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Mohy-Ud-Din N, Lin FP, Rachakonda V, Al-Khafaji A, Biggins SW, Ganesh S, Bataller R, DiMartini A, Hughes C, Humar A, Malik SM. Expedited liver transplantation as first-line therapy for severe alcohol hepatitis: ELFSAH; deferring corticosteroids in the sickest subset of patients. Clin Transplant 2024; 38:e15340. [PMID: 39049597 DOI: 10.1111/ctr.15340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 05/03/2024] [Accepted: 05/10/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND & AIMS Severe alcohol-associated hepatitis (SAH) represents a lethal subset of alcohol-associated liver disease. Although corticosteroids are recommended by guidelines, their efficacy and safety remain questionable and so liver transplantation (LT) has been increasingly utilized. The timing and indication of corticosteroid use, specifically in patients being considered for LT requires further clarification. METHODS A retrospective analysis was conducted on 256 patients with SAH between 2018 and 2022 at a single US center. RESULTS Twenty of these patients underwent LT. Of the 256 patients, 38% had what we termed "catastrophic" SAH, defined as a MELD-Na ≥35 and/or discriminant function (DF) ≥100, which carried a mortality of 90% without LT. Compared with 100 matched controls, patients undergoing LT exhibited a one-year survival rate of 100% versus 35% (p < .0005). LT provided an absolute risk reduction of 65%, with a number needed to treat of 1.5. Steroid utilization in the entire cohort was 19% with 60% developing severe complications. Patients administered steroids were younger with lower MELD and DF scores. Only 10% of those prescribed steroids derived a favorable response. Sustained alcohol use post-LT was 20%. CONCLUSIONS We propose ELFSAH: Expedited LT as First Line Therapy for SAH; challenging the current paradigm with recommendations to defer steroids in patients with "catastrophic" SAH (defined as: MELD-Na ≥35 and/or DF ≥100). Patients should be seen urgently by hepatology, transplant surgery, psychiatry and social work. Patients without an absolute contraindication should be referred for LT as first-line therapy during their index admission.
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Affiliation(s)
- Nabeeha Mohy-Ud-Din
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Fei-Pi Lin
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Vikrant Rachakonda
- Division of Gastroenterology and Hepatology, University of California Davis School of Medicine Veteran's Association Northern California Healthcare System, Sacramento, California, USA
| | - Ali Al-Khafaji
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Scott W Biggins
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Swaytha Ganesh
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | - Andrea DiMartini
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Christopher Hughes
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Abhinav Humar
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Shahid M Malik
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Ramirez-Cadiz C, Blaney H, Kubanek N, Díaz LA, Loomba R, Skladany L, Arab JP. Review article: Current indications and selection criteria for early liver transplantation in severe alcohol-associated hepatitis. Aliment Pharmacol Ther 2024; 59:1049-1061. [PMID: 38475893 DOI: 10.1111/apt.17948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 10/17/2023] [Accepted: 03/03/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND Alcohol-associated hepatitis (AH) is a severe inflammatory form of alcohol-associated liver disease (ALD) that carries a high mortality rate. Early liver transplantation for severe AH is increasingly available. However, specific criteria for referral and selection remain a subject of debate. AIMS To provide a narrative review of the natural history, diagnostic criteria and indications for referral for early liver transplantation for severe AH. METHODS We searched PubMed for articles published through August 2023. Key search terms were 'alcoholic hepatitis,' 'alcohol-associated hepatitis,' 'abstinence,' 'alcohol relapse,' and 'liver transplantation.' RESULTS Previously, a six-month period of alcohol abstinence was required before patients with ALD were considered for liver transplantation. However, studies in recent years have demonstrated that, among carefully selected patients, patients who received early transplants have much higher survival rates than patients with similarly severe disease who did not undergo transplants (77% vs. 23%). Despite these successes, early liver transplantation remains controversial, as these patients have typically not undergone treatment for alcohol use disorder, with the ensuing risk of returning to alcohol use. CONCLUSIONS While early liver transplantation for AH has survival benefits, many patients would not have received treatment for alcohol use disorder. An integrated approach to evaluating candidacy for early liver transplantation is needed.
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Affiliation(s)
- Carolina Ramirez-Cadiz
- Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada
| | - Hanna Blaney
- Division of Gastroenterology and Hepatology, University of Maryland, College Park, Maryland, USA
| | - Natalia Kubanek
- Division of Hepatology, Gastroenterology and Liver Transplantation, Department of Internal Medicine II, Slovak Medical University Faculty of Medicine, F. D. Roosevelt University Hospital, Banska Bystrica, Slovak Republic
| | - Luis Antonio Díaz
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Rohit Loomba
- Division of Gastroenterology, University of California at San Diego, San Diego, California, USA
| | - Lubomir Skladany
- Division of Hepatology, Gastroenterology and Liver Transplantation, Department of Internal Medicine II, Slovak Medical University Faculty of Medicine, F. D. Roosevelt University Hospital, Banska Bystrica, Slovak Republic
| | - Juan Pablo Arab
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine, Western University, London, Ontario, Canada
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3
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He YX, Liu MN, Wang YY, Wu H, Wei M, Xue JY, Zou Y, Zhou X, Chen H, Li Z. Hovenia dulcis: a Chinese medicine that plays an essential role in alcohol-associated liver disease. Front Pharmacol 2024; 15:1337633. [PMID: 38650630 PMCID: PMC11033337 DOI: 10.3389/fphar.2024.1337633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 03/18/2024] [Indexed: 04/25/2024] Open
Abstract
Globally, alcohol-associated liver disease (ALD) has become an increased burden for society. Disulfirams, Benzodiazepines (BZDs), and corticosteroids are commonly used to treat ALD. However, the occurrence of side effects such as hepatotoxicity and dependence, impedes the achievement of desirable and optimal therapeutic efficacy. Therefore, there is an urgent need for more effective and safer treatments. Hovenia dulcis is an herbal medicine promoting alcohol removal clearance, lipid-lowering, anti-inflammatory, and hepatoprotective properties. Hovenia dulcis has a variety of chemical components such as dihydromyricetin, quercetin and beta-sitosterol, which can affect ALD through multiple pathways, including ethanol metabolism, immune response, hepatic fibrosis, oxidative stress, autophagy, lipid metabolism, and intestinal barrier, suggesting its promising role in the treatment of ALD. Thus, this work aims to comprehensively review the chemical composition of Hovenia dulcis and the molecular mechanisms involved in the process of ALD treatment.
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Affiliation(s)
- Yi-Xiang He
- The Key Laboratory of Integrated Traditional Chinese and Western Medicine for Prevention and Treatment of Digestive System Diseases of Luzhou City, Affiliated Traditional Medicine Hospital of Southwest Medical University, Luzhou, Sichuan, China
- College of Integrated Chinese and Western Medicine, Southwest Medical University, Luzhou, Sichuan, China
| | - Meng-Nan Liu
- College of Integrated Chinese and Western Medicine, Southwest Medical University, Luzhou, Sichuan, China
| | - Yang-Yang Wang
- The Key Laboratory of Integrated Traditional Chinese and Western Medicine for Prevention and Treatment of Digestive System Diseases of Luzhou City, Affiliated Traditional Medicine Hospital of Southwest Medical University, Luzhou, Sichuan, China
- College of Integrated Chinese and Western Medicine, Southwest Medical University, Luzhou, Sichuan, China
| | - Hao Wu
- College of Integrated Chinese and Western Medicine, Southwest Medical University, Luzhou, Sichuan, China
| | - Mei Wei
- The Key Laboratory of Integrated Traditional Chinese and Western Medicine for Prevention and Treatment of Digestive System Diseases of Luzhou City, Affiliated Traditional Medicine Hospital of Southwest Medical University, Luzhou, Sichuan, China
- College of Integrated Chinese and Western Medicine, Southwest Medical University, Luzhou, Sichuan, China
| | - Jin-Yi Xue
- College of Integrated Chinese and Western Medicine, Southwest Medical University, Luzhou, Sichuan, China
| | - Yuan Zou
- College of Integrated Chinese and Western Medicine, Southwest Medical University, Luzhou, Sichuan, China
| | - Xin Zhou
- The Key Laboratory of Integrated Traditional Chinese and Western Medicine for Prevention and Treatment of Digestive System Diseases of Luzhou City, Affiliated Traditional Medicine Hospital of Southwest Medical University, Luzhou, Sichuan, China
- College of Integrated Chinese and Western Medicine, Southwest Medical University, Luzhou, Sichuan, China
- Department of Spleen and Stomach Diseases, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Hui Chen
- The Key Laboratory of Integrated Traditional Chinese and Western Medicine for Prevention and Treatment of Digestive System Diseases of Luzhou City, Affiliated Traditional Medicine Hospital of Southwest Medical University, Luzhou, Sichuan, China
- College of Integrated Chinese and Western Medicine, Southwest Medical University, Luzhou, Sichuan, China
- Department of Spleen and Stomach Diseases, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Zhi Li
- The Key Laboratory of Integrated Traditional Chinese and Western Medicine for Prevention and Treatment of Digestive System Diseases of Luzhou City, Affiliated Traditional Medicine Hospital of Southwest Medical University, Luzhou, Sichuan, China
- College of Integrated Chinese and Western Medicine, Southwest Medical University, Luzhou, Sichuan, China
- Department of Spleen and Stomach Diseases, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, Sichuan, China
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Cox B, Carrique L, Di Maira T, Sales I, Don C, Gómez-Aldana A, Koshy D, Abbey S, Lilly L, Tsien C, Bhat M, Jaeckel E, Lynch MJ, Selzner N. Outcomes of re-referrals of patients with alcohol-associated liver disease, who were previously declined for liver transplantation. Liver Transpl 2024; 30:254-261. [PMID: 37772886 DOI: 10.1097/lvt.0000000000000274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 08/28/2023] [Indexed: 09/30/2023]
Abstract
Since 2018, our program has utilized specific psychosocial criteria and a multidisciplinary approach to assess patients for liver transplant due to alcohol-associated liver disease (ALD), rather than the 6-month abstinence rule alone. If declined based on these criteria, specific recommendations are provided to patients and their providers regarding goals for re-referral to increase the potential for future transplant candidacy. Recommendations include engagement in treatment for alcohol use disorder, serial negative biomarker testing, and maintenance of abstinence from alcohol. In our current study, we evaluate the outcomes of patients with ALD, who were initially declined upon assessment and re-referred to our program. This is a retrospective cohort study that includes 98 patients with ALD, who were previously declined for liver transplantation and were subsequently re-referred for liver transplant assessment between May 1, 2018, and December 31, 2021. We assess the outcomes of patients who were re-referred including acceptance for transplantation following a second assessment. Of the 98 patients who were re-referred, 46 (46.9%) fulfilled the recommendations made and proceeded to further medical evaluation. Nine were eventually transplanted; others are listed and are waiting for transplant. The presence of a partner was independently associated with a higher rate of acceptance (OR 0.16, 95% CI: 0.03-0.97, p = 0.05). Most of the patients who did not proceed further (n = 52) were declined again due to ALD contraindications (n = 33, 63.4%), including ongoing drinking and lack of engagement in recommended addiction treatment. Others had medical contraindications (11.2%), clinically improved (6.1%), had adherence issues (5.1%), or lack of adequate support (2%). Patients with ALD previously declined for a liver transplant can be re-referred and successfully accepted for transplantation by fulfilling the recommendations made by the multidisciplinary team. Important factors including ongoing abstinence, engagement in addiction treatment, and social support are key for successful acceptance.
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Affiliation(s)
- Ben Cox
- Ajmera Transplant Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Lauren Carrique
- Ajmera Transplant Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Tommaso Di Maira
- Ajmera Transplant Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Liver Transplantation and Hepatology Unit, University Hospital La Fe, Valencia, Spain
- CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
- IIS La Fe, Valencia, Spain
| | - Isabel Sales
- Ajmera Transplant Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Caitlin Don
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Andres Gómez-Aldana
- Ajmera Transplant Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Dilip Koshy
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Susan Abbey
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Les Lilly
- Ajmera Transplant Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Cynthia Tsien
- Ajmera Transplant Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Mamatha Bhat
- Ajmera Transplant Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Elmar Jaeckel
- Ajmera Transplant Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Marie-Josee Lynch
- Ajmera Transplant Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Nazia Selzner
- Ajmera Transplant Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Listopad S, Magnan C, Day LZ, Asghar A, Stolz A, Tayek JA, Liu ZX, Jacobs JM, Morgan TR, Norden-Krichmar TM. Identification of integrated proteomics and transcriptomics signature of alcohol-associated liver disease using machine learning. PLOS DIGITAL HEALTH 2024; 3:e0000447. [PMID: 38335183 PMCID: PMC10857706 DOI: 10.1371/journal.pdig.0000447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 01/09/2024] [Indexed: 02/12/2024]
Abstract
Distinguishing between alcohol-associated hepatitis (AH) and alcohol-associated cirrhosis (AC) remains a diagnostic challenge. In this study, we used machine learning with transcriptomics and proteomics data from liver tissue and peripheral mononuclear blood cells (PBMCs) to classify patients with alcohol-associated liver disease. The conditions in the study were AH, AC, and healthy controls. We processed 98 PBMC RNAseq samples, 55 PBMC proteomic samples, 48 liver RNAseq samples, and 53 liver proteomic samples. First, we built separate classification and feature selection pipelines for transcriptomics and proteomics data. The liver tissue models were validated in independent liver tissue datasets. Next, we built integrated gene and protein expression models that allowed us to identify combined gene-protein biomarker panels. For liver tissue, we attained 90% nested-cross validation accuracy in our dataset and 82% accuracy in the independent validation dataset using transcriptomic data. We attained 100% nested-cross validation accuracy in our dataset and 61% accuracy in the independent validation dataset using proteomic data. For PBMCs, we attained 83% and 89% accuracy with transcriptomic and proteomic data, respectively. The integration of the two data types resulted in improved classification accuracy for PBMCs, but not liver tissue. We also identified the following gene-protein matches within the gene-protein biomarker panels: CLEC4M-CLC4M, GSTA1-GSTA2 for liver tissue and SELENBP1-SBP1 for PBMCs. In this study, machine learning models had high classification accuracy for both transcriptomics and proteomics data, across liver tissue and PBMCs. The integration of transcriptomics and proteomics into a multi-omics model yielded improvement in classification accuracy for the PBMC data. The set of integrated gene-protein biomarkers for PBMCs show promise toward developing a liquid biopsy for alcohol-associated liver disease.
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Affiliation(s)
- Stanislav Listopad
- Department of Computer Science, University of California, Irvine, California, United States of America
| | - Christophe Magnan
- Department of Computer Science, University of California, Irvine, California, United States of America
| | - Le Z. Day
- Biological Sciences Division and Environmental and Molecular Sciences Division, Pacific Northwest National Laboratory, Richland, Washington, United States of America
| | - Aliya Asghar
- Medical and Research Services, VA Long Beach Healthcare System, Long Beach, California, United States of America
| | - Andrew Stolz
- Division of Gastrointestinal & Liver Diseases, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, United States of America
| | - John A. Tayek
- Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Department of Internal Medicine, David Geffen School of Medicine, University of California Los Angeles, Torrance, California, United States of America
| | - Zhang-Xu Liu
- Division of Gastrointestinal & Liver Diseases, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, United States of America
| | - Jon M. Jacobs
- Biological Sciences Division and Environmental and Molecular Sciences Division, Pacific Northwest National Laboratory, Richland, Washington, United States of America
| | - Timothy R. Morgan
- Medical and Research Services, VA Long Beach Healthcare System, Long Beach, California, United States of America
| | - Trina M. Norden-Krichmar
- Department of Computer Science, University of California, Irvine, California, United States of America
- Department of Epidemiology and Biostatistics, University of California, Irvine, California, United States of America
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Zafar Y, Siddiqi AK, Shaikh N, Imran M, Javaid SS, Manzoor L, Iqbal AZ, Petrasek J. Alcohol Relapse After Early Liver Transplantation in Patients With Alcoholic Liver Disease: A Meta-Analysis. Gastroenterology Res 2024; 17:10-14. [PMID: 38463145 PMCID: PMC10923247 DOI: 10.14740/gr1674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 01/19/2024] [Indexed: 03/12/2024] Open
Abstract
Background Alcohol use disorder (AUD) is a significant source of end-stage liver disease and liver failure and an indication for liver transplant (LT). Historically, LT for alcoholic liver disease (ALD) required 6 months of alcohol abstinence. Recently, it has been demonstrated that early LT (< 6 months of abstinence) in strictly selected group of patients provides survival benefit while keeping the relapse to harmful drinking at acceptable levels. This practice has been reflected in the Dallas consensus, but more data are needed to appropriately risk stratify the patient from the perspective of return to harmful alcohol drinking post-transplant. This "6-month rule" has been highly debated and recent data demonstrated that the duration of pre-transplant sobriety is not related with an increased risk of relapse to alcohol post-transplant. We performed a meta-analysis to compare the rate of alcohol relapse in individuals having standard vs. early LT. Methods MEDLINE and SCOPUS were searched for randomized controlled trials (RCTs), observational studies, and case-control studies from their inception through June 2022. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMSA) 2009 checklist guidelines were followed for this meta-analysis. Studies comparing post-transplant outcomes, such as alcohol relapse, in individuals following standard vs. early LT, were included. Reviews, case studies, conference abstracts, clinical trials with only an abstract, and studies with inadequate data for extraction were all disqualified. The data were retrieved, gathered, and examined. The random effects model was used to generate forest plots. For the analysis, a P-value of 0.05 was considered significant. Results Thirty-four studies were discovered in the initial search. Three studies were included in this systematic review and meta-analysis incorporating 367 patients. Mean age was 51.7 years. Out of 367 patients, 173 (47%) underwent early LT. Out of three studies included, one study demonstrated decreased probability of alcohol relapse in patients undergoing early LT, whereas the other two showed the opposite result. All of the included studies were analyzed and had minimal risk of bias. Pooled analysis demonstrates that the difference in alcohol relapse between early vs. standard LT was insignificant (odds ratio: 1.24, 95% confidence interval: 0.75 - 2.06, P = 0.40). Conclusion Our results show that early LT is not associated with increased risk of alcohol relapse post-transplant when compared with a mandatory 6-month abstinence period. Hence, individuals with ALD should not be categorically rejected from LT merely on the criteria of 6 months of abstinence. Other selection criteria based on the need and post-transplant outcomes should be utilized.
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Affiliation(s)
- Yousaf Zafar
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | | | - Nafhat Shaikh
- Department of Medicine, Liaquat University of Medical & Health Sciences, Jamshoro, Pakistan
| | - Maria Imran
- Department of Medicine, Jinnah Sindh Medical University, Karachi, Pakistan
| | - Syed Sarmad Javaid
- Department of Medicine, Jinnah Sindh Medical University, Karachi, Pakistan
| | - Laila Manzoor
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | | | - Jan Petrasek
- Department of Digestive Diseases, University of Mississippi Medical Center, Jackson, MS, USA
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Kim SH, Jang Y, Kim H. Concept and risk factors of alcohol relapse in liver transplant recipients with alcohol-related aetiologies: A scoping review. Int J Ment Health Nurs 2023; 32:1583-1597. [PMID: 37475208 DOI: 10.1111/inm.13196] [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: 04/10/2023] [Revised: 06/26/2023] [Accepted: 07/11/2023] [Indexed: 07/22/2023]
Abstract
Alcohol relapse in those who received liver transplantation (LT) for alcohol-related liver disease can lead to poor graft function, low medication adherence rates and decreased chances of survival. Numerous studies have evaluated on this topic; however, discrepancies in the meaning and measurement of 'alcohol relapse' lead to heterogeneous results. This scoping review aimed to explore the conceptual and operational definitions of alcohol relapse in LT recipients with alcohol-related aetiologies and to examine newly reported risk factors of alcohol relapse. Following the Arksey and O'Malley scoping review method and PRISMA guidelines, structured searches for articles published from 2012 to 2022 were conducted in PubMed, CINAHL, Embase, Cochrane and PsycINFO. Twenty-eight studies were included in the final review. Alcohol relapse was either defined as 'any alcohol consumption' or 'a certain degree of alcohol drinking' after transplantation. Discrepancies in the incidence rates persisted even within studies that shared the same conceptual definition. Commonly reported risk factors for alcohol relapse were younger age, social isolation and shorter abstinence periods before LT. Self-efficacy and post-transplant complications were newly identified risk factors in recent studies; whereas environmental factors such as external stressors were rarely included. The variance in the definition of alcohol relapse and inconsistent identification methods make it difficult to organize a structured interventional study. A standardized stratification of post-LT alcohol relapse behaviour is needed to prior to implementing interventions that employ a harm minimization approach. Cost-effective interventions promoting self-efficacy could enable the prevention and management of alcohol relapse after LT.
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Affiliation(s)
| | - Yeonsoo Jang
- College of Nursing·Mo-im Kim Nursing Research Institute, Yonsei University, Seoul, Korea
| | - Hyunji Kim
- College of Nursing, Yonsei University, Seoul, Korea
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Torre A, Cisneros-Garza LE, Castillo-Barradas M, Navarro-Alvarez N, Sandoval-Salas R, González-Huezo MS, Pérez-Hernández JL, Méndez-Guerrero O, Ruiz-Manríquez JA, Trejo-Estrada R, Chavez-Tapia NC, Solís-Gasca LC, Moctezuma-Velázquez C, Aguirre-Valádez J, Flores-Calderón J, Higuera-de-la-Tijera F, García-Juárez I, Canedo-Castillo NA, Malé-Velázquez R, Montalvo-Gordon I, Vilatobá M, Márquez-Guillén E, Córdova-Gallardo J, Flores-García NC, Miranda-Zazueta G, Martínez-Saldívar BI, Páez-Zayas VM, Muñoz-Espinosa LE, Solís-Galindo FA. Consensus document on acute-on-chronic liver failure (ACLF) established by the Mexican Association of Hepatology. Ann Hepatol 2023; 28:101140. [PMID: 37482299 DOI: 10.1016/j.aohep.2023.101140] [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: 03/02/2023] [Revised: 05/26/2023] [Accepted: 05/31/2023] [Indexed: 07/25/2023]
Abstract
Acute-on chronic liver failure (ACLF) has been an intensively debated topic mainly due to the lack of a unified definition and diagnostic criteria. The growing number of publications describing the mechanisms of ACLF development, the progression of the disease, outcomes and treatment has contributed to a better understanding of the disease, however, it has also sparked the debate about this condition. As an attempt to provide medical professionals with a more uniform definition that could be applied to our population, the first Mexican consensus was performed by a panel of experts in the area of hepatology in Mexico. We used the most relevant and impactful publications along with the clinical and research experience of the consensus participants. The consensus was led by 4 coordinators who provided the most relevant bibliography by doing an exhaustive search on the topic. The entire bibliography was made available to the members of the consensus for consultation at any time during the process and six working groups were formed to develop the following sections: 1.- Generalities, definitions, and criteria, 2.- Pathophysiology of cirrhosis, 3.- Genetics in ACLF, 4.- Clinical manifestations, 5.- Liver transplantation in ACLF, 6.- Other treatments.
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Affiliation(s)
- Aldo Torre
- Metabolic Unit, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
| | - Laura Esthela Cisneros-Garza
- Gastroenterology and Hepatology Department, Hospital Christus Muguerza Alta Especialidad, Monterrey, Nuevo León, Mexico
| | | | - Nalu Navarro-Alvarez
- Gastroenterology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | | | | | - Osvely Méndez-Guerrero
- Gastroenterology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | | | | | - Luis Carlos Solís-Gasca
- Gastroenterology Department, Hospital General de Zona #12 Benito Juárez del Instituto Mexicano del Seguro Social, Mérida, Yucatán, Mexico
| | - Carlos Moctezuma-Velázquez
- Gastroenterology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico; Department of Medicine - Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Alberta, Canada
| | | | - Judith Flores-Calderón
- Pediatrics Department, Hospital de Pediatría, Centro Médico Nacional Siglo XXI, Mexico City, Mexico
| | | | - Ignacio García-Juárez
- Gastroenterology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | | | - Iaarah Montalvo-Gordon
- Clinic of Gastrointestinal and Hepatic Specialties, Hospital Faro del Mayab, Mérida, Yucatán, Mexico
| | - Mario Vilatobá
- Transplant Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Ernesto Márquez-Guillén
- Gastroenterology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico; Hospital Ángeles del Pedregal, Mexico City, Mexico
| | - Jacqueline Córdova-Gallardo
- Hepatology Department - General Surgery Service, Hospital General Dr. Manuel Gea González, Mexico City, Mexico
| | - Nayeli Cointa Flores-García
- Gastroenterology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Godolfino Miranda-Zazueta
- Gastroenterology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | | | - Linda Elsa Muñoz-Espinosa
- Universidad Autónoma de Nuevo León. Liver Unit, Department of Internal Medicine, University Hospital 'Dr. José E. González', Monterrey, Nuevo León, Mexico
| | - Francisco Alfonso Solís-Galindo
- Gastroenterology Department, Unidad Médica de Alta Especialidad # 71 Instituto Mexicano del Seguro Social, Torreón, Coahuila, Mexico
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9
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Odenwald MA, Roth HF, Reticker A, Segovia M, Pillai A. Evolving challenges with long-term care of liver transplant recipients. Clin Transplant 2023; 37:e15085. [PMID: 37545440 DOI: 10.1111/ctr.15085] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/17/2023] [Accepted: 07/23/2023] [Indexed: 08/08/2023]
Abstract
The number of liver transplants (LT) performed worldwide continues to rise, and LT recipients are living longer post-transplant. This has led to an increasing number of LT recipients requiring lifelong care. Optimal care post-LT requires careful attention to both the allograft and systemic issues that are more common after organ transplantation. Common causes of allograft dysfunction include rejection, biliary complications, and primary disease recurrence. While immunosuppression prevents rejection and reduces incidences of some primary disease recurrence, it has detrimental systemic effects. Most commonly, these include increased incidences of metabolic syndrome, various malignancies, and infections. Therefore, it is of utmost importance to optimize immunosuppression regimens to prevent allograft dysfunction while also decreasing the risk of systemic complications. Institutional protocols to screen for systemic disease and heightened clinical suspicion also play an important role in providing optimal long-term post-LT care. In this review, we discuss these common complications of LT as well as unique considerations when caring for LT recipients in the years after transplant.
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Affiliation(s)
- Matthew A Odenwald
- Department of Medicine, Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago Medicine, Chicago, USA
| | - Hannah F Roth
- Department of Medicine, Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago Medicine, Chicago, USA
| | - Anesia Reticker
- Department of Pharmacy, University of Chicago Medicine, Chicago, USA
| | - Maria Segovia
- Department of Medicine, Section of Gastroenterology, Duke University School of Medicine, Durham, USA
| | - Anjana Pillai
- Department of Medicine, Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago Medicine, Chicago, USA
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10
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Mitchell J, Herrick-Reynolds K, Motter JD, Teles M, Kates O, Sung H, Chen PH, King E, Cameron A. Transplant Center Attitudes Toward Early Liver Transplant for Alcohol-associated Liver Disease. Transplant Direct 2023; 9:e1532. [PMID: 37649789 PMCID: PMC10465102 DOI: 10.1097/txd.0000000000001532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/29/2023] [Accepted: 07/14/2023] [Indexed: 09/01/2023] Open
Abstract
Background Many centers have removed 6-mo pretransplant alcohol abstinence requirements to provide early liver transplant (ELT) for individuals with severe alcohol-associated liver disease (ALD), but the practice remains controversial. Using data collected from a nationally distributed survey, this study examines the practices and attitudes of transplant centers in the United States regarding ELT. Methods A 20-item survey designed to assess center practices and provider attitudes was distributed to 225 medical and surgical directors from 143 liver transplant centers via email. Results Surveys were completed by 28.9% (n = 65) of directors and 39% (n = 56) of transplant centers. All responding centers reported evaluating patients for ELT. Circumstances for considering ELT included <6 mo of survival without a transplant (96.4%) and inability to participate in alcohol addiction therapy pretransplant (75%). Most (66%) directors indicated their center had established criteria for listing candidates with severe ALD for ELT. Regarding important factors for ELT candidate listing, 57.1% indicated patient survival, 37.5% indicated graft survival, and 55.4% indicated having a low risk of relapse. Only 12.7% of directors affirmed the statement, "Six months of pretransplant abstinence decreases the risk of relapse." Conclusions More centers are providing ELT for severe ALD. Inability to participate in alcohol addiction therapy and <6 mo of survival are commonly reported circumstances for considering ELT. Continued investigation of posttransplant outcomes in patients receiving ELT is essential to establishing a national consensus for distributing this valuable resource.
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Affiliation(s)
- Jonathan Mitchell
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Jennifer D. Motter
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Mayan Teles
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Olivia Kates
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Hannah Sung
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Po-Hung Chen
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Elizabeth King
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andrew Cameron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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11
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Germani G, D’Arcangelo F, Grasso M, Burra P. Advances and Controversies in Acute Alcohol-Related Hepatitis: From Medical Therapy to Liver Transplantation. Life (Basel) 2023; 13:1802. [PMID: 37763206 PMCID: PMC10532507 DOI: 10.3390/life13091802] [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: 07/11/2023] [Revised: 08/10/2023] [Accepted: 08/18/2023] [Indexed: 09/29/2023] Open
Abstract
Alcohol-related hepatitis (AH) is a clinical syndrome characterized by recent-onset jaundice in the context of alcohol consumption. In patients with severe AH "unresponsive" to steroid therapy, mortality rates exceed 70% within six months. According to European and American guidelines, liver transplantation (LT) may be considered in highly selected patients who do not respond to medical therapy. The aim of this narrative review is to summarize current knowledge from medical therapy to liver transplantation in acute alcohol-related hepatitis. Due to the impossibility to guarantee six-month abstinence, LT for AH is controversial. Principal concerns are related to organ scarcity in the subset of stigma of "alcohol use disorder" (AUD) and the risk of relapse to alcohol use after LT. Return to alcohol use after LT is a complex issue that cannot be assessed as a yes/no variable with heterogeneous results among studies. In conclusion, present data indicate that well-selected patients have excellent outcomes, with survival rates of up to 100% at 24 and 36 months after LT. Behavioral therapy, ongoing psychological support, and strong family support seem essential to improve long-term outcomes after LT and reduce the risk in relapse of alcohol use.
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Affiliation(s)
- Giacomo Germani
- Multivisceral Transplant Unit, Azienda Ospedale—Università Padova, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35122 Padova, Italy
| | - Francesca D’Arcangelo
- Gastroenterology and Multivisceral Transplant Unit, Azienda Ospedale—Università Padova, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35122 Padova, Italy; (F.D.); (M.G.); (P.B.)
| | - Marco Grasso
- Gastroenterology and Multivisceral Transplant Unit, Azienda Ospedale—Università Padova, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35122 Padova, Italy; (F.D.); (M.G.); (P.B.)
| | - Patrizia Burra
- Gastroenterology and Multivisceral Transplant Unit, Azienda Ospedale—Università Padova, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35122 Padova, Italy; (F.D.); (M.G.); (P.B.)
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12
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Arab JP, Addolorato G, Mathurin P, Thursz MR. Alcohol-Associated Liver Disease: Integrated Management With Alcohol Use Disorder. Clin Gastroenterol Hepatol 2023; 21:2124-2134. [PMID: 36858144 DOI: 10.1016/j.cgh.2023.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 01/21/2023] [Accepted: 02/03/2023] [Indexed: 03/03/2023]
Abstract
Alcohol-associated liver disease (ALD) is the most common cause of cirrhosis and liver-related mortality in many regions worldwide. Around 75% of patients with cirrhosis are unaware of their disease until they are referred to the emergency department. An innovative, noninvasive screening approach is required for an earlier diagnosis of liver fibrosis. In patients with ALD the physician is inevitably dealing with 2 major disorders: the liver disease itself and the alcohol use disorder (AUD). Focus only on the liver disease will inevitably lead to failure because transient improvements in liver function are rapidly overturned if the patient returns to alcohol consumption. For this reason, integrated models of care provided by hepatologists and addiction specialists are an effective approach, which are, however, not widely available. There are multiple pharmacologic and non-pharmacologic therapies for AUD. Progress has recently been made in the management of patients with severe AH who have improved survival through better understanding of the concept of response to medical treatment, improved survival prediction, and the advent of early liver transplantation. The emerging concept is that listing for transplantation a patient with severe ALD could lead to adjusting the duration of abstinence according to the severity and evolution of liver dysfunction and the patient's addictive profile.
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Affiliation(s)
- Juan P Arab
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada; Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.
| | - Giovanni Addolorato
- Department of Medical and Surgical Sciences, Internal Medicine and Hepatology Unit, Catholic University of Rome, Rome, Italy
| | - Philippe Mathurin
- Service des maladies de l'appareil digestif, Hôpital Huriez, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Mark R Thursz
- Division of Digestive Diseases, Imperial College, London, United Kingdom
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13
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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
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14
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Winder GS, Clifton EG, Fernandez AC, MacEachern M, Andrews S, Perumalswami P, DiMartini AF, Mellinger JL. Definition and measurement of alcohol-associated insight in early liver transplantation for acute alcohol-associated hepatitis: A systematic review. Liver Transpl 2023; 29:757-767. [PMID: 37016758 DOI: 10.1097/lvt.0000000000000144] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 03/27/2023] [Indexed: 04/06/2023]
Abstract
BACKGROUND Alcohol accounts for a large disease burden in hepatology and liver transplantation (LT) and across the globe. Clinical evaluations and decisions about LT candidacy are challenging because they rely on detailed psychosocial assessments and interpretations of psychiatric and substance use disorder data, which often must occur rapidly according to the acuity of end-stage liver disease. Such difficulties commonly occur during the process of candidate selection and liver allocation, particularly during early LT (eLT) in patients with acute alcohol-associated hepatitis (AAH). Patients with AAH commonly have very recent or active substance use, high short-term mortality, psychiatric comorbidities, and compressed evaluation and treatment timetables. LT clinicians report that patients' alcohol-associated insight (AAI) is among the most relevant psychosocial data in this population, yet no studies exist examining how LT teams define and use AAI in eLT or its effect on clinical outcomes. In April 2022, we searched Ovid MEDLINE, Elsevier Embase, EBSCOhost PsycInfo and CINAHL, and Wiley Cochrane Central Register of Controlled Trials for reports describing AAH populations who underwent eLT, which also described psychosocial evaluation parameters. The searches retrieved 1603 unique reports. After eligibility screening, 8 were included in the qualitative analysis. This systematic review reveals that AAI is a poorly defined construct that is not measured in a standardized way. Yet it is a commonly cited parameter in articles that describe the psychosocial evaluation and decision-making of patients undergoing eLT for AAH. This article also discusses the general challenges of assessing AAI during eLT for AAH, existing AAI definitions and rating scales, how AAI has been used to date in the broader hepatology and LT literature, and future areas for clinical and research progress.
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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
| | - Anne C Fernandez
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Mark MacEachern
- Taubman Health Sciences Library, University of Michigan, Ann Arbor, Michigan, USA
| | - Sarah Andrews
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ponni Perumalswami
- Gastroenterology Section, Veterans Affairs, Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Andrea F DiMartini
- Departments of Psychiatry, Surgery, and Translational Science, University of Pittsburgh, Pittsburgh, Pennsylvania, 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
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15
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Shetty A, De La Torre S, Ibrahim B, Hong A, Meza J, Saab S. Role of Biomarkers to Assess the Use of Alcohol. J Clin Gastroenterol 2023; 57:537-545. [PMID: 37039472 DOI: 10.1097/mcg.0000000000001852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
Alcohol-associated liver disease has seen a significant rise in the last 2 decades, with an associated rise in the need for accurate alcohol use assessment. Alcohol use has been associated with poor outcomes in both the pre-liver transplant and post-liver transplant patients. Patients with alcohol use disorder often under-report their alcohol consumption because of varying factors, highlighting the need for objective assessment of alcohol use. Aside from the available self-report questionnaires, multiple serologic biomarkers are currently available to assist clinicians to assess recent alcohol consumption among patients with chronic liver disease, liver transplant candidates, and recipients. In this review, we will assess some of these alcohol biomarkers, discuss their strengths and weakness, and review-available data to discuss their role in pre-liver transplant and post-liver transplant population.
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Affiliation(s)
| | | | | | | | - Julio Meza
- Family Medicine, University of California at Los Angeles, Los Angeles, CA
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16
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Germani G, Mathurin P, Lucey MR, Trotter J. Early liver transplantation for severe acute alcohol-related hepatitis after more than a decade of experience. J Hepatol 2023; 78:1130-1136. [PMID: 37208100 DOI: 10.1016/j.jhep.2023.03.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 03/01/2023] [Accepted: 03/06/2023] [Indexed: 05/21/2023]
Abstract
In patients with severe acute alcohol-related hepatitis not responding to medical therapy, early liver transplantation (LT) represents the only effective therapy and, when performed within strict and well-defined protocols, it is associated with a clear survival benefit and acceptable rates of return to alcohol use after transplantation. However, there is still high variability in access to LT for patients with severe alcohol-related hepatitis, mainly due to a persistent overemphasis in the pre-LT evaluation on duration of pre-transplant abstinence and the stigma that patients with alcohol-related liver disease often experience, leading to marked inequity of access to this potentially lifesaving procedure and negative health outcomes. Therefore, there is an increasing need for prospective multicentre studies focusing on pre-transplant selection practices and on better interventions to treat alcohol use disorder after LT.
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Affiliation(s)
- Giacomo Germani
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University Hospital Padua, University of Padua, Padua, Italy.
| | - Philippe Mathurin
- Service des Maladies de l'appareil Digestif, Hôpital Huriez, CHU Lille, France
| | - Michael R Lucey
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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17
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Kulkarni AV, Reddy R, Arab JP, Sharma M, Shaik S, Iyengar S, Kumar N, Gupta R, Premkumar GV, Menon BP, Reddy DN, Rao PN, Reddy KR. Early Living Donor Liver Transplantation for Alcohol-Associated Hepatitis. Ann Hepatol 2023; 28:101098. [PMID: 37028597 DOI: 10.1016/j.aohep.2023.101098] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 01/15/2023] [Accepted: 03/02/2023] [Indexed: 04/09/2023]
Abstract
INTRODUCTION AND OBJECTIVES Lately, there has been a steady increase in early liver transplantation for alcohol-associated hepatitis (AAH). Although several studies have reported favorable outcomes with cadaveric early liver transplantation, the experiences with early living donor liver transplantation (eLDLT) are limited. The primary objective was to assess one-year survival in patients with AAH who underwent eLDLT. The secondary objectives were to describe the donor characteristics, assess the complications following eLDLT, and the rate of alcohol relapse. MATERIALS AND METHODS This single-center retrospective study was conducted at AIG Hospitals, Hyderabad, India, between April 1, 2020, and December 31, 2021. RESULTS Twenty-five patients underwent eLDLT. The mean time from abstinence to eLDLT was 92.4±42.94 days. The mean model for end-stage liver disease and discriminant function score at eLDLT were 28.16±2.89 and 104±34.56, respectively. The mean graft-to-recipient weight ratio was 0.85±0.12. Survival was 72% (95%CI, 50.61-88) after a median follow-up of 551 (23-932) days post-LT. Of the 18 women donors,11 were the wives of the recipient. Six of the nine infected recipients died: three of fungal sepsis, two of bacterial sepsis, and one of COVID-19. One patient developed hepatic artery thrombosis and died of early graft dysfunction. Twenty percent had alcohol relapse. CONCLUSIONS eLDLT is a reasonable treatment option for patients with AAH, with a survival of 72% in our experience. Infections early on post-LT accounted for mortality, and thus a high index of suspicion of infections and vigorous surveillance, in a condition prone to infections, are needed to improve outcomes.
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Affiliation(s)
| | - Raghuram Reddy
- Department of Liver transplantation, AIG Hospitals, Hyderabad, India
| | - Juan Pablo Arab
- Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Mithun Sharma
- Department of Hepatology, AIG Hospitals, Hyderabad, India
| | - Sameer Shaik
- Department of Hepatology, AIG Hospitals, Hyderabad, India
| | - Sowmya Iyengar
- Department of Hepatology, AIG Hospitals, Hyderabad, India
| | - Naveen Kumar
- Department of Psychiatry, AIG Hospitals, Hyderabad, India
| | - Rajesh Gupta
- Department of Hepatology, AIG Hospitals, Hyderabad, India
| | | | | | | | | | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, USA.
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18
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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.
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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
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19
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Alcoholic Hepatitis. Med Clin North Am 2023; 107:533-554. [PMID: 37001952 DOI: 10.1016/j.mcna.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
Alcoholic hepatitis (AH) is a unique clinical syndrome on the spectrum of alcohol-associated liver disease (ALD). It constitutes a rising epidemic with increasing incidence and major public health implications. In severe AH, 30-day mortality approaches 30%, yet therapeutic options remain limited. Survival benefit from corticosteroids, the mainstay of medical treatment, is short-lived. Among corticosteroid nonresponders, the use of early liver transplantation is heterogeneous across centers and remains limited by significant barriers. Long-term prognosis is largely dictated by abstinence; however, comorbid alcohol use disorder remains undertreated. Efforts to address these challenges are required to curb the AH epidemic.
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20
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Ntandja Wandji LC, Ningarhari M, Lassailly G, Dharancy S, Boleslawski E, Mathurin P, Louvet A. Liver Transplantation in Alcohol-related Liver Disease and Alcohol-related Hepatitis. J Clin Exp Hepatol 2023; 13:127-138. [PMID: 36647412 PMCID: PMC9840078 DOI: 10.1016/j.jceh.2022.06.013] [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: 04/25/2022] [Accepted: 06/25/2022] [Indexed: 02/07/2023] Open
Abstract
Alcohol-related liver disease (ARLD) remains one of the leading causes of chronic liver disease and the prevalence of alcohol-related cirrhosis is still increasing worldwide. Thus, ARLD is one of the leading indications for liver transplantation (LT) worldwide especially after the arrival of direct-acting antivirals for chronic hepatitis C infection. Despite the risk of alcohol relapse, the outcomes of LT for ARLD are as good as for other indications such as hepatocellular carcinoma (HCC), with 1-, 5-, and 10- year survival rates of 85%, 74%, and 59%, respectively. Despite these good results, certain questions concerning LT for ARLD remain unanswered, in particular because of persistent organ shortages. As a result, too many transplantation centers continue to require 6 months of abstinence from alcohol for patients with ARLD before LT to reduce the risk of alcohol relapse even though compelling data show the poor prognostic value of this criterion. A recent pilot study even observed a lower alcohol relapse rate in patients receiving LT after less than 6 months of abstinence as long as addictological follow-up is reinforced. Thus, the question should not be whether LT should be offered to patients with ARLD but how to select patients who will benefit from this treatment.
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Key Words
- AH, alcohol-related hepatitis
- ARLD, Alcohol-related liver disease
- AUDIT, Alcohol Use Disorders Identification Test
- CLD, chronic liver disease
- ELTR, European Liver Transplant Registry
- HCC, hepatocellular carcinoma
- HCV, hepatitis C virus
- LT, liver transplantation
- NASH, non-alcoholic steatohepatitis
- NIAAA, National Institute on Alcohol Abuse and Alcoholism
- UNOS, United Network for Organ Sharing
- alcohol
- alcohol-related hepatitis
- alcohol-related liver disease
- liver transplantation
- survival
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Affiliation(s)
- Line Carolle Ntandja Wandji
- University of Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, Lille, F-59000 France
| | - Massih Ningarhari
- University of Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, Lille, F-59000 France
| | - Guillaume Lassailly
- University of Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, Lille, F-59000 France
| | - Sébastien Dharancy
- University of Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, Lille, F-59000 France
| | - Emmanuel Boleslawski
- University of Lille, Inserm, CHU Lille, U1189 - ONCO-THAI - Image Assisted Laser Therapy for Oncology, Lille, F-59000 France
| | - Philippe Mathurin
- University of Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, Lille, F-59000 France
| | - Alexandre Louvet
- University of Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, Lille, F-59000 France
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21
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Adekunle AD, Adejumo A, Singal AK. Therapeutic targets in alcohol-associated liver disease: progress and challenges. Therap Adv Gastroenterol 2023; 16:17562848231170946. [PMID: 37187673 PMCID: PMC10176580 DOI: 10.1177/17562848231170946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 04/04/2023] [Indexed: 05/17/2023] Open
Abstract
Alcohol-associated liver disease (ALD) is a complex disease with rapidly increasing prevalence. Although there are promising therapeutic targets on the horizon, none of the newer targets is currently close to an Food and Drug Administration approval. Strategies are needed to overcome challenges in study designs and conducting clinical trials and provide impetus to the field of drug development in the landscape of ALD and alcoholic hepatitis. Management of ALD is complex and should include therapies to achieve and maintain alcohol abstinence, preferably delivered by a multidisciplinary team. Although associated with clear mortality benefit in select patients, the use of early liver transplantation still requires refinement to create uniformity in selection protocols across transplant centers. There is also a need for reliable noninvasive biomarkers for prognostication. Last but not the least, strategies are urgently needed to implement integrated multidisciplinary care models for treating the dual pathology of alcohol use disorder and of liver disease for improving the long-term outcomes of patients with ALD.
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Affiliation(s)
- Ayooluwatomiwa Deborah Adekunle
- Department of Internal Medicine, St. Luke’s
Hospital, Chesterfield, Missouri, USA
- Division of Hepatology, University of
Pittsburgh Medical Center, Pittsburgh, PA, USA
- Division of Transplant Hepatology, University
of South Dakota Sanford Medical School, Sioux Falls, SD
| | - Adeyinka Adejumo
- Department of Internal Medicine, St. Luke’s
Hospital, Chesterfield, Missouri, USA
- Division of Hepatology, University of
Pittsburgh Medical Center, Pittsburgh, PA, USA
- Division of Transplant Hepatology, University
of South Dakota Sanford Medical School, Sioux Falls, SD
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22
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Gómez-Medina C, Melo L, Martí-Aguado D, Bataller R. Subclinical versus advanced forms of alcohol-related liver disease: Need for early detection. Clin Mol Hepatol 2023; 29:1-15. [PMID: 35430784 PMCID: PMC9845676 DOI: 10.3350/cmh.2022.0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 04/11/2022] [Indexed: 02/02/2023] Open
Abstract
Alcohol-related liver disease (ALD) consists of a wide spectrum of clinical manifestations and pathological features, ranging from asymptomatic patients to decompensated cirrhosis and hepatocellular carcinoma. Patients with heavy alcohol intake and advanced fibrosis often develop a subacute form of liver failure called alcohol-induced hepatitis (AH). Globally, most patients with ALD are identified at late stages of the disease, limiting therapeutic interventions. Thus, there is a need for early detection of ALD patients, which is lacking in most countries. The identification of alcohol misuse is hampered by the existence of alcohol underreporting by many patients. There are useful biomarkers that can detect recent alcohol use. Moreover, there are several non-invasive techniques to assess the presence of advanced fibrosis among patients with alcohol misuse, which could identify patients at high risk of liver related events or early death. In this review, we discuss differences between early stages of ALD and AH as the cornerstone of advanced forms. A global overview of epidemiological, anthropometric, clinical, analytical, histological, and molecular differences is summarized in this article. We propose that campaigns aimed at identifying patients with subclinical forms can prevent the development of life-threatening forms.
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Affiliation(s)
- Concepción Gómez-Medina
- Division of Gastroenterology and Hepatology, Medical Department, Clinic University Hospital of Valencia, Valencia, Spain
| | - Luma Melo
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - David Martí-Aguado
- Division of Gastroenterology and Hepatology, Medical Department, Clinic University Hospital of Valencia, Valencia, Spain
| | - Ramón Bataller
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA,Corresponding author : Ramón Bataller Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, 200 Lothrop Street, BSTW Suite 1116, Pittsburgh, PA 15213, USA Tel: +1-412-383-4241, Fax: +1-412-648-4055, E-mail:
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Affiliation(s)
- Ramon Bataller
- From the Liver Unit, Hospital Clínic de Barcelona, Barcelona (R.B.); Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago (J.P.A.); the Division of Gastroenterology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, and London Health Sciences Centre, London, ON, Canada (J.P.A.); and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (V.H.S.)
| | - Juan Pablo Arab
- From the Liver Unit, Hospital Clínic de Barcelona, Barcelona (R.B.); Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago (J.P.A.); the Division of Gastroenterology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, and London Health Sciences Centre, London, ON, Canada (J.P.A.); and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (V.H.S.)
| | - Vijay H Shah
- From the Liver Unit, Hospital Clínic de Barcelona, Barcelona (R.B.); Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago (J.P.A.); the Division of Gastroenterology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, and London Health Sciences Centre, London, ON, Canada (J.P.A.); and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (V.H.S.)
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Horwich BH, Leven E, Winters AC, Pourmand K. The evolving paradigm of alcohol‐associated hepatitis and liver transplantation. Clin Liver Dis (Hoboken) 2022; 21:80-83. [PMID: 37095774 PMCID: PMC10121440 DOI: 10.1002/cld.1259] [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: 06/26/2022] [Revised: 07/18/2022] [Accepted: 08/04/2022] [Indexed: 12/03/2022] Open
Abstract
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Affiliation(s)
- Brian H. Horwich
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Emily Leven
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Adam C. Winters
- Division of Liver Diseases, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kamron Pourmand
- Division of Liver Diseases, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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25
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Zanowski SC, Price JS, Selim MA, Schumann V, Durazo F, Hong JC. Effect of an Integrated Transplantation Mental Health Program on Alcohol Relapse After Liver Transplantation for Severe Alcoholic Hepatitis: A Single-Center Prospective Study. Transplant Proc 2022; 54:2627-2633. [DOI: 10.1016/j.transproceed.2022.09.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 09/19/2022] [Accepted: 09/20/2022] [Indexed: 11/21/2022]
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Alcohol-Related Liver Disease: An Overview on Pathophysiology, Diagnosis and Therapeutic Perspectives. Biomedicines 2022; 10:biomedicines10102530. [PMID: 36289791 PMCID: PMC9599689 DOI: 10.3390/biomedicines10102530] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 10/01/2022] [Accepted: 10/08/2022] [Indexed: 11/19/2022] Open
Abstract
Alcohol-related liver disease (ALD) refers to a spectrum of liver manifestations ranging from fatty liver diseases, steatohepatitis, and fibrosis/cirrhosis with chronic inflammation primarily due to excessive alcohol use. Currently, ALD is considered as one of the most prevalent causes of liver disease-associated mortality worldwide. Although the pathogenesis of ALD has been intensively investigated, the present understanding of its biomarkers in the context of early clinical diagnosis is not complete, and novel therapeutic targets that can significantly alleviate advanced forms of ALD are limited. While alcohol abstinence remains the primary therapeutic intervention for managing ALD, there are currently no approved medications for treating ALD. Furthermore, given the similarities and the differences between ALD and non-alcoholic fatty liver disease in terms of disease progression and underlying molecular mechanisms, numerous studies have demonstrated that many therapeutic interventions targeting several signaling pathways, including oxidative stress, inflammatory response, hormonal regulation, and hepatocyte death play a significant role in ALD treatment. Therefore, in this review, we summarized several key molecular targets and their modes of action in ALD progression. We also described the updated therapeutic options for ALD management with a particular emphasis on potentially novel signaling pathways.
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Lee BP, Terrault NA. Advocacy for Equity in Transplantation Access for Alcohol-Associated Liver Disease: How Research Changed Medi-Cal Policy. Gastroenterology 2022; 163:539-542. [PMID: 35577123 PMCID: PMC10361648 DOI: 10.1053/j.gastro.2022.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 05/06/2022] [Accepted: 05/10/2022] [Indexed: 02/08/2023]
Affiliation(s)
- Brian P Lee
- Department of Gastroenterology and Liver Diseases, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Norah A Terrault
- Department of Gastroenterology and Liver Diseases, University of Southern California Keck School of Medicine, Los Angeles, California
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Virovic-Jukic L, Ljubas D, Stojsavljevic-Shapeski S, Ljubičić N, Filipec Kanizaj T, Mikolasevic I, Grgurevic I. Liver regeneration as treatment target for severe alcoholic hepatitis. World J Gastroenterol 2022; 28:4557-4573. [PMID: 36157937 PMCID: PMC9476880 DOI: 10.3748/wjg.v28.i32.4557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 05/30/2022] [Accepted: 06/16/2022] [Indexed: 02/06/2023] Open
Abstract
Severe alcoholic hepatitis (AH) is a distinct entity in the spectrum of alcohol-related liver disease, with limited treatment options and high mortality. Supportive medical care with corticosteroids in selected patients is the only currently available treatment option, often with poor outcomes. Based on the insights into the pathogenetic mechanisms of AH, which are mostly obtained from animal studies, several new treatment options are being explored. Studies have implicated impaired and deranged liver regeneration processes as one of the culprit mechanisms and a potential therapeutic target. Acknowledging evidence for the beneficial effects of granulocyte colony-stimulating factor (G-CSF) on liver regeneration and immunomodulation in animal models, several human studies investigated its role in the treatment of advanced alcohol-related liver disease and AH. Contrary to the previously published studies suggesting benefits of G-CSF in the outcomes of patients with severe AH, these effects were not confirmed by a recently published multicenter randomized trial, suggesting that other options should rather be pursued. Stem cell transplantation represents another option for improving liver regeneration, but evidence for its efficacy in patients with severe AH and advanced alcohol-related liver disease is still very scarce and unconvincing, with established lack of efficacy in patients with compensated cirrhosis. In this review, we summarize the current knowledge on the pathogenesis and experimental therapies targeting liver regeneration. The lack of high-quality studies and evidence is a major obstacle in further treatment development. New insights into the pathogenesis of not only liver injury, but also liver regeneration processes are mandatory for the development of new treatment options. A reliable experimental model of the pathogenesis of AH and processes involved in liver recovery is still missing, and data obtained from animal studies are essential for future research.
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Affiliation(s)
- Lucija Virovic-Jukic
- Department of Gastroenterology and Hepatology, Sisters of Charity University Hospital Center, Zagreb 10000, Croatia
- Department of Internal Medicine, University of Zagreb School of Medicine, Zagreb 10000, Croatia
| | - Dominik Ljubas
- Department of Internal Medicine, University of Zagreb School of Medicine, Zagreb 10000, Croatia
| | - Sanja Stojsavljevic-Shapeski
- Department of Gastroenterology and Hepatology, Sisters of Charity University Hospital Center, Zagreb 10000, Croatia
| | - Neven Ljubičić
- Department of Gastroenterology and Hepatology, Sisters of Charity University Hospital Center, Zagreb 10000, Croatia
- Department of Internal Medicine, University of Zagreb School of Medicine, Zagreb 10000, Croatia
- Department of Internal Medicine, University of Zagreb School of Dental Medicine, Zagreb 10000, Croatia
| | - Tajana Filipec Kanizaj
- Department of Internal Medicine, University of Zagreb School of Medicine, Zagreb 10000, Croatia
- Department of Gastroenterology, Merkur University Hospital, Zagreb 10000, Croatia
| | - Ivana Mikolasevic
- Department of Gastroenterology, Rijeka University Hospital Center, Rijeka 51000, Croatia
- Department of Internal Medicine, University of Rijeka School of Medicine, Rijeka 10000, Croatia
| | - Ivica Grgurevic
- Department of Internal Medicine, University of Zagreb School of Medicine, Zagreb 10000, Croatia
- Department of Gastroenterology, Hepatology and Clinical Nutrition, Dubrava University Hospital, Zagreb 10000, Croatia
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Chang WJ, Hsieh CE, Hung YJ, Hsu YL, Lin KH, Chen YL. Length of Alcohol Abstinence Predicts Posttransplant Delirium in Living Donor Liver Transplant Recipients with Alcoholic Cirrhosis. EXP CLIN TRANSPLANT 2022; 20:750-756. [DOI: 10.6002/ect.2022.0199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Shenoy A, Salajegheh A, Shen NT. Multimodal multidisciplinary management of alcohol use disorder in liver transplant candidates and recipients. Transl Gastroenterol Hepatol 2022; 7:28. [PMID: 35892051 PMCID: PMC9257538 DOI: 10.21037/tgh.2020.02.22] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 12/06/2019] [Indexed: 08/01/2023] Open
Abstract
Alcohol-related liver disease (ALD) is the most common indication for liver transplantation (LT) in the United States. The judicious allocation of organs and improvement in outcomes requires identification and monitoring of patients with ALD at high-risk for relapse post-transplantation. The controversial movement toward early LT for severe alcohol-related hepatitis (SAH) has also raised concern for alcohol relapse. While LT cures ALD, treatment of alcohol use disorder (AUD) must be included in the care plan to prevent a return to drinking and subsequent graft ALD. Patients with underlying AUD must be recognized, offered brief interventions and referred for multimodal multidisciplinary treatment that includes medications and psychotherapies along with sober support groups, family engagement, and a new dedication to healthy living in order to help sustain remission. Such comprehensive care will increase LT candidacy in patients with ALD while optimizing clinical outcomes of patients transplanted with AUD.
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Affiliation(s)
- Akhil Shenoy
- Director of Transplant Psychiatry, Assistant Professor, Columbia University Medical Center, Psychiatric Liaison to the Center for Liver Disease and Transplantation, New York-Presbyterian Hospital-Columbia, New York, NY, USA
| | - Anna Salajegheh
- Assistant Professor, Weill Cornell Psychiatry, Psychiatric Liaison to the Center for Liver Disease and Transplantation, New York-Presbyterian Hospital-Cornell, New York, NY, USA
| | - Nicole T. Shen
- Weill Cornell Medicine, Division of Clinical Epidemiology and Evaluative Sciences Research, Fellow, Transplant Hepatology, New York-Presbyterian Hospitals-Columbia and Cornell, New York, NY, USA
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Lee BP, Roth N, Rao P, Im GY, Vogel AS, Hasbun J, Roth Y, Shenoy A, Arvelakis A, Ford L, Dawe I, Schiano TD, Davis JP, Rice JP, Eswaran S, Weinberg E, Han H, Hsu C, Fix OK, Maddur H, Ghobrial RM, Therapondos G, Dilkina B, Terrault NA. Artificial intelligence to identify harmful alcohol use after early liver transplant for alcohol-associated hepatitis. Am J Transplant 2022; 22:1834-1841. [PMID: 35416409 PMCID: PMC9541176 DOI: 10.1111/ajt.17059] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 03/13/2022] [Accepted: 04/10/2022] [Indexed: 01/25/2023]
Abstract
Early liver transplantation (LT) for alcohol-associated hepatitis (AH) is the fastest growing indication for LT, but prediction of harmful alcohol use post-LT remains limited. Among 10 ACCELERATE-AH centers, we examined psychosocial evaluations from consecutive LT recipients for AH from 2006 to 2017. A multidisciplinary panel used content analysis to develop a maximal list of psychosocial variables. We developed an artificial intelligence model to predict post-LT harmful alcohol use. The cohort included training (N = 91 among 8 centers) and external validation (N = 25 among 2 centers) sets, with median follow-up of 4.4 (IQR 3.0-6.0) years post-LT. In the training set, AUC was 0.930 (95%CI 0.862-0.998) with positive predictive value of 0.891 (95%CI 0.620-1.000), internally validated through fivefold cross-validation. In the external validation set, AUC was 0.692 (95%CI 0.666-0.718) with positive predictive value of 0.82 (95%CI 0.625-1.000). The model identified specific variables related to social support and substance use as highly important to predict post-LT harmful alcohol use. We retrospectively developed and validated a model that identified psychosocial profiles at LT predicting harmful alcohol use post-LT for AH. This preliminary model may inform selection and post-LT management for AH and warrants prospective evaluation in larger studies among all alcohol-associated liver disease being considered for early LT.
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Affiliation(s)
- Brian P. Lee
- University of Southern California Keck School of MedicineLos AngelesCaliforniaUSA
| | | | - Prathik Rao
- University of Southern California Keck School of MedicineLos AngelesCaliforniaUSA
| | - Gene Y. Im
- Mount Sinai Icahn School of MedicineNew York CityNew YorkUSA
| | | | - Johann Hasbun
- New York University Grossman School of MedicineNew York CityNew YorkUSA
| | - Yoel Roth
- Twitter IncSan FranciscoCaliforniaUSA
| | - Akhil Shenoy
- Columbia University Vagelos College of Physicians and SurgeonsNew York CityNew YorkUSA
| | | | - Laura Ford
- Mount Sinai Icahn School of MedicineNew York CityNew YorkUSA
| | - Inga Dawe
- Mount Sinai Icahn School of MedicineNew York CityNew YorkUSA
| | | | - Jordan P. Davis
- University of Southern California Keck School of MedicineLos AngelesCaliforniaUSA
| | | | | | - Ethan Weinberg
- University of Pennsylvania Perelman School of MedicinePhiladelphiaPennsylvaniaUSA
| | - Hyosun Han
- University of Southern California Keck School of MedicineLos AngelesCaliforniaUSA
| | - Christine Hsu
- Georgetown School of MedicineWashingtonDistrict of ColumbiaUSA
| | - Oren K. Fix
- University of North Carolina at Chapel Hill School of MedicineChapel HillNorth CarolinaUSA
| | - Haripriya Maddur
- Northwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | | | | | - Bistra Dilkina
- University of Southern California Keck School of MedicineLos AngelesCaliforniaUSA
| | - Norah A. Terrault
- University of Southern California Keck School of MedicineLos AngelesCaliforniaUSA
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Proteomic analysis of alcohol-associated hepatitis reveals glycoprotein NMB (GPNMB) as a novel hepatic and serum biomarker. Alcohol 2022; 99:35-48. [PMID: 34923085 PMCID: PMC8919678 DOI: 10.1016/j.alcohol.2021.11.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 10/29/2021] [Accepted: 11/30/2021] [Indexed: 12/14/2022]
Abstract
Alcohol consumption remains a leading cause of liver disease worldwide, resulting in a complex array of hepatic pathologies, including steatosis, steatohepatitis, and cirrhosis. Individuals who progress to a rarer form of alcohol-associated liver disease (ALD), alcohol-associated hepatitis (AH), require immediate life-saving intervention in the form of liver transplantation. Rapid onset of AH is poorly understood and the metabolic mechanisms contributing to the progression to liver failure remain undetermined. While multiple mechanisms have been identified that contribute to ALD, no cures exist and mortality from AH remains high. To identify novel pathways associated with AH, our group utilized proteomics to investigate AH-specific biomarkers in liver explant tissues. The goal of the present study was to determine changes in the proteome as well as epigenetic changes occurring in AH. Protein abundance and acetylomic analyses were performed utilizing nHPLC-MS/MS, revealing significant changes to proteins associated with metabolic and inflammatory fibrosis pathways. Here, we describe a novel hepatic and serum biomarker of AH, glycoprotein NMB (GPNMB). The anti-inflammatory protein GPNMB was significantly increased in AH explant liver and serum compared to healthy donors by 50-fold and 6.5-fold, respectively. Further, bioinformatics analyses identified an AH-dependent decrease in protein abundance across fatty acid degradation, biosynthesis of amino acids, and carbon metabolism. The greatest increases in protein abundance were observed in pathways for focal adhesion, lysosome, phagosome, and actin cytoskeleton. In contrast with the hyperacetylation observed in murine models of ALD, protein acetylation was decreased in AH compared to normal liver across fatty acid degradation, biosynthesis of amino acids, and carbon metabolism. Interestingly, immunoblot analysis found epigenetic marks were significantly increased in AH explants, including Histone H3K9 and H2BK5 acetylation. The increased acetylation of histones likely plays a role in the altered proteomic profile observed, including increases in GPNMB. Indeed, our results reveal that the AH proteome is dramatically impacted through unanticipated and unknown mechanisms. Understanding the origin and consequences of these changes will yield new mechanistic insight for ALD as well as identify novel hepatic and serum biomarkers, such as GPNMB.
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Legaz I, Muro M. Optimizing strategies to reduce alcohol consumption and relapses, improving abstinence in liver transplant recipients. Hepatobiliary Surg Nutr 2022; 11:153-155. [PMID: 35284518 PMCID: PMC8847871 DOI: 10.21037/hbsn-21-470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 12/28/2021] [Indexed: 08/30/2023]
Affiliation(s)
- Isabel Legaz
- Department of Legal and Forensic Medicine, Biomedical Research Institute (IMIB), Regional Campus of International Excellence “Campus Mare Nostrum”, Faculty of Medicine, University of Murcia, Murcia, Spain
| | - Manuel Muro
- Immunology Service, Instituto Murciano de Investigación Biosanitaria (IMIB), Hospital Clínico Universitario Virgen de la Arrixaca (HCUVA), Murcia, Spain
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Musto J, Stanfield D, Ley D, Lucey MR, Eickhoff J, Rice JP. Recovery and outcomes of patients denied early liver transplantation for severe alcohol-associated hepatitis. Hepatology 2022; 75:104-114. [PMID: 34387875 DOI: 10.1002/hep.32110] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 07/06/2021] [Accepted: 07/18/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIMS Liver transplantation (LT) in alcohol-associated hepatitis (AH) remains controversial, in part because spontaneous recovery (SR) can occur. There is a paucity of data on SR in patients with severe AH who undergo LT evaluation. The purpose of this study was to determine factors associated with SR and survival in patients with severe AH who undergo LT evaluation. APPROACH AND RESULTS This is a retrospective study of ALD patients with Model for End-Stage Liver Disease (MELD) >25 and <90 days abstinence who underwent LT evaluation at a single center between 2012 and 2018. One hundred forty-four patients (median age, 45.5 years; 68.1% male) were included. Forty-nine (34%) underwent LT and 95 (66%) patients did not undergo LT, and of those, 34 (23.6%) experienced SR. Factors associated with recovery were younger age (OR, 0.92; p = 0.004), lower index international normalized ratio (INR; 0.31; p = 0.03), and lower peak MELD (OR, 0.83; p = 0.02). Only 7 patients (20.6%) achieved a compensated state with a MELD <15 and absence of therapy for ascites or HE. Survival was improved in patients who underwent early LT when compared to SR. Survival was impaired in SR following relapse to alcohol use when compared to SR patients who abstained and LT recipients. Among all 6-month survivors of AH, alcohol use trended toward an association with mortality (HR, 2.05; p = 0.17), but only LT was associated with decreased mortality risk (HR, 0.20; p = 0.005). CONCLUSIONS SR from AH after LT evaluation is associated with age, index INR, and lower peak MELD. Most recovered patients continue to experience end-stage complications. LT is the only factor associated with lower mortality.
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Affiliation(s)
- Jessica Musto
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Dylan Stanfield
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Dana Ley
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Michael R Lucey
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Jens Eickhoff
- Department of Biostatistic and Medical Informatics, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - John P Rice
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
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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.
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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
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Choi G, Benhammou JN, Yum JJ, Saab EG, Patel AP, Baird AJ, Aguirre S, Farmer DG, Saab S. Barriers for Liver Transplant in Patients with Alcohol-Related Hepatitis. J Clin Exp Hepatol 2022; 12:13-19. [PMID: 35068780 PMCID: PMC8766699 DOI: 10.1016/j.jceh.2021.09.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 09/13/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Liver transplantation (LT) for alcohol-related liver disease has historically been reserved for patients who have been six months abstinent. Given the increasing incidence of alcohol-related hepatitis (AH) and dismal survival in patients who fail medical therapy, transplant centers are extending their acceptance criteria for patients with less than 6 months of sobriety. We sought to determine the barriers for listing. METHODS We conducted a retrospective chart review of all inpatient LT referrals for a diagnosis of AH between September 2019 and December 2020. LT evaluations were performed by a multidisciplinary team. Descriptive statistics were reported using mean and standard deviation (SD) or percentage where appropriate. RESULTS During our study period, 82 patients were evaluated for LT. Of these 82 patients, 62 were declined for liver transplantation. The mean (SD) age of the 62-patient cohort was 44 years (10.7), and most patients were men. The mean (SD) number of reasons for denial was 2 (0.97). Four patients had medical contraindications for transplant. Twenty-seven (44%) and 35 (56%) patients lacked insight and were at risk of alcohol relapse, respectively. Forty-three (69%) and fourteen (22.5%) patients had insufficient social support and an inability to maintain a therapeutic relationship with the transplant team, respectively. CONCLUSION Patients are more likely denied for psychosocial factors than medical comorbidities. The majority were due to lack of insight, insufficient social support, and inability to maintain a therapeutic relationship with the transplant team. Resources should be allocated to address these issues.
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Affiliation(s)
- Gina Choi
- Department of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Jihane N. Benhammou
- Department of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Jung J. Yum
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Elena G. Saab
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Ankur P. Patel
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Andrew J. Baird
- Department of Nursing, University of California, Los Angeles, Los Angeles, CA, USA
| | - Stephanie Aguirre
- Department of Social Work, University of California, Los Angeles, Los Angeles, CA, USA
| | - Douglas G. Farmer
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Sammy Saab
- Department of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA, USA
- Department of Nursing, University of California, Los Angeles, Los Angeles, CA, USA
- Address for correspondence. Sammy Saab, MD, MPH, AGAF, FAASLD, Pfleger Liver Institute, UCLA Medical Center, 200 Medical Plaza, Suite 214, Los Angeles, CA 90095, USA. Tel.: +1 310 206 6705; fax: +1 310 206 4197.
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Carrique L, Quance J, Tan A, Abbey S, Sales I, Lilly L, Bhat M, Galvin Z, Cattral M, Ghanekar A, McGilvray I, Reichman T, Sapisochin G, Sayed B, Selzner M, Lynch MJ, Selzner N. Results of Early Transplantation for Alcohol-Related Cirrhosis: Integrated Addiction Treatment With Low Rate of Relapse. Gastroenterology 2021; 161:1896-1906.e2. [PMID: 34370999 DOI: 10.1053/j.gastro.2021.08.004] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 07/28/2021] [Accepted: 08/02/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS In 2018, our team initiated a prospective pilot program to challenge the paradigm of the "6-month rule" of abstinence for patients with alcohol-related liver disease (ALD) requiring transplant. Our pilot involved an in-depth examination of patients' alcohol use, social support, and psychiatric comorbidity, as well as the provision of pre- and post-transplantation addiction treatment. METHODS Patients with ALD were assessed for inclusion in the pilot by a multidisciplinary team. Relapse prevention therapy was provided directly to all patients deemed to meet the program's inclusion criteria. Random biomarker testing for alcohol was used pre and post transplantation. RESULTS We received 703 referrals from May 1, 2018 to October 31, 2020. After fulfilling the program's criteria, 101 patients (14%) were listed for transplantation and 44 (6.2%) received transplants. There were no significant differences in survival rates between those receiving transplants through the pilot program compared with a control group with more than 6 months of abstinence (P = .07). Three patients returned to alcohol use during an average post-transplantation follow-up period of 339 days. In a multivariate analysis, younger age and lower Model for End-Stage Liver Disease scores at listing were associated with an increased likelihood of a return to alcohol use (P < .05); length of abstinence was not a predictor. CONCLUSIONS Our prospective program provided direct monitoring and relapse prevention treatment for patients with ALD and with less than 6 months of abstinence and resulted in a reduction of post-transplantation return to drinking. This pilot study provides a framework for the future of more equitable transplant care.
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Affiliation(s)
- Lauren Carrique
- Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Jill Quance
- Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Adrienne Tan
- Ajmera Transplant Centre, University Health Network, Toronto, Canada; Department of Psychiatry, University of Toronto, Toronto, Canada; Centre for Mental Health, University Health Network, Toronto, Canada
| | - Susan Abbey
- Ajmera Transplant Centre, University Health Network, Toronto, Canada; Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Isabel Sales
- Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Les Lilly
- Ajmera Transplant Centre, University Health Network, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada
| | - Mamatha Bhat
- Ajmera Transplant Centre, University Health Network, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada
| | - Zita Galvin
- Ajmera Transplant Centre, University Health Network, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada
| | - Mark Cattral
- Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Anand Ghanekar
- Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Ian McGilvray
- Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Trevor Reichman
- Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | | | - Blayne Sayed
- Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Markus Selzner
- Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Marie-Josée Lynch
- Ajmera Transplant Centre, University Health Network, Toronto, Canada; Department of Psychiatry, University of Toronto, Toronto, Canada; Centre for Mental Health, University Health Network, Toronto, Canada
| | - Nazia Selzner
- Ajmera Transplant Centre, University Health Network, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada.
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38
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Liver transplantation for alcohol-related liver disease in the UK: revised UK Liver Advisory Group recommendations for referral. Lancet Gastroenterol Hepatol 2021; 6:947-955. [PMID: 34626562 DOI: 10.1016/s2468-1253(21)00195-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 05/17/2021] [Accepted: 05/24/2021] [Indexed: 12/11/2022]
Abstract
Liver disease, of which liver cirrhosis is the most advanced stage, constitutes the fourth most common cause of life-years lost in men and women younger than 75 years in England, where mortality rates from liver disease have increased by 25% in the past decade. Alcohol consumption is the most common modifiable risk factor for disease progression in these individuals, but within the UK, there is substantial variation in the distribution, prevalence, and outcome of alcohol-related liver disease, and no equity of access to tertiary transplantation services. These revised recommendations were agreed by an expert panel convened by the UK Liver Advisory Group, with the purpose of providing consensus on referral for transplant assessment in patients with alcohol-related disease, and clarifying the terminology and definitions of alcohol use in liver injury. By standardising clinical management in these patients, it is hoped that there will be an improvement in the quality of care and better access to liver transplant assessment for patients with alcohol-related liver disease in the UK.
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39
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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.
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40
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Greenberg R, Goldberg A, Anthony S, Buchman DZ, Delaney S, Gruben V, Holdsworth S, Le Foll B, Leung M, Lien D, Lynch MJ, Selzner N, Chandler JA, Fortin MC. Canadian Society of Transplantation White Paper: Ethical and Legal Considerations for Alcohol and Cannabis Use in Solid Organ Listing and Allocation. Transplantation 2021; 105:1957-1964. [PMID: 33587429 PMCID: PMC8376271 DOI: 10.1097/tp.0000000000003618] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 11/16/2020] [Accepted: 11/20/2020] [Indexed: 11/26/2022]
Abstract
Alcohol and cannabis use as a contraindication to organ transplantation is a controversial issue. Until recently, patients in Canada with alcohol-associated liver disease were required to demonstrate abstinence for 6 mo to receive a liver transplant. There is no equivalent rule that is applied consistently for cannabis use. There is some evidence that alcohol and cannabis use disorder pretransplant could be associated with worse outcomes posttransplantation. However, early liver transplantation for patients with alcohol-associated liver disease in France and in the United States has led to challenges of the 6-mo abstinence rule in Canada in the media. It has also resulted in several legal challenges arguing that the rule violates human rights laws regarding discrimination in the provision of medical services and that the rule is also unconstitutional (this challenge is still before the court). Recent legalization of cannabis use for adults in Canada has led to questions about the appropriateness of limiting transplant access based on cannabis use. The ethics committee of the Canadian Society of Transplantation was asked to provide an ethical analysis of cannabis and alcohol abstinence policies. Our conclusions were as follows: neither cannabis use nor the 6-mo abstinence rule for alcohol use should be an absolute contraindication to transplantation, and transplant could be offered to selected patients, further research should be conducted to ensure evidence-based policies; and the transplant community has a duty not to perpetuate stigma associated with alcohol and cannabis use disorders.
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Affiliation(s)
- Rebecca Greenberg
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Mount Sinai Hospital, Toronto, ON, Canada
| | - Aviva Goldberg
- Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
| | - Samantha Anthony
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
- Factor-Inwentash Faculty of Social Work, University of Toronto, ON, Canada
| | - Daniel Z. Buchman
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
| | | | - Vanessa Gruben
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
- Faculty of Law, University of Ottawa, Ottawa, ON, Canada
| | - Sandra Holdsworth
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
| | - Bernard Le Foll
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | | | - Dale Lien
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Marie-Josee Lynch
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto General Research Institute, Toronto, ON, Canada
| | - Nazia Selzner
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
- Toronto General Research Institute, Toronto, ON, Canada
| | - Jennifer A. Chandler
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
- Faculty of Law, University of Ottawa, Ottawa, ON, Canada
| | - Marie-Chantal Fortin
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
- Centre de recherche du CHUM, Montreal, QC, Canada
- Faculty of Medicine, University of Montreal, QC, Canada
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41
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Zanetto A, Shalaby S, Gambato M, Germani G, Senzolo M, Bizzaro D, Russo FP, Burra P. New Indications for Liver Transplantation. J Clin Med 2021; 10:3867. [PMID: 34501314 PMCID: PMC8432035 DOI: 10.3390/jcm10173867] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 08/20/2021] [Accepted: 08/27/2021] [Indexed: 12/12/2022] Open
Abstract
Liver transplantation (LT) is an important therapeutic option for the treatment of several liver diseases. Modern LT is characterized by remarkable improvements in post-transplant patient survival, graft survival, and quality of life. Thanks to these great improvements, indications for LT are expanding. Nowadays, clinical conditions historically considered exclusion criteria for LT, have been considered new indications for LT, showing survival advantages for patients. In this review, we provide an updated overview of the principal newer indications for LT, with particular attention to alcoholic hepatitis, acute-on-chronic liver failure (ACLF), cholangiocarcinoma and colorectal cancer metastases.
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Affiliation(s)
| | | | | | | | | | | | | | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery Oncology and Gastroenterology, University of Padova, Via Giustiniani 2, 35128 Padova, Italy; (A.Z.); (S.S.); (M.G.); (G.G.); (M.S.); (D.B.); (F.P.R.)
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42
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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.
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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
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43
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Goel A, Daugherty T. Selection Criteria for Liver Transplantation for Acute Alcohol-Associated Hepatitis. Clin Liver Dis 2021; 25:635-644. [PMID: 34229845 DOI: 10.1016/j.cld.2021.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Severe acute alcohol-associated hepatitis that is nonresponsive to medical therapy has an extremely high mortality. Liver transplantation is a feasible treatment option and available at certain transplant centers globally. Selection criteria for liver transplantation are not, uniform but there are important key criteria shared across protocols. Of equal importance to the management of liver disease is the treatment of alcohol use disorder. A thorough assessment of candidates involves input from an addiction specialist and psychiatrist. With careful selection practices, graft and patient survival among transplant recipients with severe alcohol-associated hepatitis is similar to other etiologies of chronic liver disease.
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Affiliation(s)
- Aparna Goel
- Department of Medicine, Stanford University, 750 Welch Road, Suite 110, Palo Alto, CA 94304, USA.
| | - Tami Daugherty
- Department of Medicine, Stanford University, 750 Welch Road, Suite 110, Palo Alto, CA 94304, USA
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44
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Ting PS, Gurakar A, Wheatley J, Chander G, Cameron AM, Chen PH. Approaching Alcohol Use Disorder After Liver Transplantation for Acute Alcoholic Hepatitis. Clin Liver Dis 2021; 25:645-671. [PMID: 34229846 PMCID: PMC8264137 DOI: 10.1016/j.cld.2021.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Severe alcoholic hepatitis portends a high risk of mortality without liver transplantation. Transplant outcomes in patients with severe alcoholic hepatitis exhibit a strong inverse association with post-transplant alcohol relapse. The ingredients most central to ameliorating alcohol relapse risk may include destigmatized post-transplant alcohol monitoring, a nonpunitive clinician-patient partnership, and multimodal therapies to maintain abstinence and mitigate high-risk drinking. We here review the core principles of post-liver transplant management specific to alcohol use disorder.
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Affiliation(s)
- Peng-Sheng Ting
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 431, Baltimore, MD 21287, USA
| | - Ahmet Gurakar
- Liver Transplant, Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, 720 Rutland Avenue, Ross Research Building, Suite 918, Baltimore, MD 21205, USA.
| | - Jason Wheatley
- Department of Social Work, Johns Hopkins Hospital, 600 North Wolfe Street, Carnegie Suite 100, Baltimore, MD 21287, USA
| | - Geetanjali Chander
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street, Room 8047A, Baltimore, MD 21287, USA
| | - Andrew M Cameron
- Division of Liver Transplant Surgery, Department of Surgery, Johns Hopkins University School of Medicine, 720 Rutland Avenue, Ross 765, Baltimore, MD 21205, USA
| | - Po-Hung Chen
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 429, Baltimore, MD 21287, USA
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45
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Pose E, Torrents A, Reverter E, Perez-Campuzano V, Campos-Varela I, Avitabile E, Gratacós-Ginès J, Castellote J, Castells L, Colmenero J, Tort J, Ginès P, Crespo G. A notable proportion of liver transplant candidates with alcohol-related cirrhosis can be delisted because of clinical improvement. J Hepatol 2021; 75:275-283. [PMID: 33746085 DOI: 10.1016/j.jhep.2021.02.033] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 02/03/2021] [Accepted: 02/24/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND & AIMS To what extent patients with alcohol-related decompensated cirrhosis can improve until recovery from decompensation remains unclear. We aimed to investigate the probability of recovery and delisting due to improvement in patients with alcohol-related decompensated cirrhosis on the waiting list (WL) for liver transplantation (LT). METHODS We conducted a registry-based, multicenter, retrospective study including all patients admitted to the LT WL in Catalonia (Spain) with the indication of alcohol-, HCV-, cholestasis- or non-alcoholic steatohepatitis-related decompensated cirrhosis between January 2007 and December 2018. Competing-risk analysis was used to investigate variables associated with delisting due to improvement in patients with alcohol-related decompensated cirrhosis. Criteria for delisting after improvement were not predefined. Outcomes of patients after delisting were also studied. RESULTS One-thousand and one patients were included, 420 (37%) with alcohol-related decompensated cirrhosis. Thirty-six (8.6%) patients with alcohol-related decompensated cirrhosis were delisted after improvement at a median time of 29 months after WL admission. Lower model for end-stage liver disease (MELD) score, higher platelets and either female sex or lower height were independently associated with delisting due to improvement, while time of abstinence did not reach statistical significance in multivariate analysis (p = 0.055). Five years after delisting, the cumulative probability of remaining free from liver-related death or LT was 76%, similar to patients with HCV-related decompensated cirrhosis delisted after improvement. CONCLUSIONS A significant proportion of LT candidates with alcohol-related cirrhosis can be delisted due to improvement, which is predicted by low MELD score and higher platelet count at WL admission. Women also have a higher probability of being delisted after improvement, partially due to reduced early access to LT for height discrepancies. Early identification of patients with potential for improvement may avoid unnecessary transplants. LAY SUMMARY Patients with alcohol-related cirrhosis can improve until being delisted in approximately 9% of cases. Low model for end-stage liver disease score and high platelet levels at admission predict delisting after improvement, and women have higher probabilities of being delisted due to improvement. Long-term outcomes after delisting are generally favorable.
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Affiliation(s)
- Elisa Pose
- Liver Unit, Hospital Clínic, Faculty of Medicine, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain.
| | - Abiguei Torrents
- Organització Catalana de Trasplantaments (OCATT), Servei Català de la Salut, Catalonia, Spain
| | - Enric Reverter
- Liver Unit, Hospital Clínic, Faculty of Medicine, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Valeria Perez-Campuzano
- Liver Transplant Unit, Liver Unit, Hospital Universitari de Bellvitge, IDIBELL, Universitat de Barcelona, Spain
| | - Isabel Campos-Varela
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain; Liver Unit, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Campus, Universitat Autònoma de Barcelona, Spain
| | - Emma Avitabile
- Liver Unit, Hospital Clínic, Faculty of Medicine, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Jordi Gratacós-Ginès
- Liver Unit, Hospital Clínic, Faculty of Medicine, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Jose Castellote
- Liver Transplant Unit, Liver Unit, Hospital Universitari de Bellvitge, IDIBELL, Universitat de Barcelona, Spain
| | - Lluis Castells
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain; Liver Unit, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Campus, Universitat Autònoma de Barcelona, Spain
| | - Jordi Colmenero
- Liver Unit, Hospital Clínic, Faculty of Medicine, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Jaume Tort
- Organització Catalana de Trasplantaments (OCATT), Servei Català de la Salut, Catalonia, Spain
| | - Pere Ginès
- Liver Unit, Hospital Clínic, Faculty of Medicine, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Gonzalo Crespo
- Liver Unit, Hospital Clínic, Faculty of Medicine, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain.
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A Young Patient with Brief Alcohol Use and Rapidly Progressive Alcohol-Related Hepatitis: Considerations in Transplant Eligibility. Harv Rev Psychiatry 2021; 28:133-142. [PMID: 32134837 DOI: 10.1097/hrp.0000000000000249] [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: 11/26/2022]
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Cabré N, Duan Y, Llorente C, Conrad M, Stern P, Yamashita D, Schnabl B. Colesevelam Reduces Ethanol-Induced Liver Steatosis in Humanized Gnotobiotic Mice. Cells 2021; 10:cells10061496. [PMID: 34198609 PMCID: PMC8232222 DOI: 10.3390/cells10061496] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/03/2021] [Accepted: 06/05/2021] [Indexed: 12/12/2022] Open
Abstract
Alcohol-related liver disease is associated with intestinal dysbiosis. Functional changes in the microbiota affect bile acid metabolism and result in elevated serum bile acids in patients with alcohol-related liver disease. The aim of this study was to identify the potential role of the bile acid sequestrant colesevelam in a humanized mouse model of ethanol-induced liver disease. We colonized germ-free (GF) C57BL/6 mice with feces from patients with alcoholic hepatitis and subjected humanized mice to the chronic–binge ethanol feeding model. Ethanol-fed gnotobiotic mice treated with colesevelam showed reduced hepatic levels of triglycerides and cholesterol, but liver injury and inflammation were not decreased as compared with non-treated mice. Colesevelam reduced hepatic cytochrome P450, family 7, subfamily a, polypeptide 1 (Cyp7a1) protein expression, although serum bile acids were not lowered. In conclusion, our findings indicate that colesevelam treatment mitigates ethanol-induced liver steatosis in mice.
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Affiliation(s)
- Noemí Cabré
- Department of Medicine, University of California San Diego, La Jolla, CA 92093, USA; (N.C.); (Y.D.); (C.L.)
| | - Yi Duan
- Department of Medicine, University of California San Diego, La Jolla, CA 92093, USA; (N.C.); (Y.D.); (C.L.)
| | - Cristina Llorente
- Department of Medicine, University of California San Diego, La Jolla, CA 92093, USA; (N.C.); (Y.D.); (C.L.)
| | - Mary Conrad
- Axial Therapeutics, Woburn, MA 01801, USA; (M.C.); (P.S.); (D.Y.)
| | - Patrick Stern
- Axial Therapeutics, Woburn, MA 01801, USA; (M.C.); (P.S.); (D.Y.)
| | - Dennis Yamashita
- Axial Therapeutics, Woburn, MA 01801, USA; (M.C.); (P.S.); (D.Y.)
| | - Bernd Schnabl
- Department of Medicine, University of California San Diego, La Jolla, CA 92093, USA; (N.C.); (Y.D.); (C.L.)
- Department of Medicine, VA San Diego Healthcare System, San Diego, CA 92161, USA
- Correspondence:
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48
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Ivanics T, Abreu P, De Martin E, Sapisochin G. Changing Trends in Liver Transplantation: Challenges and Solutions. Transplantation 2021; 105:743-756. [PMID: 32910093 DOI: 10.1097/tp.0000000000003454] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Despite improvements in postliver transplant outcomes through refinements in perioperative management and surgical techniques, several changing trends in liver transplantation have presented challenges. Mortality on the waitlist remains high. In the United States, Europe, and the United Kingdom, there is an increasing need for liver transplantation, primarily as a result of increased incidence of nonalcoholic steatohepatitis-related cirrhosis and cancer indications. Meanwhile, donor suitability has decreased, as donors are often older and have more comorbidities. Despite a mismatch between organ need and availability, many organs are discarded. Notwithstanding this, many solutions have been developed to overcome these challenges. Innovative techniques in allograft preservation, viability assessment, and reconditioning have allowed the use of suboptimal organs with adequate results. Refinements in surgical procedures, including live donor liver transplantations, have increased the organ pool and are decreasing the time and mortality on the waitlist. Despite many challenges, a similar number of solutions and prospects are on the horizon. This review seeks to explore the changing trends and challenges in liver transplantation and highlight possible solutions and future directions.
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Affiliation(s)
- Tommy Ivanics
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - Phillipe Abreu
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - Eleonora De Martin
- APHP, Hôpital Paul Brousse, Centre Hépato-Biliaire, INSERM 1193, Université Paris-Sud, DHU Hepatinov, Villejuif, France
| | - Gonzalo Sapisochin
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada
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Innovations in liver transplantation in 2020, position of the Belgian Liver Intestine Advisory Committee (BeLIAC). Acta Gastroenterol Belg 2021; 84:347-359. [PMID: 34217187 DOI: 10.51821/84.2.347] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Liver transplantation (LT) remains the only curative option for patients suffering from end-stage liver disease, acute liver failure and selected hepatocellular carcinomas and access to the LT-waiting list is limited to certain strict indications. However, LT has shown survival advantages for patients in certain indications such as acute alcoholic hepatitis, hepatocellular carcinoma outside Milan criteria and colorectal cancer metastases. These newer indications increase the pressure in an already difficult context of organ shortage. Strategies to increase the transplantable organ pool are therefore needed. We will discuss here the use of HCV positive grafts as the use of normothermic isolated liver perfusion. Belgian Liver Intestine Advisory Committee (BeLIAC) from the Belgian Transplant Society (BTS) aims to guarantee the balance between the new indications and the available resources.
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50
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Maddur H, Asrani SK. Alcohol-associated hepatitis and liver transplantation: Mind the (racial, sex, economic, geographic, center, waitlist, and posttransplant outcomes) gap. Am J Transplant 2021; 21:921-922. [PMID: 32860654 DOI: 10.1111/ajt.16243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/19/2020] [Accepted: 07/20/2020] [Indexed: 01/25/2023]
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