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Zanatta E, Patron E, Messerotti Benvenuti S, Pelizzaro F, Russo FP, Gambato M, Germani G, Ferrarese A, Zanetto A, Battermann F, Buccheri F, Cavalli C, Schiavo R, Ghisi M, Pasquato S, Feltracco P, Cillo U, Burra P, Senzolo M. Alcoholic Etiology, Severity of Liver Disease, and Post-Transplant Adherence Are Correlated with Worse Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) in Liver Transplant Candidates. J Clin Med 2024; 13:3807. [PMID: 38999373 PMCID: PMC11242210 DOI: 10.3390/jcm13133807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Revised: 06/25/2024] [Accepted: 06/26/2024] [Indexed: 07/14/2024] Open
Abstract
Introduction: Psychosocial pre-transplant evaluation in patients undergoing liver transplantation (LT) could help identify those patients at higher risk of pharmacological non-adherence, organ rejection, and mortality. The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) is a validated tool for assessing LT candidates' psychosocial well-being. Data on the ability of the SIPAT evaluation to predict post-transplant outcomes are sparse. Material and Methods: clinical and psychosocial data from a sample of 134 candidates for LT were analyzed. Moreover, the association between pre-transplant psychosocial evaluation and post-transplant clinical outcomes, including organ rejection, mortality, and immunosuppressant drug adherence, was calculated. Results: At the pre-transplant evaluation, patients who showed high SIPAT scores (77, 57%) also had more liver disease assessed by model for end-stage liver disease (MELD; F = 5.04; p < 0.05), alcoholic etiology (F = 35.80; p < 0.001), encephalopathy (F = 5.02; p < 0.05), and portal hypertension (F = 7.45; p < 0.01). Of the 51 transplant patients, those who had a high pre-transplant SIPAT score showed lower post-transplant immunosuppressive adherence, linked to more frequent immunological events. Conclusions: Patients with an alcoholic etiology of liver disease and more severe liver dysfunction are likelier to not adhere to medical prescriptions following transplantation. Current data suggests that this specific group of patients could benefit from early psychological pre-habilitation before undergoing liver transplantation.
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Affiliation(s)
- Elisa Zanatta
- Multivisceral Transplant Unit-Gastroenterology, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, 35128 Padua, Italy
| | - Elisabetta Patron
- Department of General Psychology, University of Padua, 35151 Padua, Italy
| | - Simone Messerotti Benvenuti
- Department of General Psychology, University of Padua, 35151 Padua, Italy
- Hospital Psychology Unit, Padua University Hospital, 35128 Padua, Italy
- Padova Neuroscience Center (PNC), University of Padua, 35131 Padua, Italy
| | - Filippo Pelizzaro
- Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, 35128 Padua, Italy
| | - Francesco Paolo Russo
- Multivisceral Transplant Unit-Gastroenterology, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, 35128 Padua, Italy
| | - Martina Gambato
- Multivisceral Transplant Unit-Gastroenterology, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, 35128 Padua, Italy
| | - Giacomo Germani
- Multivisceral Transplant Unit-Gastroenterology, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, 35128 Padua, Italy
| | - Alberto Ferrarese
- Multivisceral Transplant Unit-Gastroenterology, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, 35128 Padua, Italy
| | - Alberto Zanetto
- Multivisceral Transplant Unit-Gastroenterology, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, 35128 Padua, Italy
| | | | | | - Chiara Cavalli
- Hospital Psychology Unit, Padua University Hospital, 35128 Padua, Italy
| | - Rossana Schiavo
- Hospital Psychology Unit, Padua University Hospital, 35128 Padua, Italy
| | - Marta Ghisi
- Department of General Psychology, University of Padua, 35151 Padua, Italy
- Hospital Psychology Unit, Padua University Hospital, 35128 Padua, Italy
| | - Sara Pasquato
- Hospital Psychology Unit, Padua University Hospital, 35128 Padua, Italy
| | - Paolo Feltracco
- Department of Medicine, UO Anesthesia and Intensive Care, University of Padua, 35128 Padua, Italy
| | - Umberto Cillo
- Hepatobiliary Surgery and Liver Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, 35128 Padua, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit-Gastroenterology, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, 35128 Padua, Italy
| | - Marco Senzolo
- Multivisceral Transplant Unit-Gastroenterology, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, 35128 Padua, Italy
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Wang RX, Lee JJ, Mirda D, Hao J, Goebel AM, Deutsch-Link S, Serper M, Bittermann T. Association of psychosocial risk factors and liver transplant evaluation outcomes in metabolic dysfunction-associated steatotic liver disease. Liver Transpl 2024:01445473-990000000-00401. [PMID: 38869989 DOI: 10.1097/lvt.0000000000000421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 05/31/2024] [Indexed: 06/15/2024]
Abstract
The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) is a standardized psychosocial assessment tool used in liver transplantation (LT) evaluation and has been primarily studied in patients with alcohol-associated liver disease. We aimed to evaluate the relationship between SIPAT score and metabolic syndrome severity and LT waitlist outcomes in a large cohort of patients with metabolic dysfunction-associated steatotic liver disease (MASLD). We performed a single-center retrospective cohort study of patients with MASLD evaluated for LT from 2014 to 2021. The utility of the previously defined total SIPAT cutoff (<21 [excellent/good candidates] vs. ≥21 [minimally acceptable/high-risk candidates]) was studied. Multivariable logistic regression analyses examined associations between continuous SIPAT scores and LT waitlisting outcomes. The Youden J statistic was used to identify the optimal SIPAT cutoff for patients with MASLD. A total of 480 patients evaluated for transplant with MASLD were included. Only 9.4% of patients had a SIPAT score ≥21. Patients with SIPAT score ≥21 had higher hemoglobin A1c compared to patients with lower psychosocial risk (median [IQR]: 7.8 [6.0-9.7] vs. 6.6 [5.8-7.9]; p = 0.04). There were no other differences in metabolic comorbidities between SIPAT groups. Increasing SIPAT score was associated with decreased odds of listing (OR: 0.82 per 5-point increase; p = 0.003) in multivariable models. A SIPAT of ≥12 was identified as the optimal cutoff in this population, resulting in an adjusted OR for a listing of 0.53 versus SIPAT <12 ( p = 0.001). In this large cohort of patients with MASLD evaluated for LT, few patients met the previously defined high SIPAT cutoff for transplant suitability. Nevertheless, increasing the SIPAT score was associated with waitlist outcomes. Our suggested SIPAT cutoff of ≥12 for patients with MASLD warrants further external validation using data from other centers.
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Affiliation(s)
- Roy X Wang
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason J Lee
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Danielle Mirda
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jinxuan Hao
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anna M Goebel
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sasha Deutsch-Link
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Marina Serper
- Division of Gastroenterology and Hepatology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Therese Bittermann
- Division of Gastroenterology and Hepatology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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3
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Musto JA, Palmer G, Nemer M, Schell T, Waclawik G, Glover Q, Lucey MR, Osman F, Rice JP. Early Liver Transplant for Alcohol-associated Liver Disease Has Excellent Survival but Higher Rates of Harmful Alcohol Use. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00432-4. [PMID: 38729395 DOI: 10.1016/j.cgh.2024.04.025] [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: 07/28/2023] [Revised: 04/09/2024] [Accepted: 04/09/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND & AIMS Early liver transplantation (LT) for alcohol-associated liver disease (ALD) has increased worldwide. Short-term outcomes have been favorable, but data on longer-term outcomes are lacking. METHODS Single-center retrospective study of primary LT recipients between 2010 and 2020, with follow-up through July 1, 2022. Survival analysis was performed using log rank, Cox models, and Kaplan-Meier method. Cox models were created to identify variables associated with mortality; logistic regression to identify variables associated with post-LT alcohol use. RESULTS Of 708 patients who underwent LT, 110 (15.5%) had ALD and abstinence <6 months prior to LT (ELT), 234 (33.1%) had ALD and alcohol abstinence >6 months (SLT), and 364 (51.4%) had non-ALD diagnoses. Median follow-up was 4.6 years (interquartile range, 2.6-7.3 years). ELT recipients were younger (P = .001) with median abstinence pre-LT of 61.5 days. On adjusted Cox model, post-LT survival was similar in ELT and SLT (hazard ratio [HR], 1.31; P = .30) and superior to non-ALD (HR, 1.68; P = .04). Alcohol use (40.9% vs 21.8%; P < .001) and harmful alcohol use (31.2% vs 16.0%; P = .002) were more common in ELT recipients. Harmful alcohol use was associated with post-LT mortality on univariate (HR, 1.69; P = .03), but not multivariable regression (HR, 1.54; P = .10). Recurrence of decompensated ALD trended toward more common in ELT (9.1% vs 4.4%; P = .09). Greater than 6 months pre-LT abstinence was associated with a decreased risk of harmful alcohol use (odds ratio, 0.42; P = .001), but not in a multivariable model (odds ratio, 0.71; P = .33). CONCLUSIONS Patients who undergo ELT for ALD have similar or better survival than other diagnoses in the first 10 years after LT despite a higher incidence of post-LT alcohol use.
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Affiliation(s)
- Jessica A Musto
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
| | - Geralyn Palmer
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Mary Nemer
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Trevor Schell
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Gabrielle Waclawik
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Quarshie Glover
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Michael R Lucey
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Fay Osman
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - John P Rice
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Perry JM, Deutsch-Link S, Marfeo E, Serper M, Ladin K. Assessing reliability and validity of SIPAT and opportunities for improvement: A single-center cohort study. Liver Transpl 2024; 30:356-366. [PMID: 37938131 DOI: 10.1097/lvt.0000000000000299] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 10/30/2023] [Indexed: 11/09/2023]
Abstract
Psychosocial assessment is a standard component of patient evaluations for transplant candidacy. The Stanford Integrated Psychosocial Assessment for Transplant (SIPAT) is a widely used measure to assess psychosocial risk for transplant. However, there are questions regarding the SIPAT's reliability and validity. We examined the SIPAT's psychometric performance and its impact on equitable access to transplant in a diverse cohort of 2825 patients seeking liver transplantation between 2014 and 2021 at an urban transplant center. The SIPAT demonstrated good internal consistency reliability at the overall score [Cronbach's α = 0.85, 95% CI (0.83, 0.86)] and domain levels (0.80 > α > 0.70). There was mixed support for structural validity, with poor overall model fit in confirmatory factor analysis and 50% of questions achieving the 0.70-factor loadings threshold. Adjusting for sociodemographic variables, the odds of not being waitlisted for psychosocial reasons were three times higher for patients with Medicaid insurance than patients with private insurance [OR 3.24, 95% CI (2.09, 4.99)] or Medicare [OR 2.89, 95% CI (1.84, 4.53)], mediated by higher SIPAT scores. Black patients had nearly twice the odds of White patients [OR 1.88, 95% CI (1.20, 2.91)], partially mediated by higher social support domain scores. Patients with Medicaid, non-White patients, and those without a college degree scored significantly higher on collinear questions, disproportionately contributing to higher SIPAT scores. The SIPAT did not perform equally across insurance type, race/ethnicity, and education groups, with the lowest subgroup validity associated with patient readiness and psychopathology domains. The SIPAT should be interpreted with caution, especially as a composite score. Future studies should examine validity in other populations.
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Affiliation(s)
- Jennifer M Perry
- Department of Community Health, Tufts University, Medford, Massachusetts, USA
| | - Sasha Deutsch-Link
- Division of Gastroenterology & Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Elizabeth Marfeo
- Department of Community Health, Tufts University, Medford, Massachusetts, USA
| | - Marina Serper
- Division of Gastroenterology & Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Keren Ladin
- Department of Community Health, Tufts University, Medford, Massachusetts, USA
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Winder GS, Clifton EG, Denysenko L, DiChiara AM, Hathaway D, Perumalswami PV, Shenoy A, Suzuki J, Tareen K, Mellinger JL, Fernandez AC. "But I didn't drink!": What to do with discordant phosphatidylethanol results. Liver Transpl 2024; 30:213-222. [PMID: 37486958 DOI: 10.1097/lvt.0000000000000223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 07/08/2023] [Indexed: 07/26/2023]
Abstract
Liver transplantation (LT) teams must be adept at detecting, evaluating, and treating patients' alcohol use, given its prominence among psychological and behavioral phenomena which cause and contribute to liver diseases. Phosphatidylethanol (PEth) is a highly useful alcohol biomarker increasingly recommended for routine use in hepatology and LT. PEth is unique among alcohol biomarkers because of its wide detection window, high sensitivity and specificity, and the correlation of its numerical value with different patterns of alcohol use. Alongside myriad clinical opportunities in hepatology and LT, PEth also confers numerous challenges: little guidance exists about its clinical use; fearing loss of LT access and the reactions of their clinicians and families, candidates and recipients are incentivized to conceal their alcohol use; and liver clinicians report lack of expertise diagnosing and treating substance-related challenges. Discordance between patient self-reported alcohol use and toxicology is yet another common and particularly difficult circumstance. This article discusses the general toxicological properties of PEth; explores possible scenarios of concordance and discordance among PEth results, patient history, and self-reported drinking; and provides detailed clinical communication strategies to explore discordance with liver patients, a key aspect of its use.
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Affiliation(s)
- Gerald Scott Winder
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
| | - Erin G Clifton
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Lex Denysenko
- Department of Psychiatry, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alex M DiChiara
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - David Hathaway
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ponni V Perumalswami
- Department of Internal Medicine, Gastroenterology Section, Veterans Affairs, Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Akhil Shenoy
- Department of Psychiatry, Columbia University, New York City, New York, USA
| | - Joji Suzuki
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kinza Tareen
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jessica L Mellinger
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Anne C Fernandez
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
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Musto JA, Lucey MR. Prognostic models in alcohol-related liver disease and alcohol-related hepatitis. Best Pract Res Clin Gastroenterol 2023; 67:101867. [PMID: 38103931 DOI: 10.1016/j.bpg.2023.101867] [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: 08/06/2023] [Accepted: 08/18/2023] [Indexed: 12/19/2023]
Abstract
Alcohol-associated liver disease (ALD) and alcohol-associated hepatitis (AH) are dynamic disorders whose prognosis can be challenging to determine. A number of prognostic models have been developed to determine likelihood of death, when to refer for liver transplant (LT) and the role for glucocorticoids. Often these models were created with a specific application in mind but were found to have additional applications with further study. Those prognostic models that have stood the test of time are easy to use, have clear interpretations and employ objective parameters. These parameters most often include total bilirubin, INR and creatinine among other data points. Ideally, these models could be utilized at all phases of disease but in most, it is important for clinicians to consider drinking history and how it might alter the determined scores. Herein we provide a brief review of prognostic models in ALD and AH and provide practical tips and considerations to successfully make use of these tools in a clinical setting.
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Affiliation(s)
- Jessica Ann Musto
- Department of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
| | - Michael Ronan Lucey
- Department of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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