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Goswami A, Weinberg E, Coraluzzi L, Bittermann T, Nahas J, Addis S, Weinrieb R, Serper M. A Tailored Virtual Program for Alcohol Use Disorder Treatment Among Liver Transplant Candidates and Recipients Is Feasible and Associated With Lower Post-Transplant Relapse. Clin Transplant 2024; 38:e15381. [PMID: 38940230 PMCID: PMC11273277 DOI: 10.1111/ctr.15381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 05/05/2024] [Accepted: 06/02/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Alcohol-associated liver disease (ALD) is a leading indication for liver transplant (LT) in the United States. Rates of early liver transplant (ELT) with less than 6 months of sobriety have increased substantially. Patients who receive ELT commonly have alcohol-associated hepatitis (AH) and are often too ill to complete an intensive outpatient program (IOP) for alcohol use disorder (AUD) prior to LT. ELT recipients feel alienated from traditional IOPs. METHODS We implemented Total Recovery-LT, a tailored virtual outpatient IOP specific for patients under evaluation or waitlisted for LT who were too ill to attend community-based alcohol treatment programs. The 12-week program consisted of weekly group and individual counseling delivered by a master's level Certified Addiction Counselor trained in the basics of LT. Treatment consisted of 12-Step Facilitation, Motivational Interviewing, and Cognitive Behavioral Therapy. We report on program design, implementation, feasibility and early outcomes. RESULTS From March 2021 to September 2022, 42 patients (36% female, 23 in LT evaluation, 19 post-transplant) enrolled across five cohorts with 76% (32/42) completing the program. Alcohol relapse was more common among noncompleters versus those who completed the program (8/10, 80% vs. 7/32, 22%, p = 0.002). History of trauma or post-traumatic stress symptoms were associated with lower likelihood of completion. Patients' desire for continued engagement after completion led to the creation of a monthly alumni group. CONCLUSIONS Our integrated IOP model for patients with high-risk AUD in LT evaluation or post-transplant is well-received by patients and could be considered a model for LT programs.
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Affiliation(s)
- Arpita Goswami
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia PA
| | - Ethan Weinberg
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia PA
| | | | - Therese Bittermann
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia PA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia PA
| | - Jonathan Nahas
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia PA
| | - Senayish Addis
- Penn Transplant Institute, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Robert Weinrieb
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia PA
| | - Marina Serper
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia PA
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2
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Ayyala-Somayajula D, Dodge JL, Zhou K, Terrault NA, Yuan L. The impact of surging transplantation of alcohol-associated liver disease on transplantation for HCC and other indications. Hepatol Commun 2024; 8:e0455. [PMID: 38967588 PMCID: PMC11227353 DOI: 10.1097/hc9.0000000000000455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 04/01/2024] [Indexed: 07/06/2024] Open
Abstract
BACKGROUND Liver transplantation (LT) for alcohol-associated liver disease (ALD) is increasing and may impact LT outcomes for patients listed for HCC and other indications. METHODS Using US adults listed for primary LT (grouped as ALD, HCC, and other) from October 8, 2015, to December 31, 2021, we examined the impact of center-level ALD LT volume (ATxV) on waitlist outcomes in 2 eras: Era 1 (6-month wait for HCC) and Era 2 (MMaT-3). The tertile distribution of ATxV (low to high) was derived from the listed candidates as Tertile 1 (T1): <28.4%, Tertile 2 (T2): 28.4%-37.6%, and Tertile 3 (T3): >37.6% ALD LTs per year. Cumulative incidence of waitlist death and LT within 18 months from listing by LT indication were compared using the Gray test, stratified on eras and ATxV tertiles. Multivariable competing risk regression estimated the adjusted subhazard ratios (sHRs) for the risk of waitlist mortality and LT with interaction effects of ATxV by LT indication (interaction p). RESULTS Of 56,596 candidates listed, the cumulative waitlist mortality for those with HCC and other was higher and their LT probability was lower in high (T3) ATxV centers, compared to low (T1) ATxV centers in Era 2. However, compared to ALD (sHR: 0.92 [0.66-1.26]), the adjusted waitlist mortality for HCC (sHR: 1.15 [0.96-1.38], interaction p = 0.22) and other (sHR: 1.13 [0.87-1.46], interaction p = 0.16) were no different suggesting no differential impact of ATxV on the waitlist mortality. The adjusted LT probability for HCC (sHR: 0.89 [0.72-1.11], interaction p = 0.08) did not differ by AtxV while it was lower for other (sHR: 0.82 [0.67-1.01], interaction p = 0.02) compared to ALD (sHR: 1.04 [0.80-1.34]) suggesting a differential impact of ATxV on LT probability. CONCLUSIONS The high volume of LT for ALD does not impact waitlist mortality for HCC and others but affects LT probability for other in the MMAT-3 era warranting continued monitoring.
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Affiliation(s)
- Divya Ayyala-Somayajula
- Division of Gastrointestinal and Liver Disease, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Jennifer L. Dodge
- Division of Gastrointestinal and Liver Disease, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA
| | - Kali Zhou
- Division of Gastrointestinal and Liver Disease, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Norah A. Terrault
- Division of Gastrointestinal and Liver Disease, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Liyun Yuan
- Division of Gastrointestinal and Liver Disease, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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3
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Tanaka T, Axelrod D. Evolving trends and outcomes on the US liver transplant waitlist of alcohol-associated hepatitis patients with very high MELD scores. Liver Int 2024. [PMID: 38924203 DOI: 10.1111/liv.16017] [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: 03/18/2024] [Revised: 05/28/2024] [Accepted: 06/15/2024] [Indexed: 06/28/2024]
Abstract
Liver transplantation (LT) in patients with alcohol-associated hepatitis (AH) has rapidly increased following the coronavirus disease 2019 pandemic and the implementation of the Acuity Circle policy, raising questions of equity and utility. Waitlist mortality among high (≥37) Model for End-Stage Liver Disease LT candidates with AH and post-transplant survival were assessed with a semiparametric survival regression and a generalized linear mixed-effect model with LT centre- and listing date-level random intercepts. These models demonstrate a lower mortality for the candidates listed with AH (adjusted sub-hazard ratio .58_.72_.90 and odds ratio .44_.66_.99) when compared to other diagnoses (autoimmune hepatitis, metabolic dysfunction-associated fatty liver disease and primary biliary cholangitis). Post-LT survival was comparable. This study highlights the limitations of current tools in characterizing the risk of mortality, and thus need for the modifications in prioritizing LT candidates with AH. Policy revision may be needed to ensure equivalent access to LT regardless of diagnosis.
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Affiliation(s)
- Tomohiro Tanaka
- Division of Gastroenterology and Hepatology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Department of Health Management and Policy, University of Iowa Collage of Public Health, Iowa City, Iowa, USA
| | - David Axelrod
- Division of Transplantation and Hepatobiliary Surgery, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
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Winder GS, Fernandez AC, Perumalswami PV, Mellinger JL, Clifton EG. Reexamining "psychosocial clearance": A procedural framework for psychosocial evaluation in liver transplantation. Liver Transpl 2024; 30:431-442. [PMID: 38009890 DOI: 10.1097/lvt.0000000000000306] [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: 08/12/2023] [Accepted: 11/17/2023] [Indexed: 11/29/2023]
Abstract
Psychosocial and "nonmedical" phenomena are commonly encountered in liver transplantation (LT) evaluations. They are simultaneously crucial decision-making factors and some of the most difficult and controversial clinical matters clinicians confront. Epidemiology, societal trends, and the preponderance of psychological and behavioral factors underpinning common end-stage liver diseases ensure that LT teams will continue to encounter highly complex psychosocial patient presentations. Psychosocial policies, practices, and opinions vary widely among clinicians and LT centers. Liver clinicians already report insufficient psychosocial expertise, which creates a large gap between the stark need for psychosocial expansion, improvement, and innovation in LT and the lack of accompanying guidance on how to achieve it. While the clinical domains of an LT psychosocial evaluation have been well-described, few articles analyze the procedures by which teams determine candidates' "psychosocial clearance" and no conceptual frameworks exist. This article proposes a framework of core domains of psychosocial evaluation procedures, common pitfalls, and practical improvement strategies.
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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
| | - Anne C Fernandez
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Ponni V Perumalswami
- Department of Internal Medicine, Veterans Affairs, Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, 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
| | - Erin G Clifton
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
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5
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Winder GS, Clifton EG, Denysenko L, DiChiara AM, Hathaway D, Perumalswami PV, Shenoy A, Suzuki J, Tareen K, Mellinger JL, Fernandez AC. "But I didn't drink!": What to do with discordant phosphatidylethanol results. Liver Transpl 2024; 30:213-222. [PMID: 37486958 DOI: 10.1097/lvt.0000000000000223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 07/08/2023] [Indexed: 07/26/2023]
Abstract
Liver transplantation (LT) teams must be adept at detecting, evaluating, and treating patients' alcohol use, given its prominence among psychological and behavioral phenomena which cause and contribute to liver diseases. Phosphatidylethanol (PEth) is a highly useful alcohol biomarker increasingly recommended for routine use in hepatology and LT. PEth is unique among alcohol biomarkers because of its wide detection window, high sensitivity and specificity, and the correlation of its numerical value with different patterns of alcohol use. Alongside myriad clinical opportunities in hepatology and LT, PEth also confers numerous challenges: little guidance exists about its clinical use; fearing loss of LT access and the reactions of their clinicians and families, candidates and recipients are incentivized to conceal their alcohol use; and liver clinicians report lack of expertise diagnosing and treating substance-related challenges. Discordance between patient self-reported alcohol use and toxicology is yet another common and particularly difficult circumstance. This article discusses the general toxicological properties of PEth; explores possible scenarios of concordance and discordance among PEth results, patient history, and self-reported drinking; and provides detailed clinical communication strategies to explore discordance with liver patients, a key aspect of its use.
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Affiliation(s)
- Gerald Scott Winder
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
| | - Erin G Clifton
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Lex Denysenko
- Department of Psychiatry, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alex M DiChiara
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - David Hathaway
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ponni V Perumalswami
- Department of Internal Medicine, Gastroenterology Section, Veterans Affairs, Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Akhil Shenoy
- Department of Psychiatry, Columbia University, New York City, New York, USA
| | - Joji Suzuki
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kinza Tareen
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jessica L Mellinger
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Anne C Fernandez
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
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6
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Manfready RA, Rzepczynski A, Janardhan SV. Which patient should be prioritized for liver transplant: NAFLD? Clin Liver Dis (Hoboken) 2024; 23:e0163. [PMID: 38860126 PMCID: PMC11164004 DOI: 10.1097/cld.0000000000000163] [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: 07/11/2023] [Accepted: 02/27/2024] [Indexed: 06/12/2024] Open
Affiliation(s)
- Richard A. Manfready
- Department of Internal Medicine, Division of Digestive Diseases and Nutrition, Rush University Medical Center, Chicago, Illinois, USA
| | - Allison Rzepczynski
- Department of Internal Medicine, Division of Digestive Diseases and Nutrition, Rush University Medical Center, Chicago, Illinois, USA
| | - Sujit V. Janardhan
- Department of Internal Medicine, Section of Hepatology, Rush University Medical Center, Chicago, Illinois, USA
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7
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Aby ES, Vogel AS, Winters AC. Intersection of Coronavirus Disease 2019 and Alcohol-associated Liver Disease: A Review of Emerging Trends and Implications. Clin Ther 2023; 45:1164-1170. [PMID: 37758533 DOI: 10.1016/j.clinthera.2023.08.019] [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: 05/11/2023] [Revised: 08/04/2023] [Accepted: 08/24/2023] [Indexed: 09/29/2023]
Abstract
PURPOSE This review will provide an overview of alcohol use and alcohol associated liver disease (ALD) prior to the coronavirus disease 2019 (COVID-19) pandemic and the impact of the pandemic on alcohol use and ALD. Furthermore, this review will explore strategies to mitigate the growing disease burden of AUD and ALD. METHODS A search using PubMed was performed for articles on topics related to alcohol use, ALD, and COVID-19. The literature was reviewed and pertinent sources were used for this narrative review. FINDINGS In the United States (US), excessive alcohol use is the third leading cause of preventable death. Prior to the COVID-19 pandemic, the increasing prevalence of alcohol use disorder (AUD) and ALD in the US had already constituted a public health crisis given the association between alcohol misuse, AUD, and ALD with significant medical, economic, and societal burdens. The COVID-19 pandemic led to increased alcohol consumption and downstream consequences, including increased prevalence of AUD, ALD, ALD-related hospitalization and death, and liver transplantation for ALD. IMPLICATIONS There is a critical need for additional, multi-pronged interventions to mitigate the mortality and morbidity linked to ALD.
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Affiliation(s)
- Elizabeth S Aby
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota.
| | - Alexander S Vogel
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Adam C Winters
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York
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8
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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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9
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Liu J, Man K. Biomarkers for monitoring alcohol sobriety after liver transplantation for alcoholic liver disease. J Gastroenterol Hepatol 2023; 38:1227-1232. [PMID: 37353915 DOI: 10.1111/jgh.16269] [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: 05/31/2023] [Revised: 06/08/2023] [Accepted: 06/08/2023] [Indexed: 06/25/2023]
Abstract
Alcoholic liver disease (ALD) has become the most common indication for liver transplantation in Western countries, and its incidence is rapidly increasing in East Asia. Alcohol abstinence remains the standard of care for promoting liver transplantation for ALD and for preventing posttransplant graft loss. However, efficient monitoring methods are still being developed due to the limitations of traditional biomarkers, interviews, and questionnaires. The development of alcohol biomarkers has shifted from detecting alcohol and methanol to indirect byproducts, and to current mid-term and long-term direct alcohol metabolites, which provide higher accuracy and cover almost all types of alcohol relapse detection. However, in most clinical studies, biomarkers are used and validated in healthy individuals and alcohol use disorder (AUD) patients and for pretransplant evaluations. The evidence for their use in posttransplant abstinence monitoring is still lacking, but it is crucial for early detection of alcohol relapse and initiating intervention. This review aims to summarize the current evidence of the use of biomarkers for monitoring sobriety and alcohol relapse after liver transplantation, as well as to cover the diagnostic accuracy, detection window, and optimal multidisciplinary strategies.
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Affiliation(s)
- Jiang Liu
- Department of Surgery, LKS Faculty of Medicine and HKU-Shenzhen Hospital, The University of Hong Kong, Hong Kong, Hong Kong
- Hepato-pancreato-biliary Center, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - Kwan Man
- Department of Surgery, LKS Faculty of Medicine and HKU-Shenzhen Hospital, The University of Hong Kong, Hong Kong, Hong Kong
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10
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Colletta A, Cooper KM, Devuni D. The progression of hepatorenal syndrome-acute kidney injury in acute alcohol-associated hepatitis: renal outcomes after liver transplant. Therap Adv Gastroenterol 2023; 16:17562848231188813. [PMID: 37533707 PMCID: PMC10392193 DOI: 10.1177/17562848231188813] [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: 11/21/2022] [Accepted: 06/20/2023] [Indexed: 08/04/2023] Open
Abstract
Background Hepatorenal syndrome-acute kidney injury (HRS-AKI) is a complication of advanced liver disease in patients with ascites and circulatory dysfunction. Little data remain on the relationship between HRS-AKI outcomes and different etiologies of liver disease post-liver transplant (LT). Objectives The primary aim was to evaluate the effect of HRS-AKI on renal outcomes in patients with acute alcohol-associated hepatitis (AAH) compared to chronic liver disease (CLD) after LT. The secondary aim was to evaluate the impact of acuity and chronicity of alcohol-associated liver disease in patients with HRS-AKI post-LT renal outcomes. Design A retrospective observational study of patients undergoing urgent inpatient liver transplant evaluation (LTE) for cirrhosis and AAH at single academic LT center between October 2017 and July 2021 was conducted. Methods Patients with HRS-AKI were selected based on indication for LTE: acute AAHHRS or CLDHRS. CLDHRS was categorized by disease etiology: cirrhosis due to alcohol (A-CLDHRS) versus cirrhosis from other causes (O-CLDHRS). CLD patients without HRS-AKI were labeled CLDno HRS. Results A total of 210 subjects underwent LTE; 25% were evaluated for AAH and 75% were evaluated for CLD. Hepatorenal syndrome was more common in subjects evaluated for AAH (37/47) than CLD (104/163) (78.7 versus 63.8%, p = 0.04). For the primary outcome, AAHHRS subjects required ⩾30 days post-LT renal replacement therapy (RRT) more often than subjects with CLDHRS (p = 0.02) and CLDno HRS (p < 0.01). There was no significant difference in other forms of long-term renal outcomes including kidney transplant referral and kidney transplant among cohorts. In subgroup analysis, 30-days post-LT RRT was more common in AAHHRS than in A-CLDHRS (p = 0.08). Logistic regression showed that AAHHRS conferred a 20× and 3.3× odds of requiring ⩾30 days post-LT RRT compared to CLDno HRS and CLDHRS, respectively. Postoperative complications were similar across cohorts, but had a significant effect on 30-day renal outcome post-LT. Conclusions Patients with AAH were more likely to develop HRS and require RRT pre- and post-LT at our center. The etiology of hepatic decompensation and postoperative complications affect renal recovery post-LT. The systemic inflammation of AAH in addition to conditions favoring renal hypoperfusion may contribute to the unfavorable outcomes of HRS-AKI after LT in this patient population.
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Affiliation(s)
| | | | - Deepika Devuni
- UMass Chan Medical School, Division of Gastroenterology, Worcester, MA, USA
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11
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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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12
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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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13
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Samuel S, Choubey A, Koizumi N, Ekwenna O, Baxter PR, Li MH, Malik R, Ortiz J. Demographic inequities exist and influence transplant outcomes in liver transplantation for acute alcohol-associated hepatitis. HPB (Oxford) 2023:S1365-182X(23)00116-8. [PMID: 37088642 DOI: 10.1016/j.hpb.2023.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/01/2023] [Accepted: 04/05/2023] [Indexed: 04/25/2023]
Abstract
BACKGROUND Liver transplantation has inherent disparities but data is scarce in liver transplant (LT) candidates with acute alcohol-associated hepatitis (AAH). We aimed to investigate demographic inequities and its impact on survival outcomes among AAH LT candidates. METHODS A retrospective analysis using the United Network of Organ Sharing database was conducted between 2000 and 2021. 25 981 LT recipients with alcohol-associated liver cirrhosis and 662 recipients with AAH were included. Waitlisted candidates were also evaluated. RESULTS In comparison with alcohol-associated liver cirrhosis, AAH LT recipients were more likely Asian or "other" race and younger. Hispanics demonstrated better graft and patient survival (p < 0.05) but were less likely to be waitlisted and transplanted for AAH than for liver cirrhosis. Women with AAH were more likely to be waitlisted and transplanted. Pre-existing diabetes and male sex were associated with higher graft failure (25% and 8% respectively). Increasing recipient age were 2% more likely to experience negative outcomes. Chronicity of liver disease did not impact graft (p = 0.137) or patient survival (p = 0.145). CONCLUSION Our results revealed demographic factors have a significant impact on transplant listing, organ allocation and survival outcomes. Further investigations are imperative to minimize disparities in LT evaluation and provide equity in healthcare.
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Affiliation(s)
- Sonia Samuel
- Department of Internal Medicine, Albany Medical Center, Albany, NY, 12208, USA.
| | - Ankur Choubey
- Department of Surgery, Robert Wood Johnson University Hospital, New Brunswick, NJ, 08901, USA
| | - Naoru Koizumi
- Schar School of Policy and Government, George Mason University, Fairfax, VA, 22030, USA
| | - Obi Ekwenna
- Department of Urology, The University of Toledo Medical Center, Toledo, OH, 43614, USA
| | - Patrick R Baxter
- Schar School of Policy and Government, George Mason University, Fairfax, VA, 22030, USA
| | - Meng-Hao Li
- Schar School of Policy and Government, George Mason University, Fairfax, VA, 22030, USA
| | - Raza Malik
- Department of Gastroenterology and Hepatology, Albany Medical Center, Albany, NY, 12208, USA
| | - Jorge Ortiz
- Department of Surgery, Erie County Medical Center, Buffalo, NY, 14215, USA
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14
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Hsu CC, Dodge JL, Weinberg E, Im G, Ko J, Davis W, Rutledge S, Dukewich M, Shoreibah M, Aryan M, Vosooghi A, Lucey M, Rice J, Terrault NA, Lee BP. Multicentered study of patient outcomes after declined for early liver transplantation in severe alcohol-associated hepatitis. Hepatology 2023; 77:1253-1262. [PMID: 36651183 DOI: 10.1097/hep.0000000000000267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 11/06/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Early liver transplantation for alcohol-associated hepatitis is controversial in part because patients may recover, and obviate the need for liver transplantation. METHODS In this retrospective study among 5 ACCELERATE-AH sites, we randomly sampled patients evaluated and then declined for liver transplantation for alcohol-associated hepatitis. All had Model of End-Stage Liver Disease (MELD) >20 and <6 months of abstinence. Recompensation was defined as MELD <15 without variceal bleeding, ascites, or overt HE requiring treatment. Multilevel mixed effects linear regression was used to calculate probabilities of recompensation; multivariable Cox regression was used for mortality analyses. RESULTS Among 145 patients [61% men; median abstinence time and MELD-Na was 33 days (interquartile range: 13-70) and 31 (interquartile range: 26-36), respectively], 56% were declined for psychosocial reasons. Probability of 30-day, 90-day, 6-month, and 1-year survival were 76% (95% CI, 68%-82%), 59% (95% CI, 50%-66%), 49% (95% CI, 40%-57%), and 46% (95% CI, 37%-55%), respectively. Probability of 1-year recompensation was low at 10.0% (95% CI, 4.5%-15.4%). Among patients declined because of clinical improvement, 1-year probability of recompensation was 28.0% (95% CI, 5.7%-50.3%). Among survivors, median MELD-Na at 30 days, 90 days, and 1-year were 29 (interquartile range: 22-38), 19 (interquartile range : 14-29), and 11 (interquartile range : 7-17). Increased MELD-Na (adjusted HR: 1.13, p <0.001) and age (adjusted HR: 1.03, p <0.001) were associated with early (≤90 d) death, and only history of failed alcohol rehabilitation (adjusted HR: 1.76, p =0.02) was associated with late death. CONCLUSIONS Liver recompensation is infrequent among severe alcohol-associated hepatitis patients declined for liver transplantation. Higher MELD-Na and age were associated with short-term mortality, whereas only history of failed alcohol rehabilitation was associated with long-term mortality. The distinction between survival and liver recompensation merits further attention.
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Affiliation(s)
- Christine C Hsu
- Georgetown University School of Medicine, Washington, District of Columbia, USA
- Medstar Georgetown University Hospital, Washington, District of Columbia, USA
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Jennifer L Dodge
- University of Southern California, Los Angeles, California, USA
- University of Southern California, Keck School of Medicine, Los Angeles, California, USA
| | - Ethan Weinberg
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Gene Im
- Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Jimin Ko
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - William Davis
- Medstar Georgetown University Hospital, Washington, District of Columbia, USA
| | | | - Matthew Dukewich
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Mohamed Shoreibah
- University of Alabama at Birmingham School of Medicine, Birmingham Alabama, USA
| | - Mahmoud Aryan
- University of Alabama at Birmingham School of Medicine, Birmingham Alabama, USA
| | - Aidan Vosooghi
- University of Southern California, Keck School of Medicine, Los Angeles, California, USA
| | - Michael Lucey
- University of Wisconsin School of Medicine, Madison, Wisconsin, USA
| | - John Rice
- University of Wisconsin School of Medicine, Madison, Wisconsin, USA
| | - Norah A Terrault
- University of Southern California, Los Angeles, California, USA
- University of Southern California, Keck School of Medicine, Los Angeles, California, USA
| | - Brian P Lee
- University of Southern California, Los Angeles, California, USA
- University of Southern California, Keck School of Medicine, Los Angeles, California, USA
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15
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Lee BP, Dodge JL, Terrault NA. Liver transplant for alcohol-associated liver disease continues to rise 2 years into the COVID-19 pandemic especially among young adults. J Hepatol 2023; 78:e139-e141. [PMID: 36567054 PMCID: PMC9773781 DOI: 10.1016/j.jhep.2022.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Brian P Lee
- Division of Gastroenterology and Liver Diseases, University of Southern California Keck School of Medicine, Los Angeles, CA, USA.
| | - Jennifer L Dodge
- Division of Gastroenterology and Liver Diseases, University of Southern California Keck School of Medicine, Los Angeles, CA, USA; Department of Population and Public Health Sciences, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Norah A Terrault
- Division of Gastroenterology and Liver Diseases, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
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16
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Early but not easy: recipients' experiences of alcohol-associated liver disease and early transplantation. Liver Transpl 2023:01445473-990000000-00095. [PMID: 36789649 DOI: 10.1097/lvt.0000000000000102] [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: 01/24/2023] [Accepted: 01/24/2023] [Indexed: 02/16/2023]
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17
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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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Shenoy A, Appel JM. Rethinking Second Chances: When Rejected Liver Transplant Candidates Seek Reevaluation Elsewhere. THE JOURNAL OF CLINICAL ETHICS 2023; 34:196-203. [PMID: 37229743 DOI: 10.1086/724232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
AbstractLiver transplantation offers a lifesaving treatment for patients suffering from end-stage liver failure, but not all candidates in the United States are eligible owing to center-specific criteria. When a patient is rejected at a transplantation center for medical, surgical, or psychosocial issues, they are often referred to other centers. We focus on this practice of reevaluation at a second center when the candidate was rejected for psychosocial reasons. We review the criteria used by health professionals to determine psychosocial eligibility and present three case examples from a large teaching hospital that demonstrate this phenomenon in practice. The cases illustrate the conflicts among autonomy, beneficence, nonmaleficence, and justice. We present arguments for and against this practice and provide concrete solutions as a path forward.
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Winder GS, Clifton EG, Perumalswami P, Mellinger JL. The art of interprofessional psychosocial communication: Optimizing patient interfaces with psychiatric specialists in liver transplantation. Transplant Rev (Orlando) 2022; 36:100728. [DOI: 10.1016/j.trre.2022.100728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 10/24/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022]
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20
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Lung Infection in Severe Alcohol-related Hepatitis: Not to be Underestimated. Am J Gastroenterol 2022; 117:1044-1045. [PMID: 35765906 DOI: 10.14309/ajg.0000000000001864] [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: 04/13/2022] [Accepted: 06/07/2022] [Indexed: 12/11/2022]
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Affiliation(s)
- James Trotter
- Division of Transplant Hepatology, Baylor University Medical Center, Dallas, TX
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