Defining the alcoholic liver transplant population: implications for future research

Designing clinical trials to address alcohol use and alcohol-associated liver disease: an expert panel Consensus Statement

Most patients with alcohol-associated liver disease (ALD) engage in heavy drinking defined as 4 or more drinks per day (56 g) or 8 (112 g) or more drinks per week for women and 5 or more drinks per day (70 g) or 15 (210 g) or more drinks per week for men. Although abstinence from alcohol after diagnosis of ALD improves life expectancy and reduces the risk of decompensation of liver disease, few studies have evaluated whether treatment of alcohol use disorders will reduce progression of liver disease and improve liver-related outcomes. In November 2021, the National Institute of Alcohol Abuse and Alcoholism commissioned a task force that included hepatologists, addiction medicine specialists, statisticians, clinical trialists and members of regulatory agencies to develop recommendations for the design and conduct of clinical trials to evaluate the effect of alcohol use, particularly treatment to reduce or eliminate alcohol use in patients with ALD. The task force conducted extensive reviews of relevant literature on alcohol use disorders and ALD. Findings were presented at one in-person meeting and discussed over the next 16 months to develop the final recommendations. As few clinical trials directly address this topic, the 28 recommendations approved by all members of the task force represent a consensus of expert opinions.

Alcohol use disorder in alcohol-associated liver disease: Two sides of the same coin

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.

Clusters of alcohol use disorders diagnostic criteria and predictors of alcohol use after liver transplantation for alcoholic liver disease

BACKGROUND

Establishing the correct alcohol use disorder diagnosis is clinically relevant because several reports of post-transplant alcohol use suggest that a pre-transplant diagnosis of alcohol dependence (rather than abuse) predicts relapse to alcohol use. Numerous combinations of specific symptoms are possible to achieve diagnostic significance.

OBJECTIVE

The authors hypothesized that there would be distinct clusters of liver transplant recipients who showed specific combinations of alcohol-related symptoms and that these clusters would be predictive of alcohol-abuse outcome after transplant.

METHOD

A group of 120 ALD liver transplant recipients received the Structured Clinical Interview for DSM-IV (SCID) module for alcohol abuse/dependence, and a cluster analysis was performed.

RESULTS

Within the clusters of those with alcohol dependence, cluster assignment did not predict those more likely to drink. However, those assigned to the alcohol abuse cluster were significantly less likely to drink than those with alcohol dependence.

CONCLUSION

Results therefore suggest that the prognosis regarding continued abstinence posttransplant is much more positive for individuals with a diagnosis of abuse than for those who meet criteria for alcohol dependence.

Cognitive lifetime drinking history in nonalcoholic fatty liver disease: some cases may be alcohol related

OBJECTIVES

We aimed to determine the prevalence of significant alcohol intake in previously diagnosed nonalcoholic fatty liver (NAFL) patients.

METHODS

We measured current and total lifetime alcohol intake (TLAI) in biopsy-proven NAFL patients using the cognitive lifetime drinking history (CLDH), a computerized questionnaire. One nurse administered the CLDH without physician presence. Physicians took alcohol histories prior to any knowledge of this study. Advanced and nonadvanced fibrosis patients were tested. A single pathologist (ST) scored all biopsies (inflammation 0-6; fibrosis 0-4).

RESULTS

Twenty-three patients (11 men) were studied. Thirteen had bridging fibrosis or cirrhosis. [mean age: 52.3 yr (range 28-69); mean body mass index (BMI): 37 kg/m2 (range 27-48.6)]. All but three had hyperlipidemia, diabetes, and/or hypertension. Mean TLAI was 60.2 kg (range 0.17-471.7), but three patients were above 100 kg (threshold for cirrhosis risk) at 305.5, 336.7, and 471.7. These three had inflammation/fibrosis scores of 3/3, 3/0, and 5/2, respectively. Those with >100 kg tended to have higher serum AST and inflammation score. Prior physician-obtained alcohol history determined <or=20 g/day for all patients and did not mention TLAI in any. CLDH confirmed <or=20 g/day current alcohol intake in 21 of 23 patients, but intakes were 30.2 g/day and 41.2 g/day in two.

CONCLUSIONS

Some NAFL patients may have alcohol fatty liver disease instead. Routine physician interviews obtain less accurate alcohol histories compared to CLDH. The clinical significance of past alcohol intake and methods of measuring alcohol ingestion in fatty liver patients deserves further investigation.