALD patients, the efficacy of behavioral interventions for pre- and posttransplant alcohol relapse remains to be established.
Collapse
Affiliation(s)
- Hera E Schlagintweit
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Marie-Josée Lynch
- Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Christian S Hendershot
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.,Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Psychology, University of Toronto, Toronto, Ontario, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
45
|
Ranasinghe I, Sin J, Norman I, Lau-Walker M. Predicting and preventing alcohol relapse in alcohol-related liver disease. ACTA ACUST UNITED AC 2019; 27:190-196. [PMID: 29457938 DOI: 10.12968/bjon.2018.27.4.190] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND despite a 450% increase in UK alcohol-related liver disease mortality over the past 30 years, little evidence-based guidance exists regarding preventing recidivism post-liver transplant for alcohol-related liver disease. METHOD a systematic literature review was conducted to identify demographic variables predictive of alcohol relapse and effective psychosocial interventions for alcohol-related liver disease patients post-liver transplant. RESULTS variables most significantly predictive of alcohol relapse post-transplant were-less than 12 months pre-liver transplant abstinence; patients with children; poor pre-liver transplant psychosomatic evaluation; non-compliance with post-liver transplant treatment plan; and patients with active insurance policies. Structured management was the most effective psychosocial intervention in preventing alcohol relapse. CONCLUSION findings should be interpreted cautiously, due to limited and poor-quality evidence. Rigorously designed further research of the psychosocial interventions targeting predictive demographic variables is recommended.
Collapse
Affiliation(s)
- Iyoni Ranasinghe
- Quality Improvement Facilitator, South London and Maudsley NHS Trust
| | - Jacqueline Sin
- Associate Professor in Clinical Health and National Institute for Health Research Post Doctoral Research Fellow, University of Reading and St George's, University of London
| | - Ian Norman
- Executive Dean of Faculty, King's College London
| | - Margaret Lau-Walker
- Senior Lecturer, Cluster Lead for Acute, Critical and Emergency Care and Programme Lead for Health Education England and National Institute for Health Research Integrated Clinical Academic Programme, University of Surrey, Guildford
| |
Collapse
|
46
|
Schult A, Stokkeland K, Ericzon BG, Hultcrantz R, Franck J, Stål P, Castedal M. Alcohol and drug use prior to liver transplantation: more common than expected in patients with non-alcoholic liver disease. Scand J Gastroenterol 2019; 54:1146-1154. [PMID: 31453745 DOI: 10.1080/00365521.2019.1656772] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Objective: Liver transplantation (LT) is a life-saving procedure for patients with end-stage liver disease, acute liver failure or hepatocellular carcinoma (HCC). Patients with known alcoholic liver cirrhosis (ALC) are usually assessed by an addiction specialist, but patients with other liver diseases may also exhibit harmful drinking. This study aims to assess the drinking habits in LT-recipients with or without a diagnosis of ALC. Patients and methods: Between April 2012 and December 2015, 190 LT-recipients were interviewed using the Lifetime Drinking History (LDH) and the Addiction Severity Index (ASI). Patients were categorized according to their diagnoses: ALC (group A, n = 39), HCC or hepatitis C (group B, n = 56) or other liver diseases (group C, n = 95). Data were analysed using descriptive statistic methods. Results: Fifteen of 95 patients (15.8%) in group C - a cohort without suspected addiction problems - had either alcohol consumption or binge drinking within the upper quartile of the overall cohort. The aetiology of liver disease in this subgroup included mainly cholestatic and cryptogenic liver disease. Illicit drugs had been used by 35% of all patients. Cannabis and amphetamine were the most common drugs and had the longest duration of regular use. Conclusions: LT candidates without known alcohol or drug use may have a clinically significant consumption of alcohol and previous illicit drug use. Efforts should be put on identification of these patients during LT evaluation. The use of structured questionnaires such as the ASI and the LDH could facilitate detection of alcohol and drug problems.
Collapse
Affiliation(s)
- Andreas Schult
- The Transplant Institute, Sahlgrenska University Hospital , Gothenburg , Sweden.,Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden
| | - Knut Stokkeland
- Department of Medicine, Visby Hospital , Visby , Sweden.,Department of Clinical Neuroscience, Karolinska Institutet , Stockholm , Sweden
| | - Bo-Göran Ericzon
- Division of Transplantation Surgery, CLINTEC, Karolinska Institutet , Stockholm , Sweden.,Department of Transplantation Surgery, Karolinska University Hospital , Stockholm , Sweden
| | - Rolf Hultcrantz
- Department of Medicine, Solna, Karolinska Institutet , Stockholm , Sweden
| | - Johan Franck
- Department of Clinical Neuroscience, Karolinska Institutet , Stockholm , Sweden
| | - Per Stål
- Department of Upper GI Diseases, Unit of Liver Diseases, Karolinska University Hospital , Stockholm , Sweden.,Department of Medicine, Huddinge, Karolinska Institutet , Stockholm , Sweden
| | - Maria Castedal
- The Transplant Institute, Sahlgrenska University Hospital , Gothenburg , Sweden.,Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden
| |
Collapse
|
47
|
Temporal Trends Associated With the Rise in Alcoholic Liver Disease-related Liver Transplantation in the United States. Transplantation 2019; 103:131-139. [PMID: 30300285 DOI: 10.1097/tp.0000000000002471] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND In the United States, alcoholic liver disease (ALD) has recently become the leading indication for liver transplantation. METHODS Using the United Network for Organ Sharing registry, we examined temporal trends in adult liver transplant waitlist (WL) registrants and recipients with chronic liver disease (CLD) due to ALD from 2007 to 2016. RESULTS From 2007 to 2016, ALD accounted for 20.4% (18 399) of all CLD WL additions. The age-standardized ALD WL addition rate was 0.459 per 100 000 US population in 2007; nearly doubled to 0.872 per 100 000 US population in 2016 and increased with an average annual percent change of 47.56% (95% confidence interval, 30.33% to 64.72%).The ALD WL addition rate increased over twofold among young (18-39 years) and middle-aged (40-59 years) adults during the study period. Young adult ALD WL additions presented with a higher severity of liver disease including Model for End-Stage Liver Disease score compared to middle aged and older adults (≥60 years). The number of annual ALD WL deaths readily rose from 2014 to 2016, despite an overall annual decline in all CLD WL deaths. Severe hepatic encephalopathy, low body mass index (<18.5) and diabetes mellitus were significant predictors for 1-year WL mortality. CONCLUSIONS Alcoholic liver disease-related WL registrations and liver transplantation have increased over the past decade with a disproportionate increase in young and middle-aged adults. These subpopulations within the ALD cohort need to be evaluated in future studies to improve our understanding of factors associated with these alarming trends.
Collapse
|
48
|
Szabo G, Kamath PS, Shah VH, Thursz M, Mathurin P, Bataller R, Burra P, Castera L, Cortez Pinto H, Diehl AM, Gao B, Gilmore SI, Hampe J, Jürgen R, Karin M, Krag A, Leon D, Leptak C, Louvet A, Lucey M, McClain C, Nagy L, Pageaux G, Sanyal A, Schnabl B, Tiniakos D, Trautwein C, Tsukamoto H. Alcohol-Related Liver Disease: Areas of Consensus, Unmet Needs and Opportunities for Further Study. Hepatology 2019; 69:2271-2283. [PMID: 30645002 DOI: 10.1002/hep.30369] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 10/31/2018] [Indexed: 12/16/2022]
Abstract
A joint meeting of the European Association for the Study of the Liver (EASL) and the American Association for the Study of Liver Diseases (AASLD) was held in London on September 30 and October 1, 2017. The goals of the meeting were to identify areas of broad agreement and disagreement, develop consensus, and determine future directions to ultimately reduce the burden, morbidity, and mortality of alcohol-related liver disease (previously termed alcoholic liver disease). The specific aims of the meeting were to identify unmet needs and areas for future investigation, in order to reduce alcohol consumption, develop markers for diagnosis and prognosis of disease, and create a framework to test novel pharmacological agents with pre-specified treatment endpoints. A table summary of these goals and aims is provided in the context of epidemiology, current management strategies, next steps for future trials and translational science.
Collapse
Affiliation(s)
- Gyongyi Szabo
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, US
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN, US
| | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN, US
| | - Mark Thursz
- Digestive Diseases Division, Department of Surgery & Cancer, Imperial College, London, UK
| | - Philippe Mathurin
- Service des Maladies de l'Appareil Digestif, Hôpital Claude Huriez, Lille, France
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
49
|
Weinrieb RM. New Treatment Models for Alcohol Use Disorders and Alcoholic Liver Disease. Clin Liver Dis (Hoboken) 2019; 13:118-122. [PMID: 31236257 PMCID: PMC6544411 DOI: 10.1002/cld.804] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 11/27/2018] [Indexed: 02/04/2023] Open
Affiliation(s)
- Robert M. Weinrieb
- Department of Psychiatry of the University of PennsylvaniaPerelman School of MedicinePhiladelphiaPA
| |
Collapse
|
50
|
Alcohol-related liver disease: Areas of consensus, unmet needs and opportunities for further study. J Hepatol 2019; 70:521-530. [PMID: 30658117 DOI: 10.1016/j.jhep.2018.10.041] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 10/26/2018] [Accepted: 10/31/2018] [Indexed: 12/19/2022]
Abstract
A joint meeting of the European Association for the Study of the Liver (EASL) and the American Association for the Study of Liver Diseases (AASLD) was held in London on September 30 and October 1, 2017. The goals of the meeting were to identify areas of broad agreement and disagreement, develop consensus, and determine future directions to ultimately reduce the burden, morbidity, and mortality of alcohol-related liver disease (previously termed alcoholic liver disease). The specific aims of the meeting were to identify unmet needs and areas for future investigation, in order to reduce alcohol consumption, develop markers for diagnosis and prognosis of disease, and create a framework to test novel pharmacological agents with pre-specified treatment endpoints.
Collapse
|