Liver transplantation for alcoholic cirrhosis with anti-HCV antibodies

The Lower Survival in Patients With Alcoholism and Hepatitis C Continues in the DAA Era

BACKGROUND

Alcohol liver disease (ALD) may coexist with hepatitis C (HCV) in many transplant recipients (alcoholic cirrhosis with hepatitis C [AHC]). Our objective was to determine whether there were differences in postliver transplantation outcomes of patients with AHC when compared with those with alcoholic cirrhosis (AC) and/or alcoholic hepatitis (AH).

METHODS

Using UNOS explant data sets (2016-2020), the survival probabilities of AC, AH, and AHC were compared by Kaplan-Meier survival analysis. Cox proportional-hazard regression analysis was used to determine outcomes after adjusting for disease confounders. The outcomes were also compared with predirect antiviral agent (DAA) period.

RESULTS

During study period, 8369 biopsy-proven ALD liver transplant recipients were identified. Of those, 647 had AHC (HCV + alcohol), 353 had AH, and 7369 had AC. MELD-Na score (28.7 ± 9.5 versus 23.8 ± 10.7; P  < 0.001) and presence of ACLF-3 (19% versus 11%; P  < 0.001) were higher in AC + AH as compared with AHC. AHC and AC+AH has similar adjusted mortality at 1-y, but 3-y (hazard ratios, 1.76; 95% confidence intervals, 1.32-2.35; P  < 0.0001) and 5-y (hazard ratios, 1.64; 95% confidence intervals, 1.24-2.15; P  = 0.0004) mortality rates were higher in AHC. Survival improved in the DAA era (2016-2020) compared with 2009 to 2013 in AHC, but remained worse in AHC group versus AC and/or AH. Malignancy-related mortality was higher in AHC (15% versus 9.3% in AC) in the DAA era.

CONCLUSIONS

AHC was associated with lower 3- and 5-y post-LT survival as compared with ALD without HCV and the worse outcomes in AHC group continued in the DAA era.

Determinants of Medication Adherence in Liver Transplant Recipients

BACKGROUND

The aim of this study was to study the determinants of nonadherence to immunosuppressant drugs in liver transplant (LT) recipients using personalised interview and questionnaire methods.

METHODS

The study was conducted on adult LT recipients (deceased donor liver transplant [DDLT] and living donor liver transplant [LDLT]) from the Indian subcontinent, at post-LT clinic visit between July and December 2016. Recipient details included baseline demography, comorbidity, psychological status, details of addiction, indication and type of transplant. Details on financial support for transplantation, admissions for rejection, infection and posttransplant complications were obtained from the hospital records. An adherence questionnaire was completed by direct interview and using a questionnaire.

RESULTS

Sixty-seven LT recipients (56 males, median age 48.17 years) constituted the study group. Overall, 11 patients (16.47%) were nonadherent to treatment. LDLT recipients were more adherent than DDLT recipients. Nonadherent recipients were believers in alternative systems of medicine. Medication-related factors such as improper dosing, meagre drug knowledge difficulty in remembering drug dose and timings and economic constraints in continuing medical treatment were statistically significant in nonadherent recipients. Although variation in the tacrolimus levels were significantly more common in the nonadherent group, acute cellular rejection and infection were not statistically different.

CONCLUSIONS

The prevalence of nonadherence was 16.5%. Determinants of nonadherence were DDLT, belief in alternative medications, high regimen complexity, poor knowledge about medications and cost issues with long-term medications.

Outcome after liver transplantation for cirrhosis due to alcohol and hepatitis C: comparison to alcoholic cirrhosis and hepatitis C cirrhosis

BACKGROUND AND AIM

Data on outcome of patients after liver transplantation (LT) for cirrhosis due to hepatitis C virus (HCV+) alcohol are limited.

METHODS AND RESULTS

Analysis from United Network for Organ sharing data set (1991 to 2010) for cirrhotics with first LT for HCV (group I, N=17,722), alcohol or alcoholic cirrhosis (AC; group II, N=9617), and alcohol+HCV (group III, N=6822). Five-year graft and patient survival for group III were similar to group I (73% vs. 69%; P=0.33 and 76% vs. 76%; P=0.87) and worse than group II (70% vs. 74%; P<0.0001 and 76% vs. 79%; P<0.0001). Cox regression analysis adjusted for recipient and donor characteristics showed (a) graft survival for group III similar to group I [hazard ratio (HR) 1.03 (95% confidence interval (CI), 0.97-1.09)] and worse than group II [HR 1.27 (95% CI, 1.19-1.35)] and (b) patient survival for group III worse than both groups I [HR 1.09 (95% CI, 1.02-1.15)] and II [HR 1.27 (95% CI, 1.19-1.36)]. In group III, graft failure was common for graft and patient loss and de novo malignancy more common compared with group I.

CONCLUSIONS

Patients undergoing LT for cirrhosis due to combined alcohol and HCV have (a) graft survival similar to patients with HCV cirrhosis and worse than AC and (b) worse patient survival compared with AC and HCV cirrhosis. Better strategies for anti-HCV treatment and screening for tumors are needed for patients undergoing LT for combined alcohol and HCV.

Adherence in liver transplant recipients

Adherence to a medical regimen has been defined as the extent to which a patient's behavior coincides with clinical prescriptions. In liver transplant patients, adherence to immunosuppressive therapy and to medical indications in general is crucial for short- and long-term outcomes. Nonadherence to immunosuppression carries a risk of graft rejection and potential graft loss, whereas nonadherence to general medical indications (eg, avoiding alcohol intake and smoking after transplantation) may be associated with other complications such as de novo tumors and increasing health care costs. Among adult liver transplant patients, the rate of nonadherence to immunosuppressive drugs ranges from 15% to 40%, whereas the rate of nonadherence to clinical appointments ranges from 3% to 47%. The wide range of reported rates is due to different definitions of the term nonadherence and the variety of methods used to measure adherence in the medical literature. Nonadherence seems to be nearly 4 times higher in pediatric and adolescent patients versus adult transplant recipients. Several nonadherence risk factors, such as high medication costs, psychiatric disorders, the conviction that the medication is harmful, and side effects of immunosuppressive therapy, have been described among adult liver transplant patients. The risk factors for nonadherence in pediatric and adolescent liver transplant patients are psychological distress, the functional status of their families, and the impact of immunosuppressive side effects on their physical appearance. A single approach to promoting adherence to general medical prescriptions has been proved to be ineffectual, so a multidisciplinary strategy should be adopted to achieve significant improvements in this field. The aim of this review is to analyze the published literature on adherence in liver transplant patients with a particular focus on the reported prevalence and the identified risk factors. Patients have been split into 2 age groups (adults and children/adolescents) because the scale of the problem and the potential risk factors differ in the 2 groups.

Cirrhosis of mixed etiology (hepatitis C virus and alcohol): Posttransplantation outcome-Comparison with hepatitis C virus-related cirrhosis and alcoholic-related cirrhosis

Hepatitis C virus (HCV)-related liver disease is enhanced by alcohol consumption. Of HCV-related liver transplantation (LT) recipients, 25% have a history of alcohol intake. The purpose of this research was to determine whether LT outcome differs between patients with cirrhosis of mixed etiology compared to HCV or alcohol alone. Of 494 LT (1997-2001), recipient/donor features, post-LT histological, metabolic complications [hypertension, diabetes-diabetes mellitus (DM)], and de novo tumors were compared in 3 groups [HCV-related cirrhosis = 170 (HCV group), alcohol-related cirrhosis (alcohol group) = 107, and cirrhosis of mixed etiology (mixed group) = 60]. Protocol biopsies were done in HCV patients. Severe recurrent HCV disease was defined as: 1-year fibrosis >1, cholestatic hepatitis, recurrent cirrhosis, or HCV-related liver retransplantation (reLT) within 5 years. Patients in the mixed group were younger (mean age: HCV group = 59 years; mixed group = 49 years; alcohol group = 53 years; P < 0.05) and mainly men (% men: HCV group = 51%; mixed group = 97%; alcohol group = 87%). Hepatocellular carcinoma (HCC) was more frequent in HCV patients (HCV group = 44%; mixed group = 35%; alcohol group = 18%; P = 0.05). Five-year survival was lowest in the HCV group (HCV group = 49% versus mixed group = 73% versus alcohol group = 76%; and P < 0.01 for the HCV group versus the alcohol group or the HCV group versus the mixed group; P = 0.74 for the alcohol group versus the mixed group). Metabolic complications and de novo tumors were more frequent in the alcohol groups. Severe HCV disease was similar in the HCV+ groups (HCV group = 45%; mixed group = 45%; P = 0.66). Patients with in the mixed group were more frequently treated with antivirals (32% versus HCV group = 18%; P = 0.03). In HCV patients, factors independently associated with lower survival were older donor age, LT indication (HCV alone), and increased body mass index (BMI). Antiviral therapy was a protective factor. Post-LT survival was lower in the isolated HCV group compared to the alcohol or mixed groups despite a similar recurrence of HCV disease. A greater use of antiviral therapy in the mixed group may explain these differences. The incidence of metabolic complications and de novo tumors was greater in the alcohol groups.

Liver transplantation for alcoholic liver disease: current concepts and length of sobriety

1. The 1-year and 5-year actuarial survival rates following liver transplantation for patients with alcoholic liver disease are 82% and 68%, respectively, in the United States and 85% and 70%, respectively, in Europe. These survival rates are similar to the outcomes of patients who undergo transplantation for other types of chronic liver disease. 2. Posttransplant improvements in health-related quality of life are similar in patients who undergo transplantation for alcoholic liver disease compared to those who undergo transplantation for other causes of end-stage liver disease. 3. Approximately 20% of patients who undergo transplantation for alcoholic liver disease use alcohol posttransplant, with one-third of these individuals exhibiting repetitive or heavy drinking. Surprisingly, little evidence exists to document a significant detrimental effect on graft or patient survival associated with resumption of drinking. 4. There are few reliable predictors of relapse in alcoholic patients after liver transplantation. Although not supported by all studies, abstinence of fewer than 6 months prior to transplantation may be a reasonable predictor of recidivism and is widely employed as a criterion for listing for liver transplantation. There are no good data to determine if some patients with sobriety fewer than 6 months might benefit from liver transplantation.

Alcohol relapse after liver transplantation for alcoholic liver disease: does it matter?

BACKGROUND/AIMS

The aim of this study was to distinguish the types of alcohol consumption after liver transplantation (LT) for alcoholic cirrhosis and to assess the consequences of heavy drinking.

METHODS

Patients transplanted for alcoholic cirrhosis were studied. Alcoholic relapse diagnosis was based upon patient's and family members' reports, liver enzyme tests, graft biopsy, and use of urine alcohol test.

RESULTS

One hundred twenty-eight patients were studied, with a mean follow-up of 53.8 months. After LT, 69% of patients were abstinent, 10% were occasional drinkers, and 21% were heavy drinkers. Actuarial survival rates were not different, but three of the seven deaths observed among heavy drinkers were directly related to alcohol relapse. Although there was no difference between the three groups concerning the rejection rates, all rejection episodes observed in the group of heavy drinkers were related to poor compliance with immunosuppressive drugs. One heavy drinker developed alcoholic cirrhosis.

CONCLUSIONS

The present study indicates that patients can resume heavy alcohol consumption after LT for alcoholic liver disease (ALD) and their grafts can be injured because of poor compliance with immunosuppressive drugs and alcohol-related liver injury. Although patient survival was not influenced by alcohol relapse, heavy alcohol consumption can be responsible for patients' death.

Liver transplantation for HCV-associated liver cirrhosis: predictors of outcomes in a population with significant genotype 3 and 4 distribution

End-stage liver disease associated with hepatitis C virus (HCV) infection is now the leading indication for liver transplantation in adults. However, reinfection of the graft is universal. We aimed to determine predictors of outcome of HCV-liver transplant recipients in the Australian and New Zealand communities. The following variables were analysed: demographic factors, coexistent pathology at the time of transplantation, HCV genotype, and donor age. Outcomes measures were: 1. mortality; 2. development of HCV-related complications, which were stage 3 or 4 fibrosis, or mortality from HCV-related graft failure, or both. Between January 1989 and December 30, 1999, 182 patients were transplanted for HCV-associated cirrhosis. The median follow-up period was 4 years (range, 0 to 13 years). Genotype data were available on 157 patients. The distribution of genotypes among the 157 patients was as follows: 36 (23%) genotype 1a, 30 (19%) genotype 1b, 4 (9%) genotype 1, 17 (11%) genotype 2, 41 (26%) genotype 3a, and 16 (10%) genotype 4. Eight (5%) patients were HCV-polymerase chain reaction (PCR)-negative (but HCV-antibody-positive). Donor age and genotype 4 were associated with an increased risk of retransplantation or death (P <.001 and.05, respectively). Meanwhile, donor age, genotype 4, and pretransplant excess alcohol were risk factors for the development of HCV-related complications (P =.004,.008, and.02, respectively). In contrast, patients with genotype 3a were less likely to develop HCV-related complications (P =.05). In a population of HCV liver transplant recipients with a heterogeneous genotype distribution, donor age, and genotype 4, were predictors of a worse outcome, whereas genotype 3 was associated with a more favorable outcome.

Liver transplantation for alcoholic liver disease with or without hepatitis C

Alcoholic cirrhosis with or without hepatitis C is a common indication for liver transplantation (LT). Comparative post-LT data for the 2 groups are not available. Our aim is to compare the clinicopathologic features of patients with alcoholic liver disease (ETOH) and ETOH/HCV at the time of and after LT and to determine the impact of concomitant hepatitis C virus (HCV) on ETOH patients undergoing LT. A comparative clinical and pathologic analysis at LT and after LT was performed for 56 patients with ETOH and 32 patients with ETOH/HCV. All 88 had cirrhosis at LT. Other native liver features for ETOH and ETOH/HCV, respectively, were: >2+ inflammation 50/56 and 26/32, Mallory's hyalin 12/56 and 6/32, steatosis 9/56 and 7/32, large cell dysplasia 12/56 and 6/32, hepatoma 4/56 and 4/32, iron deposition 24/56 and 12/32; none was statistically significant. The post-LT findings for ETOH and ETOH/HCV were as follows: 1-year survival 93% and 97%; alive 36/56 (419-4,348 days) and 27/32 (488-5,516 days); deaths 20/56 and 5/32; ETOH recurrence 5/56 (all alive) and 3/32 (1 dead); post-LT HCV 4/56 (acquired) and 22/32 (recurrent). Native liver histology in ETOH and ETOH/HCV patients was similar. Post-LT HCV recurrence was common (69%) in ETOH/HCV patients but resulted in death in only 6%. Post-LT ETOH recurrence was uncommon (9%) and progression to liver failure was rare (1.1%). Post-LT outcome for ETOH was excellent, and concomitant HCV did not affect survival.

Histological features after liver transplantation in alcoholic cirrhotics

BACKGROUND/AIMS

Though alcoholic cirrhosis is a common indication for liver transplantation, it carries the risk of alcohol recidivism and consequent graft failure. This study aims to evaluate the effect of alcohol recidivism on survival rates and histological parameters in patients transplanted for alcoholic cirrhosis, with and without hepatitis C virus (HCV) infection.

METHODS

Fifty-one out of 189 consecutive transplanted patients underwent psychosocial evaluation and liver biopsy at 6 and 12 months, then yearly after transplantation.

RESULTS

The cumulative 84 month survival rate was identical in patients transplanted for alcoholic (51%) and non-alcoholic cirrhosis (52%). No difference emerged between anti-HCV negative vs. positive alcoholic cirrhosis patients. Psycho-social evaluation revealed alcohol recidivism in 11/34 long-term survivors, but this did not affect overall survival rate in patients with or without HCV. In anti-HCV negative cases, fatty changes and pericellular fibrosis were significantly more common in heavy drinkers than in occasional drinkers and abstainers. When HCV status was considered regardless of alcohol intake, fibrosis was significantly more frequent in patients with HCV.

CONCLUSION

Alcohol recidivism after transplantation in alcoholic cirrhosis patients does not affect survival, irrespective of HCV status. Fatty changes and pericellular fibrosis are the most relevant histological signs of heavy alcohol intake.