Ethical analysis and consideration of health behaviors in organ allocation: focus on tobacco use

Addictive behaviors in liver transplant recipients: The real problem?

Liver transplantation (LT) is the gold standard treatment for end-stage liver disease. Whatever the primary indication of LT, substance abuse after surgery may decrease survival rates and quality of life. Prevalence of severe alcohol relapse is between 11 and 26%, and reduces life expectancy regardless of the primary indication of LT. Many patients on waiting lists for LT are smokers and this is a major risk factor for both malignant tumors and cardiovascular events post-surgery. The aim of this review is to describe psychoactive substance consumption after LT, and to assess the impact on liver transplant recipients. This review describes data about alcohol and illicit drug use by transplant recipients and suggests guidelines for behavior management after surgery. The presence of an addiction specialist in a LT team seems to be very important.

Impact of cigarette smoking on early complications after liver transplantation: A single-center experience and a meta-analysis

BACKGROUND

While studies have shown that cigarette smoking has negative implications on the long-term outcome following liver transplantation, its role in early complications is inconclusive.

METHODS

The clinical data of 162 consecutive adult patients who underwent elective liver transplantation from January, 2012 to March, 2016 were analyzed. Patients were defined as active smokers, ex-smokers, or non-smokers on the basis of documentation at the time of liver transplantation. The overall complications following liver transplantation were expressed as the comprehensive complication index (CCI). The specific complications such as the incidence of hepatic artery thrombosis, biliary complications, acute kidney injury were also assessed. A meta-analysis was carried out based on results from the present study and 11 published studies.

RESULTS

We found that cigarette smoking was not associated with higher CCI scores and smokers did not have a higher risk for developing hepatic artery thrombosis, biliary complications, acute kidney injury after liver transplantation. Meta-analysis confirmed the null association between cigarette smoking and an increased incidence of hepatic artery thrombosis or biliary complications in liver transplant recipients. However, the pooled results showed a significantly higher risk of cardiovascular diseases and de-novo malignancies in smokers following liver transplantation.

CONCLUSION

There is not enough evidence supporting an association between cigarette smoking and early mortality and morbidity after liver transplantation. However, smokers should still be encouraged to quit before and after liver transplantation due to the long-term health benefits of smoking cessation.

Accuracy of self-reported tobacco use status among hematopoietic SCT patients

Tobacco use is a risk factor for adverse outcomes among Hematopoietic Stem Cell Transplant (HSCT) patients. Accurate identification of tobacco use offers a vital opportunity to treat this risk factor. The current study compared self-reported tobacco use status to serum cotinine levels among HSCT patients at time of pre-transplant evaluation. A total of 444 participants completed both assessments; 44 participants (9.9%) were classified as tobacco users with serum cotinine concentrations > 2ng/Ml versus 29 with self-report. Sensitivity and specificity of self-report were 65.9% and 100%. Positive predictive and negative predictive values were 100% and 96.4%. Comparing tobacco use documented in the medical record with cotinine, sensitivity and specificity were 51.2% and 99.2%. Factors associated with tobacco use were male gender, single relationship status, less education, and younger age. In summary, utilization of serum cotinine assays increased detection of tobacco use cases more than 50% over self-report. Results are discussed in context of translation to care, including clinical and ethical implications, and current tobacco use treatment guidelines. When cotinine assays are not available, self-report of any tobacco use in the year prior to HSCT should trigger brief advice and cessation or relapse prevention counseling.