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Gabrielli F, Golfieri L, Nascimbeni F, Andreone P, Gitto S. Metabolic Disorders in Liver Transplant Recipients: The State of the Art. J Clin Med 2024; 13:1014. [PMID: 38398327 PMCID: PMC10889804 DOI: 10.3390/jcm13041014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 02/05/2024] [Accepted: 02/08/2024] [Indexed: 02/25/2024] Open
Abstract
Liver transplantation represents a chief therapeutic approach for acute liver failure, end-stage liver disease and hepatocellular carcinoma. Despite witnessing advancements in short- and medium-term survival over recent decades, attributed to refinements in surgical techniques and immunosuppressive protocols, long-term mortality remains impervious to modification. Notably, cardiovascular disease emerges as a predominant cause of mortality among liver transplant recipients. This trend is accentuated by the increasing prominence of non-alcoholic steatohepatitis-related cirrhosis as an indication for liver transplantation. Moreover, the administration of immunosuppressive agents is intricately linked to the degradation of the metabolic profile in liver transplant recipients, thereby contributing to the initiation or exacerbation of cardiovascular risk factors, such as hypertension, diabetes, and dyslipidaemia. In addition, the post-liver transplantation period is marked by a decline in lifestyle quality and a failure to acknowledge the psychological distress experienced by patients throughout the transplant process. These factors can precipitate a deterioration in the patient's metabolic profile, exacerbated by suboptimal therapeutic compliance. This narrative review aims to comprehensively address the principal metabolic disorders intricately associated with liver transplantation.
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Affiliation(s)
- Filippo Gabrielli
- Internal and Metabolic Medicine, Department of Medical and Surgical Sciences for Children & Adults, AOU di Modena, University of Modena and Reggio Emilia, 41126 Modena, Italy
- Department of Surgical Sciences, University of Bologna, 40126 Bologna, Italy
| | - Lucia Golfieri
- Clinical Psychology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di Sant’Orsola, 40138 Bologna, Italy
| | - Fabio Nascimbeni
- Internal and Metabolic Medicine, Department of Medical and Surgical Sciences for Children & Adults, AOU di Modena, University of Modena and Reggio Emilia, 41126 Modena, Italy
| | - Pietro Andreone
- Internal and Metabolic Medicine, Department of Medical and Surgical Sciences for Children & Adults, AOU di Modena, University of Modena and Reggio Emilia, 41126 Modena, Italy
- Postgraduate School of Allergology and Clinical Immunology, University of Modena and Reggio Emilia, 41126 Modena, Italy
| | - Stefano Gitto
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 3, 50134 Florence, Italy
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Singal AK, Leggio L, DiMartini A. Alcohol use disorder in alcohol-associated liver disease: Two sides of the same coin. Liver Transpl 2024; 30:200-212. [PMID: 37934047 DOI: 10.1097/lvt.0000000000000296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 10/16/2023] [Indexed: 11/08/2023]
Abstract
Alcohol-associated liver disease (ALD) has emerged as the leading indication for liver transplantation (LT) worldwide, with 40% of LTs in the United States performed for ALD in 2019. The ALD-related health care burden accelerated during the COVID-19 pandemic, especially in young individuals. Alcohol use disorder (AUD), which focuses on the negative effects of alcohol on psychosocial, physical, and mental health, is present in the majority of patients with ALD, with moderate to severe AUD in 75%-80%. During the last decade, early liver transplantation (eLT) has emerged as a lifesaving treatment for selected patients with alcohol-associated hepatitis; these patients may have a higher risk of using alcohol after LT. The risk of alcohol use recurrence may be reduced during the pretransplant or post-transplant period with AUD treatment using behavioral and/or pharmacological therapies and with regular monitoring for alcohol use (self-reported and complemented with biomarkers like phosphatidylethanol). However, AUD treatment in patients with ALD is challenging due to patient, clinician, and system barriers. An integrated model to provide AUD and ALD care by hepatologists and addiction experts in a colocated clinic starting from LT evaluation and selection to monitoring listed candidates and then to following up on recipients of LT should be promoted. However, the integration of addiction and hepatology teams in an LT program in the real world is often present only during evaluation and candidate selection for LT. Data are emerging to show that a multidisciplinary integrated AUD treatment within an LT program reduces recurrent alcohol use after LT. If we want to continue using early liver transplantation for patients with severe alcohol-associated hepatitis, LT programs should focus on building integrated multidisciplinary care teams for the integrated treatment of both AUD and ALD.
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Affiliation(s)
- Ashwani K Singal
- Department of Medicine, University of South Dakota, Vermillion, South Dakota, USA
- Department of Gastroenterology and Hepatology, Avera McKennan University Hospital, Sioux Falls, South Dakota, USA
- Department of Transplant Hepatology, Avera Transplant Institute, Sioux Falls, South Dakota, USA
- Department of Medicine, VA Medical Center, Sioux Falls, South Dakota, USA
| | - Lorenzo Leggio
- Department of Neuropsychopharmacology Clinical Psychoneuroendocrinology and Neuropsychopharmacology Section, Translational Addiction Medicine Branch, Division of Intramural Clinical and Biological Research, National Institute on Drug Abuse Intramural Research Program and National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland, USA
- Department of Behavioral and Social Sciences, Center for Alcohol and Addiction Studies, Brown University, Providence, Rhode Island, USA
- Department of Medicine, Division of Addiction Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Neuroscience, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Andrea DiMartini
- Departments of Psychiatry and Transplant Surgery, and the Clinical and Translational Science Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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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.
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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
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Kim SH, Jang Y, Kim H. Concept and risk factors of alcohol relapse in liver transplant recipients with alcohol-related aetiologies: A scoping review. Int J Ment Health Nurs 2023; 32:1583-1597. [PMID: 37475208 DOI: 10.1111/inm.13196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/26/2023] [Accepted: 07/11/2023] [Indexed: 07/22/2023]
Abstract
Alcohol relapse in those who received liver transplantation (LT) for alcohol-related liver disease can lead to poor graft function, low medication adherence rates and decreased chances of survival. Numerous studies have evaluated on this topic; however, discrepancies in the meaning and measurement of 'alcohol relapse' lead to heterogeneous results. This scoping review aimed to explore the conceptual and operational definitions of alcohol relapse in LT recipients with alcohol-related aetiologies and to examine newly reported risk factors of alcohol relapse. Following the Arksey and O'Malley scoping review method and PRISMA guidelines, structured searches for articles published from 2012 to 2022 were conducted in PubMed, CINAHL, Embase, Cochrane and PsycINFO. Twenty-eight studies were included in the final review. Alcohol relapse was either defined as 'any alcohol consumption' or 'a certain degree of alcohol drinking' after transplantation. Discrepancies in the incidence rates persisted even within studies that shared the same conceptual definition. Commonly reported risk factors for alcohol relapse were younger age, social isolation and shorter abstinence periods before LT. Self-efficacy and post-transplant complications were newly identified risk factors in recent studies; whereas environmental factors such as external stressors were rarely included. The variance in the definition of alcohol relapse and inconsistent identification methods make it difficult to organize a structured interventional study. A standardized stratification of post-LT alcohol relapse behaviour is needed to prior to implementing interventions that employ a harm minimization approach. Cost-effective interventions promoting self-efficacy could enable the prevention and management of alcohol relapse after LT.
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Affiliation(s)
| | - Yeonsoo Jang
- College of Nursing·Mo-im Kim Nursing Research Institute, Yonsei University, Seoul, Korea
| | - Hyunji Kim
- College of Nursing, Yonsei University, Seoul, Korea
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Manikat R, Ahmed A, Kim D. The Impact of Alcohol Consumption and Addiction on Liver Transplantation Programs in the COVID-19 Era. Hepat Med 2023; 15:141-149. [PMID: 37794854 PMCID: PMC10546995 DOI: 10.2147/hmer.s384070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 09/26/2023] [Indexed: 10/06/2023] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has caused significant shifts in alcohol consumption patterns in the United States, with potential long-term implications for liver transplantation (LT) programs. Alcohol consumption has increased, particularly in women, leading to a rise in alcohol-related liver disease (ALD) and alcohol use disorder. Psychological distress associated with the pandemic may further exacerbate alcohol addiction. ALD is now the most common indication for LT, with higher disease severity and complex clinical presentations, demanding a fundamental transformation in LT programs. Multidisciplinary cooperation among medical specialists, telemedicine, and remote healthcare are essential strategies to address these challenges. However, barriers to telemedicine and costs must be overcome. Curbing alcohol consumption at the societal level and bolstering mental health programs to mitigate healthcare workforce moral injury are recommended to optimize patient care in the post-COVID-19 era. Adequate planning and compassionate management of finite resources will be crucial for the successful continuation of LT programs amidst the concerning trends in alcohol consumption and addiction.
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Affiliation(s)
- Richie Manikat
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Aijaz Ahmed
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Donghee Kim
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Falari SS, Mohapatra N, Patil NS, Pattnaik B, Varshney M, Choudhury A, Sarin SK, Pamecha V. Incidence and predictors of alcohol relapse following living donor liver transplantation for alcohol related liver disease. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2023; 30:1015-1024. [PMID: 36866490 DOI: 10.1002/jhbp.1325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/18/2023] [Accepted: 02/21/2023] [Indexed: 03/04/2023]
Abstract
BACKGROUND Alcohol relapse after liver transplantation has a negative impact on outcomes. There is limited data on its burden, the predictors, and impact following live donor liver transplantation (LDLT). METHODS A single-center observational study was carried out between July 2011 and March 2021 for patients undergoing LDLT for alcohol associated liver disease (ALD). The incidence, predictors of alcohol relapse, and post-transplant outcomes were assessed. RESULTS Altogether 720 LDLT were performed during the study period, 203 (28.19%) for ALD. The overall relapse rate was 9.85% (n = 20) with a median follow-up of 52 months (range, 12-140 months). Sustained harmful alcohol use was seen in 4 (1.97%). On multivariate analysis, pre-LT relapse (P = .001), duration of abstinence period (P = .007), daily intake of alcohol (P = .001), absence of life partner (P = .021), concurrent tobacco abuse before transplant (P = .001), the donation from second-degree relative (P = .003) and poor compliance with medications (P = .001) were identified as predictors for relapse. Alcohol relapse was associated with the risk of graft rejection (HR 4.54, 95% CI: 1.751-11.80, P = .002). CONCLUSION Our results show that the overall incidence of relapse and rate of harmful drinking following LDLT is low. Donation from spouse and first degree relative was protective. History of daily intake, prior relapse, shorter pretransplant abstinence duration and lack of family support significantly predicted relapse.
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Affiliation(s)
- Sanyam Santosh Falari
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Nihar Mohapatra
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Nilesh Sadashiv Patil
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Bramhadatta Pattnaik
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Mohit Varshney
- Department of Psychiatry, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ashok Choudhury
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shiv K Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Viniyendra Pamecha
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
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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.
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Thakral N, Deutsch-Link S, Singal AK. Therapeutic Pipeline in Alcohol-Associated Liver Disease. Semin Liver Dis 2023; 43:60-76. [PMID: 36572032 DOI: 10.1055/s-0042-1759614] [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] [Indexed: 12/28/2022]
Abstract
Alcohol-associated liver disease is a leading cause of mortality and morbidity worldwide. Patients with alcohol-associated liver disease are often diagnosed at advanced stage and disease spectrum including alcoholic hepatitis, a severe manifestation with a high short-term mortality. Corticosteroid, recommended first-line treatment for patients with alcoholic hepatitis, is a very suboptimal treatment. Although the use of early liver transplantation has increased with consistent benefit in select patients with alcoholic hepatitis, its use remains heterogeneous worldwide due to lack of uniform selection criteria. Over the last decade, several therapeutic targets have evolved of promise with ongoing clinical trials in patients with cirrhosis and alcoholic hepatitis. Even with availability of effective medical therapies for alcohol-associated liver disease, long-term outcome depends on abstinence from alcohol use in any spectrum of alcohol-associated liver disease. However, alcohol use disorder treatment remains underutilized due to several barriers even in patients with advanced disease. There is an urgent unmet need to implement and promote integrated multidisciplinary care model with hepatologists and addiction experts to provide comprehensive management for these patients. In this review, we will discuss newer therapies targeting liver disease and therapies targeting alcohol use disorder in patients with alcohol-associated liver disease.
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Affiliation(s)
- Nimish Thakral
- Division of Gastroenterology and Hepatology, University of Kentucky, Lexington, Kentucky
| | - Sasha Deutsch-Link
- Department of Medicine, University of North Carolina at Chapel Hill, North Carolina
| | - Ashwani K Singal
- Department of Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota
- Division of Transplant Hepatology, Avera Transplant Institute, Sioux Falls, South Dakota
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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.
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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
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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
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VIGNOLI T, ZAVAN V, COZZOLINO E, ADDOLORATO G, AMENDOLA MF, CAPUTO F, CIBIN M, LUCCHINI A, NAVA FA, PELLICANO R, FAILLACE G, STELLA L, TESTINO G. Proposal for the enhancement of alcohology (prevention, treatment and rehabilitation of alcohol problems): the position of Società Italiana di Alcologia (SIA), Federazione Italiana degli Operatori dei Dipartimenti e dei Servizi delle Dipendenze (FeDerSerD) and Società Italiana Tossicodipendenze (SITD). Panminerva Med 2022; 64:311-313. [DOI: 10.23736/s0031-0808.22.04689-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Heterogeneity in Center Practices in Liver Transplantation for Alcohol-Associated Liver Disease in the United States. Am J Gastroenterol 2022; 117:1530-1535. [PMID: 35916539 DOI: 10.14309/ajg.0000000000001863] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 05/16/2022] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Alcohol-related liver disease (ALD) is now the leading indication for liver transplantation (LT) in the United States (US). It remains unclear how centers are managing the medical and psychosocial issues associated with these patients. METHODS We conducted a web-based survey of LT centers in the United States to identify center-level details on peri-LT management of ALD and related issues. RESULTS Of the 117 adult LT centers, 100 responses (85.5%) were collected, representing all Organ Procurement and Transplantation Network regions. For alcohol-associated cirrhosis, 70.0% of the centers reported no minimum sobriety requirement while 21.0% required 6 months of sobriety. LT for severe alcohol-associated hepatitis was performed at 85.0% of the centers. Monitoring protocols for pre-LT and post-LT alcohol use varied among centers. DISCUSSION Our findings highlight a change in center attitudes toward LT for ALD, particularly for severe alcohol-associated hepatitis.
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Kools N, Dekker GG, Kaijen BAP, Meijboom BR, Bovens RHLM, Rozema AD. Interdisciplinary collaboration in the treatment of alcohol use disorders in a general hospital department: a mixed-method study. Subst Abuse Treat Prev Policy 2022; 17:59. [PMID: 35962380 PMCID: PMC9372961 DOI: 10.1186/s13011-022-00486-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2022] [Indexed: 12/17/2022] Open
Abstract
Background Interdisciplinary collaborations (i.e., where various disciplines work coordinated and interdependently toward shared goals) are stated to yield higher team effectiveness than multidisciplinary approaches (i.e., where various disciplines work in parallel within their professional boundaries) in somatic health care settings. Nevertheless, research is lacking on interdisciplinary approaches for alcohol use disorder (AUD) treatment of hospitalized patients as these types of approaches are still uncommon. This study aims to evaluate an innovative interdisciplinary AUD treatment initiative at a general hospital department by 1) identifying which and to what extent network partners are involved and 2) to explore how network partners experienced the interdisciplinary collaboration. Methods A mixed-method study was conducted, using 1) measures of contact frequency and closeness in a social network analysis and 2) semi-structured interviews, which were analyzed thematically. Respondents were network partners of an interdisciplinary collaboration in a general hospital department, initially recruited by the collaborations’ project leader. Results The social network analysis identified 16 network partners, including a ‘core’ network with five central network partners from both inside and outside the hospital. The project leader played an important central role in the network and the resident gastroenterologist seemed to have a vulnerable connection within the network. Closeness between network partners was experienced regardless of frequency of contact, although this was especially true for the ‘core’ group that (almost) always consisted of the same network partners that were present at biweekly meetings. Interview data showed that presence of the ‘core’ network partners was reported crucial for an efficient collaboration. Respondents desired knowledge about the collaborations’ effectiveness, and one structured protocol with working procedures, division of responsibilities and agreements on information sharing and feedback. Conclusions The design of this interdisciplinary collaboration has potential in improving the treatment of hospital patients with AUD and was evaluated positively by the involved network partners. Interdisciplinary collaborations may offer a critical solution to increase treatment rates of patients with AUD and should be adopted in hospitals on a larger scale. Research towards the effectiveness of interdisciplinary collaborations in the treatment of hospitalized patients with AUD is needed.
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Tarli C, Mirijello A, Addolorato G. Treating Alcohol Use Disorder in Patients with Alcohol-Associated Liver Disease: Controversies in Pharmacological Therapy. Semin Liver Dis 2022; 42:138-150. [PMID: 35292951 DOI: 10.1055/a-1798-2872] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Alcohol use disorder (AUD) is one of the main causes of global death and disability. The liver represents the main target of alcohol damage, and alcohol-associated liver disease (ALD) represents the first cause of liver cirrhosis in Western countries. Alcohol abstinence is the main goal of treatment in AUD patients with ALD, as treatments for ALD are less effective when drinking continues. Moreover, the persistence of alcohol consumption is associated with higher mortality, increased need for liver transplantation, and graft loss. The most effective treatment for AUD is the combination of psychosocial interventions, pharmacological therapy, and medical management. However, the effectiveness of these treatments in patients with ALD is doubtful even because AUD patients with ALD are usually excluded from pharmacological trials due to concerns on liver safety. This narrative review will discuss the treatment options for AUD-ALD patients focusing on controversies in pharmacological therapy.
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Affiliation(s)
- Claudia Tarli
- Internal Medicine and Alcohol Related Disease Unit, Department of Medical and Surgical Sciences, Columbus-Gemelli Hospital, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of Rome, Rome, Italy
| | - Antonio Mirijello
- Internal Medicine Unit, Department of Medical Sciences, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Giovanni Addolorato
- Internal Medicine and Alcohol Related Disease Unit, Department of Medical and Surgical Sciences, Columbus-Gemelli Hospital, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of Rome, Rome, Italy.,CEMAD Digestive Disease Center, Department of Medical and Surgical Sciences, Hepatology and Gastroenterology Unit, Catholic University of Rome, l.go Gemelli, Rome, Italy.,Internal Medicine Unit, Department of Internal Medicine and Gastroenterology, Columbus-Gemelli Hospital, Fondazione Policlinico Universitario A.Gemelli IRCCS, Rome, Italy
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Cabezas J. Management of Alcohol-Related Liver Disease and Its Complications. Clin Drug Investig 2022; 42:47-53. [PMID: 35467296 PMCID: PMC9205805 DOI: 10.1007/s40261-022-01143-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2022] [Indexed: 12/19/2022]
Abstract
Alcohol-related liver disease (ALD) is a major healthcare/economic burden and one of the leading causes of liver transplantation. New epidemiological studies that detail the course of the disease are needed since, despite its high prevalence, it is still a stigmatised condition with underlying pathology. Alcoholic hepatitis, as the highest expression of ALD, has high morbidity. Current treatments have suboptimal results with the exception of liver transplantation. Epidemiological studies must also be developed to improve prevention and implement early diagnosis policies. It is essential to develop multidisciplinary health models that allow the liver transplantation candidate to be approached in a holistic way, both for indication and follow up. The implementation of alcohol consumption biomarkers (ethyl glucuronide, phosphatidylethanol) can assist in diagnosing and supporting recovery. There are several initiatives with new therapies that must be validated to establish their effectiveness and indication.
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Affiliation(s)
- Joaquín Cabezas
- Gastroenterology and Hepatology Department, Marqués de Valdecilla University Hospital, Clinical and Translational Research in Digestive Diseases Group-IDIVAL, Santander, Cantabria, Spain.
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15
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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
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16
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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.
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17
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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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18
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Syed A, Sadler MD, Borman MA, Burak KW, Congly SE. Assessment of Canadian policies regarding liver transplant candidacy of people who use alcohol, tobacco, cannabis, and opiates. CANADIAN LIVER JOURNAL 2020; 3:372-380. [PMID: 35990508 PMCID: PMC9202737 DOI: 10.3138/canlivj.2020-0005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 03/18/2020] [Indexed: 07/29/2023]
Abstract
BACKGROUND When last assessed in 2013, all Canadian liver transplant programs required 6 months of abstinence from alcohol. New studies have questioned the validity of this policy. Moreover, with recreational cannabis now legal in Canada, more transplant candidates may use cannabis. Given these changes, our objective was to obtain an understanding of current Canadian practices regarding liver transplantation and candidates with addiction or alcohol, tobacco, cannabis, or opiate use. METHODS Electronic surveys were distributed to the medical directors of all seven adult liver transplant programs in Canada. Questions were based on either a Likert-scale ranking or free response. The complete data set was aggregated to provide a national perspective on this topic and ensure each individual program remained anonymous. RESULTS All seven programs responded to the survey. Of these programs, 43% always require 6-month abstinence from alcohol, 29% usually require it, and 14% sometimes require it. Formal alcohol rehabilitation is mandatory in two programs. The majority (57%) of programs never or rarely consider transplant for patients with acute alcoholic hepatitis; 29% require smoking cessation before consideration for transplant; and 71% felt that cannabis use is rarely or never a contraindication to liver transplantation. CONCLUSIONS Significantly more Canadian programs now perform liver transplant for patients who have less than 6 months abstinence from alcohol, and alcoholic hepatitis is no longer an absolute contraindication in Canada. Policies on smoking and opiates are quite variable. Further study and discussion are critical for development of national policies to obtain equitable access to liver transplant for all.
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Affiliation(s)
- Ahsan Syed
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matthew D Sadler
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Meredith A Borman
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kelly W Burak
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Stephen E Congly
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute of Public Health, University of Calgary, Calgary, Alberta, Canada
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19
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Golfieri L, Gitto S, Vukotic R, Andreone P, Marra F, Morelli MC, Cescon M, Grandi S. Impact of psychosocial status on liver transplant process. Ann Hepatol 2020; 18:804-809. [PMID: 31471202 DOI: 10.1016/j.aohep.2019.06.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 05/16/2019] [Accepted: 06/25/2019] [Indexed: 02/07/2023]
Abstract
Liver transplant candidates and recipients are at high risk of psychological distress. Social, psychological and psychiatric patterns seem to influence morbidity and mortality of patients before and after transplant. An accurate organ allocation is mandatory to guarantee an optimal graft and recipient survival. In this context, the pre-transplant social, psychological and psychiatric selection of potential candidates is essential for excluding major psychiatric illness and for estimating the patient compliance. Depression is one of the most studied psychological conditions in the field of organ transplantation. Notably, an ineffectively treated depression in the pre-transplant period has been associated to a worst long-term recipient survival. After transplant, personalized psychological intervention might favor recovery process, improvement of quality of life and immunosuppressant adherence. Active coping strategy represents one of the most encouraging ways to positively influence the clinical course of transplanted patients. In conclusion, multidisciplinary team should act in three directions: prevention of mood distress, early diagnosis and effective treatment. Active coping, social support and multidisciplinary approach might improve the clinical outcome of transplanted patients.
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Affiliation(s)
| | - Stefano Gitto
- Department of Experimental and Clinical Medicine, University of Florence, Italy.
| | - Ranka Vukotic
- Department of Medical and Surgical Sciences, University of Bologna, Italy
| | - Pietro Andreone
- Department of Medical and Surgical Sciences, University of Bologna, Italy
| | - Fabio Marra
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| | | | - Matteo Cescon
- General Surgery and Transplant Unit, Department of Medical and Surgical Sciences, University of Bologna, Italy
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20
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Neuberger J. Liver Transplantation for Alcoholic Liver Disease: What Is the Risk and Consequence of Relapse? Dig Dis Sci 2020; 65:1600-1607. [PMID: 32060813 DOI: 10.1007/s10620-020-06127-3] [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] [Indexed: 12/17/2022]
Abstract
Although short- and medium-term outcomes after liver transplantation for alcohol-related liver disease (ARLD) are generally excellent and similar to outcomes for transplantation for other indications, a return to alcohol consumption commonly occurs even though rates of alcohol consumption after transplantation for ARLD are comparable to those seen in other indications. Transplant recipients should be questioned about alcohol use post-transplantation and, where appropriate, monitored; those drinking significant amounts should be offered treatment with the help of a multi-disciplinary team. Although short-term significant alcohol use is associated with an increased risk of non-compliance and rejection, medium-term outcomes are similar to other groups. Patients transplanted for ARLD have a greater risk of some de novo malignancies, especially of the lung and the upper GI tract. More work is required both to identify those at risk of a return to destructive patterns of alcohol use at an early stage and to develop effective treatments aimed at reaching and maintaining abstinence.
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Affiliation(s)
- James Neuberger
- Liver Unit, Queen Elizabeth Hospital, Birmingham, B15 2TH, UK.
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21
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Erard-Poinsot D, Dharancy S, Hilleret MN, Faure S, Lamblin G, Chambon-Augoyard C, Donnadieu-Rigole H, Lassailly G, Boillot O, Ursic-Bedoya J, Guillaud O, Leroy V, Pageaux GP, Dumortier J. Natural History of Recurrent Alcohol-Related Cirrhosis After Liver Transplantation: Fast and Furious. Liver Transpl 2020; 26:25-33. [PMID: 31562696 DOI: 10.1002/lt.25647] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Accepted: 08/10/2019] [Indexed: 12/13/2022]
Abstract
Alcohol-related liver disease (ALD) is one of the main indications for liver transplantation (LT). Severe alcohol relapse can rapidly lead to recurrent alcohol-related cirrhosis (RAC) for the graft. The aim of this study was to describe the natural history of RAC and the overall survival after LT and after an RAC diagnosis. From 1992 to 2012, 812 patients underwent primary LT for ALD in 5 French transplant centers. All patients with severe alcohol relapse and an RAC diagnosis on the graft were included. The diagnosis of cirrhosis was based on the analysis of liver biopsy or on the association of clinical, biological, radiological, and/or endoscopic features of cirrhosis. RAC was diagnosed in 57/162 patients (35.2%) with severe alcohol relapse, and 31 (54.4%) of those patients had at least 1 episode of liver decompensation. The main types of decompensation were ascites (70.9%), jaundice (58.0%), and hepatic encephalopathy (9.6%). The cumulative probability of decompensation was 23.8% at 5 years, 50.1% at 10 years, and 69.9% at 15 years after LT. During the follow-up, 36 (63.2%) patients died, the main cause of death being liver failure (61.1%). After diagnosis of cirrhosis, the survival rate was 66.3% at 1 year, 37.8% at 5 years, and 20.6% at 10 years. In conclusion, RAC is associated with a high risk of liver decompensation and a poor prognosis. Prevention of severe alcohol relapse after LT is a major goal to improve patient survival.
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Affiliation(s)
- Domitille Erard-Poinsot
- Fédération des Spécialités Digestives, Hôpital Édouard Herriot, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Sébastien Dharancy
- Service de Chirurgie Digestive et Transplantation, Pôle Médico-Chirurgical Huriez, Hôpital Claude Huriez, Université Lille 2, Lille, France
| | - Marie-Noëlle Hilleret
- Clinique Universitaire d'Hépato-Gastroentérologie, Pole Digidune, Centre Hospitalier Universitaire de Grenoble, Université Grenoble Alpes, INSERM U823, Grenoble, France
| | - Stéphanie Faure
- Unité de Transplantation Hépatique, Pôle Digestif, Centre Hospitalier Universitaire de Saint-Eloi, Université Montpellier, Montpellier, France
| | - Géraldine Lamblin
- Service d'Hépatologie et Gastroentérologie, Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, France
| | - Christine Chambon-Augoyard
- Fédération des Spécialités Digestives, Hôpital Édouard Herriot, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Hélène Donnadieu-Rigole
- Unité de Transplantation Hépatique, Pôle Digestif, Centre Hospitalier Universitaire de Saint-Eloi, Université Montpellier, Montpellier, France
| | - Guillaume Lassailly
- Service de Chirurgie Digestive et Transplantation, Pôle Médico-Chirurgical Huriez, Hôpital Claude Huriez, Université Lille 2, Lille, France
| | - Olivier Boillot
- Fédération des Spécialités Digestives, Hôpital Édouard Herriot, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - José Ursic-Bedoya
- Unité de Transplantation Hépatique, Pôle Digestif, Centre Hospitalier Universitaire de Saint-Eloi, Université Montpellier, Montpellier, France
| | - Olivier Guillaud
- Fédération des Spécialités Digestives, Hôpital Édouard Herriot, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Vincent Leroy
- Clinique Universitaire d'Hépato-Gastroentérologie, Pole Digidune, Centre Hospitalier Universitaire de Grenoble, Université Grenoble Alpes, INSERM U823, Grenoble, France
| | - Georges-Philippe Pageaux
- Unité de Transplantation Hépatique, Pôle Digestif, Centre Hospitalier Universitaire de Saint-Eloi, Université Montpellier, Montpellier, France
| | - Jérôme Dumortier
- Fédération des Spécialités Digestives, Hôpital Édouard Herriot, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Lyon, France
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22
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Winder GS, Fernandez AC, Klevering K, Mellinger JL. Confronting the Crisis of Comorbid Alcohol Use Disorder and Alcohol-Related Liver Disease With a Novel Multidisciplinary Clinic. PSYCHOSOMATICS 2019; 61:238-253. [PMID: 32033835 DOI: 10.1016/j.psym.2019.12.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 12/03/2019] [Accepted: 12/05/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Alcohol-related liver disease (ALD) is prevalent and deadly and increasingly affects younger people and women. No single discipline is adequately equipped to manage its biopsychosocial complexity. OBJECTIVES Depict the scope of the ALD problem, provide a narrative review of other integrated care models, share our experience forming and maintaining a multidisciplinary ALD clinic for over a year, and provide recommendations for replication elsewhere. METHODS Critical evaluation of clinic implementation and its first year of operation. RESULTS The clinical rationale for multidisciplinary ALD treatment is clear and supported by the literature. Such models are feasible although surprisingly rare and vulnerable to various surmountable challenges. CONCLUSIONS Successful ALD clinics must be built by teams with solid personal and professional relationships, supported by institutional leadership, and must use a new kind of multidisciplinary paradigm and training. Consultation-liaison psychiatry is uniquely positioned to lead future efforts in the care and study of ALD.
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Affiliation(s)
- Gerald Scott Winder
- Department of Psychiatry, University of Michigan, Ann Arbor, MI; Department of Surgery, University of Michigan, Ann Arbor, MI.
| | | | | | - Jessica L Mellinger
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
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