1
|
Varshney M, Dhingra K, Choudhury A. Psychosocial Assessment and Management-related Issues Among Liver Transplant Recipients. J Clin Exp Hepatol 2023. [DOI: 10.1016/j.jceh.2023.07.414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
|
2
|
Antoniou T, Pritlove C, Shearer D, Tadrous M, Shah H, Gomes T. Accessing hepatitis C direct acting antivirals among people living with hepatitis C: a qualitative study. Int J Equity Health 2023; 22:112. [PMID: 37280588 PMCID: PMC10243011 DOI: 10.1186/s12939-023-01924-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 05/23/2023] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND Hepatitis C is curable with direct-acting antivirals (DAAs). However, treatment uptake remains low among marginalized populations such as people who inject drugs. We sought to understand challenges to treatment uptake with DAAs among people living with hepatitis C and compare treatment experiences between people who do and do not inject prescription and/or unregulated drugs. METHODS We conducted a qualitative study using focus groups with 23 adults aged 18 years and over who completed DAA treatment or were about to begin such treatment at the time of the study. Participants were recruited from hepatitis C treatment clinics across Toronto, Ontario. We drew upon stigma theory to interpret participants' accounts. RESULTS Following analysis and interpretation, we generated five theoretically-informed themes characterizing the experiences of individuals accessing DAAs: "being 'worthy' of the cure", "spatially enacted stigma", "countering social and structural vulnerability: the importance of peers", "identity disruption and contagion: attaining a 'social cure'" and "challenging stigma with population-based screening". Overall, our findings suggest that structural stigma generated and reproduced through healthcare encounters limits access to DAAs among people who inject drugs. Peer-based programs and population-based screening were proposed by participants as mechanisms for countering stigma within health care settings and 'normalizing' hepatitis C among the general population. CONCLUSIONS Despite the availability of curative therapies, access to such treatment for people who inject drugs is limited by stigma enacted in and structured within healthcare encounters. Developing novel, low-threshold delivery programs that remove power differentials and attend to the social and structural determinants of health and reinfection are needed to facilitate further scale up of DAAs and support the goal of eradicating hepatitis C as a public health threat.
Collapse
Affiliation(s)
- Tony Antoniou
- Li Ka Shing Knowledge Institute, Unity Health, Toronto, ON, Canada.
- Department of Family and Community Medicine, Unity Health, Toronto, ON, Canada.
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.
| | - Cheryl Pritlove
- Li Ka Shing Knowledge Institute, Unity Health, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Dana Shearer
- Li Ka Shing Knowledge Institute, Unity Health, Toronto, ON, Canada
| | - Mina Tadrous
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Women's College Research Institute, Toronto, ON, Canada
| | - Hemant Shah
- Toronto Centre for Liver Disease, University Health Network, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Tara Gomes
- Li Ka Shing Knowledge Institute, Unity Health, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
3
|
Durkin C, Bittermann T. Liver transplantation for alcohol-associated hepatitis. Curr Opin Organ Transplant 2023; 28:85-94. [PMID: 36512482 PMCID: PMC9992110 DOI: 10.1097/mot.0000000000001044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Early liver transplantation is emerging as a treatment option for severe alcohol-associated hepatitis refractory to pharmacotherapies. This review outlines the current status of transplantation for alcohol-associated hepatitis and the treatment of alcohol use disorder after liver transplantation. RECENT FINDINGS Rates of early liver transplantation for alcohol-associated hepatitis are increasing with significant heterogeneity in practices across the Unites States. Recent studies have demonstrated a substantial survival benefit in patients transplanted for alcohol-associated hepatitis with improved outcomes in early vs. late transplantation, first vs. prior hepatic decompensation, and posttransplant abstinence/delayed relapse vs. early return to alcohol use. Several prediction algorithms have been developed to ascertain patients' risk of alcohol relapse and aid in candidate selection, though data on treatment of alcohol use disorders in transplant recipients remains limited. SUMMARY Although controversial, early liver transplantation for severe alcohol-associated hepatitis has shown to be a lifesaving intervention. Additional research is needed to evaluate its long-term outcomes, optimize candidate selection, and understand treatment of alcohol use disorder posttransplant.
Collapse
Affiliation(s)
- Claire Durkin
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Therese Bittermann
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
4
|
Liver transplantation in alcohol-associated liver disease: ensuring equity through new processes. Liver Transpl 2023; 29:539-547. [PMID: 36738082 DOI: 10.1097/lvt.0000000000000088] [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: 09/22/2022] [Accepted: 12/14/2022] [Indexed: 02/05/2023]
Abstract
Worsened by the COVID-19 pandemic, alcohol use is one of the leading causes of preventable death in the US, in large part due to alcohol-associated liver disease. Throughout history, liver transplantation for this population has been controversial, and many policies and regulations have existed to limit access to lifesaving transplant for patients who use alcohol. In recent years, the rates of liver transplantation for patients with alcohol-associated liver disease have increased dramatically; however, disparities persist. For instance, many criteria used in evaluation for transplant listing, such as social support and prior knowledge of the harms of alcohol use, are not evidence based and may selectively disadvantage patients with alcohol use disorder. In addition, few transplant providers have adequate training in the treatment of alcohol use disorder, and few transplant centers offer specialized addiction treatment. Finally, current approaches to liver transplantation would benefit from adopting principles of harm reduction, which have demonstrated efficacy in the realm of addiction medicine for years. As we look toward the future, we must emphasize the use of evidence-based measures in selecting patients for listing, ensure access to high-quality addiction care for all patients pretransplant and posttransplant, and adopt harm reduction beliefs to better address relapse when it inevitably occurs. We believe that only by addressing each of these issues will we be able to ensure a more equitable distribution of resources in liver transplantation for all patients.
Collapse
|
5
|
Dienstag A, Dienstag P, Mohan K, Mirza O, Schubert E, Ford L, Edelman M, Im G, Shenoy A. An Assessment of the Psychosocial Evaluation for Early Liver Transplantation in Patients With Acute Alcoholic Hepatitis in the Context of Alcohol Use Disorder, a Case-Control Study. Subst Abuse 2022; 16:11782218221115659. [PMID: 35966615 PMCID: PMC9373124 DOI: 10.1177/11782218221115659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 07/07/2022] [Indexed: 11/25/2022]
Abstract
Background: Severe acute alcoholic hepatitis (AAH) has an extremely poor prognosis with a
high short term mortality rate. As a result, many centers, including our
own, have allowed transplant patients to be listed for transplantation prior
to achieving 6-months of sobriety. Several scoring systems, designed to
target patients with a minimal period of sobriety, have been proposed to
identify patients with alcohol use disorder (AUD), who would be predisposed
to relapse after liver transplantation. We investigated whether these
scoring systems corroborated the results of the non-structured selection
criteria used by our center regarding decision to list for transplant. Methods: We conducted a retrospective case-control study of 11 patients who underwent
early liver transplantation for AAH matched with 11 controls who were
declined secondary to low insight into AUD. Blinded raters confirmed the
severity of the diagnosis of DSM-5 and scored the patients on a variety of
structured psychometric scales used to predict alcohol relapse. These
included the High Risk for Alcohol Relapse Scale (HRAR), Stanford Integrated
Psychosocial Assessment Tool (SIPAT), Alcohol Relapse Risk Assessment
(ARRA), Hopkins Psychosocial Scale (HPSS), Michigan Alcoholism Prognosis
Score (MAPS), Alcohol Use Disorders Identification Test -Consumption
(AUDIT-C), and Sustained Alcohol Use Post-Liver Transplant (SALT) scales.
All patients who underwent transplantation were followed for harmful and
non-harmful drinking until the end of the study period. Results: The transplant recipients had significantly favorable MAPS, HRAR, SIPAT,
ARRA, and HPSS scores with cutoffs that matched their previous research. The
SALT and AUDIT-C scores were not predictive of our selection of patients for
transplantation. Despite an expedited evaluation and no significant period
of sobriety, our case cohort had a 30% relapse to harmful drinking after an
average of 6.6 years (5-8.5 years) of follow-up. Discussion: Despite the rapid assessment and the short to no period of sobriety, the
patient cohort demonstrated a 30% relapse to harmful drinking, consistent
with the 20% to 30% relapse to drinking rate reported after liver
transplantation for all forms of alcoholic liver disease. Average scores
from MAPS, HRAR, SIPAT, ARRA, and HPSS corroborated our current
stratification procedures, with lower mean risk scores found in the
transplanted group. Conclusion: Patients with AUD and severe AAH who obtain new insight into their disease
and posses other favorable psychosocial factors have low rates of AUD
relapse post-liver-transplantation. The psychosocial selection criteria for
patients with alcoholic hepatitis in our institution are consistent with 4
of the 5 scoring systems investigated in their prediction of sobriety
post-transplant.
Collapse
Affiliation(s)
- Aryeh Dienstag
- Department of Psychiatry, Hadassah Hebrew University School of Medicine, Jerusalem, Israel
| | - Penina Dienstag
- Department of Anesthesia, Hadassah Hebrew University School of Medicine, Jerusalem, Israel
| | - Kanwal Mohan
- Department of Psychiatry, University of Calgary, Calgary, Canada
| | - Omar Mirza
- Department of Psychiatry, Harlem Hospital Center, New York, NY, USA
| | - Elizabeth Schubert
- Recanati-Miller Transplantation Institute, Mount Sinai Hospital, New York, NY, USA
| | - Laura Ford
- Recanati-Miller Transplantation Institute, Mount Sinai Hospital, New York, NY, USA
| | - Margot Edelman
- Recanati-Miller Transplantation Institute, Mount Sinai Hospital, New York, NY, USA
| | - Gene Im
- Recanati-Miller Transplantation Institute, Mount Sinai Hospital, New York, NY, USA
| | - Akhil Shenoy
- Department of Psychiatry, Columbia University Medical Center, New York, NY, USA
| |
Collapse
|
6
|
Scoring systems to assess relapse risk in alcohol use disorder presenting for early liver transplantation: A systematic review. Gen Hosp Psychiatry 2021; 72:23-30. [PMID: 34229280 DOI: 10.1016/j.genhosppsych.2021.06.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 06/14/2021] [Accepted: 06/24/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Early liver transplantation (LT) is considered for patients with alcohol use disorder (AUD) despite limited sober time when acute mortality risk from liver disease is high. The objective of this paper is to find psychosocial tools that do not rely on extended sober time and predict alcohol relapse post-LT. METHODS We conducted a systematic review of Pubmed, Embase, and Scopus for studies testing psychosocial tools that used numeric scoring to predict post-LT alcohol relapse. Tools that afforded points for length of sobriety were excluded. Each study was analyzed for its clinical context, post-LT relapse outcomes and predictive validity. RESULTS Five scoring systems across fourteen samples showed varied validity in predicting post-LT alcohol relapse. Relapse to any alcohol use after LT revealed an average relapse rate of 23%. Most scoring systems were understudied but four of five provided cut-off scores with high negative predictive values for relapse. CONCLUSION Scoring systems may have a place in candidate selection but the data on cut-off scores and predictability are still lacking for their use alone in high stakes LT selection. Larger studies with prospective scoring and standardized follow ups for relapse post-LT will better allow the predictive validity of these psychosocial tools to be compared.
Collapse
|
7
|
Herrick-Reynolds KM, Punchhi G, Greenberg RS, Strauss AT, Boyarsky BJ, Weeks-Groh SR, Krach MR, Anders RA, Gurakar A, Chen PH, Segev DL, King EA, Philosophe B, Ottman SE, Wesson RN, Garonzik-Wang JM, Cameron AM. Evaluation of Early vs Standard Liver Transplant for Alcohol-Associated Liver Disease. JAMA Surg 2021; 156:1026-1034. [PMID: 34379106 DOI: 10.1001/jamasurg.2021.3748] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Importance Traditionally, liver transplant (LT) for alcohol-associated liver disease (ALD) requires 6 months of abstinence. Although early LT before 6 months of abstinence has been associated with decreased mortality for decompensated ALD, this practice remains controversial and concentrated at a few centers. Objective To define patient, allograft, and relapse-free survival in early LT for ALD, and to investigate the association between these survival outcomes and early vs standard LT. Design, Setting, and Participants This cohort study analyzed all patients with ALD who underwent their first LT at a single academic referral center between October 1, 2012, and November 13, 2020. Patients with known pretransplant hepatocellular carcinoma, hepatitis B or C, or an alternative cause of liver failure were excluded. Follow-up period was defined as the time from LT to the most recent encounter with a transplant center or death. Exposures The exposure of interest was early LT, which was defined as less than 180 days of pre-LT abstinence. Standard LT was defined as 180 days or more of pre-LT abstinence. Patients were separated into early LT and standard LT by time from abstinence to LT. Main Outcomes and Measures The outcomes were patient, allograft, relapse-free, and hazardous relapse-free survival for patients who underwent early LT or standard LT. These groups were compared by log-rank testing of Kaplan-Meier estimates. Hazardous relapse was defined as binge, at-risk, or frequent drinking. Abstinence was reassessed at the most recent follow-up visit for all patients. Results Of the 163 patients with ALD included in this study, 88 (54%) underwent early LT and 75 (46%) underwent standard LT. This cohort had a mean (SD) age at transplant of 52 (10) years and was predominantly composed of 108 male patients (66%). Recipients of early LT vs standard LT were younger (median [interquartile range (IQR)] age, 49.7 [39.0-54.2] years vs 54.6 [48.7-60.0] years; P < .001) and had a higher median (IQR) Model for End-stage Liver Disease score at listing (35.0 [29.0-39.0] vs 20.0 [13.0-26.0]; P < .001). Both recipients of early LT and standard LT had similar 1-year patient survival (94.1% [95% CI, 86.3%-97.5%] vs 95.9% [95% CI, 87.8%-98.7%]; P = .60), allograft survival (92.7% [95% CI, 84.4%-96.7%] vs 90.5% [95% CI, 81.0%-95.3%]; P = .42), relapse-free survival (80.4% [95% CI, 69.1%-88.0%] vs 83.5% [95% CI, 72.2%-90.6%]; P = .41), and hazardous relapse-free survival (85.8% [95% CI, 75.1%-92.2%] vs 89.6% [95% CI, 79.5%-94.9%]; P = .41). Conclusions and Relevance Adherence to the 6-month rule was not associated with superior patient survival, allograft survival, or relapse-free survival among selected patients. This finding suggests that patients with ALD should not be categorically excluded from LT solely on the basis of 6 months of abstinence, but rather alternative selection criteria should be identified that are based on need and posttransplant outcomes.
Collapse
Affiliation(s)
- Kayleigh M Herrick-Reynolds
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Gopika Punchhi
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ross S Greenberg
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alexandra T Strauss
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Brian J Boyarsky
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sharon R Weeks-Groh
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michelle R Krach
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Robert A Anders
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ahmet Gurakar
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Po-Hung Chen
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Elizabeth A King
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Benjamin Philosophe
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shane E Ottman
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Russell N Wesson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Andrew M Cameron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| |
Collapse
|
8
|
Nagai S, Safwan M, Kitajima T, Yeddula S, Abouljoud M, Moonka D. Disease-specific waitlist outcomes in liver transplantation - a retrospective study. Transpl Int 2021; 34:499-513. [PMID: 33423330 DOI: 10.1111/tri.13814] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 11/24/2020] [Accepted: 01/01/2021] [Indexed: 12/13/2022]
Abstract
This study aimed to evaluate possible discrepancies in waitlist outcomes between liver diseases, including alcohol-related liver disease (ALD), nonalcoholic steatohepatitis (NASH), hepatitis C virus infection (HCV), primary biliary cirrhosis (PBC), and primary sclerosing cholangitis (PSC). Patients registered for liver transplantation from January 11, 2016, to June 30, 2018, were evaluated using OPTN/UNOS registry. Waitlist outcomes were compared between the five-disease groups. Patients were categorized by initial MELD-Na-score (6-20, 21-29, and ≥30) to identify outcome variations. Prognostic impact of transplantation was assessed according to final MELD-Na scores using Cox regression analysis modeling transplantation as a time-dependent covariate. 6053 with ALD, 3814 with NASH, 1558 with HCV, 602 with PBC, and 819 with PSC were eligible. Compared to ALD with comparable MELD-Na-scores, NASH with lower [adjusted hazard ratio (aHR) = 1.30, P = 0.042] and mid-scores (aHR = 1.35, P = 0.008) showed significantly higher risk of 1-year waitlist mortality, and PBC with higher scores showed significantly higher risk of 90-day (aHR = 1.69, P = 0.03) and 1-year waitlist mortality (aHR = 1.69, P = 0.02). Positive prognostic impact of transplantation was not seen until score of 24-27 in ALD, 18-20 in HCV, 15-17 in NASH, and 24-27 in PBC and PSC. There are significant differences in waitlist outcomes among etiologies, which may differ the optimal transplant timing.
Collapse
Affiliation(s)
- Shunji Nagai
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Mohamed Safwan
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Toshihiro Kitajima
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Sirisha Yeddula
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Marwan Abouljoud
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Dilip Moonka
- Division of Gastroenterology, Henry Ford Hospital, Detroit, MI, USA
| |
Collapse
|
9
|
Listabarth S, Gmeiner A, Pruckner N, Vyssoki S, Wippel A, König D. When demand exceeds supply: Liver transplantation due to alcohol use disorder in Austria. NEUROPSYCHIATRIE : KLINIK, DIAGNOSTIK, THERAPIE UND REHABILITATION : ORGAN DER GESELLSCHAFT ÖSTERREICHISCHER NERVENÄRZTE UND PSYCHIATER 2020; 34:157-163. [PMID: 33141424 PMCID: PMC7732788 DOI: 10.1007/s40211-020-00364-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 10/06/2020] [Indexed: 12/17/2022]
Abstract
Background Alcohol use disorder (AUD) is associated with a high prevalence rate and causes a significant burden on health systems globally. The most severe condition associated with AUD is end-stage alcohol-related liver disease (ARLD), for which liver transplantation (LTX) is the only curative therapy. However, the determination of key epidemiologic figures of both conditions is limited by several difficulties and challenges. Therefore, the goal of this paper is to discuss different epidemiological models to estimate AUD and ARLD prevalence, and compare the results of these models with LTX data. Methods A literature search for epidemiological models estimating the prevalence of AUD and associated secondary diseases was conducted. Identified approaches are discussed and recalculated, applying the newest available data for Austria. The thus estimated numbers were, in a further step, set in relation to the national LTX statistics. Results Besides health survey-based estimations and models based on economic data, estimations based on the mortality of ARLD (Jellinek formula) were identified. Depending on the prediction scenario, the calculated rates of prevalence of AUD ranged between 4.1% and 10.1% for the population aged older than 15 years. Furthermore, while the prevalence of secondary diseases due to AUD is high, only a marginal proportion (about 4%) of end-stage ARLD patients receive a new organ. Conclusion These results suggest that the prevalence of AUD and associated diseases remain underestimated. Furthermore, a pronounced discrepancy between the number of ARLD deaths and the number of LTXs due to ARLD, and distinct regional differences in the supply of LTXs, were found.
Collapse
Affiliation(s)
- Stephan Listabarth
- Clinical Division of Social Psychiatry, Department of Psychiatry and Psychotherapy, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Andrea Gmeiner
- Clinical Division of Social Psychiatry, Department of Psychiatry and Psychotherapy, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Nathalie Pruckner
- Clinical Division of Social Psychiatry, Department of Psychiatry and Psychotherapy, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Sandra Vyssoki
- Department of Health Sciences, St. Pölten University of Applied Sciences, Sankt Pölten, Austria
| | - Andreas Wippel
- Clinical Division of Social Psychiatry, Department of Psychiatry and Psychotherapy, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Daniel König
- Clinical Division of Social Psychiatry, Department of Psychiatry and Psychotherapy, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
| |
Collapse
|
10
|
Gitto S, Aspite S, Golfieri L, Caputo F, Vizzutti F, Grandi S, Patussi V, Marra F. Alcohol use disorder and liver transplant: new perspectives and critical issues. Korean J Intern Med 2020; 35:797-810. [PMID: 32241080 PMCID: PMC7373982 DOI: 10.3904/kjim.2019.409] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 03/03/2020] [Indexed: 12/13/2022] Open
Abstract
Alcoholic liver disease is a consolidated indication for liver transplantation, but many unsolved issues can be highlighted. Patients with alcohol use disorder develop peculiar comorbidities that can become contraindications for transplantation. Moreover, a number of social and psychological patterns should be evaluated to select candidates with a low risk of alcohol relapse and adequate post-transplant adherence. In this context, the 6-month rule is too rigid to be widely applied. A short period of abstinence (1 to 3 months) is useful to estimate recovery of liver function and, possibly to avoid transplant. Cardiovascular disorders and extra-hepatic malignancies represent the main clinical issues after transplant. Patients transplanted due to alcoholic disease are a major risk for other liver diseases. Severe corticosteroid-resistant alcoholic acute hepatitis is a debated indication for transplant. However, available data indicate that well-selected patients have excellent post-transplant outcomes. Behavioral therapy, continued psychological support and a multidisciplinary team are essential to achieve and maintain complete alcohol abstinence during the transplant process. Alcoholic liver disease is an excellent indication for a liver transplant but patients with alcohol use disorder deserve a personalized approach and dedicated resources.
Collapse
Affiliation(s)
- Stefano Gitto
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Silvia Aspite
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Lucia Golfieri
- Department of Psychology, University of Bologna, Bologna, Italy
| | - Fabio Caputo
- Department of Internal Medicine, SS Annunziata Hospital, University of Ferrara, Cento, Italy
| | - Francesco Vizzutti
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Silvana Grandi
- Department of Psychology, University of Bologna, Bologna, Italy
| | | | - Fabio Marra
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Research Center Denothe, University of Florence, Italy
| |
Collapse
|
11
|
Traina G, Feiring E. 'There is no such thing as getting sick justly or unjustly' - a qualitative study of clinicians' beliefs on the relevance of personal responsibility as a basis for health prioritisation. BMC Health Serv Res 2020; 20:497. [PMID: 32493300 PMCID: PMC7268691 DOI: 10.1186/s12913-020-05364-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 05/25/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Concerns have been raised regarding the reasonableness of using personal health responsibility as a principle or criterion for setting priorities in healthcare. While this debate continues, little is known about clinicians' views on the role of patient responsibility in clinical contexts. This paper contributes to the knowledge on the empirical relevance of personal responsibility for priority setting at the clinical level. METHODS A qualitative study of Norwegian clinicians (n = 15) was designed, using semi-structured interviews with vignettes to elicit beliefs on the relevance of personal responsibility as a basis for health prioritisation. Sampling was undertaken purposefully. The interviews were conducted in three hospital trusts in South-Eastern Norway between May 2018 and February 2019 and were analysed with conceptually driven thematic analysis. RESULTS The findings suggest that clinicians endorsed a general principle of personal health responsibility but were reluctant to introduce personal health responsibility as a formal priority setting criterion. Five main objections were cited, relating to avoidability, causality, harshness, intrusiveness, and inequity. Still, both retrospective and prospective attributions of personal responsibility were perceived as relevant in specific clinical settings. The most prominent argument in favour of personal health responsibility was grounded in the idea that holding patients responsible for their conduct would contribute to the efficient use of healthcare resources. Other arguments included fairness to others, desert and autonomy, but such standpoints were controversial and held only marginal relevance. CONCLUSIONS Our study provides important novel insights into the clinicians' beliefs about personal health responsibility improving the empirical knowledge concerning its fairness and potential applications to healthcare prioritisation. These findings suggest that although personal health responsibility would be difficult to implement as a steering criterion within the main priority setting framework, there might be clinical contexts where it could figure in prioritisation practices. Additional research on personal health responsibility would benefit from considering the multiple clinical encounters that shape doctor-patient relationships and that create the information basis for eligibility and prioritisation for treatment.
Collapse
Affiliation(s)
- Gloria Traina
- Department of Health Management and Health Economics, University of Oslo, Post box 1089 Blindern, 0317, Oslo, Norway.
| | - Eli Feiring
- Department of Health Management and Health Economics, University of Oslo, Post box 1089 Blindern, 0317, Oslo, Norway
| |
Collapse
|
12
|
Morales MK, Lambing T, Husson J. Review: Evaluation and Management of the HIV/HCV Co-Infected Kidney or Liver Transplant Candidate. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2020. [DOI: 10.1007/s40506-020-00220-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
13
|
Notini L, Vasileva D, Orchanian-Cheff A, Buchman DZ. Ethical issues associated with solid organ transplantation and substance use: a scoping review. Monash Bioeth Rev 2020; 37:111-135. [PMID: 31749129 DOI: 10.1007/s40592-019-00100-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
While solid organ transplantation for patients with substance use issues has attracted ethical discussion, a typology of the ethics themes has not been articulated in the literature. We conducted a scoping review of peer-reviewed literature on solid organ transplantation and substance use published between January 1997 and April 2016. We aimed to identify and develop a typology of the main ethical themes discussed in this literature and to identify gaps worthy of future research. Seventy articles met inclusion criteria and underwent inductive content analysis. Four main ethical themes were identified: (1) personal responsibility; (2) utility; (3) moral character; and (4) fairness. Each theme had multiple sub-themes and there was substantial overlap between themes. This scoping review identified a disproportionate emphasis in the literature regarding personal responsibility, which was referenced by each of the other themes, and a narrow focus on alcohol and liver. We recommend future research further investigate these connections between ethical themes and focus on ethical issues associated with transplants from organ groups other than liver for patients who use substances other than alcohol.
Collapse
Affiliation(s)
- Lauren Notini
- Joint Centre for Bioethics, University of Toronto, 155 College Street, Suite 754, Toronto, ON, M5T 1P8, Canada.,Melbourne Law School, The University of Melbourne, 185 Pelham Street, Carlton, VIC, 3053, Australia.,Biomedical Ethics Research Group, Murdoch Children's Research Institute, 50 Flemington Road, Parkville, VIC, 3052, Australia
| | | | - Ani Orchanian-Cheff
- Library and Information Services, University Health Network, Toronto, ON, Canada
| | - Daniel Z Buchman
- Joint Centre for Bioethics, University of Toronto, 155 College Street, Suite 754, Toronto, ON, M5T 1P8, Canada. .,Bioethics Department, Toronto Western Hospital, University Health Network, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada. .,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada. .,Krembil Research Institute, Toronto, ON, Canada.
| |
Collapse
|
14
|
Shipley LC, Singal AK. Liver transplantation for alcoholic hepatitis. Transl Gastroenterol Hepatol 2020; 5:26. [PMID: 32258530 DOI: 10.21037/tgh.2019.11.17] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 11/05/2019] [Indexed: 12/12/2022] Open
Abstract
Alcoholic hepatitis (AH) is associated with a high short-term mortality. Currently, most transplant centers require minimum six months of abstinence from alcohol use before considering liver transplant for patients with end stage liver disease. Some recent data are emerging on the benefits and safety of early liver transplantation for patients with severe AH, a population who cannot meet the minimum six months sobriety. This article reviews the current status, benefits, challenges, barriers, and future prospects on early liver transplantation in patients with severe, acute AH.
Collapse
Affiliation(s)
- Lindsey C Shipley
- Division of Internal Medicine, University of Alabama, Birmingham, AL, USA
| | - Ashwani K Singal
- Division of Gastroenterology and Hepatology, University of South Dakota, Avera McKennan University Health Center and Transplant Institute, Sioux Falls, SD, USA
| |
Collapse
|
15
|
Ayyala-Somayajula D, Han H, Terrault NA. Selective use of liver transplantation for severe alcohol-associated hepatitis. Expert Rev Gastroenterol Hepatol 2020; 14:175-184. [PMID: 32077333 DOI: 10.1080/17474124.2020.1733414] [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] [Indexed: 10/25/2022]
Abstract
Introduction: Severe alcohol-associated hepatitis (sAH) portends high morbidity and mortality and there are no effective therapies for those ineligible or unresponsive to corticosteroids. Early liver transplantation (LT) defined as transplantation without a mandated period of sobriety, for sAH, is being increasingly considered as a rescue therapy.Areas covered: PubMed and manual searches were combined and last performed on 28 October 2019. Key search terms were 'alcoholic hepatitis', 'abstinence', 'alcohol relapse', and 'liver transplantation'. Terms were combined within each database. General reviews and references from published trials were also used.Expert opinion: Early LT is indicated in highly selected patients with sAH. While long-term data are sparse, 1 and 3-year survival post-transplantation are excellent and comparable to other liver diseases. Alcohol relapse is uncommon but approaches 10-25% at 3 years and if use is heavy and/or sustained leads to reduced survival. Thus, for continued application of transplantation for this indication, there is a need to further refine selection criteria and to optimize management of alcohol use disorder (AUD) in the transplant setting. Integral to advancing these objectives is the elimination of societal stigmatization and an acknowledgment that AUD is a medical condition that requires long-term management.
Collapse
Affiliation(s)
| | - Hyosun Han
- Department of Medicine, USC Keck School of Medicine, Los Angeles, CA, USA.,Division of Gastrointestinal and Liver Diseases, USC Keck School of Medicine, Los Angeles, CA, USA
| | - Norah A Terrault
- Department of Medicine, USC Keck School of Medicine, Los Angeles, CA, USA.,Division of Gastrointestinal and Liver Diseases, USC Keck School of Medicine, Los Angeles, CA, USA
| |
Collapse
|
16
|
The Forgotten Member of Patient Selection Committees: The US Constitution. Transplantation 2019; 104:452-453. [PMID: 31205259 DOI: 10.1097/tp.0000000000002794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
17
|
Obed A, Bashir A, Stern S, Jarrad A. Severe acute alcoholic hepatitis and liver transplant: A never-ending mournful story. Clin Mol Hepatol 2018; 24:358-366. [PMID: 30360030 PMCID: PMC6313024 DOI: 10.3350/cmh.2018.0044] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Accepted: 08/16/2018] [Indexed: 02/06/2023] Open
Abstract
Severe acute alcoholic liver disease (SAAH) unresponsive to medical therapy shows one-year-mortality rates of up to 90%. Most transplant centers request six months of alcohol abstinence prior to transplantation, the so-called "6-month rule." This regulation is not based on strong evidence, repeatedly making it a topic of controversial debates. The majority of patients with SAAH will die before fulfilling the 6-month rule. Therefore, liver transplantation (LT) protocols are becoming more flexible towards the rigid abstinence regulation, especially concerning SAAH patients. We conducted a literature review regarding LT in SAAH and its outcomes, including post-transplant mortality and recidivism. We studied available data on PubMed from 2011 and onwards whilst including articles dealing with genetic components, medical therapy and historic snapshots of alcoholism. Emerging studies recommend LT in SAAH not responding to medical therapies even without realizing the required abstinence period, since the majority of these patients would die within 6 months. SAAH without response to medical therapy has one-year-mortality rates of up to 90%. The 6-month rule is not based on strong evidence and is repeatedly a topic of controversial debates. There is genetic linkage to alcoholism and medical therapy is not as effective as estimated, yet. The 6-months-regulation has not shown to evidently decrease the risk of recidivism post-LT, which is a lifesaving treatment in SAAH patients. Insisting on rigid sobriety rules results in excluding patients with a low risk of recidivism from being transplanted. Moreover, the genetic linkage of alcoholism must be recognized.
Collapse
Affiliation(s)
- Aiman Obed
- Division of General, Hepatobiliary and Transplant Surgery, Jordan Hospital, Amman, Jordan
| | - Abdalla Bashir
- Division of General, Hepatobiliary and Transplant Surgery, Jordan Hospital, Amman, Jordan
| | - Steffen Stern
- Faculty of Law, Bielefeld University, Bielefeld, Germany
| | - Anwar Jarrad
- Division of Gastroenterology, Jordan Hospital, Amman, Jordan
| |
Collapse
|
18
|
Schieber K, Lindner M, Sowa JP, Gerken G, Scherbaum N, Kahraman A, Canbay A, Erim Y. Self-reports on symptoms of alcohol abuse: liver transplant patients versus rehabilitation therapy patients. Prog Transplant 2018; 25:203-9. [PMID: 26308778 DOI: 10.7182/pit2015618] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Context-Self-report measures often underestimate the severity of symptoms of alcohol abuse. It is generally supposed that patients who abuse alcohol tend to minimize their drinking behavior. However, the validity of self-reports also can be influenced by external factors such as the setting. Objective-To investigate how the setting influences self-reporting on symptoms of alcohol abuse in patients with alcoholic liver disease. Design, Setting and Participants-Cross-sectional study in patients before liver transplant (n = 40) and patients in rehabilitation therapy (n = 44). Main Outcome Measure-Scores on the Munich Alcoholism Test, which consists of a self-report-scale and an expert-rating scale. Results-The discrepancy in scores on the self-report scale and the expert-rating scale differed significantly between patients before liver transplant and patients in rehabilitation therapy. Furthermore, patients in the rehabilitation therapy group reported higher alcoholism scores on the self-report questionnaire than did patients before liver transplant, but the groups did not differ in the expert evaluation value. Conclusion-The transplant setting seems to evoke minimizing in self-reports in patients with alcohol abuse. Minimizing or denying symptoms of alcohol abuse does not seem to be a specific characteristic of persons with alcohol abuse, as it is also caused by the circumstances. In the transplant setting, more attention should be given to the psychologically difficult situation for patients with potential alcohol abuse. Implementation of psychoeducational interventions in the treatment process before transplant could be a first step toward reaching this goal.
Collapse
Affiliation(s)
- Katharina Schieber
- University Hospital of Erlangen (KS, YE), University Hospital, University Duisburg-Essen (ML, J-PS, GG, NS, AK, AC), Germany
| | - Marion Lindner
- University Hospital of Erlangen (KS, YE), University Hospital, University Duisburg-Essen (ML, J-PS, GG, NS, AK, AC), Germany
| | - Jan-Peter Sowa
- University Hospital of Erlangen (KS, YE), University Hospital, University Duisburg-Essen (ML, J-PS, GG, NS, AK, AC), Germany
| | - Guido Gerken
- University Hospital of Erlangen (KS, YE), University Hospital, University Duisburg-Essen (ML, J-PS, GG, NS, AK, AC), Germany
| | - Norbert Scherbaum
- University Hospital of Erlangen (KS, YE), University Hospital, University Duisburg-Essen (ML, J-PS, GG, NS, AK, AC), Germany
| | - Alisan Kahraman
- University Hospital of Erlangen (KS, YE), University Hospital, University Duisburg-Essen (ML, J-PS, GG, NS, AK, AC), Germany
| | - Ali Canbay
- University Hospital of Erlangen (KS, YE), University Hospital, University Duisburg-Essen (ML, J-PS, GG, NS, AK, AC), Germany
| | - Yesim Erim
- University Hospital of Erlangen (KS, YE), University Hospital, University Duisburg-Essen (ML, J-PS, GG, NS, AK, AC), Germany
| |
Collapse
|
19
|
Attilia ML, Lattanzi B, Ledda R, Galli AM, Farcomeni A, Rotondo C, Di Gregorio V, Mennini G, Poli E, Attilia F, Ginanni Corradini S, Rossi M, Merli M. The multidisciplinary support in preventing alcohol relapse after liver transplantation: A single-center experience. Clin Transplant 2018; 32:e13243. [PMID: 29573476 DOI: 10.1111/ctr.13243] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIM Alcoholic liver disease (ALD) represents a frequent indication for liver transplantation (LT). Since 2004, we have adopted a program of multidisciplinary support(MS) to assist patients undergoing LT for ALD. We aimed at analyzing the relapse rate and the risk factors for relapse. The relapse rate was also compared with that of a historical group of patients who underwent transplantation. Their survival rate was also analyzed. PATIENTS AND METHODS Consecutive patients with ALD transplanted from 2004 were included. The most important demographic, psychosocial, and clinical characteristics known to be associated with alcohol relapse were recorded. RESULTS Sixty-nine patients underwent MS: 8.7% presented alcohol relapse. At multivariate analysis female gender (sHR 9.02, 95% CI 1.71-47.56, P = .009), alcohol withdrawal syndrome (sHR 5.89, 95% CI 1.42-24.46, P = .015) and a shorter time of MS program before LT (sHR 0.928 per month, 95% CI 0.870-0.988, P = .021) were identified as independent risk factors for relapse. The rate of alcohol relapse was significantly lower than that of the historical group who did not undergo MS (sHR 0.21, 95% CI: 0.06-0.68; P = .009). CONCLUSION This study shows that a MS program may contribute to alcohol relapse prevention after LT in ALD patients. However, the relevance of this support needs to be confirmed by clinical trials.
Collapse
Affiliation(s)
- Maria Luisa Attilia
- Department of Clinical Medicine, Alcohol Dependence Unit, Sapienza University of Rome, Rome, Italy
| | - Barbara Lattanzi
- Department of Clinical Medicine, Gastroenterology Unit, Sapienza University of Rome, Rome, Italy
| | - Roberta Ledda
- Department of Clinical Medicine, Alcohol Dependence Unit, Sapienza University of Rome, Rome, Italy
| | - Anna Maria Galli
- Department of Clinical Medicine, Alcohol Dependence Unit, Sapienza University of Rome, Rome, Italy
| | - Alessio Farcomeni
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Claudia Rotondo
- Department of Clinical Medicine, Alcohol Dependence Unit, Sapienza University of Rome, Rome, Italy
| | - Vincenza Di Gregorio
- Department of Clinical Medicine, Gastroenterology Unit, Sapienza University of Rome, Rome, Italy
| | - Gianluca Mennini
- Department of General Surgery and Organ Transplantation, Sapienza University of Rome, Rome, Italy
| | - Edoardo Poli
- Department of Clinical Medicine, Gastroenterology Unit, Sapienza University of Rome, Rome, Italy
| | - Fabio Attilia
- Department of Clinical Medicine, Alcohol Dependence Unit, Sapienza University of Rome, Rome, Italy
| | | | - Massimo Rossi
- Department of General Surgery and Organ Transplantation, Sapienza University of Rome, Rome, Italy
| | - Manuela Merli
- Department of Clinical Medicine, Gastroenterology Unit, Sapienza University of Rome, Rome, Italy
| |
Collapse
|
20
|
Lucey MR. Liver transplantation for severe alcoholic hepatitis- The PRO view. Liver Int 2017; 37:343-344. [PMID: 28240837 DOI: 10.1111/liv.13343] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 12/08/2016] [Indexed: 12/18/2022]
Abstract
Although liver transplantation has become accepted as a life-saving treatment of last resort for most life-threatening liver disorders, the use of liver transplantation to rescue patients with severe alcoholic hepatitis unresponsive to medical therapy remains controversial. I propose the concepts that alcohol use disorder is an illness, that on occasion results in alcoholic liver disease and that treatment of alcoholic liver disease, including treatment of patients with severe alcoholic hepatitis, combines treatment of the alcohol use disorder and of alcoholic liver disease. From this I derive the following principal to govern selection of patients for liver transplantation of patients with alcohol use disorder: that alcohol use disorder should impact suitability for liver transplantation as a co-morbid disorder, in the same way as other common co-morbid disorders such as diabetes mellitus or systemic hypertension, are factored in the selection process. We should relate the risk of drinking relapse to the prognosis of the patient after transplantation, rather than in a binary construct of likelihood of maintaining abstinence vs drinking.
Collapse
Affiliation(s)
- Michael R Lucey
- Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| |
Collapse
|
21
|
Onishi Y, Kimura H, Hori T, Kishi S, Kamei H, Kurata N, Tsuboi C, Yamaguchi N, Takahashi M, Sunada S, Hirano M, Fujishiro H, Okada T, Ishigami M, Goto H, Ozaki N, Ogura Y. Risk of alcohol use relapse after liver transplantation for alcoholic liver disease. World J Gastroenterol 2017; 23:869-875. [PMID: 28223731 PMCID: PMC5296203 DOI: 10.3748/wjg.v23.i5.869] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 11/06/2016] [Accepted: 12/08/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate factors, including psychosocial factors, associated with alcoholic use relapse after liver transplantation (LT) for alcoholic liver disease (ALD).
METHODS The clinical records of 102 patients with ALD who were referred to Nagoya University Hospital for LT between May 2003 and March 2015 were retrospectively evaluated. History of alcohol intake was obtained from their clinical records and scored according to the High-Risk Alcoholism Relapse scale, which includes duration of heavy drinking, types and amount of alcohol usually consumed, and previous inpatient treatment history for alcoholism. All patients were assessed for eligibility for LT according to comprehensive criteria, including Child-Pugh score, Model for End-Stage Liver Disease score, and psychosocial criteria.
RESULTS Of the 102 patients with ALD referred for LT, seven (6.9%) underwent LT. One (14.3%) of these seven patients returned to heavy drinking, but that patient was able to successfully quit drinking following an immediate intervention, consisting of psychotherapeutic education and supportive psychotherapy, by a psychiatrist. A comparison between the transplantation/registration (T/R) group, consisting of the seven patients who underwent LT and 10 patients listed for deceased donor LT, and 50 patients who did not undergo LT and were not listed for deceased donor LT (non-T/R group), showed statistically significant differences in duration of abstinence period (P < 0.01), duration of heavy drinking (P < 0.05), adherence to medical treatment (P < 0.01), and declaration of abstinence (P < 0.05).
CONCLUSION Patients with ALD referred for LT require comprehensive evaluation, including evaluation of psychosocial criteria, to prevent alcoholic recidivism.
Collapse
|
22
|
Dom G. Confidentiality and the Role of the Addiction Specialist Team in Liver Transplantation Procedures. Commentary on Donnadieu-Rigole et al., 2017, Follow-Up of Alcohol Consumption After Liver Transplantation: Interest of an Addiction Team? Alcohol Clin Exp Res 2017; 41:504-506. [PMID: 28055117 DOI: 10.1111/acer.13324] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Accepted: 12/30/2016] [Indexed: 12/12/2022]
Affiliation(s)
- Geert Dom
- Collaborative Antwerp Psychiatric Research Institute (CAPRI), Antwerp University (UA), Antwerp, Belgium.,Antwerp University Hospital (UZA), Edegem, Belgium
| |
Collapse
|
23
|
Saberi B, Dadabhai AS, Jang YY, Gurakar A, Mezey E. Current Management of Alcoholic Hepatitis and Future Therapies. J Clin Transl Hepatol 2016; 4:113-22. [PMID: 27350941 PMCID: PMC4913072 DOI: 10.14218/jcth.2016.00006] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Revised: 03/27/2016] [Accepted: 03/28/2016] [Indexed: 12/12/2022] Open
Abstract
Alcohol is one of the most common etiologies of liver disease, and alcoholic liver disease overall is the second most common indication for liver transplantation in the United States. It encompasses a spectrum of disease, including fatty liver disease, alcoholic hepatitis (AH), and alcoholic cirrhosis. AH can range from mild to severe disease, with severe disease being defined as: Discriminant Function (DF) ≥ 32, or Model for End-stage Liver Disease (MELD) ≥ 21, or presence of hepatic encephalopathy. Management of the mild disease consists mainly of abstinence and supportive care. Severe AH is associated with significant mortality. Currently, there is no ideal medical treatment for this condition. Besides alcohol cessation, corticosteroids have been used with conflicting results and are associated with an inherent risk of infection. Overall steroids have shown short term benefit when compared to placebo, but they have no obvious long term benefits. Pentoxifylline does not improve survival in patients with severe AH and is no longer recommended based on the results of the STOPAH (Steroid Or Pentoxifylline for Alcoholic Hepatitis) trial. Anti-tumor necrosis factor (TNF) agents are associated with increased risk of life threatening infections and death. Currently, early stage trials are underway, mainly targeting novel pathways based on disease pathogenesis, including modulation of innate immune system, inhibition of gut-liver axis and cell death pathways, and activation of transcription factor farnesyl X receptor (FXR). Future treatment may lie in human induced pluripotent stem cell (iPSC) technology, which is currently under investigation for the study of pathogenesis, drug discovery, and stem cell transplantation. Liver transplantation has been reported with good results in highly selected patients but is controversial due to limited organ supply.
Collapse
Affiliation(s)
- Behnam Saberi
- Division of Gastroenterology and Hepatology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- *Correspondence to: Behnam Saberi, Division of Gastroenterology and Hepatology, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA. Tel: +1-410-614-2543, Fax: +1-410-614-7340, E-mail:
| | - Alia S. Dadabhai
- Division of Gastroenterology and Hepatology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Yoon-Young Jang
- Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ahmet Gurakar
- Division of Gastroenterology and Hepatology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Esteban Mezey
- Division of Gastroenterology and Hepatology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
24
|
Lucey MR, Rice JP. Liver Transplantation for Severe Alcoholic Hepatitis Crosses the Atlantic. Am J Transplant 2016; 16:739-40. [PMID: 26780360 DOI: 10.1111/ajt.13587] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 10/10/2015] [Accepted: 10/14/2015] [Indexed: 01/25/2023]
Affiliation(s)
- M R Lucey
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - J P Rice
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| |
Collapse
|
25
|
Im GY, Kim-Schluger L, Shenoy A, Schubert E, Goel A, Friedman SL, Florman S, Schiano TD. Early Liver Transplantation for Severe Alcoholic Hepatitis in the United States--A Single-Center Experience. Am J Transplant 2016; 16:841-9. [PMID: 26710309 DOI: 10.1111/ajt.13586] [Citation(s) in RCA: 174] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 08/16/2015] [Accepted: 08/31/2015] [Indexed: 01/25/2023]
Abstract
Early liver transplantation (LT) in European centers reportedly improved survival in patients with severe alcoholic hepatitis (AH) not responding to medical therapy. Our aim was to determine if a strategy of early LT for severe AH could be applied successfully in the United States. We reviewed 111 patients with severe AH at our center from January 2012 to January 2015. The primary end point was mortality at 6 months or early LT, with a secondary end point of alcohol relapse after LT. Survival was compared between those receiving early LT and matched patients who did not. Using a process similar to the European trial, 94 patients with severe AH not responding to medical therapy were evaluated for early LT. Overall, 9 (9.6%) candidates with favorable psychosocial profiles underwent early LT, comprising 3% of all adult LT during the study period. The 6-month survival rate was higher among those receiving early LT compared with matched controls (89% vs 11%, p<0.001). Eight recipients are alive at a median of 735 days with 1 alcohol relapse. Early LT for severe AH can achieve excellent clinical outcomes with low impact on the donor pool and low rates of alcohol relapse in highly selected patients in the United States.
Collapse
Affiliation(s)
- G Y Im
- Recanati/Miller Transplantation Institute, Division of Liver Diseases, Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - L Kim-Schluger
- Recanati/Miller Transplantation Institute, Division of Liver Diseases, Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - A Shenoy
- Department of Psychiatry, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - E Schubert
- Social Work Services, The Mount Sinai Medical Center, New York, NY
| | - A Goel
- Division of Liver Diseases, Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - S L Friedman
- Division of Liver Diseases, Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - S Florman
- Recanati/Miller Transplantation Institute, Division of Liver Diseases, Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - T D Schiano
- Recanati/Miller Transplantation Institute, Division of Liver Diseases, Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY
| |
Collapse
|
26
|
|
27
|
Kuntz K, Weinland SR, Butt Z. Psychosocial Challenges in Solid Organ Transplantation. J Clin Psychol Med Settings 2015; 22:122-35. [DOI: 10.1007/s10880-015-9435-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
|
28
|
Obed A, Stern S, Jarrad A, Lorf T. Six month abstinence rule for liver transplantation in severe alcoholic liver disease patients. World J Gastroenterol 2015; 21:4423-4426. [PMID: 25892898 PMCID: PMC4394109 DOI: 10.3748/wjg.v21.i14.4423] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2014] [Revised: 01/12/2015] [Accepted: 01/30/2015] [Indexed: 02/06/2023] Open
Abstract
Alcoholic liver disease (ALD) is the second most common diagnosis among patients undergoing liver transplantation (LT). The recovery results of patients transplanted for ALD are often at least as good as those of patients transplanted for other diagnoses and better than those suffering from hepatitis C virus, cryptogenic cirrhosis, or hepatocellular carcinoma. In the case of medically non-responding patients with severe acute alcoholic hepatitis or acute-on chronic liver failure, the refusal of LT is often based on the lack of the required alcohol abstinence period of six months. The obligatory abidance of a period of abstinence as a transplant eligibility requirement for medically non-responding patients seems unfair and inhumane, since the majority of these patients will not survive the six-month abstinence period. Data from various studies have challenged the 6-mo rule, while excellent survival results of LT have been observed in selected patients with severe alcoholic hepatitis not responding to medical therapy. Patients with severe advanced ALD should have legal access to LT. The mere lack of pre-LT abstinence should not be an obstacle for being listed.
Collapse
|
29
|
Dom G, Wojnar M, Crunelle CL, Thon N, Bobes J, Preuss UW, Addolorato G, Seitz HK, Wurst FM. Assessing and treating alcohol relapse risk in liver transplantation candidates. Alcohol Alcohol 2015; 50:164-72. [PMID: 25557607 DOI: 10.1093/alcalc/agu096] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
In Europe between 30 and 50% of all liver transplantations (LTX) are done within the context of chronic end-stage alcoholic liver disease (ALD). However, post-operatively 20-25% of these patients lapse or relapse into heavy alcohol use. Thus, assessment of alcohol relapse risk before enlisting and therapeutic follow-up during and after LTX is of utmost importance. However, as yet there are enormous differences between European countries and between transplant centers, with regard to the assessment methods and criteria and the implementation of therapeutic follow-up. Only the so-called '6-month abstinence' rule is widely used. However, there are not much scientific data validating its use in predicting relapse. Thus, there is a clear need of a more homogeneous approach, which was the focus of a symposium of the European Federation of Addiction Societies during the 14th conference of the European Society for Biomedical Research on Alcoholism, 2013 (ESBRA), entitled 'Liver transplantation: A European perspective'. In a follow-up on this symposium, the authors aim to sum up the evidence of psychiatric assessment criteria and psychiatric treatment interventions relevant in the context of patient selection and patient follow-up within ALD transplantation procedures. Based upon these findings, we propose elements of a procedure that can serve as a first step toward a model of good practice regarding addiction-specialist input within the pre- and post-transplantation period.
Collapse
Affiliation(s)
- G Dom
- Collaborative Antwerp Psychiatric Research Institute (CAPRI), Antwerp University (UA), Antwerpen, Belgium
| | - M Wojnar
- Medical University of Warsaw, Warszawa, Poland
| | - C L Crunelle
- Collaborative Antwerp Psychiatric Research Institute (CAPRI) & Department of Toxicology, Antwerp University (UA), Antwerpen, Belgium
| | - N Thon
- Universitätsklinik für Psychiatrie und Psychotherapie II, Salzburg, Austria
| | - J Bobes
- University of Oviedo, CIBERSAM, Oviedo, Spain
| | - U W Preuss
- Hospital of Prignitz, Perleberg, Germany
| | - G Addolorato
- Catholic University of Rome & Gemelli Hospital, Rome, Italy
| | - H K Seitz
- Center of Alcohol Research, Liver Disease and Nutrition, Salem Medical Center, Heidelberg, Germany
| | - F M Wurst
- Universitätsklinik für Psychiatrie und Psychotherapie II, Christian-Doppler-Klinik & Gemeinnützige Salzburger Landeskliniken Betriebsgesellschaft mbH, Salzburg, Austria
| |
Collapse
|
30
|
Testino G, Burra P, Bonino F, Piani F, Sumberaz A, Peressutti R, Castiglione AG, Patussi V, Fanucchi T, Ancarani O, Cerce GD, Iannini AT, Greco G, Mosti A, Durante M, Babocci P, Quartini M, Mioni D, Aricò S, Baselice A, Leone S, Lozer F, Scafato E, Borro P. Acute alcoholic hepatitis, end stage alcoholic liver disease and liver transplantation: An Italian position statement. World J Gastroenterol 2014; 20:14642-14651. [PMID: 25356027 PMCID: PMC4209530 DOI: 10.3748/wjg.v20.i40.14642] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 01/18/2014] [Accepted: 06/23/2014] [Indexed: 02/06/2023] Open
Abstract
Alcoholic liver disease encompasses a broad spectrum of diseases ranging from steatosis steatohepatitis, fibrosis, and cirrhosis to hepatocellular carcinoma. Forty-four per cent of all deaths from cirrhosis are attributed to alcohol. Alcoholic liver disease is the second most common diagnosis among patients undergoing liver transplantation (LT). The vast majority of transplant programmes (85%) require 6 mo of abstinence prior to transplantation; commonly referred to as the “6-mo rule”. Both in the case of progressive end-stage liver disease (ESLD) and in the case of severe acute alcoholic hepatitis (AAH), not responding to medical therapy, there is a lack of evidence to support a 6-mo sobriety period. It is necessary to identify other risk factors that could be associated with the resumption of alcohol drinking. The “Group of Italian Regions” suggests that: in a case of ESLD with model for end-stage liver disease < 19 a 6-mo abstinence period is required; in a case of ESLD, a 3-mo sober period before LT may be more ideal than a 6-mo period, in selected patients; and in a case of severe AAH, not responding to medical therapies (up to 70% of patients die within 6 mo), LT is mandatory, even without achieving abstinence. The multidisciplinary transplant team must include an addiction specialist/hepato-alcohologist. Patients have to participate in self-help groups.
Collapse
|
31
|
Abstract
Alcoholic hepatitis is an acute manifestation of alcoholic liver disease with mortality as high as 40-50% in severe cases. Patients usually have a history of prolonged alcohol abuse with or without a known history of liver disease. Although there is significant range in severity at presentation, patients with severe alcoholic hepatitis typically present with anorexia, fatigue, fever, jaundice, and ascites. The use of either pentoxifylline or corticosteroids in those with severe disease (Maddrey's discriminate function >32) has significant mortality benefit. The addition of N-acetylcysteine to corticosteroids decreases the incidences of hepatorenal syndrome, infection, and short-term mortality, but does not appear to significantly affect 6-month mortality. Nutritional support with high-calorie, high-protein diet is recommended in all patients screening positive for malnutrition. Liver transplantation for a highly selected group of patients with severe alcoholic hepatitis may be an option in the future, but is not currently recommended or available at most transplant institutions.
Collapse
|
32
|
Berlakovich GA. Challenges in transplantation for alcoholic liver disease. World J Gastroenterol 2014; 20:8033-8039. [PMID: 25009374 PMCID: PMC4081673 DOI: 10.3748/wjg.v20.i25.8033] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Revised: 01/28/2014] [Accepted: 03/13/2014] [Indexed: 02/06/2023] Open
Abstract
Transplantation for the treatment of alcoholic cirrhosis is more controversially discussed than it is for any other indication. The crucial aspect in this setting is abstinence before and after liver transplantation. We established pre-transplant selection criteria for potential transplant candidates. Provided that the underlying disease can be treated, there is no reason to withhold liver transplantation in a patient suffering from alcoholic cirrhosis. Evaluation of the patient by a multidisciplinary team, including an addiction specialist, is considered to be the gold standard. However, several centers demand a specified period of abstinence - usually 6 mo- irrespective of the specialist’s assessment. The 6-mo rule is viewed critically because liver transplantation was found to clearly benefit selected patients with acute alcoholic hepatitis; the benefit was similar to that achieved for other acute indications. However, the discussion may well be an academic one because the waiting time for liver transplantation exceeds six months at the majority of centers. The actual challenge in liver transplantation for alcoholic cirrhosis may well be the need for lifelong post-transplant follow-up rather than the patient’s pre-transplant evaluation. A small number of recipients experience a relapse of alcoholism; these patients are at risk for organ damage and graft-related death. Post-transplant surveillance protocols should demonstrate alcohol relapse at an early stage, thus permitting the initiation of adequate treatment. Patients with alcoholic cirrhosis are at high risk of developing head and neck, esophageal, or lung cancer. The higher risk of malignancies should be considered in the routine assessment of patients suffering from alcoholic cirrhosis. Tumor surveillance protocols for liver transplant recipients, currently being developed, should become a part of standard care; these will improve survival by permitting diagnosis at an early stage. In conclusion, the key factor determining the outcome of transplantation for alcoholic cirrhosis is intensive lifelong medical and psychological care. Post-transplant surveillance might be much more important than pre-transplant selection.
Collapse
|
33
|
Overview of the indications and contraindications for liver transplantation. Cold Spring Harb Perspect Med 2014; 4:4/5/a015602. [PMID: 24789874 DOI: 10.1101/cshperspect.a015602] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Liver transplantation is the only definitive treatment option for patients with irrevocable acute or chronic liver failure. In the last four decades, liver transplantation has developed from an experimental approach with a very high mortality to an almost routine procedure with good short- and long-term survival rates. Here, we present an up-to-date overview of the indications and contraindications for liver transplantation. It is shown how the evaluation of a candidate and finally listing for transplantation has to be performed in a multidisciplinary setting. Meticulous listing, timing, and organ allocation are the crucial factors to achieve an optimal outcome for the individual patient on the one hand, and reasonably using the limited deceased donor pool on the other hand. Living-donor liver transplantation is demanding but necessarily increasing. Because patients after liver transplantation need lifelong aftercare, it is important for primary care clinicians to understand the basic medical problems and risks.
Collapse
|
34
|
Congly SE, Doucette KE, Coffin CS. Outcomes and management of viral hepatitis and human immunodeficiency virus co-infection in liver transplantation. World J Gastroenterol 2014; 20:414-424. [PMID: 24574710 PMCID: PMC3923016 DOI: 10.3748/wjg.v20.i2.414] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Revised: 10/22/2013] [Accepted: 11/05/2013] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation for human immunodeficiency virus (HIV) positive patients with viral hepatitis co-infection is increasingly offered in many North American and European liver transplant centers. Prior studies have demonstrated acceptable post-transplant outcomes and no increased risk of HIV complications in patients co-infected with hepatitis B virus (HBV). However, liver transplantation in HIV positive patients with hepatitis C virus (HCV) has poorer outcomes overall, requiring careful selection of candidates. This review aims to summarize the published literature on outcomes after transplant in HIV patients with HBV or HCV related end-stage liver disease and recommendations for management. In particular the pre-transplant factors impacting outcomes in HCV/HIV co-infected candidates and importance of multidisciplinary management will be discussed.
Collapse
|