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Branagan WT, Norvell JP. Assessment and Evaluation of Alcohol Use Disorder in Liver Transplant. Transplantation 2024; 108:654-661. [PMID: 37408098 DOI: 10.1097/tp.0000000000004722] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
Alcohol-related liver disease is the most common indication for liver transplantation. It is essential for providers in transplantation to be informed of the state of the science in evaluation of alcohol use disorder (AUD). This review examines the broad range of approaches to the evaluation of AUD ranging from traditional interview approaches to recent literature on artificial intelligence models. The empirical support for methods of evaluation is examined. The authors discuss the use of each method in the context of patients seeking a liver transplant for alcohol-related liver disease. This review emphasizes the importance of using objective assessments so that transplant centers make evidence-based decisions and reduce cognitive bias. The review concludes with a proposed assessment battery for evaluation and bridges to future directions in the field of AUD assessment in liver transplantation.
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Affiliation(s)
- William T Branagan
- Department of Psychiatry, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO
| | - J P Norvell
- Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO
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2
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Durkin C, Bittermann T. Liver transplantation for alcohol-associated hepatitis. Curr Opin Organ Transplant 2023; 28:85-94. [PMID: 36512482 PMCID: PMC9992110 DOI: 10.1097/mot.0000000000001044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Early liver transplantation is emerging as a treatment option for severe alcohol-associated hepatitis refractory to pharmacotherapies. This review outlines the current status of transplantation for alcohol-associated hepatitis and the treatment of alcohol use disorder after liver transplantation. RECENT FINDINGS Rates of early liver transplantation for alcohol-associated hepatitis are increasing with significant heterogeneity in practices across the Unites States. Recent studies have demonstrated a substantial survival benefit in patients transplanted for alcohol-associated hepatitis with improved outcomes in early vs. late transplantation, first vs. prior hepatic decompensation, and posttransplant abstinence/delayed relapse vs. early return to alcohol use. Several prediction algorithms have been developed to ascertain patients' risk of alcohol relapse and aid in candidate selection, though data on treatment of alcohol use disorders in transplant recipients remains limited. SUMMARY Although controversial, early liver transplantation for severe alcohol-associated hepatitis has shown to be a lifesaving intervention. Additional research is needed to evaluate its long-term outcomes, optimize candidate selection, and understand treatment of alcohol use disorder posttransplant.
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Affiliation(s)
- Claire Durkin
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Therese Bittermann
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
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3
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Alcohol-Related Liver Disease Including New Developments. Clin Liver Dis 2023; 27:157-172. [PMID: 36400463 DOI: 10.1016/j.cld.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The prevalence of alcohol consumption, alcohol use disorder (AUD), and alcohol-related liver disease (ALD) has exponentially increased over the last several years and rates continue to increase. Significant alcohol use can cause progression from steatosis in the liver to inflammation, fibrosis, and eventually cirrhosis. Additional risk factors for the progression of ALD disease include gender, race, and genetic predisposition. As such, it is essential for clinicians to understand and implement screening tools for early diagnosis of both AUD and ALD and be aware of emerging novel treatment options.
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4
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Alcoholic Hepatitis. Med Clin North Am 2023; 107:533-554. [PMID: 37001952 DOI: 10.1016/j.mcna.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
Alcoholic hepatitis (AH) is a unique clinical syndrome on the spectrum of alcohol-associated liver disease (ALD). It constitutes a rising epidemic with increasing incidence and major public health implications. In severe AH, 30-day mortality approaches 30%, yet therapeutic options remain limited. Survival benefit from corticosteroids, the mainstay of medical treatment, is short-lived. Among corticosteroid nonresponders, the use of early liver transplantation is heterogeneous across centers and remains limited by significant barriers. Long-term prognosis is largely dictated by abstinence; however, comorbid alcohol use disorder remains undertreated. Efforts to address these challenges are required to curb the AH epidemic.
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5
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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.
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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
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6
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Zanowski SC, Price JS, Selim MA, Schumann V, Durazo F, Hong JC. Effect of an Integrated Transplantation Mental Health Program on Alcohol Relapse After Liver Transplantation for Severe Alcoholic Hepatitis: A Single-Center Prospective Study. Transplant Proc 2022; 54:2627-2633. [DOI: 10.1016/j.transproceed.2022.09.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 09/19/2022] [Accepted: 09/20/2022] [Indexed: 11/21/2022]
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7
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Legaz I, Muro M. Optimizing strategies to reduce alcohol consumption and relapses, improving abstinence in liver transplant recipients. Hepatobiliary Surg Nutr 2022; 11:153-155. [PMID: 35284518 PMCID: PMC8847871 DOI: 10.21037/hbsn-21-470] [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] [Received: 12/17/2021] [Accepted: 12/28/2021] [Indexed: 08/30/2023]
Affiliation(s)
- Isabel Legaz
- Department of Legal and Forensic Medicine, Biomedical Research Institute (IMIB), Regional Campus of International Excellence “Campus Mare Nostrum”, Faculty of Medicine, University of Murcia, Murcia, Spain
| | - Manuel Muro
- Immunology Service, Instituto Murciano de Investigación Biosanitaria (IMIB), Hospital Clínico Universitario Virgen de la Arrixaca (HCUVA), Murcia, Spain
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8
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Choi G, Benhammou JN, Yum JJ, Saab EG, Patel AP, Baird AJ, Aguirre S, Farmer DG, Saab S. Barriers for Liver Transplant in Patients with Alcohol-Related Hepatitis. J Clin Exp Hepatol 2022; 12:13-19. [PMID: 35068780 PMCID: PMC8766699 DOI: 10.1016/j.jceh.2021.09.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 09/13/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Liver transplantation (LT) for alcohol-related liver disease has historically been reserved for patients who have been six months abstinent. Given the increasing incidence of alcohol-related hepatitis (AH) and dismal survival in patients who fail medical therapy, transplant centers are extending their acceptance criteria for patients with less than 6 months of sobriety. We sought to determine the barriers for listing. METHODS We conducted a retrospective chart review of all inpatient LT referrals for a diagnosis of AH between September 2019 and December 2020. LT evaluations were performed by a multidisciplinary team. Descriptive statistics were reported using mean and standard deviation (SD) or percentage where appropriate. RESULTS During our study period, 82 patients were evaluated for LT. Of these 82 patients, 62 were declined for liver transplantation. The mean (SD) age of the 62-patient cohort was 44 years (10.7), and most patients were men. The mean (SD) number of reasons for denial was 2 (0.97). Four patients had medical contraindications for transplant. Twenty-seven (44%) and 35 (56%) patients lacked insight and were at risk of alcohol relapse, respectively. Forty-three (69%) and fourteen (22.5%) patients had insufficient social support and an inability to maintain a therapeutic relationship with the transplant team, respectively. CONCLUSION Patients are more likely denied for psychosocial factors than medical comorbidities. The majority were due to lack of insight, insufficient social support, and inability to maintain a therapeutic relationship with the transplant team. Resources should be allocated to address these issues.
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Affiliation(s)
- Gina Choi
- Department of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Jihane N. Benhammou
- Department of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Jung J. Yum
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Elena G. Saab
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Ankur P. Patel
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Andrew J. Baird
- Department of Nursing, University of California, Los Angeles, Los Angeles, CA, USA
| | - Stephanie Aguirre
- Department of Social Work, University of California, Los Angeles, Los Angeles, CA, USA
| | - Douglas G. Farmer
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Sammy Saab
- Department of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA, USA
- Department of Nursing, University of California, Los Angeles, Los Angeles, CA, USA
- Address for correspondence. Sammy Saab, MD, MPH, AGAF, FAASLD, Pfleger Liver Institute, UCLA Medical Center, 200 Medical Plaza, Suite 214, Los Angeles, CA 90095, USA. Tel.: +1 310 206 6705; fax: +1 310 206 4197.
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9
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Hause J, Rice JP. Transplants for Acute Alcoholic Hepatitis: Controversies and Early Successes. Clin Liver Dis 2021; 25:229-252. [PMID: 33978581 DOI: 10.1016/j.cld.2020.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Liver transplant for severe alcohol-associated hepatitis remains a controversial practice despite evidence for a substantial survival benefit compared with medical therapy and posttransplant alcohol relapse rates comparable with previously published studies in alcohol-associated cirrhosis. The controversy stems in part from concern regarding patient selection practices, lack of long-term follow-up data, and the potential negative public perception of the practice affecting organ donation. Despite these concerns, it seems that early liver transplant for alcohol-associated hepatitis is increasingly being offered to selected patients across the United States and the world.
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Affiliation(s)
- Jessica Hause
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, 4th Floor MFCB, 1685 Highland Avenue, Madison, WI 53705, USA
| | - John P Rice
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, 4th Floor MFCB, 1685 Highland Avenue, Madison, WI 53705, USA.
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10
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Im GY, Neuberger J. Debate on Selection Criteria for Liver Transplantation for Alcoholic Hepatitis: Tighten or Loosen? Liver Transpl 2020; 26:916-921. [PMID: 32614520 DOI: 10.1002/lt.25783] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 03/17/2020] [Accepted: 04/12/2020] [Indexed: 02/07/2023]
Abstract
Although liver transplantation (LT) for alcohol-associated liver disease (ALD) is a well-accepted practice, LT for severe alcoholic hepatitis (AH) remains controversial due to concerns about the limited organ supply and the risk of return to harmful drinking. Recognizing an increasing body of favorable evidence, a convergence of practice guideline recommendations from leading hepatology and gastroenterology societies have suggested that the length of abstinence should not be a sole criterion for LT selection and, thus, that LT may be considered in carefully selected severe AH patients with favorable psychosocial profiles not responding to medical therapy. We sought to examine this new consensus in greater detail, debating whether candidate selection criteria for LT in AH should be tightened or loosened.
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Affiliation(s)
- Gene Y Im
- Division of Liver Diseases, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - James Neuberger
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
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11
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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: 415] [Impact Index Per Article: 103.8] [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
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12
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Uygun E, Özer Ü. Alkolik karaciğer hastalığı nedeniyle karaciğer nakli yapılan hastalarda psikiyatrik eştanı ve yeniden alkol kullanımı: Bir ön çalışma. EGE TIP DERGISI 2020. [DOI: 10.19161/etd.452206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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13
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Giard JM, Dodge JL, Terrault N. Superior Wait-List Outcomes in Patients with Alcohol-Associated Liver Disease Compared With Other Indications for Liver Transplantation. Liver Transpl 2019; 25:1310-1320. [PMID: 31063642 PMCID: PMC8544021 DOI: 10.1002/lt.25485] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 04/17/2019] [Indexed: 01/18/2023]
Abstract
Alcohol-associated liver disease (ALD) is the most common indication for liver transplantation (LT) in the United States and Europe. A 6-month alcohol abstinence period has been required by many transplant programs prior to listing, which may influence wait-list (WL) outcomes. Therefore, we examined WL events in patients with ALD versus non-ALD with a special interest in whether these outcomes differed by sex. All US adults listed for LT from January 2002 to December 2016 were eligible except status 1 patients, Model for End-Stage Liver Disease exceptions, retransplants and those with acute alcoholic hepatitis. The outcomes of interest were cumulative WL death or being too sick and WL removal for improvement within 2 years of listing. Competing risk regression models were used to evaluate recipient factors associated with the outcomes. Among the 83,348 eligible WL patients, 23% had ALD. Unadjusted cumulative WL removal within 2 years was 19.0% for ALD versus 21.1% for non-ALD (P < 0.001). In fully adjusted models, ALD was associated with a significantly lower risk of WL removal for death or being too sick (subhazard ratio [SHR], 0.84; 95% confidence interval [CI], 0.81-0.87; P < 0.001) and a higher risk of removal for improvement (SHR, 2.91; 95% CI, 2.35-3.61; P < 0.001) versus non-ALD patients. After adjusting for potential confounders, women with ALD had a higher risk of removal for death or being too sick (SHR, 1.09; 95% CI, 1.00-1.08; P < 0.001) and a higher chance for improvement (SHR, 2.91; 95% CI, 2.35-3.61; P < 0.001) than men with ALD. In conclusion, WL candidates with ALD have more favorable WL outcomes than non-ALD patients with a 16% lower risk of removal for deterioration and 191% higher risk of removal for improvement. This result likely reflects the benefits of alcohol abstinence, but it suggests that listing criteria for ALD may be too restrictive, with patients who might derive benefit from LT not being listed.
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Affiliation(s)
- Jeanne-Marie Giard
- University of California San Francisco, San Francisco, CA, United States.,Université de Montréal, Montréal, Québec, Canada
| | - Jennifer L. Dodge
- University of California San Francisco, San Francisco, CA, United States
| | - Norah Terrault
- University of California San Francisco, San Francisco, CA, United States
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14
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Rice JP, Lee BP. Early Liver Transplantation for Alcohol-Associated Liver Disease: Need for Engagement and Education of All Stakeholders. Hepatol Commun 2019; 3:1019-1021. [PMID: 31388622 PMCID: PMC6671773 DOI: 10.1002/hep4.1385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 05/19/2019] [Indexed: 11/16/2022] Open
Abstract
Editorial for HEP4-19-0054 "Patients' Perspective on Early Liver Transplantation in Alcoholic Liver Disease."
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Affiliation(s)
- John P. Rice
- School of Medicine and Public Health, Gastroenterology and HepatologyUniversity of WisconsinMadisonWI
| | - Brian P. Lee
- Department of GastroenterologyUniversity of California, San FranciscoSan FranciscoCA
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15
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Mazumder N, Boike J, Maddur H. Con: The Abstinence Period Should Be Determined on a Case-by-Case Basis. Clin Liver Dis (Hoboken) 2019; 13:87-89. [PMID: 30988944 PMCID: PMC6446453 DOI: 10.1002/cld.730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 05/11/2018] [Indexed: 02/04/2023] Open
Affiliation(s)
- Nikhilesh Mazumder
- Department of Medicine, Division of Gastroenterology and HepatologyNorthwestern UniversityChicagoIL
| | - Justin Boike
- Department of Medicine, Division of Gastroenterology and HepatologyNorthwestern UniversityChicagoIL
| | - Haripriya Maddur
- Department of Medicine, Division of Gastroenterology and HepatologyNorthwestern UniversityChicagoIL
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16
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Liver transplantation for alcoholic hepatitis. J Hepatol 2019; 70:328-334. [PMID: 30658734 DOI: 10.1016/j.jhep.2018.11.007] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 11/05/2018] [Accepted: 11/08/2018] [Indexed: 12/19/2022]
Abstract
While liver transplantation (LT) has become a standard therapy for life-threatening alcohol related cirrhosis, LT as a treatment for severe alcoholic hepatitis (AH) has remained a taboo owing to concerns about the limited organ supply and the risk that the AH liver recipient will return to harmful drinking. The adoption of a 6-month abstinence requirement (the so-called '6-month rule') by many centres made AH a contraindication to LT. Given the high short-term mortality of severe AH, the lack of effective medical therapies and an increasing recognition that the 6-month rule unfairly excluded otherwise favourable candidates, a seminal European pilot study of LT for AH was performed. The success of the European study, which has been corroborated in retrospective analyses from the United States, represented a paradigm shift in therapy for highly selected patients with severe AH who are not responding to medical therapy. However, prospective studies are urgently needed to resolve the controversies that still surround the criteria for selection of patients with AH for LT and the long-term outcomes of the associated alcohol use disorder.
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17
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Contemporary Policies Regarding Alcohol and Marijuana Use Among Liver Transplant Programs in the United States. Transplantation 2018; 102:433-439. [PMID: 29019813 DOI: 10.1097/tp.0000000000001969] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Alcoholic liver disease is a common indication for orthotopic liver transplantation (OLT). Although OLT has been shown to confer survival benefit to patients with acute alcoholic hepatitis (AAH), historically most programs require a 6-month abstinence period before OLT which excludes patients with AAH. Marijuana has become legal in more than half the states in the United States. This survey of liver transplant programs was conducted to evaluate current policies regarding alcohol, marijuana and methadone use. METHODS A questionnaire was distributed to 100 United Network for Organ Sharing-approved liver transplant programs in North America that have performed at least 30 liver transplants/year in the last 5 years. RESULTS Forty-nine programs responded. Only 43% of the programs required a specific period of abstinence before transplant for alcoholic liver disease and only 26% enforced 6-month abstinence policy. For patients with AAH, 71% programs waived the 6-month abstinence requirement and considered psychosocial factors, such as family support, patient's motivation, or commitment to rehabilitate. Few programs used validated instruments to assess risk of relapse in AAH patients. Fourteen percent of programs transplant patients actively using marijuana and an additional 28% of programs listed patients using marijuana provided they discontinue by the time of OLT. Active methadone users were accepted in 45% of the programs. CONCLUSIONS Policies regarding alcohol use have become more flexible particularly toward patients with AAH. Marijuana use is also more accepted. Although policies regarding alcohol and marijuana have changed significantly in the last decade, they remain highly variable among programs.
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18
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Kang SH, Choi Y, Han HS, Yoon YS, Cho JY, Kim S, Kim KH, Hyun IG, Shehta A. Fatigue and weakness hinder patient social reintegration after liver transplantation. Clin Mol Hepatol 2018; 24:402-408. [PMID: 30300990 PMCID: PMC6313025 DOI: 10.3350/cmh.2018.0028] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 06/29/2018] [Indexed: 02/07/2023] Open
Abstract
Background/Aims With improvements in the survival of liver transplantation (LT) recipients, the focus is shifting to patient quality of life (QOL), and employment is an important factor in aiding the social reintegration of LT patients. This study aims to evaluate the current employment status of liver graft recipients and various factors that may hinder reemployment. Methods Fifty patients above age 18 who underwent either living or deceased donor LT at a single center from March 2009 to July 2016 were interviewed during their visit to the outpatient clinic. The internally developed questionnaire consisted of 10 items. The Karnofsky Performance Scale and EQ-5D were used to evaluate patient function and QOL. Results A total of 25 (50%) patients returned to work after transplantation (the working group), and 21 (84%) patients in the working group returned to work within the first year after transplantation. In the non-working group (n=25), 17 (68%) answered that their health was the reason for unemployment. Fatigue and weakness were the most frequent symptoms. Conclusions The data shows that as many as 50% of total patients returned to work after receiving LT. Fatigue and weakness were the most common complaints of the unemployed group, and resolving the causes of these symptoms may help to increase the employment rate.
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Affiliation(s)
- So Hyun Kang
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - YoungRok Choi
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Ho-Seong Han
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jai Young Cho
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sungho Kim
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Kil Hwan Kim
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - In Gun Hyun
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ahmed Shehta
- Gastrointestinal Surgery Center, Department of Surgery, Mansoura University College of Medicine, Dakahlia Governorate, Egypt
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19
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Heyes CM, Schofield T, Gribble R, Day CA, Haber PS. Reluctance to Accept Alcohol Treatment by Alcoholic Liver Disease Transplant Patients: A Qualitative Study. Transplant Direct 2016; 2:e104. [PMID: 27795986 PMCID: PMC5068203 DOI: 10.1097/txd.0000000000000617] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 07/11/2016] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Liver transplantation (LT) is the optimum treatment for patients with end-stage alcoholic liver disease (ALD). However, despite a recognized risk of relapse to harmful drinking, ALD transplant patients are reluctant to use speciality alcohol treatment to support their abstinence, even when offered within the LT context. This study aimed to understand and identify factors contributing to alcohol treatment reluctance by ALD patients undergoing transplantation. METHODS We conducted an in-depth qualitative study of ALD transplant patients. Minimally structured face-to-face interviews explored participants' alcohol-related experiences and their reasons for not using alcohol treatment during the course of their transplantation. Thematic analysis was used to analyze and interpret interview data to understand treatment reluctance based on participants' experiences. RESULTS Five major themes were identified among 3 subgroups of patients (pretransplant and posttransplant abstainers and posttransplant relapsers): (i) the "contract" of mandatory abstinence, (ii) the "gap in the program" involving the lack of candour between patient and staff about alcohol-related matters and the lack of addiction services, (iii) a preference by participants to self-manage their alcohol use disorder, (iv) social support as a facilitator of abstinence and the risk of relapse when social support is diminished, and (v) the fear of stigmatization. Each of these factors were dynamically interrelated and differed slightly for each subgroup. CONCLUSIONS The LT services may benefit from the inclusion of integrated specialist addiction services in their model of care. Such an approach may enhance the acceptability of alcohol treatment and reduce the risk of relapse among ALD transplant participants, especially for those whose social supports have diminished.
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Affiliation(s)
- Cathy M. Heyes
- Drug Health Services, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- NHMRC Centre for Research Excellence in Mental Health and Substance Use, Australia
| | - Toni Schofield
- Discipline of Behavioural and Social Sciences in Health, The University of Sydney, NSW, Australia
| | - Robert Gribble
- Drug Health Services, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- Consultation Liaison Psychiatry, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Carolyn A. Day
- Discipline of Addiction Medicine, Central Clinical School, The University of Sydney, NSW, Australia
| | - Paul S. Haber
- Drug Health Services, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- NHMRC Centre for Research Excellence in Mental Health and Substance Use, Australia
- Discipline of Addiction Medicine, Central Clinical School, The University of Sydney, NSW, Australia
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20
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Abstract
Excessive alcohol use is a common health care problem worldwide and is associated with significant morbidity and mortality. Alcoholic liver disease represents the second most frequent indication for liver transplantation in North America and Europe. The pretransplant evaluation of patients with alcoholic liver disease should aim at identifying those at high risk for posttransplant relapse of alcohol use disorder, as return to excessive drinking can be deleterious to graft and patient survival. Carefully selected patients with alcoholic liver disease, including those with severe alcoholic hepatitis, will have similar short-term and long-term outcomes when compared with other indications for liver transplantation.
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Heyes CM, Baillie AJ, Schofield T, Gribble R, Haber PS. The Reluctance of Liver Transplant Participants with Alcoholic Liver Disease to Participate in Treatment for Their Alcohol Use Disorder: An Issue of Treatment Matching? ALCOHOLISM TREATMENT QUARTERLY 2016. [DOI: 10.1080/07347324.2016.1148515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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22
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Lucey MR, Rice JP. Liver Transplantation for Severe Alcoholic Hepatitis Crosses the Atlantic. Am J Transplant 2016; 16:739-40. [PMID: 26780360 DOI: 10.1111/ajt.13587] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 10/10/2015] [Accepted: 10/14/2015] [Indexed: 01/25/2023]
Affiliation(s)
- M R Lucey
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - J P Rice
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
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Im GY, Kim-Schluger L, Shenoy A, Schubert E, Goel A, Friedman SL, Florman S, Schiano TD. Early Liver Transplantation for Severe Alcoholic Hepatitis in the United States--A Single-Center Experience. Am J Transplant 2016; 16:841-9. [PMID: 26710309 DOI: 10.1111/ajt.13586] [Citation(s) in RCA: 171] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 08/16/2015] [Accepted: 08/31/2015] [Indexed: 01/25/2023]
Abstract
Early liver transplantation (LT) in European centers reportedly improved survival in patients with severe alcoholic hepatitis (AH) not responding to medical therapy. Our aim was to determine if a strategy of early LT for severe AH could be applied successfully in the United States. We reviewed 111 patients with severe AH at our center from January 2012 to January 2015. The primary end point was mortality at 6 months or early LT, with a secondary end point of alcohol relapse after LT. Survival was compared between those receiving early LT and matched patients who did not. Using a process similar to the European trial, 94 patients with severe AH not responding to medical therapy were evaluated for early LT. Overall, 9 (9.6%) candidates with favorable psychosocial profiles underwent early LT, comprising 3% of all adult LT during the study period. The 6-month survival rate was higher among those receiving early LT compared with matched controls (89% vs 11%, p<0.001). Eight recipients are alive at a median of 735 days with 1 alcohol relapse. Early LT for severe AH can achieve excellent clinical outcomes with low impact on the donor pool and low rates of alcohol relapse in highly selected patients in the United States.
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Affiliation(s)
- G Y Im
- Recanati/Miller Transplantation Institute, Division of Liver Diseases, Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - L Kim-Schluger
- Recanati/Miller Transplantation Institute, Division of Liver Diseases, Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - A Shenoy
- Department of Psychiatry, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - E Schubert
- Social Work Services, The Mount Sinai Medical Center, New York, NY
| | - A Goel
- Division of Liver Diseases, Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - S L Friedman
- Division of Liver Diseases, Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - S Florman
- Recanati/Miller Transplantation Institute, Division of Liver Diseases, Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - T D Schiano
- Recanati/Miller Transplantation Institute, Division of Liver Diseases, Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY
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24
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Abstract
Alcoholic liver disease is the second most common indication for orthotopic liver transplantation in western countries. The majority of patients with alcoholic liver disease, however, are not referred for transplant evaluation. If evaluated, a 6 month period of sobriety is required before waitlisting for transplant. The consequences of relapse to alcohol use in patients on the waitlist are usually removal from the list. Therefore, identification and treatment of alcohol use disorder in patients with end-stage liver disease greatly impacts quality of life, treatment options and survival in patients’ course with this grave illness. Psychosocial and behavioral interventions prior to transplant appear to reduce drinking in the period before the surgery as well as reduce relapse rates post-transplant. Only one of the three medications approved by the Food and Drug Administration, acamprosate, seems feasible for use in patients with end-stage liver disease, while several other medications currently under investigation for the treatment of alcohol use disorder can be considered for use in this population. While only baclofen has been formally studied in alcoholic patients with end-stage liver disease with positive results for safety and efficacy, other medications also hold promise to treat alcohol use disorder in this population. Transplant programs with addictions specialists who function as an integral part of the treatment team may offer better outcomes to patients in terms of success of maintaining sobriety both pre- and post-transplant.
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Affiliation(s)
- Mary R. Lee
- Section on Clinical Psychoneuroendocrinology and Neuropsychopharmacology, National Institute on Alcohol Abuse and Alcoholism and National Institute on Drug Abuse, National Institutes of Health, Bethesda, MD
| | - Lorenzo Leggio
- Section on Clinical Psychoneuroendocrinology and Neuropsychopharmacology, National Institute on Alcohol Abuse and Alcoholism and National Institute on Drug Abuse, National Institutes of Health, Bethesda, MD,Center for Alcohol and Addiction Studies, Department of Behavioral and Social Sciences, Brown University, Providence, RI,Contact information: Lorenzo Leggio, M.D., Ph.D., M.Sc., Section on Clinical Psychoneuroendocrinology and Neuropsychopharmacology, NIAAA & NIDA, NIH, 10 Center Drive (10CRC/15330) MSC 1108; Room 1-5429, Bethesda, MD 20892-1108, Phone: +1 301 435 9398; Fax: + 1 301 402 0445,
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25
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Abstract
Liver transplantation has become the treatment of choice for nearly all causes of end-stage liver disease, fulminant liver failure, and selected primary hepatic malignancies. The demand for liver transplantation has persistently outmatched the availability of donor organs leading to the development of novel strategies to expand the donor pool. The authors review the process of liver transplant evaluation, methods used to address the donor shortage, and disease-specific outcomes and challenges and discuss posttransplant care.
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Affiliation(s)
- Ming-Ming Xu
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University College of Physicians & Surgeons, 622 West 168th Street, PH14, New York, NY 10032, USA
| | - Robert S Brown
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University College of Physicians & Surgeons, 622 West 168th Street, PH14, New York, NY 10032, USA.
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26
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Willey JZ, Tolchin BD. Liver transplant for intentional acetaminophen overdose and hepatic encephalopathy: a conflict between beneficence and justice. Continuum (Minneap Minn) 2014; 20:681-5. [PMID: 24893242 PMCID: PMC10564018 DOI: 10.1212/01.con.0000450974.91699.b8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In cases of severe acetaminophen-induced acute liver failure and hepatic encephalopathy, liver transplant can be the only real hope for neurologic recovery and indeed survival. In such cases, the bioethical principles of beneficence and justice often come into conflict. This article examines a case in which a neurologist managing an acetaminophen-overdose patient in the neurologic intensive care unit is faced with a conflict between her patient's need for a liver transplant and the needs of other patients on the transplant list.
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Abstract
Alcoholic liver disease (ALD) is the major cause of life-threatening liver disease in Western countries. Abstinence from alcohol is the foundation of all treatment programmes for patients with ALD. Liver transplantation is a valuable option for patients with life-threatening ALD. Although the role of liver transplantation in the treatment of alcoholic hepatitis that is unresponsive to medical therapy is controversial, the latest prospective studies support this approach. No single measure gives a reliable estimate of the risk of drinking relapses before or after liver transplantation, but careful evaluation by an addiction specialist with a particular interest in transplant medicine is the best available approach. Survival, both on the waiting list and after the operation, is better in patients with ALD than in patients with HCV infection. Alcohol relapse may lead to liver damage and increased mortality, albeit usually after many years of renewed drinking. After liver transplantation, patients with ALD have increased rates of mortality and morbidity that are attributable to cardiovascular disease and new-onset cancers of the aerodigestive tract. The latter are probably linked to the high prevalence of smoking in this population. Cessation of smoking is thus an important goal in the care of patients with ALD after they have undergone liver transplantation.
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Martin P, DiMartini A, Feng S, Brown R, Fallon M. Evaluation for liver transplantation in adults: 2013 practice guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation. Hepatology 2014; 59:1144-65. [PMID: 24716201 DOI: 10.1002/hep.26972] [Citation(s) in RCA: 589] [Impact Index Per Article: 58.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Should length of sobriety be a major determinant in liver transplant selection? Curr Opin Organ Transplant 2013; 18:259-64. [PMID: 23492643 DOI: 10.1097/mot.0b013e32835fb94b] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW For patients with alcoholic liver disease, most liver transplant programs enforce a mandatory period of sustained abstinence prior to considering transplant. The '6-month' rule may eliminate potentially acceptable transplant candidates from a lifesaving procedure. This review focuses on the use of sobriety length as a determinant of transplant candidacy and as a predictor of future alcohol use. We will also review the use of liver transplant in patients with severe alcoholic hepatitis, and the impact of alcohol use on posttransplant outcomes. RECENT FINDINGS Patients with alcoholic hepatitis that underwent transplantation had an increased survival when compared with controls. Alcohol relapse after transplantation was infrequent. Similarly, a United Network for Organ Sharing database review revealed similar survival in patients transplanted for alcoholic hepatitis versus alcoholic cirrhosis. Allograft loss due to alcohol use was not seen. However, alcohol usage after transplantation has been associated with a lower long-term survival in both alcoholic and nonalcoholic recipients. SUMMARY The 6-month rule is insufficient in predicting relapse risk. Liver transplantation may be lifesaving in cases of alcoholic hepatitis and inflexible sobriety rules may eliminate patients from transplant consideration at a low risk of relapse. An ongoing alcohol use assessment, both pre- and posttransplant, are critical to achieving good long-term outcomes.
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31
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Dimartini AF, Dew MA. Monitoring alcohol use on the liver transplant wait list: therapeutic and practical issues. Liver Transpl 2012; 18:1267-9. [PMID: 22887916 DOI: 10.1002/lt.23529] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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32
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Leong J, Im GY. Evaluation and selection of the patient with alcoholic liver disease for liver transplant. Clin Liver Dis 2012; 16:851-63. [PMID: 23101986 DOI: 10.1016/j.cld.2012.08.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Alcoholic liver cirrhosis is the second most common indication for liver transplantation in the United States. Studies have shown that these patients do as well as those transplanted for nonalcoholic liver disease. Recently, transplantation of patients with alcoholic liver disease has come under closer scrutiny following an article in the New England Journal of Medicine demonstrating comparable outcomes and survival in patients transplanted for acute alcoholic hepatitis. This article reviews the literature and data on the evaluation and selection of patients with alcoholic cirrhosis for liver transplant, and discusses the most recent indication (once a contraindication), acute alcoholic hepatitis.
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Affiliation(s)
- Jennifer Leong
- Recanati/Miller Transplantation Institute, Mount Sinai School of Medicine, One Gustave Levy Place, New York, NY 10029, USA.
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33
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Abstract
Identifying whether someone is a good candidate for liver transplantation is a complex process that requires a team approach. There are several medical and psychosocial considerations involved, each of which is thoroughly explored during the evaluation process. Both the indications and contraindications to transplantation can change over time, reflecting advances in understanding of, and ability to treat, certain disease processes. Ultimately, the goal of liver transplantation remains to provide a survival benefit to those with acute or chronic liver diseases.
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34
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Mathurin P, Moreno C, Samuel D, Dumortier J, Salleron J, Durand F, Castel H, Duhamel A, Pageaux GP, Leroy V, Dharancy S, Louvet A, Boleslawski E, Lucidi V, Gustot T, Francoz C, Letoublon C, Castaing D, Belghiti J, Donckier V, Pruvot FR, Duclos-Vallée JC. Early liver transplantation for severe alcoholic hepatitis. N Engl J Med 2011; 365:1790-800. [PMID: 22070476 DOI: 10.1056/nejmoa1105703] [Citation(s) in RCA: 598] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND A 6-month abstinence from alcohol is usually required before patients with severe alcoholic hepatitis are considered for liver transplantation. Patients whose hepatitis is not responding to medical therapy have a 6-month survival rate of approximately 30%. Since most alcoholic hepatitis deaths occur within 2 months, early liver transplantation is attractive but controversial. METHODS We selected patients from seven centers for early liver transplantation. The patients had no prior episodes of alcoholic hepatitis and had scores of 0.45 or higher according to the Lille model (which calculates scores ranging from 0 to 1, with a score ≥ 0.45 indicating nonresponse to medical therapy and an increased risk of death in the absence of transplantation) or rapid worsening of liver function despite medical therapy. Selected patients also had supportive family members, no severe coexisting conditions, and a commitment to alcohol abstinence. Survival was compared between patients who underwent early liver transplantation and matched patients who did not. RESULTS In all, 26 patients with severe alcoholic hepatitis at high risk of death (median Lille score, 0.88) were selected and placed on the list for a liver transplant within a median of 13 days after nonresponse to medical therapy. Fewer than 2% of patients admitted for an episode of severe alcoholic hepatitis were selected. The centers used 2.9% of available grafts for this indication. The cumulative 6-month survival rate (±SE) was higher among patients who received early transplantation than among those who did not (77 ± 8% vs. 23 ± 8%, P<0.001). This benefit of early transplantation was maintained through 2 years of follow-up (hazard ratio, 6.08; P = 0.004). Three patients resumed drinking alcohol: one at 720 days, one at 740 days, and one at 1140 days after transplantation. CONCLUSIONS Early liver transplantation can improve survival in patients with a first episode of severe alcoholic hepatitis not responding to medical therapy. (Funded by Société Nationale Française de Gastroentérologie.).
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Affiliation(s)
- Philippe Mathurin
- Hôpital Claude Huriez, Services Maladies de l'Appareil Digestif and INSERM Unité 995, Centre Hospitalier Universitaire, de Lille and Université Nord de France, Lille
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35
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Abstract
In this article the epidemiology of substance use and substance disorders in the United States and their association with liver disease are reviewed. The relevance of tobacco use and issues of candidacy as it pertains to substance use are discussed. The use of alcohol while on the waitlist and short sobriety are also addressed. The merits of monitoring of patients are discussed, and the outcomes of these patients after liver transplantation are examined. The article concludes with a summary of recommendations for clinicians working with these patients and possible future directions for both clinical care and research.
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Affiliation(s)
- Andrea DiMartini
- Consultation Liaison to the Liver Transplant Program, Starzl Transplant Institute, University of Pittsburgh Medical Center, PA 15213, USA.
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36
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Gramenzi A, Gitto S, Caputo F, Biselli M, Lorenzini S, Bernardi M, Andreone P. Liver transplantation for patients with alcoholic liver disease: an open question. Dig Liver Dis 2011; 43:843-9. [PMID: 21550324 DOI: 10.1016/j.dld.2011.03.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2010] [Revised: 03/08/2011] [Accepted: 03/27/2011] [Indexed: 12/11/2022]
Abstract
End-stage alcoholic liver disease is a recognised indication for liver transplantation but some questions on the matter remain open. It is difficult to quantify alcohol consumption, and a single definition of post-transplant relapse is lacking. Moreover, there are no internationally accepted criteria for the selection of candidates for liver transplantation and the eligibility parameters for these patients are controversial. Additional clinical and psychological evaluations are necessary in this setting, especially to establish the risk of alcohol relapse. Nevertheless, patient and graft survival rates after liver transplantation in alcoholic liver disease are comparable to those after transplant for other aetiologies, alcohol consumption relapse being one of the most important problems in the post-transplant phase. In conclusion, alcohol-related liver disease is a good indication for liver transplantation. The main future goals are to formulate a well-defined pre-transplant approach and a single definition of alcohol relapse and to improve prevention strategies.
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Affiliation(s)
- Annagiulia Gramenzi
- Department of Clinical Medicine, University of Bologna, Semeiotica Medica, S.Orsola-Malpighi Hospital, Bologna, Italy
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37
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Weinrieb RM, Van Horn DHA, Lynch KG, Lucey MR. A randomized, controlled study of treatment for alcohol dependence in patients awaiting liver transplantation. Liver Transpl 2011; 17:539-47. [PMID: 21506242 DOI: 10.1002/lt.22259] [Citation(s) in RCA: 96] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Alcohol is the second most common cause of cirrhosis necessitating liver transplantation in the United States, yet rates of posttransplant drinking approach 50% and no controlled clinical trials of alcoholism treatment exist in this population. Eligible patients were randomly assigned to receive Motivational Enhancement Therapy (MET), or referral to local treatment sources ("treatment as usual" [TAU]). Addictive behavior, mood states, and general health were compared. Candor concerning alcohol use was encouraged by keeping drinking questionnaires in confidence, except in medical emergencies. Ninety-one subjects were studied; 46 received MET, 45 received TAU, 29 proceeded to transplantation (MET, n = 13; TAU, n = 16). A total of 69 subjects completed 24 weeks of observation, and 25 subjects were assessed at 96 weeks. No difference in study attendance was observed, but significantly more MET subjects attended 1 or more treatment sessions. Twenty-three subjects (25% of sample) drank after randomization but before transplant. Excluding an extreme outlier, MET drinkers had significantly fewer drinks per drinking days than TAU drinkers. Neither treatment plan resulted in significant variances in measures of psychosocial health. In conclusion, although MET afforded no significant benefit over TAU for mood or general health outcomes, this study provides some degree of support for MET to limit the quantity and frequency of pretransplant alcohol consumption among liver transplant candidates with alcohol dependence. However, because of the limited number of study subjects, these data must be interpreted cautiously. Further research to validate our findings or to identify better methods to identify and intervene with patients at risk of pretransplant and posttransplant drinking should continue.
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Affiliation(s)
- Robert M Weinrieb
- Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
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38
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Tan HH, Virmani S, Martin P. Controversies in the management of alcoholic liver disease. ACTA ACUST UNITED AC 2011; 76:484-98. [PMID: 19787655 DOI: 10.1002/msj.20135] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Alcohol is a risk factor for chronic disease burden in developed countries. Alcoholic liver disease affects 1% of the North American population and is the second most frequent indication for liver transplantation in the United States. It is a spectrum that ranges from simple hepatic steatosis to alcoholic hepatitis to steatohepatitis and eventually cirrhosis. The clinical spectrum of alcoholic hepatitis is wide and ranges from the asymptomatic patient to overt liver failure and death. Liver biopsy as a means of prognostication in alcoholic hepatitis has mostly been replaced with less invasive scoring systems. The management of alcoholic liver disease is challenging. Abstinence is the cornerstone of therapy and should include rehabilitation with a multidisciplinary approach. No specific treatment is required in mild to moderate alcoholic hepatitis. In patients with severe hepatitis, there appears to be a moderate survival benefit from the use of either corticosteroids or pentoxifylline in the absence of contraindications to their use. Nonresponders should have steroid therapy withdrawn by day 7, as persistence with therapy is not beneficial. Orthotopic liver transplantation remains the definitive therapy for decompensated alcoholic cirrhosis despite alcohol abstinence. More studies are needed to define the optimal timing of orthotopic liver transplantation and patients at risk of alcohol relapse post-transplant. Mt Sinai J Med 76:484-498, 2009. (c) 2009 Mount Sinai School of Medicine.
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Affiliation(s)
- Hui-Hui Tan
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.
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Varma V, Mehta N, Kumaran V, Nundy S. Indications and contraindications for liver transplantation. Int J Hepatol 2011; 2011:121862. [PMID: 22007310 PMCID: PMC3189562 DOI: 10.4061/2011/121862] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Accepted: 08/10/2011] [Indexed: 12/12/2022] Open
Abstract
Patients with chronic liver disease and certain patients with acute liver failure require liver transplantation as a life-saving measure. Liver transplantation has undergone major improvements, with better selection of candidates for transplantation and allocation of scarce deceased donor organs (according to more objective criteria). Living donor liver transplantation came into existence to overcome the shortage of donor organs especially in countries where there was virtually no deceased donor programme. Advances in the technical aspects of the procedure, the intraoperative and postoperative care of both recipients and donors, coupled with the introduction of better immunosuppression protocols, have led to graft and patient survivals of over 90% in most high volume centres. Controversial areas like transplantation in alcoholic liver disease without abstinence, acute alcoholic hepatitis, and retransplantation for recurrent hepatitis C virus infection require continuing discussion.
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Affiliation(s)
- Vibha Varma
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital Room No. 2221, SSR Block, Rajinder Nagar, New Delhi 110060, India
| | - Naimish Mehta
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital Room No. 2221, SSR Block, Rajinder Nagar, New Delhi 110060, India
| | - Vinay Kumaran
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital Room No. 2221, SSR Block, Rajinder Nagar, New Delhi 110060, India
| | - Samiran Nundy
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital Room No. 2221, SSR Block, Rajinder Nagar, New Delhi 110060, India,*Samiran Nundy:
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40
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Abstract
Alcoholic liver disease (ALD) is the second commonest indication for liver transplantation after viral hepatitis in the United States and Europe. Controversies surround the indications and allocation of scarce and expensive resource for this so called self inflicted disease. Controversies stem from the apprehension that alcoholic recipients are likely to relapse and cause damage to the graft. There is a need to select those candidates with lower risk for relapse with the available predictive factors and scores. Substance abuse specialist and psychiatrists are mandatory in the pre-transplant evaluation and in the post-transplant follow-up. There is conflicting evidence to support a fixed period of pretransplant abstinence, although most units do follow this. Alcoholic hepatitis (AH) continues to be a contraindication for transplantation, however there is a need for further research in this field as a subset of patients with AH who do not respond to medical treatment, have high early mortality and could benefit from transplantation. One year, 3-year, and 5-year survival post-transplant is similar for both ALD and non-ALD recipients. The incidence of post-transplant rejection and retransplantation is also similar to other recipients. ALD with viral hepatitis especially hepatitis C virus leads to a more aggressive liver disease with early presentation for transplantation. ALD patients are more prone to develop de-novo malignancy; this is attributed to the long term effect of alcohol, tobacco combined with immunosuppression. Post-transplant surveillance is important to detect early relapse to alcoholism, presence of de-novo malignancy and treat the same adequately.
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41
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Abstract
BACKGROUND Alcoholic hepatitis is a severe, cholestatic liver disease occurring in patients with alcohol abuse. Mortality is substantial; however, therapies may improve clinical outcomes. AIM To provide an updated review of the epidemiology, diagnosis, staging and treatment of alcoholic hepatitis. METHODS A MEDLINE literature search was performed to identify pertinent articles. Relevant clinical abstracts were also reviewed. RESULTS Severe alcoholic hepatitis occurs in a small fraction of patients who abuse alcohol. The 28-day mortality ranges from 30% to 50% in most series. Diagnosis is generally based on clinical features, with a limited role for liver biopsy. Beneficial treatment options include alcohol abstinence and nutritional therapy. Despite variable results in clinical trials, corticosteroids and pentoxifylline appear to provide moderate survival benefit. Anti-tumour necrosis factor agents and antioxidants have not proven beneficial, and should be limited to clinical trials. Liver transplant is not a frequent option given the active or recent alcohol use. CONCLUSIONS Severe alcoholic hepatitis is a clinically-diagnosed condition associated with significant mortality. Alcohol abstinence and nutritional therapy have been associated with improved clinical parameters and should be considered in all patients. Corticosteroid therapy and pentoxifylline therapy appear to show moderate survival benefit and should be considered as first-line therapeutic agents.
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Affiliation(s)
- S M Cohen
- Section of Hepatology, Rush University Medical Center, Chicago, IL 60612, USA.
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42
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Abstract
The widespread availability of transplantation in most major medical centers in the United States, together with a growing number of transplant candidates, has made it necessary for primary care providers, especially internal medicine and family practice physicians to be active in the clinical care of these patients before and after transplantation. This review provides an overview of the liver transplantation process, including indications, contraindications, time of referral to a transplant center, the current organ allocation system, and briefly touches on the expanding field of living donor liver transplantation.
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Affiliation(s)
- Juan F Gallegos-Orozco
- Division of Gastroenterology, Department of Medicine, Mayo Clinic Arizona, 13400 E. Shea Boulevard, Scottsdale, AZ 85259, USA
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43
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44
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Affiliation(s)
- Michael R Lucey
- Section of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792, USA.
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45
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Morana JG. Psychological evaluation and follow-up in liver transplantation. World J Gastroenterol 2009; 15:694-6. [PMID: 19222092 PMCID: PMC2653437 DOI: 10.3748/wjg.15.694] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2008] [Revised: 10/12/2008] [Accepted: 10/19/2008] [Indexed: 02/06/2023] Open
Abstract
An increasingly number of transplant centers have integrated a psychological assessment within their protocol for evaluation of patients being considered for transplantation. This paper highlights the psychological criteria for inclusion or exclusion for listing, briefly discusses the psychological dynamics of patients, and addresses possible psychotherapy and pharmacological therapy, before and after transplant.
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46
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Predictors of relapse to alcohol and illicit drugs after liver transplantation for alcoholic liver disease. Transplantation 2008; 86:1090-5. [PMID: 18946347 DOI: 10.1097/tp.0b013e3181872710] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Alcoholic liver disease (ALD) is a common indication for transplantation worldwide. This study identifies factors predicting posttransplant recidivism. METHODS Clinical and laboratory data were reviewed. Uni- and multivariate analyses for survival and relapse to alcohol and illicit drugs were performed. RESULT Between July 1995 and November 2007, 387 patients underwent liver transplantation at our institution. Of these, 147 patients (38%) were found to have ALD. Five patients (3.4%) were excluded because of perioperative mortality. Overall survival was 96.2%, 89.6%, and 84.4% at 1, 3, and 5 years, respectively, with a median follow-up of 41.2 months. Twenty-seven patients (19%) returned to alcohol after transplantation. By univariate analysis, depression was the only significant factor affecting survival (P=0.01), whereas posttransplant relapse to alcohol trended toward significance (P=0.059). Multivariate analysis showed both factors to be independently associated with poor survival (P=0.008 and 0.017, respectively). Factors associated with relapse included less than 12 months of abstinence before transplant (P=0.019) and participation in rehabilitation (P=0.026). Multivariate analysis showed pretransplant abstinence less than 12 months as the only independent factor (P=0.037) associated with alcohol relapse after transplantation. Twenty-five patients (17.2%) had documented drug use after transplantation. Drug abuse before transplantation was the only independent predictor of drug abuse after transplantation (P=0.017). CONCLUSIONS Excellent results can be obtained in patients undergoing liver transplantation for ALD, though depression and recidivism adversely impact survival. In our series, abstinence less than 12 months was associated with relapse to alcohol. Similarly, those with prior drug abuse are more likely to continue drug use after transplantation.
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Day E, Best D, Sweeting R, Russell R, Webb K, Georgiou G, Neuberger J. Detecting lifetime alcohol problems in individuals referred for liver transplantation for nonalcoholic liver failure. Liver Transpl 2008; 14:1609-13. [PMID: 18975295 DOI: 10.1002/lt.21528] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Transplantation for alcoholic liver disease is becoming increasingly common, and with adequate screening, short- to medium-term outcomes are very good. However, while conducting a prospective study of the outcome of liver transplantation in Birmingham, United Kingdom, we observed that a research diagnosis of alcohol abuse or dependence was made in a number of cases in which no reference to alcohol problems had been made by the referring agency. This article explores the characteristics of these "missed" cases and highlights key patient characteristics that might prompt a more detailed assessment of alcohol consumption. Two hundred eight individuals completed the research interview, and 80 (39%) met Diagnostic and Statistical Manual of Mental Disorders IV criteria for a lifetime diagnosis of either alcohol abuse (n = 29) or dependence (n = 51). When the initial referral details were reviewed, the possibility of alcohol problems had not been raised in 10 (12.5%) of these cases. Hepatitis C was the most common primary diagnosis in the missed cases, but there was no difference between diagnosed and missed cases in terms of demographic factors, severity of liver disease, or the number or degree of lifetime problems associated with alcohol. However, members of the missed group were more likely to have drunk alcohol in the past 6 months and in a greater volume and were more likely to have used illicit drugs such as opiates, amphetamines, hallucinogens, and cannabis. These findings point to the need to take an adequate history of lifetime alcohol problems in all patients being considered for liver transplantation.
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Affiliation(s)
- Ed Day
- University of Birmingham Department of Psychiatry, Queen Elizabeth Psychiatric Hospital, Birmingham, UK.
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Alcohol abstinence criteria for living liver donors and their organ recipients. Curr Opin Organ Transplant 2008; 13:207-10. [DOI: 10.1097/mot.0b013e3282f4cb03] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Kotlyar DS, Burke A, Campbell MS, Weinrieb RM. A critical review of candidacy for orthotopic liver transplantation in alcoholic liver disease. Am J Gastroenterol 2008; 103:734-43; quiz 744. [PMID: 18081918 DOI: 10.1111/j.1572-0241.2007.01691.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The majority of candidates with end-stage alcoholic liver disease (ESALD) in the United States who are eligible for referral for liver transplantation (LT) are not being referred. There is a lack of firm consensus for the duration of abstinence from alcohol as well as what constitutes good psychosocial criteria for listing for LT. Evidence shows that the general public and the practicing physicians outside the transplant community perceive that patients with a history of alcohol abuse will make poor transplant candidates. However, physicians in the transplant community perceive selected patients with ESALD as good candidates. When considering patients for listing for LT, 3 months of alcohol abstinence may be more ideal than 6 months. Patients with a lack of social support, active smoking, psychotic or personality disorders, or a pattern of nonadherence should be listed only with reservation. Those who have a diagnosis of alcohol abuse as opposed to alcohol dependence may make better transplant candidates. Patients who have regular appointments with a psychiatrist or psychologist in addictions treatment training also seem to do more favorably.
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Affiliation(s)
- David S Kotlyar
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA
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Wells JT, Said A, Agni R, Tome S, Hughes S, Dureja P, Lucey MR. The impact of acute alcoholic hepatitis in the explanted recipient liver on outcome after liver transplantation. Liver Transpl 2007; 13:1728-35. [PMID: 18044757 DOI: 10.1002/lt.21298] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Patients with clinical acute alcoholic hepatitis (AAH) are not considered suitable candidates for orthotopic liver transplantation (OLT). The histological correlates of AAH are often seen in the explanted liver at the time of transplantation. The importance of these findings remains inconclusive regarding their role as a prognostic marker for patient or allograft health. Our aim was to examine the explanted liver of patients with purely alcoholic liver disease (ALD) for findings of histologic AAH and to correlate these to patient and graft outcomes. We compared patients with and without histological AAH with patients transplanted for non-ALD. Of 1,097 liver transplant recipients, 148 had ALD and 125 were non-ALD control patients with similar demographics. Thirty-two of 148 ALD patients had histologic AAH, and 116 had bland alcoholic cirrhosis (BAC). Twenty-eight percent of the ALD patients reported <6 months abstinence, and 54% reported <12 months abstinence. There was a statistically significant relationship between the presence of histologic AAH and abstinence durations<12 months (P=0.009), but not <6 months. Overall, posttransplantation patient and graft survival between the ALD and non-ALD groups was not significantly different (P=0.53). Furthermore, patient and graft survival between ALD patients with histologic AAH and BAC were similar (P=0.13 and P=0.11, respectively). The rate of posttransplantation relapse among ALD patients was 16%; however, there was no increase in graft loss, nor was there decreased survival compared with controls. The patients with histologic AAH and those with BAC had no differences in posttransplantation relapse (P=0.13). In multivariate analysis, patient and graft survival was not influenced by pretransplantation abstinence or posttransplantation relapse. In conclusion, histological alcoholic hepatitis in the explant did not predict worse outcome regarding relapse, and allograft or patient survival for liver transplant recipients. Caution should be exercised when liver histology is used to discriminate among suitable candidates for OLT concerning alcoholic patients.
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Affiliation(s)
- Jennifer T Wells
- Section of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI 53711, USA
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