Management of alcohol use disorder in patients with cirrhosis in the setting of liver transplantation

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.

Salivary Carbohydrate-Deficient Transferrin in Alcohol- and Nicotine-Dependent Males

Serum carbohydrate-deficient transferrin (CDT), an 80 kDa glycoprotein, is one of the most commonly employed biomarkers to detect alcohol dependence. Some salivary glycoproteins such as α-amylase, clusterin, haptoglobin, light/heavy-chain immunoglobulin, and transferrin, which alter glycosylation in alcohol-dependent persons, have been suggested to be potential alcohol markers. However, their identification is based on indirect analysis of lectin glycosidic bonds and molecular weight. We investigated the CDT content in the saliva of alcohol- and nicotine-dependent men. The CDT concentration (ng/mL, ng/mg protein) was determined by an Enzyme-Linked Immunosorbent Assay (ELISA) commercial kit in 55 men: 20 healthy social drinkers (C), 10 chronic cigarette smokers (S), 10 alcohol-dependent non-smokers (A), and 15 alcohol-dependent smokers (AS). Surprisingly, there were no differences in the concentrations of CDT between the studied groups. Salivary pH was the lowest in the AS and the highest in the A group. Therefore, salivary CDT cannot be used as an alcohol dependence marker as measured by ELISA. We suggest that direct identification of glycoproteins is necessary to search for potential salivary alcohol biomarkers. Molecules smaller than 40 kDa, which easily translocate from blood to the saliva, might be preferred as salivary alcohol markers.

Long-term changes of salivary exoglycosidases and their applicability as chronic alcohol-drinking and dependence markers

OBJECTIVES

Investigation of long-term dynamic changes of salivary activity/output of exoglycosidases, deglycosylation processes and their applicability as alcohol markers.

METHODS

Exoglycosidase (α-fucosidase (FUC), β-galactosidase (GAL), β-glucuronidase (GLU), β-hexosaminidase (HEX, HEX A and HEX B isoenzymes) and α-mannosidase (MAN)) activities were measured in the saliva of healthy social drinking controls (C), alcohol-dependent non-smokers (ANS) and alcohol-dependent smokers (AS) at the 1st, 15th, 30th and 50th day of abstinence after chronic alcohol drinking.

RESULTS

The activity of exoglycosidases was 2-3-fold (MAN), 2-6 fold (FUC), 8-25-fold (HEX A) and 19-40-fold (GLU) higher in the ANS and AS groups than in controls, and had good/excellent sensitivity, specificity and accuracy. The higher outputs of exoglycosidases were in the AS and ANS groups than in controls at the 1st day (GLU, HEX A) and at the 50th day (GLU, FUC, MAN) of abstinence. We found numerous correlations between alcohol-drinking days with GLU and HEX A, alcohol amounts with HEX A and duration of alcohol dependence with FUC and MAN activity/output.

CONCLUSIONS

Salivary exoglycosidases/deglycosylation processes were still very high up to 50 days after the end of alcohol consumption. We found markers of chronic alcohol consumption (HEX A), alcohol dependence (FUC and MAN) and chronic alcohol consumption and dependence (GLU).

A rapid and non-invasive method to determine toxic levels of alcohols and γ-hydroxybutyric acid in saliva samples by gas chromatography-differential mobility spectrometry

A polydimethylsiloxane oral sampler was used to extract methanol, ethanol, ethylene glycol, 1,3-propandiol and γ-hydroxybutyric acid from samples of human saliva obtained using a passive drool approach. The extracted compounds were recovered by thermal desorption, isolated by gas chromatography and detected with differential mobility spectrometry, operating with a programmed dispersion field. Complex signal behaviours were also observed that were consistent with hitherto unobserved fragmentation behaviours in differential mobility spectrometry. These yielded high-mobility fragments obscured within the envelope of the water-based reactant ion peak. Further, compensation field maxima shifts were also observed which were attributable to transport gas modification phenomena. Nevertheless, the responses obtained indicated that in vivo saliva sampling with thermal desorption gas chromatography may be used to provide a semi-quantitative diagnostic screen over the toxicity threshold concentration ranges of 100 mg dm(-3) to 3 g dm(-3). A candidate method suitable for use in low resource settings for the non-invasive screening of patients intoxicated by alcohols and volatile sedatives has been demonstrated.

Diagnosis of toxic alcohols: limitations of present methods

CONTEXT

Methanol, ethylene glycol, diethylene glycol, and propylene glycol intoxications are associated with cellular dysfunction and an increased risk of death. Adverse effects can develop quickly; thus, there is a need for methods for rapidly detecting their presence.

OBJECTIVE

To examine the value and limitations of present methods to diagnose patients with possible toxic alcohol exposure.

METHODS

I searched MEDLINE for articles published between 1969 and 2014 using the terms: toxic alcohols, serum osmolality, serum osmol gap, serum anion gap, metabolic acidosis, methanol, ethylene glycol, diethylene glycol, propylene glycol, and fomepizole. Each article was reviewed for additional references.

RESULTS

The diagnosis of toxic alcohol exposure is often made on the basis of this history and physical findings along with an increase in the serum osmol and anion gaps. However, an increase in the osmol and/or anion gaps is not always present. Definitive detection in blood requires gas or liquid chromatography, laborious and expensive procedures which are not always available. Newer methods including a qualitative colorimetric test for detection of all alcohols or enzymatic tests for a specific alcohol might allow for more rapid diagnosis.

CONCLUSIONS

Exposure to toxic alcohols is associated with cellular dysfunction and increased risk of death. Treatment, if initiated early, can markedly improve outcome, but present methods of diagnosis including changes in serum osmol and anion gap, and use of gas or liquid chromatography have important limitations. Development of more rapid and effective tests for detection of these intoxications is essential for optimal care of patients.

Semen quality: variations among fathers and effects of moderate alcohol drinking

Semen analysis results from over 750 fathers in the USA demonstrated marked differences in the quality of semen from men at different locations and of different ethnic groups. Another paper failed to demonstrate any effects of moderate alcohol consumption during the week before provision of an ejaculate on semen quality and few on serum hormones, of over 8300 men in Europe and the USA. While these observations are interesting, the reasons for regional and ethnic differences in semen quality of fathers are unclear. Although, there was no attempt to confirm the participant-provided level of alcohol consumption, an increase in serum testosterone in the men at the higher end of alcohol intake is compatible with an alcohol effect on liver metabolism, although whether alcohol intake was the cause of higher testosterone, or men with higher androgen levels consume more alcohol, is not known.

Salivary hexosaminidase in smoking alcoholics with bad periodontal and dental states

BACKGROUND

A sensitive alcohol marker, β-hexosaminidase (HEX), in the saliva of alcoholics, is investigated for the first time.

METHODS

The activity, specific-activity and output of total HEX and its isoenzymes HEX A and HEX B were measured in the saliva of healthy controls (C), alcohol-dependent non-smokers (ANS), and alcohol-dependent smokers (AS).

RESULTS

We observed a significantly increased activity/specific-activity and output of HEX A in the ANS and AS groups, due to the inflammatory state of the oral-cavity/salivary-glands. Significantly increased activity of HEX A contributed to an increase in the salivary activity of the total HEX in the ANS group. A significant decrease in the activity/specific-activity of HEX B in AS seemed to be due to HEX B inactivation by cigarette smoke. We noticed a tendency for deteriorated dental state (lower decayed-missing-filled-teeth index - DMFT), worse periodontal state (higher gingival index - GI and papilla-bleeding index - PBI) in AS, and worse periodontal state (higher GI) in ANS, as compared to the controls. We found no differences in the salivary protein concentrations between all groups and decreased salivary flow in both alcoholic groups as compared to the controls. In alcoholics, the area under the curve (AUC) for HEX A activity/specific-activity was significantly greater than for HEX and HEX B. The salivary HEX A activity/specific-activity had good/excellent sensitivity and specificity in smoking and non-smoking alcoholics, whereas salivary HEX and HEX B had poor/fair sensitivity and specificity.

CONCLUSIONS

Salivary HEX A may be helpful in the diagnosis of chronic alcohol intoxication, even in smokers.