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Likhitsup A, Hassan A, Mellinger J, Askari F, Winder GS, Saeed N, Sonnenday CJ, Sharma P, Fontana RJ. Impact of a Prohibitive Versus Restrictive Tobacco Policy on Liver Transplant Candidate Outcomes. Liver Transpl 2019; 25:1165-1176. [PMID: 31116906 DOI: 10.1002/lt.25497] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 04/23/2019] [Indexed: 02/07/2023]
Abstract
Tobacco use has been associated with poorer outcomes after liver transplantation (LT). Our study examined the effect on LT listing outcomes of a newly implemented policy prohibiting the use of all tobacco products compared with a prior restrictive policy. Medical records of consecutive adult patients evaluated for LT from January 2010 to July 2013 (era 1, n = 1344) and August 2013 to March 2017 (era 2, n = 1350) were reviewed. The proportion of LT candidates listed was the primary outcome. The mean age of the 2694 LT candidates was 54 ± 11 years, 60% were male, and the mean Model for End-Stage Liver Disease (MELD) score was 15 ± 7. Although the proportion of LT candidates who were smokers was significantly higher in era 2 (33% versus 23%; P < 0.005), the proportion of smokers listed for LT remained stable (13% versus 17%; P = 0.25). However, there were more smokers excluded for ongoing tobacco use in era 2 compared with era 1 (9.6% versus 4.4%; P = 0.001). Factors independently associated with LT listing included a diagnosis of hepatocellular carcinoma, being married, private insurance, absence of psychiatry comorbidity, and absence of tobacco, marijuana, or opiate use but evaluation during era 2 was not associated with LT listing. However, the median time to listing significantly increased over time, especially in smokers (from 65 to 122 days; P = 0.001), and this trend was independently associated with evaluation during era 2, a lower MELD score, not having children, and a lower level of education (P < 0.05). In conclusion, despite an increasing incidence of active smokers being referred for LT evaluation, the proportion of smoker candidates listed for LT was unchanged after instituting our prohibitive tobacco use policy. However, the time to get on the waiting list for smokers who were eventually listed was significantly longer due to the need to achieve complete tobacco cessation.
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Affiliation(s)
- Alisa Likhitsup
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - Ammar Hassan
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - Jessica Mellinger
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - Frederick Askari
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - Gerald S Winder
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
| | - Naba Saeed
- Department of Internal Medicine, Beaumont Hospital, Dearborn, MI
| | | | - Pratima Sharma
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - Robert J Fontana
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
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Ursic-Bedoya J, Donnadieu-Rigole H, Faure S, Pageaux GP. Alcohol use and smoking after liver transplantation; complications and prevention. Best Pract Res Clin Gastroenterol 2017. [PMID: 28624106 DOI: 10.1016/j.bpg.2017.03.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The last thirty years have been very prosperous in the field of liver transplantation (LT), with great advances in organ conservation, surgical techniques, peri-operative management and long-term immunosuppression, resulting in improved patient and graft survival rates as well as quality of life. However, substance addiction after LT, namely alcohol and tobacco, results in short term morbidity together with medium and long-term mortality. The main consequences can be vascular (increased risk of hepatic artery thrombosis in smokers), hepatic (recurrent alcoholic cirrhosis in alcohol relapsers) and oncological (increased risk of malignancy in patients consuming tobacco and/or alcohol after LT). This issue has thus drawn attention in the field of LT research. The management of these two at-risk behaviors addictions need the implication of hepatologists and addiction specialists, before and after LT. This review will summarize our current knowledge in alcohol use and cigarette smoking in the setting of LT, give practical tools for identification of high risk patients and treatment options.
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Affiliation(s)
- José Ursic-Bedoya
- Liver Transplantation Unit, Digestive Department, Saint Eloi University Hospital, University of Montpellier, 34295, Montpellier Cedex 5, France
| | - Hélène Donnadieu-Rigole
- Addictology Department, Saint Eloi University Hospital, University of Montpellier, 34295, Montpellier Cedex 5, France
| | - Stéphanie Faure
- Liver Transplantation Unit, Digestive Department, Saint Eloi University Hospital, University of Montpellier, 34295, Montpellier Cedex 5, France
| | - Georges-Philippe Pageaux
- Liver Transplantation Unit, Digestive Department, Saint Eloi University Hospital, University of Montpellier, 34295, Montpellier Cedex 5, France.
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Zmeškal M, Králíková E, Kurcová I, Pafko P, Lischke R, Fila L, Valentová Bartáková L, Fraser K. Continued Smoking in Lung Transplant Patients: A Cross Sectional Survey. Zdr Varst 2015; 55:29-35. [PMID: 27647086 PMCID: PMC4820179 DOI: 10.1515/sjph-2016-0005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 09/03/2015] [Indexed: 11/30/2022] Open
Abstract
Introduction Smoking is associated with a higher incidence of post-lung transplantation complications and mortality. Prior to inclusion on the lung transplant waiting list in the Czech Republic, patients are supposed to be tobacco free for at least 6 months. Our aim was to determine the prevalence of smoking, validated by urinary cotinine, among patients post lung transplantation and prior to inclusion on the transplant waiting list. Methods Between 2009 and 2012, we conducted a cross-sectional survey of urinary cotinine to assess tobacco exposure in 203 patients in the Lung Transplant Program in the Czech Republic. We measured urinary cotinine in 163 patients prior to inclusion on the transplantation waiting list, and 53 patients post bilateral lung transplantation. Results 15.1% (95% CI 0.078 to 0.269) of all lung transplant recipients had urinary cotinine levels corresponding to active smoking; and a further 3.8% (95% CI 0.007 to 0.116) had borderline results. Compared to patients with other diagnoses, patients with COPD were 35 times more likely to resume smoking post- transplantation (95% CI 1.92 to 637.37, p-value 0.016). All patients who tested positive for urinary cotinine levels were offered smoking cessation support. Only one Tx patient sought treatment for tobacco dependence, but was unsuccessful. Conclusion Smoking resumption may be an underrecognized risk for lung transplantation recipients, particularly among patients with chronic obstructive pulmonary disease. More rigorous screening, as well as support and treatment to stop smoking among these patients are needed.
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Affiliation(s)
- Miroslav Zmeškal
- Department of Orthopaedics and Traumatology, Regional Hospital Kolín, Kolín 280 02, Czech Republic
| | - Eva Králíková
- Center for Tobacco-Dependence, 3rd Medical Department - Department of Endocrinology and Metabolism, 1st Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Institute of Hygiene and Epidemiology, 1st Faculty of Medicine, Prague 128 21, Czech Republic
| | - Ivana Kurcová
- Department of Forensic Medicine and Toxicology, 1st Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague 128 21, Czech Republic
| | - Pavel Pafko
- 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital in Motol, Prague 121 08, Czech Republic
| | - Robert Lischke
- 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital in Motol, Prague 121 08, Czech Republic
| | - Libor Fila
- Department of Pneumology, 2nd Faculty of Medicine, Charles University in Prague and University Hospital in Motol, Prague 150 06, Czech Republic
| | - Lucie Valentová Bartáková
- Department of Pneumology, 2nd Faculty of Medicine, Charles University in Prague and University Hospital in Motol, Prague 150 06, Czech Republic
| | - Keely Fraser
- Center for Tobacco-Dependence, 3rd Medical Department - Department of Endocrinology and Metabolism, 1st Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Institute of Hygiene and Epidemiology, 1st Faculty of Medicine, Prague 128 21, Czech Republic
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Mangus RS, Fridell JA, Kubal CA, Loeffler AL, Krause AA, Bell JA, Tiwari S, Tector J. Worse Long-term Patient Survival and Higher Cancer Rates in Liver Transplant Recipients With a History of Smoking. Transplantation 2015; 99:1862-8. [PMID: 26308417 DOI: 10.1097/tp.0000000000000671] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND This study is a retrospective review of liver transplant (LT) recipients to determine the impact of tobacco exposure on 10-year survival and de novo cancer (CA) incidence. METHODS The records of 1275 consecutive LT patients were reviewed (2001 to 2011). Patients were categorized as current, previous, or never smokers (NS) at listing for LT. Additionally, smokers were stratified by pack-years of tobacco exposure. Events included patient death, cardiovascular events, and de novo cancers. Cox regression analysis was used to evaluate survival. A complete cause of death analysis is provided, as well as a detailed tumor registry. RESULTS Current (n = 279) and previous smokers (n = 323) were more likely to have hepatocellular carcinoma (HCC) at transplant (25%, 29% vs 18% [NS], P < 0.001), and these 2 groups had higher HCC recurrence rates (21%, 14% vs 11% [NS], P = 0.18). De novo non-HCC CA was higher for current and previous smokers, compared to NS (18%, 16% vs 12% [NS], P = 0.05). Among those with de novo CA (n = 180), the 2 smoking groups were more likely to have non-skin CA (60%, 54% vs 27% [NS], P < 0.001). Patient survival at 10 years was worse for current smokers than the other study groups (55% vs 70%, P < 0.01). These results were largely mirrored with increased tobacco exposure. CONCLUSIONS The LT outcomes are uniformly worse for patients with a history of smoking, and the risk of negative events increases with increasing tobacco use. Smokers have higher rates of HCC and recurrence, de novo cancer, and worse long-term survival. SUMMARY STATEMENT This study summarizes the clinical outcomes for 1275 LT patients over 10 years, analyzing the impact of pre transplant recipient tobacco use. There are 47% of patients with a history of smoking. Because of demonstrated higher cancer rates and decreased survival, patients with a significant smoking history should be carefully scrutinized for liver transplantation.
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Affiliation(s)
- Richard S Mangus
- Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
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Ehlers SL, Bronars CA, Patten CA, Brockman T, Hughes C, Decker PA, Cerhan JR, Hogan W, Dispenzieri A, Ansell S, Ebbert J, Gastineau D. Accuracy of self-reported tobacco use status among hematopoietic SCT patients. Bone Marrow Transplant 2014; 49:961-5. [PMID: 24732958 PMCID: PMC4162628 DOI: 10.1038/bmt.2014.70] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Revised: 02/20/2014] [Accepted: 02/26/2014] [Indexed: 11/21/2022]
Abstract
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.
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Affiliation(s)
- S L Ehlers
- 1] Department of Psychiatry and Psychology, Mayo Clinic College of Medicine, Rochester, MN, USA [2] Behavioral Health Research Program, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - C A Bronars
- 1] Department of Psychiatry and Psychology, Mayo Clinic College of Medicine, Rochester, MN, USA [2] Behavioral Health Research Program, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - C A Patten
- 1] Department of Psychiatry and Psychology, Mayo Clinic College of Medicine, Rochester, MN, USA [2] Behavioral Health Research Program, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - T Brockman
- Behavioral Health Research Program, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - C Hughes
- Behavioral Health Research Program, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - P A Decker
- Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - J R Cerhan
- Division of Epidemiology, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN, USA
| | - W Hogan
- Division of Hematology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - A Dispenzieri
- Division of Hematology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - S Ansell
- Division of Hematology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - J Ebbert
- 1] Nicotine Dependence Center Research Program, Mayo Clinic College of Medicine, Rochester, MN, USA [2] Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - D Gastineau
- 1] Division of Hematology, Mayo Clinic College of Medicine, Rochester, MN, USA [2] Human Cellular Therapy Laboratory, Mayo Clinic College of Medicine, Rochester, MN, USA
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Abstract
Smoking, both by donors and by recipients, has a major impact on outcomes after organ transplantation. Recipients of smokers' organs are at greater risk of death (lungs hazard ratio [HR], 1.36; heart HR, 1.8; and liver HR, 1.25), extended intensive care stays, and greater need for ventilation. Kidney function is significantly worse at 1 year after transplantation in recipients of grafts from smokers compared with nonsmokers. Clinicians must balance the use of such higher-risk organs with the consequences on waiting list mortality if the donor pool is reduced further by exclusion of such donors. Smoking by kidney transplant recipients significantly increases the risk of cardiovascular events (29.2% vs. 15.4%), renal fibrosis, rejection, and malignancy (HR, 2.56). Furthermore, liver recipients who smoke have higher rates of hepatic artery thrombosis, biliary complications, and malignancy (13% vs. 2%). Heart recipients with a smoking history have increased risk of developing coronary atherosclerosis (21.2% vs. 12.3%), graft dysfunction, and loss after transplantation. Self-reporting of smoking is commonplace but unreliable, which limits its use as a tool for selection of transplant candidates. Despite effective counseling and pharmacotherapy, recidivism rates after transplantation remain high (10-40%). Transplant services need to be more proactive in educating and implementing effective smoking cessation strategies to reduce rates of recidivism and the posttransplantation complications associated with smoking. The adverse impact of smoking by the recipient supports the requirement for a 6-month period of abstinence in lung recipients and cessation before other solid organs.
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