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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 DOI: 10.1111/ctr.15381] [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: 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, Pennsylvania, USA
| | - Ethan Weinberg
- Division of Gastroenterology and Hepatology, School of Medicine, University of Pennsylvania Perelman, Philadelphia, Pennsylvania, USA
| | - Lynda Coraluzzi
- Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA
| | - Therese Bittermann
- Division of Gastroenterology and Hepatology, School of Medicine, University of Pennsylvania Perelman, Philadelphia, Pennsylvania, USA
- Center for Clinical Epidemiology and Biostatistics, School of Medicine, University of Pennsylvania Perelman, Philadelphia, Pennsylvania, USA
| | - Jonathan Nahas
- Division of Gastroenterology and Hepatology, School of Medicine, University of Pennsylvania Perelman, Philadelphia, Pennsylvania, USA
| | - Senayish Addis
- Penn Transplant Institute, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert Weinrieb
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Marina Serper
- Division of Gastroenterology and Hepatology, School of Medicine, University of Pennsylvania Perelman, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Sharma P, Shenoy A, Shroff H, Kwong A, Lim N, Pillai A, Devuni D, Haque LY, Balliet W, Serper M. Management of alcohol-associated liver disease and alcohol use disorder in liver transplant candidates and recipients: Challenges and opportunities. Liver Transpl 2024:01445473-990000000-00343. [PMID: 38471008 DOI: 10.1097/lvt.0000000000000362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 03/01/2024] [Indexed: 03/14/2024]
Abstract
Alcohol-associated liver disease poses a significant global health burden, with rising alcohol consumption and prevalence of alcohol use disorder (AUD) contributing to increased morbidity and mortality. This review examines the challenges and opportunities in the care of candidates and recipients of liver transplant (LT) with AUD. Despite advancements in posttransplant patient survival, the risk of disease recurrence and alcohol relapse remains substantial. Several challenges have been identified, including (1) rising disease burden of alcohol-associated liver disease, variable transplant practices, and systemic barriers; (2) disparities in mental health therapy access and the impact on transplant; (3) variable definitions, underdiagnosis, and stigma affecting access to care; and (4) post-LT relapse, its risk factors, and consequential harm. The review focuses on the opportunities to improve AUD care for candidates and recipients of LT through effective biochemical monitoring, behavioral and pharmacologic approaches, creating Centers of Excellence for post-LT AUD care, advocating for policy reforms, and ensuring insurance coverage for necessary services as essential steps toward improving patient outcomes. The review also highlights unmet needs, such as the scarcity of addiction specialists, and calls for further research on personalized behavioral treatments, digital health, and value-based care models to optimize AUD care in the LT setting.
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Affiliation(s)
- Pratima Sharma
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Akhil Shenoy
- Department of Psychiatry, Columbia University Medical Center, New York, New York, USA
| | - Hersh Shroff
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Allison Kwong
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Stanford University, Stanford, California, USA
| | - Nicholas Lim
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Anjana Pillai
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, University of Chicago, Chicago, Illinois, USA
| | - Deepika Devuni
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, UMass Chan Medical School, Worcester, Massachusetts, USA
| | - Lamia Y Haque
- Department of Internal Medicine, Section of Digestive Diseases and Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Wendy Balliet
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Marina Serper
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Singal AK, Leggio L, DiMartini A. Alcohol use disorder in alcohol-associated liver disease: Two sides of the same coin. Liver Transpl 2024; 30:200-212. [PMID: 37934047 DOI: 10.1097/lvt.0000000000000296] [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: 05/16/2023] [Accepted: 10/16/2023] [Indexed: 11/08/2023]
Abstract
Alcohol-associated liver disease (ALD) has emerged as the leading indication for liver transplantation (LT) worldwide, with 40% of LTs in the United States performed for ALD in 2019. The ALD-related health care burden accelerated during the COVID-19 pandemic, especially in young individuals. Alcohol use disorder (AUD), which focuses on the negative effects of alcohol on psychosocial, physical, and mental health, is present in the majority of patients with ALD, with moderate to severe AUD in 75%-80%. During the last decade, early liver transplantation (eLT) has emerged as a lifesaving treatment for selected patients with alcohol-associated hepatitis; these patients may have a higher risk of using alcohol after LT. The risk of alcohol use recurrence may be reduced during the pretransplant or post-transplant period with AUD treatment using behavioral and/or pharmacological therapies and with regular monitoring for alcohol use (self-reported and complemented with biomarkers like phosphatidylethanol). However, AUD treatment in patients with ALD is challenging due to patient, clinician, and system barriers. An integrated model to provide AUD and ALD care by hepatologists and addiction experts in a colocated clinic starting from LT evaluation and selection to monitoring listed candidates and then to following up on recipients of LT should be promoted. However, the integration of addiction and hepatology teams in an LT program in the real world is often present only during evaluation and candidate selection for LT. Data are emerging to show that a multidisciplinary integrated AUD treatment within an LT program reduces recurrent alcohol use after LT. If we want to continue using early liver transplantation for patients with severe alcohol-associated hepatitis, LT programs should focus on building integrated multidisciplinary care teams for the integrated treatment of both AUD and ALD.
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Affiliation(s)
- Ashwani K Singal
- Department of Medicine, University of South Dakota, Vermillion, South Dakota, USA
- Department of Gastroenterology and Hepatology, Avera McKennan University Hospital, Sioux Falls, South Dakota, USA
- Department of Transplant Hepatology, Avera Transplant Institute, Sioux Falls, South Dakota, USA
- Department of Medicine, VA Medical Center, Sioux Falls, South Dakota, USA
| | - Lorenzo Leggio
- Department of Neuropsychopharmacology Clinical Psychoneuroendocrinology and Neuropsychopharmacology Section, Translational Addiction Medicine Branch, Division of Intramural Clinical and Biological Research, National Institute on Drug Abuse Intramural Research Program and National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland, USA
- Department of Behavioral and Social Sciences, Center for Alcohol and Addiction Studies, Brown University, Providence, Rhode Island, USA
- Department of Medicine, Division of Addiction Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Neuroscience, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Andrea DiMartini
- Departments of Psychiatry and Transplant Surgery, and the Clinical and Translational Science Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Ivkovic A, Nisavic M, Yang AH, Punko D, Aaron AE, Keegan E, Bethea ED, Yeh H. Single-center experience with early liver transplantation for acute alcohol-related hepatitis-Limitations of the SALT score and directions for future study. Clin Transplant 2024; 38:e15194. [PMID: 37964668 DOI: 10.1111/ctr.15194] [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: 11/20/2022] [Revised: 10/18/2023] [Accepted: 10/28/2023] [Indexed: 11/16/2023]
Abstract
Alcohol-related liver disease (ALD) is the leading indication for liver transplantation worldwide. Since Mathurin et al. described their experience in providing early liver transplantation for patients with ALD in 2011, other centers have followed suit with generally favorable survival outcomes. This patient population poses a unique clinical challenge given the expedited nature of the evaluation and the lack of any significant sobriety period prior to transplantation. The SALT (Sustained Alcohol Use Post-Liver Transplant) score is a standardized psychometric tool increasingly used to help stratify the risk of relapse and guide listing decisions for these challenging clinical situations. In 2018, our center introduced a protocol for early liver transplantation for acute alcohol-related hepatitis (AAH). In this article, we offer a retrospective review of 26 patients transplanted between May 2018 and May 2021, including at least 1-year follow-up, and compare outcomes to initial SALT scores; we further identify additional factors that may impact post-transplant success. As transplant committees continue to weigh the ethical dilemma of denying lifesaving treatment against the obligation to remain stewards of a limited resource, we aim to contribute to a more nuanced understanding of risk regarding early transplantation for ALD.
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Affiliation(s)
- Ana Ivkovic
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
- Center for Transplantation, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Mladen Nisavic
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
- Center for Transplantation, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Alexander H Yang
- Center for Transplantation, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Division of Gastroenterology and Hepatology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Diana Punko
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
- Center for Transplantation, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Ashley Elizabeth Aaron
- Department of Surgery, Division of Surgical Immunology and Transplantation, Eastern Carolina University, Greenville, South Carolina, USA
| | - Eileen Keegan
- Center for Transplantation, Massachusetts General Hospital, Boston, Massachusetts, USA
- Social Service Department, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Emily D Bethea
- Center for Transplantation, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Division of Gastroenterology and Hepatology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Heidi Yeh
- Center for Transplantation, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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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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6
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Mellinger JL, Medley S, Kidwell KM, Asefah H, Winder GS, Fernandez AC, Lok ASF, Blow F. Improving alcohol treatment engagement using integrated behavioral interventions in alcohol-associated liver disease: A randomized pilot trial. Hepatol Commun 2023; 7:e0181. [PMID: 37708435 PMCID: PMC10503679 DOI: 10.1097/hc9.0000000000000181] [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: 03/06/2023] [Accepted: 04/24/2023] [Indexed: 09/16/2023] Open
Abstract
INTRODUCTION Alcohol cessation improves mortality in alcohol-associated liver disease (ALD), but few ALD patients will engage in treatment. We aimed to demonstrate the feasibility and acceptability of a mobile health intervention to increase alcohol use disorder (AUD) treatment among ALD patients. METHODS We conducted a pilot randomized controlled trial (September 2020 to June 2022) at a single tertiary care center in adults with any stage of ALD, past 6-month drinking, and no past-month AUD treatment. Sixty participants were randomized 1:1 to a mobile health application designed to increase AUD treatment engagement through preference elicitation and matching to treatment and misconception correction. Controls received enhanced usual care. The primary outcomes were feasibility (recruitment and retention rates) and acceptability. Exploratory outcomes were AUD treatment engagement and alcohol use, measured by Timeline Followback. Outcomes were measured at 3 and 6 months. RESULTS Baseline characteristics were balanced. The recruitment rate was 46%. Retention was 65% at 6 months. The intervention was highly acceptable to participants (91% were mostly/very satisfied; 95% felt that the intervention matched them well to AUD treatment). Secondary outcomes showed increased AUD treatment at 6 months in the intervention group (intent-to-treat: 27.3% vs. 13.3%, OR 2.3, 95% CI, 0.61-8.76). There was a trend toward a 1-level or greater reduction in World Health Organization (WHO) drinking risk levels in the intervention group (OR 2.25, 95% CI, 0.51-9.97). CONCLUSIONS A mobile health intervention for AUD treatment engagement was highly feasible, acceptable, and produced promising early outcomes, with improved AUD treatment engagement and alcohol reduction in ALD patients.
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Affiliation(s)
- Jessica L. Mellinger
- Michigan Medicine, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Ann Arbor, Michigan, United States
- Michigan Medicine, Department of Psychiatry, Ann Arbor, Michigan, United States
| | - Sarah Medley
- Department of Biostatistics, University of Michigan, School of Public Health, Ann Arbor, Michigan, United States
| | - Kelley M. Kidwell
- Department of Biostatistics, University of Michigan, School of Public Health, Ann Arbor, Michigan, United States
| | - Haila Asefah
- Michigan Medicine, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Ann Arbor, Michigan, United States
| | - G. Scott Winder
- Michigan Medicine, Department of Psychiatry, Ann Arbor, Michigan, United States
- Department of Surgery Michigan Medicine, Ann Arbor, Michigan, United States
- Department of Neurology Michigan Medicine, Ann Arbor, Michigan, United States
| | - Anne C. Fernandez
- Michigan Medicine, Department of Psychiatry, Ann Arbor, Michigan, United States
| | - Anna S. F. Lok
- Michigan Medicine, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Ann Arbor, Michigan, United States
| | - Fred Blow
- Michigan Medicine, Department of Psychiatry, Ann Arbor, Michigan, United States
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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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Verma M, Winder GS. Treatment of substance use disorders in patients with chronic liver disease. Clin Liver Dis (Hoboken) 2022; 20:66-71. [PMID: 36033425 PMCID: PMC9405498 DOI: 10.1002/cld.1248] [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: 11/02/2021] [Revised: 06/11/2022] [Accepted: 06/19/2022] [Indexed: 02/04/2023] Open
Affiliation(s)
- Manisha Verma
- Department of MedicineEinstein Healthcare NetworkPhiladelphiaPennsylvaniaUSA
| | - Gerald Scott Winder
- Departments of Psychiatry, Surgery, and NeurologyUniversity of MichiganAnn ArborMichiganUSA
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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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10
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DiMartini AF, Leggio L, Singal AK. Barriers to the management of alcohol use disorder and alcohol-associated liver disease: strategies to implement integrated care models. Lancet Gastroenterol Hepatol 2022; 7:186-195. [DOI: 10.1016/s2468-1253(21)00191-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/20/2021] [Accepted: 05/25/2021] [Indexed: 02/07/2023]
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11
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Integration of addiction treatment and behavioral therapies in comprehensive liver transplantation care to augment adherence and reduce alcohol relapse. JOURNAL OF LIVER TRANSPLANTATION 2022. [DOI: 10.1016/j.liver.2021.100061] [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] [Indexed: 12/19/2022] Open
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Im GY, Mellinger JL, Winters A, Aby ES, Lominadze Z, Rice J, Lucey MR, Arab JP, Goel A, Jophlin LL, Sherman CB, Parker R, Chen PH, Devuni D, Sidhu S, Dunn W, Szabo G, Singal AK, Shah VH. Provider Attitudes and Practices for Alcohol Screening, Treatment, and Education in Patients With Liver Disease: A Survey From the American Association for the Study of Liver Diseases Alcohol-Associated Liver Disease Special Interest Group. Clin Gastroenterol Hepatol 2021; 19:2407-2416.e8. [PMID: 33069880 PMCID: PMC8291372 DOI: 10.1016/j.cgh.2020.10.026] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/28/2020] [Accepted: 10/12/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS While abstinence-promoting behavioral and pharmacotherapies are part of the therapeutic foundation for alcohol use disorder (AUD) and alcohol-associated liver disease (ALD), these therapies, along with alcohol screening and education, are often underutilized. Our aim was to examine provider attitudes and practices for alcohol screening, treatment and education in patients with liver disease. METHODS We conducted a survey of primarily (89%) hepatology and gastroenterology providers within (80%) and outside the United States (20%). Surveys were sent to 921 providers with 408 complete responses (44%), of whom 343 (80%) work in a tertiary liver transplant center. RESULTS While alcohol screening rates in liver disease patients was nearly universal, less than half of providers reported practicing with integrated addiction providers, using alcohol biomarkers and screening tools. Safe alcohol use by liver disease patients was felt to exist by 40% of providers. While 60% of providers reported referring AUD patients for behavioral therapy, 71% never prescribed AUD pharmacotherapy due to low comfort (84%). Most providers (77%) reported low addiction education and 90% desired more during GI/hepatology fellowship training. Amongst prescribers, baclofen was preferred, but with gaps in pharmacotherapy knowledge. Overall, there was low adherence to the 2019 AASLD practice guidance for ALD, although higher in hepatologists and experienced providers. CONCLUSIONS While our survey of hepatology and gastroenterology providers demonstrated higher rates of alcohol screening and referrals for behavioral therapy, we found low rates of prescribing AUD pharmacotherapy due to knowledge gaps from insufficient education. Further studies are needed to assess interventions to improve provider alignment with best practices for treating patients with AUD and ALD.
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Affiliation(s)
- Gene Y Im
- Division of Liver Diseases, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Jessica L Mellinger
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Adam Winters
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - Elizabeth S Aby
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota
| | - Zurabi Lominadze
- Division of Gastroenterology, Department of Medicine, University of Maryland, Baltimore, Maryland
| | - John Rice
- Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine, Madison, Wisconsin
| | - Michael R Lucey
- Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine, Madison, Wisconsin
| | - Juan P Arab
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Aparna Goel
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
| | - Loretta L Jophlin
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Courtney B Sherman
- Division of Gastroenterology and Hepatology, University of California, San Francisco, San Francisco, California
| | - Richard Parker
- Leeds Liver Unit, St James's University Hospital, Leeds, United Kingdom
| | - Po-Hung Chen
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Deepika Devuni
- Division of Gastroenterology, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Sandeep Sidhu
- Department of Gastroenterology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Winston Dunn
- Department of Internal Medicine, The University of Kansas Medical Center, Kansas City, Kansas
| | - Gyongyi Szabo
- Division of Gastroenterology and Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ashwani K Singal
- Division of Gastroenterology and Hepatology, Department of Medicine, Avera McKennan University Hospital Transplant Institute, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota
| | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
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13
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Winder GS, Shenoy A, Dew MA, DiMartini AF. Alcohol and other substance use after liver transplant. Best Pract Res Clin Gastroenterol 2020; 46-47:101685. [PMID: 33158473 DOI: 10.1016/j.bpg.2020.101685] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 08/31/2020] [Indexed: 01/31/2023]
Abstract
In this article we tackle the controversial subject of alcohol and other substance use following liver transplantation (LT). Most of the literature on and importance of this topic pertains not to recreational use of alcohol or substances but to patients who have alcohol or substance use disorders (AUDs/SUDs). To understand these behaviors after such a lifesaving and resource-intensive procedure as LT necessitates an understanding of these disorders as chronic medical diseases. It also requires an awareness that management of these disorders begins before transplant, so we will briefly touch on considerations to prepare patients for the transplantation. Additionally, we review not only the rates of alcohol and substance use post-LT but strategies clinicians could adopt to identify and manage these events post-LT. Thus, we will summarize approaches for monitoring use and a range of therapeutic treatment options, including pharmacotherapy, to employ once use is discovered. While clinical gastroenterologists may be the primary clinicians responsible for the care of LT recipients, we emphasize a multidisciplinary team approach which, especially for the behavioral health components of the treatment, is likely to be the most successful. This article concludes with a summary of recommendations for clinicians working with these patients and possible future directions for both clinical care and research. While the bulk of the literature is on LT in the context of AUD, we review the smaller body of literature available on non-alcohol substance use.
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Affiliation(s)
- Gerald Scott Winder
- Departments of Psychiatry and Surgery, University of Michigan, Ann Arbor, MI, 48109, USA.
| | - Akhil Shenoy
- Department of Psychiatry, Columbia University Medical Center, 622 West 168th Street, PH14-105, New York, NY, 10032, USA.
| | - Mary Amanda Dew
- Departments of Psychiatry, Psychology, Epidemiology, Nursing, Biostatistics and Clinical and Translational Science, University of Pittsburgh, Pittsburgh, PA, 15213, USA.
| | - Andrea F DiMartini
- Departments of Psychiatry, Surgery and Clinical and Translational Science, University of Pittsburgh, Pittsburgh, PA, 15213, USA.
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14
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Gitto S, Aspite S, Golfieri L, Caputo F, Vizzutti F, Grandi S, Patussi V, Marra F. Alcohol use disorder and liver transplant: new perspectives and critical issues. Korean J Intern Med 2020; 35:797-810. [PMID: 32241080 PMCID: PMC7373982 DOI: 10.3904/kjim.2019.409] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 03/03/2020] [Indexed: 12/13/2022] Open
Abstract
Alcoholic liver disease is a consolidated indication for liver transplantation, but many unsolved issues can be highlighted. Patients with alcohol use disorder develop peculiar comorbidities that can become contraindications for transplantation. Moreover, a number of social and psychological patterns should be evaluated to select candidates with a low risk of alcohol relapse and adequate post-transplant adherence. In this context, the 6-month rule is too rigid to be widely applied. A short period of abstinence (1 to 3 months) is useful to estimate recovery of liver function and, possibly to avoid transplant. Cardiovascular disorders and extra-hepatic malignancies represent the main clinical issues after transplant. Patients transplanted due to alcoholic disease are a major risk for other liver diseases. Severe corticosteroid-resistant alcoholic acute hepatitis is a debated indication for transplant. However, available data indicate that well-selected patients have excellent post-transplant outcomes. Behavioral therapy, continued psychological support and a multidisciplinary team are essential to achieve and maintain complete alcohol abstinence during the transplant process. Alcoholic liver disease is an excellent indication for a liver transplant but patients with alcohol use disorder deserve a personalized approach and dedicated resources.
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Affiliation(s)
- Stefano Gitto
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Silvia Aspite
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Lucia Golfieri
- Department of Psychology, University of Bologna, Bologna, Italy
| | - Fabio Caputo
- Department of Internal Medicine, SS Annunziata Hospital, University of Ferrara, Cento, Italy
| | - Francesco Vizzutti
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Silvana Grandi
- Department of Psychology, University of Bologna, Bologna, Italy
| | | | - Fabio Marra
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Research Center Denothe, University of Florence, Italy
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15
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Prior Relapse, Ongoing Alcohol Consumption, and Failure to Engage in Treatment Predict Alcohol Relapse After Liver Transplantation. Dig Dis Sci 2020; 65:2089-2103. [PMID: 31707529 DOI: 10.1007/s10620-019-05937-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 11/02/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Alcohol-related liver disease (ALD) is the leading indication for liver transplantation (LT) in the USA. Alcohol relapse post-LT can negatively impact long-term outcomes, and prognostic scoring systems are available for further study. AIMS Our study aims were to: (1) evaluate the relationship between alcohol relapse and rejection and mortality, (2) investigate risk factors for relapse, and (3) assess predictive validity of the SIPAT (Stanford Integrated Psychosocial Assessment for Transplant) and SALT (Sustained Alcohol Use Post-Liver Transplant) scores on post-LT alcohol relapse. METHODS We conducted a retrospective chart review of 155 patients transplanted for chronic ALD at a single transplant center. Cox proportional hazard models assessed the relationship between alcohol relapse and allograft rejection and psychosocial risk factors for relapse. RESULTS 20% of patients met criteria for alcohol relapse. Alcohol relapse was associated with allograft rejection (HR 2.33, 95% CI 1.11-4.91, p = .03). Three variables most strongly associated with alcohol relapse: prior relapse, failure to engage in recommended alcohol treatment, and continued drinking with liver disease, which were combined into a psychosocial model. SIPAT score≥ 21 and SALT score ≥ 7 were associated with alcohol relapse (HR 6.40, 95% CI 1.36-30.18, p = .019 and HR 2.30, 95% CI 1.12-4.75, p = .024). Receiver operator characteristic analysis compared predictive ability of our psychosocial model to SIPAT (C-statistic .83 compared to .71) and SALT (C-statistic = .77 compared to .62). CONCLUSION We identified important psychosocial predictors of post-LT alcohol relapse and validated SIPAT and SALT scores as pre-transplant risk factors for alcohol relapse.
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16
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Luchsinger W, Zimbrean P. Systematic Review: Treatment for Addictive Disorder in Transplant Patients. Am J Addict 2020; 29:445-462. [PMID: 32410396 DOI: 10.1111/ajad.13054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 04/04/2020] [Accepted: 04/23/2020] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The number of patients with substance use disorders in need for organ transplantation is expected to increase. Patients with addictive disorders are considered a higher risk of negative outcomes after organ transplantation due to the impact of substance use upon medical status and adherence with treatment. The goal of this systematic review was to assess the current literature on treatment for addiction transplant candidates and recipients. METHODS We conducted a literature search within four databases PubMed, MEDLINE, EMBASE, and PsycINFO for publications dated 1/1/1988 to 12/31/2018. RESULTS Out of 3108 articles identified through database screening, 39 were included in the qualitative synthesis. Sixteen studies described addiction treatment in groups over five patients. All the articles included liver transplant patients, with only two studies including patients who needed a kidney or a heart transplant. Nine articles described treatment of alcohol use disorder exclusively, five focused on treatment of opioid use disorders. Although 9 of 16 studies were prospective, the variability of the treatment intervention, outcome measures, and control group when applicable prohibited a meaningful meta-analysis of the results. Eight articles that described the case reports are analyzed separately. DISCUSSION AND CONCLUSIONS Promising treatment options for alcohol use disorder have been reported but more studies are needed to confirm their effectiveness and their feasibility. Methadone appears effective for opioid disorder in transplant patients. SCIENTIFIC SIGNIFICANCE To the best of our knowledge, this is the first systematic review on the treatment of addictive disorders in transplant patients. (Am J Addict 2020;29:445-462).
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Affiliation(s)
| | - Paula Zimbrean
- Yale University School of Medicine, New Haven, Connecticut.,Yale New Haven Hospital, New Haven, Connecticut
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17
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Ayyala-Somayajula D, Han H, Terrault NA. Selective use of liver transplantation for severe alcohol-associated hepatitis. Expert Rev Gastroenterol Hepatol 2020; 14:175-184. [PMID: 32077333 DOI: 10.1080/17474124.2020.1733414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Severe alcohol-associated hepatitis (sAH) portends high morbidity and mortality and there are no effective therapies for those ineligible or unresponsive to corticosteroids. Early liver transplantation (LT) defined as transplantation without a mandated period of sobriety, for sAH, is being increasingly considered as a rescue therapy.Areas covered: PubMed and manual searches were combined and last performed on 28 October 2019. Key search terms were 'alcoholic hepatitis', 'abstinence', 'alcohol relapse', and 'liver transplantation'. Terms were combined within each database. General reviews and references from published trials were also used.Expert opinion: Early LT is indicated in highly selected patients with sAH. While long-term data are sparse, 1 and 3-year survival post-transplantation are excellent and comparable to other liver diseases. Alcohol relapse is uncommon but approaches 10-25% at 3 years and if use is heavy and/or sustained leads to reduced survival. Thus, for continued application of transplantation for this indication, there is a need to further refine selection criteria and to optimize management of alcohol use disorder (AUD) in the transplant setting. Integral to advancing these objectives is the elimination of societal stigmatization and an acknowledgment that AUD is a medical condition that requires long-term management.
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Affiliation(s)
| | - Hyosun Han
- Department of Medicine, USC Keck School of Medicine, Los Angeles, CA, USA.,Division of Gastrointestinal and Liver Diseases, USC Keck School of Medicine, Los Angeles, CA, USA
| | - Norah A Terrault
- Department of Medicine, USC Keck School of Medicine, Los Angeles, CA, USA.,Division of Gastrointestinal and Liver Diseases, USC Keck School of Medicine, Los Angeles, CA, USA
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18
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Addolorato G, Vassallo GA, Mirijello A, Gasbarrini A. Diagnosis and Management of Alcohol Use Disorder in Patients with Liver Disease: Lights and Shadows. Neurotherapeutics 2020; 17:127-141. [PMID: 31713188 PMCID: PMC7007485 DOI: 10.1007/s13311-019-00802-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Alcohol use disorder is the most common cause of advanced liver disease in the Western world. Diagnosis of alcohol use disorder can be difficult because patients with liver disease tend to deny alcohol intake for the fear of being excluded from treatment and because available biomarkers of alcohol intake have poor specificity in these patients. Alcohol abstinence is the cornerstone of the therapy in these patients. However, pharmacological treatments for alcohol use disorders have not been formally tested in patients with advanced liver disease, except for baclofen. Psychosocial intervention became crucial in these patients considering the limited pharmacological choice. However, psychosocial approach and an appropriate team to manage these patients are not still well defined. In this review, we critically discuss the diagnosis and the management of alcohol use disorder in patients with liver disease.
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Affiliation(s)
- Giovanni Addolorato
- "Internal Medicine and Alcohol Related Disease" Unit, Department of Internal Medicine and Gastroenterology, Catholic University of Rome, Rome, Italy.
- Fondazione Policlinico Universitario A Gemelli IRCCS Research Hospital, Rome, Italy.
| | - Gabriele A Vassallo
- "Internal Medicine and Alcohol Related Disease" Unit, Department of Internal Medicine and Gastroenterology, Catholic University of Rome, Rome, Italy
- Department of Internal Medicine, Barone Lombardo Hospital, Canicattì, Italy
| | - Antonio Mirijello
- "Internal Medicine and Alcohol Related Disease" Unit, Department of Internal Medicine and Gastroenterology, Catholic University of Rome, Rome, Italy
- Department of Medical Sciences, IRCCS Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, Italy
| | - Antonio Gasbarrini
- Fondazione Policlinico Universitario A Gemelli IRCCS Research Hospital, Rome, Italy
- Department of Internal Medicine and Gastroenterology, Catholic University of Rome, Rome, Italy
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19
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Winder GS, Fernandez AC, Klevering K, Mellinger JL. Confronting the Crisis of Comorbid Alcohol Use Disorder and Alcohol-Related Liver Disease With a Novel Multidisciplinary Clinic. PSYCHOSOMATICS 2019; 61:238-253. [PMID: 32033835 DOI: 10.1016/j.psym.2019.12.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 12/03/2019] [Accepted: 12/05/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Alcohol-related liver disease (ALD) is prevalent and deadly and increasingly affects younger people and women. No single discipline is adequately equipped to manage its biopsychosocial complexity. OBJECTIVES Depict the scope of the ALD problem, provide a narrative review of other integrated care models, share our experience forming and maintaining a multidisciplinary ALD clinic for over a year, and provide recommendations for replication elsewhere. METHODS Critical evaluation of clinic implementation and its first year of operation. RESULTS The clinical rationale for multidisciplinary ALD treatment is clear and supported by the literature. Such models are feasible although surprisingly rare and vulnerable to various surmountable challenges. CONCLUSIONS Successful ALD clinics must be built by teams with solid personal and professional relationships, supported by institutional leadership, and must use a new kind of multidisciplinary paradigm and training. Consultation-liaison psychiatry is uniquely positioned to lead future efforts in the care and study of ALD.
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Affiliation(s)
- Gerald Scott Winder
- Department of Psychiatry, University of Michigan, Ann Arbor, MI; Department of Surgery, University of Michigan, Ann Arbor, MI.
| | | | | | - Jessica L Mellinger
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
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20
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Insights Into the Experience of Liver Transplant Recipients With Alcoholic Liver Disease: A Descriptive Qualitative Study. Transplant Direct 2019; 5:e506. [PMID: 32095501 PMCID: PMC7004591 DOI: 10.1097/txd.0000000000000951] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 09/21/2019] [Indexed: 12/01/2022] Open
Abstract
Background. Alcoholic liver disease (ALD) due to alcohol use disorder (AUD) is the primary cause of liver transplantation (LT) in the United States. Studies have found that LT recipients experience a range of physical and emotional difficulties posttransplantation including return to alcohol use, depression, and anxiety. The aim of this study is to better understand the experiences of LT recipients with ALD because they recovered posttransplant to inform the development of a patient-centered intervention to assist patients during recovery. Methods. Using qualitative methods, researchers conducted semi-structured interviews with 16 ALD LT recipients. The primary topics of the interview were physical recovery, mental health, substance use including alcohol and tobacco use, and financial experiences. Common patient themes were identified and coded. Results. Within the domain of physical health, patients stressed that undergoing LT was a near-death experience, they were helpless, changes in weight influenced their perception of their illness, and they have ongoing medical problems. In the domain of mental health, patients described cognitive impairments during their initial recovery, difficulty in processing the emotions of having a terminal condition, ongoing depression, anxiety, and irritability. The patients also described their perception of having AUD, the last time they used alcohol and their attitude to AUD treatment posttransplant. Patients also described their reliance on one member of their social support network for practical assistance during their recovery and identified one member of their medical team as being of particular importance in providing emotional as well as medical support during recovery. Conclusions. The patient’s description of their lived experience during the months following transplant informed the development of a patient-centered intervention that colocates behavioral health components with medical treatment that helps broaden their social network while addressing topics that emerged from this study.
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21
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Schlagintweit HE, Lynch MJ, Hendershot CS. A review of behavioral alcohol interventions for transplant candidates and recipients with alcohol-related liver disease. Am J Transplant 2019; 19:2678-2685. [PMID: 31419015 DOI: 10.1111/ajt.15569] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 07/16/2019] [Accepted: 08/06/2019] [Indexed: 01/25/2023]
Abstract
Alcohol-related liver disease (ALD) is a common indication for liver transplantation. Reflecting growing consensus that early transplant (ie, prior to sustained abstinence) can be a viable option for acute alcoholic hepatitis, access to liver transplantation for ALD patients has increased. Prevention of alcohol relapse is critical to pretransplant stabilization and posttransplant survival. Behavioral interventions are a fundamental component of alcohol use disorder treatment, but have rarely been studied in the transplant context. This scoping review summarizes published reports of behavioral and psychosocial alcohol interventions conducted with ALD patients who were liver transplant candidates and/or recipients. A structured review identified 11 eligible reports (3 original research studies, 8 descriptive papers). Intervention characteristics and clinical outcomes were summarized. Interventions varied significantly in orientation, content, delivery format, and timing/duration. Observational findings illustrate the importance of situating alcohol interventions within a multidisciplinary treatment context, and suggest the potential efficacy of cognitive-behavioral and motivational enhancement interventions. However, given extremely limited research evaluating behavioral alcohol interventions among ALD patients, the efficacy of behavioral interventions for pre- and posttransplant alcohol relapse remains to be established.
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Affiliation(s)
- Hera E Schlagintweit
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Marie-Josée Lynch
- Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Christian S Hendershot
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.,Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Psychology, University of Toronto, Toronto, Ontario, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
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22
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Ranasinghe I, Sin J, Norman I, Lau-Walker M. Predicting and preventing alcohol relapse in alcohol-related liver disease. ACTA ACUST UNITED AC 2019; 27:190-196. [PMID: 29457938 DOI: 10.12968/bjon.2018.27.4.190] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND despite a 450% increase in UK alcohol-related liver disease mortality over the past 30 years, little evidence-based guidance exists regarding preventing recidivism post-liver transplant for alcohol-related liver disease. METHOD a systematic literature review was conducted to identify demographic variables predictive of alcohol relapse and effective psychosocial interventions for alcohol-related liver disease patients post-liver transplant. RESULTS variables most significantly predictive of alcohol relapse post-transplant were-less than 12 months pre-liver transplant abstinence; patients with children; poor pre-liver transplant psychosomatic evaluation; non-compliance with post-liver transplant treatment plan; and patients with active insurance policies. Structured management was the most effective psychosocial intervention in preventing alcohol relapse. CONCLUSION findings should be interpreted cautiously, due to limited and poor-quality evidence. Rigorously designed further research of the psychosocial interventions targeting predictive demographic variables is recommended.
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Affiliation(s)
- Iyoni Ranasinghe
- Quality Improvement Facilitator, South London and Maudsley NHS Trust
| | - Jacqueline Sin
- Associate Professor in Clinical Health and National Institute for Health Research Post Doctoral Research Fellow, University of Reading and St George's, University of London
| | - Ian Norman
- Executive Dean of Faculty, King's College London
| | - Margaret Lau-Walker
- Senior Lecturer, Cluster Lead for Acute, Critical and Emergency Care and Programme Lead for Health Education England and National Institute for Health Research Integrated Clinical Academic Programme, University of Surrey, Guildford
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23
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Weinrieb RM. New Treatment Models for Alcohol Use Disorders and Alcoholic Liver Disease. Clin Liver Dis (Hoboken) 2019; 13:118-122. [PMID: 31236257 PMCID: PMC6544411 DOI: 10.1002/cld.804] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 11/27/2018] [Indexed: 02/04/2023] Open
Affiliation(s)
- Robert M. Weinrieb
- Department of Psychiatry of the University of PennsylvaniaPerelman School of MedicinePhiladelphiaPA
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24
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Misconceptions, preferences and barriers to alcohol use disorder treatment in alcohol-related cirrhosis. J Subst Abuse Treat 2018; 91:20-27. [PMID: 29910011 DOI: 10.1016/j.jsat.2018.05.003] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 05/16/2018] [Accepted: 05/17/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND While alcohol cessation improves mortality in alcoholic liver disease (ALD), many patients struggle to achieve abstinence. Our aim was to characterize ALD patients' preferences, misconceptions, and barriers to alcohol use treatment options. METHODS This mixed-methods study included outpatients with a history of alcohol-related cirrhosis or alcoholic hepatitis recruited from a hepatology clinic for a survey or an in-depth semi-structured interview. We purposefully sampled men and women, compensated and decompensated patients to ensure adequate representation of gender and severity of liver disease for the qualitative interviews. RESULTS 123 patients completed surveys among which 50% reported having at least one drink within the past year while only 20 patients were in any form of current alcohol treatment. Of the 23 patients reporting drinking within 3 months, only 3 were in AUD treatment currently. 17% had at least one misconception about alcohol use or treatment. An additional 22 ALD patients (10 women, 12 men) completed phone interviews of which two-third self-reported alcohol abstinence. All 22 interview participants had awareness of some form of alcohol treatment, but 13 felt that they did not need treatment with several characterizing it as ineffective or a "waste of time." Misconceptions included inaccurate perceptions of relapse medication side effects, beliefs that the presence of advanced liver disease symptoms means it is too late to treat alcohol use, and a lack of understanding about the chronicity of alcohol use disorders. The most common barriers to treatment included unwillingness to be in treatment, financial/insurance and transportation barriers. CONCLUSIONS Alcohol use treatment was underutilized in many ALD patients, despite active drinking in many. Tailored education and preference sensitive treatment engagement may overcome barriers to alcohol use treatment and promote abstinence.
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25
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Lim J, Sundaram V. Risk factors, scoring systems, and interventions for alcohol relapse after liver transplantation for alcoholic liver disease. Clin Liver Dis (Hoboken) 2018; 11:105-110. [PMID: 30992798 PMCID: PMC6385952 DOI: 10.1002/cld.696] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 12/22/2017] [Accepted: 01/08/2018] [Indexed: 02/04/2023] Open
Affiliation(s)
- Jane Lim
- Department of MedicineCedars‐Sinai Medical CenterLos AngelesCA
| | - Vinay Sundaram
- Division of Gastroenterology and Comprehensive Transplant CenterCedars‐Sinai Medical CenterLos AngelesCA
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26
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Attilia ML, Lattanzi B, Ledda R, Galli AM, Farcomeni A, Rotondo C, Di Gregorio V, Mennini G, Poli E, Attilia F, Ginanni Corradini S, Rossi M, Merli M. The multidisciplinary support in preventing alcohol relapse after liver transplantation: A single-center experience. Clin Transplant 2018; 32:e13243. [PMID: 29573476 DOI: 10.1111/ctr.13243] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIM Alcoholic liver disease (ALD) represents a frequent indication for liver transplantation (LT). Since 2004, we have adopted a program of multidisciplinary support(MS) to assist patients undergoing LT for ALD. We aimed at analyzing the relapse rate and the risk factors for relapse. The relapse rate was also compared with that of a historical group of patients who underwent transplantation. Their survival rate was also analyzed. PATIENTS AND METHODS Consecutive patients with ALD transplanted from 2004 were included. The most important demographic, psychosocial, and clinical characteristics known to be associated with alcohol relapse were recorded. RESULTS Sixty-nine patients underwent MS: 8.7% presented alcohol relapse. At multivariate analysis female gender (sHR 9.02, 95% CI 1.71-47.56, P = .009), alcohol withdrawal syndrome (sHR 5.89, 95% CI 1.42-24.46, P = .015) and a shorter time of MS program before LT (sHR 0.928 per month, 95% CI 0.870-0.988, P = .021) were identified as independent risk factors for relapse. The rate of alcohol relapse was significantly lower than that of the historical group who did not undergo MS (sHR 0.21, 95% CI: 0.06-0.68; P = .009). CONCLUSION This study shows that a MS program may contribute to alcohol relapse prevention after LT in ALD patients. However, the relevance of this support needs to be confirmed by clinical trials.
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Affiliation(s)
- Maria Luisa Attilia
- Department of Clinical Medicine, Alcohol Dependence Unit, Sapienza University of Rome, Rome, Italy
| | - Barbara Lattanzi
- Department of Clinical Medicine, Gastroenterology Unit, Sapienza University of Rome, Rome, Italy
| | - Roberta Ledda
- Department of Clinical Medicine, Alcohol Dependence Unit, Sapienza University of Rome, Rome, Italy
| | - Anna Maria Galli
- Department of Clinical Medicine, Alcohol Dependence Unit, Sapienza University of Rome, Rome, Italy
| | - Alessio Farcomeni
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Claudia Rotondo
- Department of Clinical Medicine, Alcohol Dependence Unit, Sapienza University of Rome, Rome, Italy
| | - Vincenza Di Gregorio
- Department of Clinical Medicine, Gastroenterology Unit, Sapienza University of Rome, Rome, Italy
| | - Gianluca Mennini
- Department of General Surgery and Organ Transplantation, Sapienza University of Rome, Rome, Italy
| | - Edoardo Poli
- Department of Clinical Medicine, Gastroenterology Unit, Sapienza University of Rome, Rome, Italy
| | - Fabio Attilia
- Department of Clinical Medicine, Alcohol Dependence Unit, Sapienza University of Rome, Rome, Italy
| | | | - Massimo Rossi
- Department of General Surgery and Organ Transplantation, Sapienza University of Rome, Rome, Italy
| | - Manuela Merli
- Department of Clinical Medicine, Gastroenterology Unit, Sapienza University of Rome, Rome, Italy
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27
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Eccleston JL, Lucey MR. Substance use disorders before and after liver transplantation. Clin Liver Dis (Hoboken) 2017; 10:100-102. [PMID: 31186896 PMCID: PMC6499221 DOI: 10.1002/cld.657] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 07/19/2017] [Indexed: 02/04/2023] Open
Affiliation(s)
- Jason L. Eccleston
- Department of MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonWI
| | - Michael R. Lucey
- Division of Gastroenterology and HepatologyUniversity of Wisconsin School of Medicine and Public HealthMadisonWI
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28
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Heyes CM, Schofield T, Gribble R, Day CA, Haber PS. Reluctance to Accept Alcohol Treatment by Alcoholic Liver Disease Transplant Patients: A Qualitative Study. Transplant Direct 2016; 2:e104. [PMID: 27795986 PMCID: PMC5068203 DOI: 10.1097/txd.0000000000000617] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 07/11/2016] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Liver transplantation (LT) is the optimum treatment for patients with end-stage alcoholic liver disease (ALD). However, despite a recognized risk of relapse to harmful drinking, ALD transplant patients are reluctant to use speciality alcohol treatment to support their abstinence, even when offered within the LT context. This study aimed to understand and identify factors contributing to alcohol treatment reluctance by ALD patients undergoing transplantation. METHODS We conducted an in-depth qualitative study of ALD transplant patients. Minimally structured face-to-face interviews explored participants' alcohol-related experiences and their reasons for not using alcohol treatment during the course of their transplantation. Thematic analysis was used to analyze and interpret interview data to understand treatment reluctance based on participants' experiences. RESULTS Five major themes were identified among 3 subgroups of patients (pretransplant and posttransplant abstainers and posttransplant relapsers): (i) the "contract" of mandatory abstinence, (ii) the "gap in the program" involving the lack of candour between patient and staff about alcohol-related matters and the lack of addiction services, (iii) a preference by participants to self-manage their alcohol use disorder, (iv) social support as a facilitator of abstinence and the risk of relapse when social support is diminished, and (v) the fear of stigmatization. Each of these factors were dynamically interrelated and differed slightly for each subgroup. CONCLUSIONS The LT services may benefit from the inclusion of integrated specialist addiction services in their model of care. Such an approach may enhance the acceptability of alcohol treatment and reduce the risk of relapse among ALD transplant participants, especially for those whose social supports have diminished.
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Affiliation(s)
- Cathy M. Heyes
- Drug Health Services, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- NHMRC Centre for Research Excellence in Mental Health and Substance Use, Australia
| | - Toni Schofield
- Discipline of Behavioural and Social Sciences in Health, The University of Sydney, NSW, Australia
| | - Robert Gribble
- Drug Health Services, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- Consultation Liaison Psychiatry, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Carolyn A. Day
- Discipline of Addiction Medicine, Central Clinical School, The University of Sydney, NSW, Australia
| | - Paul S. Haber
- Drug Health Services, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- NHMRC Centre for Research Excellence in Mental Health and Substance Use, Australia
- Discipline of Addiction Medicine, Central Clinical School, The University of Sydney, NSW, Australia
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Askgaard G, Tolstrup JS, Gerds TA, Hamberg O, Zierau L, Kjær MS. Predictors of heavy drinking after liver transplantation for alcoholic liver disease in Denmark (1990-2013): a nationwide study with competing risks analyses. Scand J Gastroenterol 2016; 51:225-35. [PMID: 26161590 DOI: 10.3109/00365521.2015.1067903] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Heavy drinking following liver transplantation decreases survival. Little is known of predictors of heavy drinking, which should guide clinicians identifying patients at high risk of return to heavy drinking after transplantation. MATERIAL AND METHODS We calculated the cumulative incidence of heavy drinking among patients transplanted for alcoholic liver disease in Denmark 1990-2013. We then analyzed pre-transplant demographic and psychiatric characteristics as predictors of post-transplant heavy drinking. Information was obtained from medical records, from nationwide registries and by interview. RESULTS Among 156 liver-transplanted patients, the cumulative incidence of heavy drinking was 18%, 24% and 27% after 5, 10 and 15 years post-transplant. In univariate analyses of pre-transplant predictors of heavy drinking after transplantation, younger age (p < 0.001), being retired (p = 0.007), anxiety (p = 0.04), personality disorder (p = 0.05) and no lifetime diagnosis of alcohol dependence (p = 0.03) were associated with heavy drinking after transplantation. Smoking (p = 0.06) tended to be associated, whereas depression (p = 0.7) or being married was not (p = 0.7). In the multivariate analysis, only younger age (p = 0.03), being retired (p = 0.007) and no lifetime diagnosis of alcohol dependence (p = 0.003) remained significant predictors. Heavy drinking after transplantation decreased survival beyond 5 years post-transplant (p = 0.004). CONCLUSIONS There is a high incidence of heavy drinking after liver transplantation for alcoholic cirrhosis in Denmark. Younger age, being retired and no lifetime diagnosis of alcohol dependence were predictors of heavy drinking after transplantation.
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Affiliation(s)
- Gro Askgaard
- a 1 Department of Hepatology, Copenhagen University Hospital , Rigshospitalet, Copenhagen, Denmark.,b 2 National Institute of Public Health, University of Southern Denmark , Copenhagen, Denmark
| | - Janne S Tolstrup
- b 2 National Institute of Public Health, University of Southern Denmark , Copenhagen, Denmark
| | - Thomas A Gerds
- c 3 Department of Biostatistics, University of Copenhagen , Copenhagen, Denmark
| | - Ole Hamberg
- a 1 Department of Hepatology, Copenhagen University Hospital , Rigshospitalet, Copenhagen, Denmark
| | - Louise Zierau
- d 4 Department of Respiratory Medicine, Bispebjerg Hospital , Copenhagen, Denmark
| | - Mette S Kjær
- a 1 Department of Hepatology, Copenhagen University Hospital , Rigshospitalet, Copenhagen, Denmark
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Lucey MR, Rice JP. Alcoholic relapse damages liver allografts. Liver Transpl 2016; 22:720-2. [PMID: 27043926 DOI: 10.1002/lt.24454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 04/01/2016] [Indexed: 12/31/2022]
Affiliation(s)
- Michael R Lucey
- Division of Gastroenterology and Hepatology Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - John P Rice
- Division of Gastroenterology and Hepatology Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
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31
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Heyes CM, Baillie AJ, Schofield T, Gribble R, Haber PS. The Reluctance of Liver Transplant Participants with Alcoholic Liver Disease to Participate in Treatment for Their Alcohol Use Disorder: An Issue of Treatment Matching? ALCOHOLISM TREATMENT QUARTERLY 2016. [DOI: 10.1080/07347324.2016.1148515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Telles-Correia D, Mega I. Candidates for liver transplantation with alcoholic liver disease: Psychosocial aspects. World J Gastroenterol 2015; 21:11027-11033. [PMID: 26494959 PMCID: PMC4607902 DOI: 10.3748/wjg.v21.i39.11027] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 06/23/2015] [Accepted: 08/31/2015] [Indexed: 02/07/2023] Open
Abstract
In Europe, 30% to 50% of liver transplantations are currently due to alcoholic liver disease (ALD). In the United States, this percentage is 17.2%. Post-transplant survival and other predictors of clinical course do not differ significantly from those in other types of transplanted patients, as long as there is no relapse of drinking. However, 20%-25% of these patients lapse or relapse to heavy drinking post-operatively, which has been associated with an increased risk of liver damage and mortality. It is therefore crucial to design specific selection and follow-up strategies aimed at this particular type of patient. Several good and poor prognosis factors that could help to predict a relapse have been suggested, among them the duration of abstinence, social support, a family history of alcoholism, abuse diagnosis versus alcohol dependence, non-acceptance of diagnosis related to alcohol use, presence of severe mental illness, non-adherence in a broad sense, number of years of alcoholism, and daily quantity of alcohol consumption. In this article, we discuss these and other, more controversial factors in selecting ALD patients for liver transplantation. Abstinence should be the main goal after transplantation in an ALD patient. In this article, we review the several definitions of post-transplant relapse, its monitoring and the psychopharmacological and psychotherapeutic treatment.
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Erim Y, Böttcher M, Schieber K, Lindner M, Klein C, Paul A, Beckebaum S, Mayr A, Helander A. Feasibility and Acceptability of an Alcohol Addiction Therapy Integrated in a Transplant Center for Patients Awaiting Liver Transplantation. Alcohol Alcohol 2015; 51:40-6. [PMID: 26124208 DOI: 10.1093/alcalc/agv075] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 06/04/2015] [Indexed: 02/06/2023] Open
Abstract
AIMS To evaluate the feasibility and acceptability of an addiction program within the setting of liver transplantation, with classification of behavior change techniques used to reduce excessive drinking. METHOD Patients with alcohol-related liver disease (N = 100) participated in a manualized addiction group therapy over 12 sessions, pre-transplantation. Relapses were identified by measurement of urinary ethyl glucuronide (EtG). RESULTS Two groups were identified according to the frequency of participation: completers (n = 42) vs. drop-outs (n = 58). A total of 16.5% of the samples of completers in comparison to 30.5% of the samples of drop-outs tested positive for EtG (P < 0.001). CONCLUSIONS The results suggest that implementation of an addiction therapy program during the waiting time might help to limit the frequency of drinking. These patients appeared often to under-report their alcohol consumption; including a biomarker such as urinary EtG in such settings is recommended.
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Affiliation(s)
- Yesim Erim
- Department of Psychosomatic and Psychotherapeutic Medicine, University Hospital of Erlangen, Erlangen, Germany
| | | | - Katharina Schieber
- Department of Psychosomatic and Psychotherapeutic Medicine, University Hospital of Erlangen, Erlangen, Germany
| | - Marion Lindner
- Department of Psychosomatic and Psychotherapeutic Medicine, University Hospital of Essen, Essen, Germany
| | - Christian Klein
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, Essen, Germany
| | - Andreas Paul
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, Essen, Germany
| | - Susanne Beckebaum
- Department of Transplant Medicine, University Hospital Münster, Münster, Germany
| | - Andreas Mayr
- Department of Medical Informatics, Biometry and Epidemiology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Anders Helander
- Department of Laboratory Medicine, Karolinska Institutet and Karolinska University Laboratory, Stockholm, Sweden
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Ferro EG, Weikum D, Vagenas P, Copenhaver MM, Gonzales P, Peinado J, Cabello R, Lama JR, Sanchez J, Altice FL. Alcohol use disorders negatively influence antiretroviral medication adherence among men who have sex with men in Peru. AIDS Care 2014; 27:93-104. [PMID: 25277252 DOI: 10.1080/09540121.2014.963013] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
As international guidelines increase access to antiretroviral therapy (ART) globally, ART adherence becomes increasingly important to achieve HIV treatment as prevention (TasP) goals. In the concentrated HIV epidemic among men who have sex with men (MSM) and transgendered women (TGW) in Lima, Peru, the independent correlates of ART nonadherence were examined to inform treatment intervention priorities. Cross sectional survey of HIV-infected MSM and TGW who are engaged in clinical care in Lima, Peru. From June to August 2012, 302 HIV-infected Peruvian MSM/TGW from three clinical care sites were recruited using convenience sampling to participate in a cross-sectional computer-assisted adherence survey. Several standardized screening measures associated with ART nonadherence were examined in order to determine the independent correlates of optimal (≥90%) and perfect (100%) adherence, which were assessed using logistic regression. Of the 302 participants recruited, 263 (87.1%) were prescribed ART. Among those prescribed ART, 229 (87.1%) reported optimal and 146 (55.5%) reported perfect adherence. The prevalence of alcohol use disorders (AUD; 43.2%), alcohol dependence (5.3%), recent drug use (6.0%), and depression (44.5%) was high, and most participants had some evidence of neurocognitive impairment. Meeting criteria for having an AUD and depression were collinear (p < 0.001). On multivariate analysis, having an AUD was inversely related and the only independent correlate of optimal (AOR = 0.427; 95% CI = 0.187-0.976) and perfect (AOR = 0.552; 95% CI = 0.327-0.930) ART adherence. AUDs are highly prevalent among Peruvian HIV-infected MSM and contribute significantly to ART nonadherence. These findings support the need for screening and treating underlying AUDs. In order to meet HIV TasP goals, evidence-based strategies targeting AUDs are likely to directly improve ART adherence and indirectly improve overall individual health, HIV treatment engagement, and reduce transmission to sexual partners among this vulnerable and disproportionally affected population.
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Affiliation(s)
- Enrico G Ferro
- a Section of Infectious Diseases, AIDS Program , Yale School of Medicine , New Haven , CT , USA
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Rustad JK, Stern TA, Prabhakar M, Musselman D. Risk factors for alcohol relapse following orthotopic liver transplantation: a systematic review. PSYCHOSOMATICS 2014; 56:21-35. [PMID: 25619671 DOI: 10.1016/j.psym.2014.09.006] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 09/03/2014] [Accepted: 09/04/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND Each year, 5000-6000 individuals undergo orthotopic liver transplantation (OLT) in the United States, and of these, nearly 18% have alcoholic liver disease. Relapse to alcohol occurs in more than 40% of patients with OLT for alcoholic liver disease. OBJECTIVES We sought to identify factors that predict relapse to alcohol or medication nonadherence following OLT in patients with alcoholic liver disease and to review what randomized clinical interventions have addressed these factors following OLT. Our hypothesis was that there would be factors before and after OLT that predict relapse to alcohol following OLT, and that these, if targeted, might improve sobriety and associated outcomes of adherence with medications and appointments. METHODS We performed a review (focusing on articles published since 2004) with PubMed and MEDLINE searches using the following search terms: liver transplantation, recidivism, alcohol relapse, and predictors of alcohol relapse. We supplemented the online searches with manual reviews of article reference lists and selected relevant articles for further review by author consensus. RESULTS In largely white populations, prospective studies document that shorter length of pretransplantation sobriety is a significant predictor of time to first drink and time to binge use. Presence of psychiatric comorbidity, high score on standardized High-risk Alcoholism Relapse Scale, and diagnosis of Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) alcohol dependence are predictive of posttransplantation alcohol relapse. Pretransplantation alcohol use history variables (e.g., family history of alcoholism) reliably discriminate between complete abstainers and those who drink, while medical and psychosocial characteristics at early post-liver transplantation period (e.g., more bodily pain) maximally discriminate patterns of alcohol use. Alcoholic individuals with early-onset, rapidly accelerating moderate use and early-onset, continuously increasing heavy use have more than double the prevalence of steatohepatitis or rejection on biopsy and graft failure and more frequent mortality resulting from recurrent alcoholic liver disease than late-onset (i.e., peak of heaviest drinking at 6y posttransplantation) alcohol users do. Fortunately, pretransplantation screening combined with a structured pretransplantation management program and a 12-step program attendance reduced recidivism. No randomized clinical trials have been performed that target pretransplantation risk factors in individuals with alcoholic liver disease before or after OLT to improve post-OLT outcomes. CONCLUSIONS Recent research findings suggest that screening can reveal individuals who are vulnerable to alcohol relapse and targeted intervention can prevent their relapse to alcohol. Based on existing addiction treatments (e.g., relapse prevention plan construction), randomized clinical trials tailored to post-OLT patients should be conducted to improve their survival and quality of life.
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Affiliation(s)
- James K Rustad
- Department of Psychiatry and Behavioral Neurosciences, University of South Florida Morsani College of Medicine, Tampa, FL (JKR).
| | - Theodore A Stern
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA (TAS)
| | - Maithri Prabhakar
- Department of Epidemiology, Robert Stempel College of Public Health & Social Work, Florida International University, Miami, FL (MP)
| | - Dominique Musselman
- Department of Psychiatry and Behavioral Sciences, University of Miami Leonard H. Miller School of Medicine, Miami, FL (DM)
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Abstract
Alcoholic liver disease (ALD) is the major cause of life-threatening liver disease in Western countries. Abstinence from alcohol is the foundation of all treatment programmes for patients with ALD. Liver transplantation is a valuable option for patients with life-threatening ALD. Although the role of liver transplantation in the treatment of alcoholic hepatitis that is unresponsive to medical therapy is controversial, the latest prospective studies support this approach. No single measure gives a reliable estimate of the risk of drinking relapses before or after liver transplantation, but careful evaluation by an addiction specialist with a particular interest in transplant medicine is the best available approach. Survival, both on the waiting list and after the operation, is better in patients with ALD than in patients with HCV infection. Alcohol relapse may lead to liver damage and increased mortality, albeit usually after many years of renewed drinking. After liver transplantation, patients with ALD have increased rates of mortality and morbidity that are attributable to cardiovascular disease and new-onset cancers of the aerodigestive tract. The latter are probably linked to the high prevalence of smoking in this population. Cessation of smoking is thus an important goal in the care of patients with ALD after they have undergone liver transplantation.
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37
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Affiliation(s)
- Patrizia Burra
- De: Unidad de Gastroenterología y Trasplantes Multiviscerales, Servicio de Cirugía, Oncología y GastroenterologíaHospital Universitario de PaduaPaduaItalia, y
| | - Michael R. Lucey
- Servicio de Gastroenterología y Hepatología, Departamento de MedicinaUniversity of Wisconsin School of Medicine and Public HealthMadisonWI, EE. UU.
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Rodrigue JR, Hanto DW, Curry MP. Substance abuse treatment and its association with relapse to alcohol use after liver transplantation. Liver Transpl 2013; 19:1387-95. [PMID: 24123780 DOI: 10.1002/lt.23747] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Accepted: 08/31/2013] [Indexed: 12/20/2022]
Abstract
Many liver transplantation (LT) programs require substance abuse (SA) treatment for candidates with a history of alcohol abuse. However, there are no data indicating that SA treatment prevents post-LT alcohol relapse. We examined 118 adults who underwent LT from May 2002 to February 2011 to explore the relationship between SA treatment and post-LT relapse to any alcohol use. Sixty-one patients (52%) with a history of alcohol abuse or dependence received SA treatment before LT. Relapse to any alcohol use was identified in 40 LT recipients (34%). Patients who received SA treatment before LT did not differ significantly in the rate of post-LT alcohol relapse from patients who did not receive treatment before transplantation(30% versus 39%, P = 0.20). However, patients who received SA treatment both before and after transplantation had significantly lower rates of alcohol relapse (16%) than patients who received no SA treatment (41%) or SA treatment only before LT (45%, P = 0.03). Our findings suggest that LT programs should consider placing more emphasis on the continuation of some type of SA treatment after transplantation. Future research should prospectively examine the optimal timing for SA treatment that will attenuate the risk of alcohol relapse after transplantation.
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Affiliation(s)
- James R. Rodrigue
- Center for Transplant Outcomes and Quality Improvement, Transplant Institute; Beth Israel Deaconess Medical Center; Boston MA
- Harvard Medical School; Boston MA
| | - Douglas W. Hanto
- Continuing Medical Education Office; Washington University School of Medicine; St. Louis MO
| | - Michael P. Curry
- Center for Transplant Outcomes and Quality Improvement, Transplant Institute; Beth Israel Deaconess Medical Center; Boston MA
- Harvard Medical School; Boston MA
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Burra P, Lucey MR. Liver transplantation for alcoholic liver disease. Clin Liver Dis (Hoboken) 2013; 2:92-95. [PMID: 30992833 PMCID: PMC6448626 DOI: 10.1002/cld.204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Revised: 03/14/2013] [Accepted: 03/25/2013] [Indexed: 02/04/2023] Open
Affiliation(s)
- Patrizia Burra
- Gastroenterology, Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Michael R. Lucey
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
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40
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Addolorato G, Mirijello A, Leggio L, Ferrulli A, Landolfi R. Management of alcohol dependence in patients with liver disease. CNS Drugs 2013; 27:287-99. [PMID: 23456576 PMCID: PMC4979989 DOI: 10.1007/s40263-013-0043-4] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Alcohol dependence represents a chronic and relapsing disease affecting nearly 10 % of the general population both in the USA and in Europe, with a widespread burden of morbidity and mortality. Alcohol dependence represents the most common cause of liver damage in the Western world. Although alcoholic liver disease is associated primarily with heavy drinking, continued alcohol consumption, even in low doses after the onset of liver disease, increases the risk of severe consequences, including mortality. Consequently, the ideal treatment of patients affected by alcohol dependence and alcoholic liver disease should aim at achieving long-term total alcohol abstinence and preventing relapse. The aim of the present review is to provide an update on the management of alcohol dependence in patients with alcoholic liver disease. Increasing evidence suggests the usefulness of psychosocial interventions and medications combined in order to reduce alcohol intake, promote abstinence and prevent relapse in alcohol-dependent patients. Disulfiram, naltrexone and acamprosate have been approved for this indication; gamma-hydroxybutyric acid (GHB) is approved in Italy and Austria. However, these drugs have not been tested in patients with advanced liver disease. Amongst other emerging pharmacotherapies for alcoholism, topiramate, ondansetron, and baclofen seem the most promising ones. Both topiramate and ondansetron have a safe profile in alcoholic patients; however, none of them has been tested in alcoholic patients with advanced liver disease. To date, baclofen represents the only anti-craving medication formally tested in a randomized clinical trial in alcoholic patients affected by liver cirrhosis, although additional confirmatory studies are warranted.
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Affiliation(s)
- Giovanni Addolorato
- Department of Internal Medicine, Institute of Internal Medicine, Catholic University of Rome, Gemelli Hospital, Largo Gemelli 8, 00168 Rome, Italy.
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41
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EASL clinical practical guidelines: management of alcoholic liver disease. J Hepatol 2012; 57:399-420. [PMID: 22633836 DOI: 10.1016/j.jhep.2012.04.004] [Citation(s) in RCA: 431] [Impact Index Per Article: 35.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Accepted: 04/04/2012] [Indexed: 12/12/2022]
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Abstract
In this article the epidemiology of substance use and substance disorders in the United States and their association with liver disease are reviewed. The relevance of tobacco use and issues of candidacy as it pertains to substance use are discussed. The use of alcohol while on the waitlist and short sobriety are also addressed. The merits of monitoring of patients are discussed, and the outcomes of these patients after liver transplantation are examined. The article concludes with a summary of recommendations for clinicians working with these patients and possible future directions for both clinical care and research.
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Affiliation(s)
- Andrea DiMartini
- Consultation Liaison to the Liver Transplant Program, Starzl Transplant Institute, University of Pittsburgh Medical Center, PA 15213, USA.
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43
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Gramenzi A, Gitto S, Caputo F, Biselli M, Lorenzini S, Bernardi M, Andreone P. Liver transplantation for patients with alcoholic liver disease: an open question. Dig Liver Dis 2011; 43:843-9. [PMID: 21550324 DOI: 10.1016/j.dld.2011.03.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2010] [Revised: 03/08/2011] [Accepted: 03/27/2011] [Indexed: 12/11/2022]
Abstract
End-stage alcoholic liver disease is a recognised indication for liver transplantation but some questions on the matter remain open. It is difficult to quantify alcohol consumption, and a single definition of post-transplant relapse is lacking. Moreover, there are no internationally accepted criteria for the selection of candidates for liver transplantation and the eligibility parameters for these patients are controversial. Additional clinical and psychological evaluations are necessary in this setting, especially to establish the risk of alcohol relapse. Nevertheless, patient and graft survival rates after liver transplantation in alcoholic liver disease are comparable to those after transplant for other aetiologies, alcohol consumption relapse being one of the most important problems in the post-transplant phase. In conclusion, alcohol-related liver disease is a good indication for liver transplantation. The main future goals are to formulate a well-defined pre-transplant approach and a single definition of alcohol relapse and to improve prevention strategies.
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Affiliation(s)
- Annagiulia Gramenzi
- Department of Clinical Medicine, University of Bologna, Semeiotica Medica, S.Orsola-Malpighi Hospital, Bologna, Italy
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Abstract
Although alcoholic liver disease (ALD) is one of the most common indications for liver transplantation (LT), there are still unresolved controversies about the goals of treatment, the referral, evaluation, and selection of patients with ALD for LT, and their care after LT. It is uncertain whether there is a large unmet need for LT among patients with ALD because of the unmeasured effects of recent drinking, relapse, and recovery with abstinence in this population. A careful assessment of the extrahepatic effects of alcohol-related end-organ damage is needed for ALD patients who are referred for an LT evaluation. Although there clearly is a relationship between the length of sobriety and future abstinence, the present methods for predicting future drinking are inexact. The survival of ALD patients after LT is as good as the survival of non-ALD patients, although patients with coincident ALD and hepatitis C virus have higher mortality and morbidity rates. After LT, ALD patients have an increased risk of developing malignancies and cardiovascular disease. These risks appear to be linked to cigarette smoking. Covert drinking occurs both before and after transplantation, and approximately 20% of patients return to harmful drinking after LT. Harmful drinking after LT (instead of slips) causes liver damage and reduces survival. Better therapies for controlling addictions to alcohol and nicotine are needed for ALD patients both before and after LT.
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Affiliation(s)
- Michael R Lucey
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin, Madison, WI 53792, USA.
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45
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Weinrieb RM, Van Horn DHA, Lynch KG, Lucey MR. A randomized, controlled study of treatment for alcohol dependence in patients awaiting liver transplantation. Liver Transpl 2011; 17:539-47. [PMID: 21506242 DOI: 10.1002/lt.22259] [Citation(s) in RCA: 96] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Alcohol is the second most common cause of cirrhosis necessitating liver transplantation in the United States, yet rates of posttransplant drinking approach 50% and no controlled clinical trials of alcoholism treatment exist in this population. Eligible patients were randomly assigned to receive Motivational Enhancement Therapy (MET), or referral to local treatment sources ("treatment as usual" [TAU]). Addictive behavior, mood states, and general health were compared. Candor concerning alcohol use was encouraged by keeping drinking questionnaires in confidence, except in medical emergencies. Ninety-one subjects were studied; 46 received MET, 45 received TAU, 29 proceeded to transplantation (MET, n = 13; TAU, n = 16). A total of 69 subjects completed 24 weeks of observation, and 25 subjects were assessed at 96 weeks. No difference in study attendance was observed, but significantly more MET subjects attended 1 or more treatment sessions. Twenty-three subjects (25% of sample) drank after randomization but before transplant. Excluding an extreme outlier, MET drinkers had significantly fewer drinks per drinking days than TAU drinkers. Neither treatment plan resulted in significant variances in measures of psychosocial health. In conclusion, although MET afforded no significant benefit over TAU for mood or general health outcomes, this study provides some degree of support for MET to limit the quantity and frequency of pretransplant alcohol consumption among liver transplant candidates with alcohol dependence. However, because of the limited number of study subjects, these data must be interpreted cautiously. Further research to validate our findings or to identify better methods to identify and intervene with patients at risk of pretransplant and posttransplant drinking should continue.
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Affiliation(s)
- Robert M Weinrieb
- Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
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Springer SA, Azar MM, Altice FL. HIV, alcohol dependence, and the criminal justice system: a review and call for evidence-based treatment for released prisoners. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2010; 37:12-21. [PMID: 21171933 DOI: 10.3109/00952990.2010.540280] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND People with both HIV and alcohol use disorders (AUDs) are disproportionately concentrated within the U.S. criminal justice system; approximately one-quarter of all people with HIV cycle through the system each year. HIV-infected prisoners with AUDs face many obstacles as they transition back to the community. Specifically, although they have impressive HIV treatment outcomes during the period of incarceration while they are free from alcohol; upon [corrected] release, however, they face inordinate challenges including relapse to alcohol use resulting in significant morbidity and mortality. OBJECTIVE To review the existing literature regarding the relationship of HIV and treatment for AUDs within the criminal justice system in an effort to determine "best practices" that might effectively result in improved treatment of HIV and AUDs for released prisoners. METHODS PubMed, PsychInfo and Medline were queried for articles published in English from 1990 to 2009. Selected references from primary articles were also examined. RESULTS Randomized controlled trials affirm the role of pharmacotherapy using naltrexone (NTX) as the therapeutic option conferring the best treatment outcome for AUDs in community settings. Absent from these trials were inclusion of released prisoners or HIV-infected individuals. Relapse to alcohol abuse among HIV-infected prisoners is associated with reduced retention in care, poor adherence to antiretroviral therapy with consequential poor HIV treatment outcomes and higher levels of HIV risk behaviors. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE Untreated alcohol dependence, particularly for released HIV-infected prisoners, has negative consequences both for the individual and society and requires a concentrated effort and rethinking of our existing approaches for this vulnerable population.
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Affiliation(s)
- Sandra A Springer
- Yale University School of Medicine, Department of Medicine, Section of Infectious Diseases, AIDS Program, 135 College Street, Suite 323, New Haven, CT 06511, USA
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Li KK, Neuberger J. Recurrent nonviral liver disease following liver transplantation. Expert Rev Gastroenterol Hepatol 2009; 3:257-68. [PMID: 19485808 DOI: 10.1586/egh.09.16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Recurrent disease after liver transplantation is well recognized and remains a potential cause of premature graft loss. The rates of recurrence are difficult to establish because of the lack of consistency in diagnostic criteria and approaches to diagnosis. Owing to the fact that recurrent parenchymal disease may occur in the presence of normal liver tests, those centers that use protocol biopsies will report greater rates of recurrence. It is important to recognize that rates of recurrence vary according to indication and show little correlation with rates of graft loss from recurrent disease. Recurrance rates are greatest for primary sclerosing cholangitis and autoimmune hepatitis, and low reccurrance rates are reported for alcoholic liver disease and recurrent primary biliary cirrhosis. The impact of recurrent nonalcoholic fatty liver disease is not yet clear. Patients and clinicians need to be aware of the possibility of recurrent disease in the differential diagnosis of abnormal liver tests, and management stategies may require alteration to reduce the impact of disease recurrence on outcome. Finally, an understanding of which diseases do recur after transplantation and identification of the risk factors may lead to a better understanding of the pathogenetic mechanisms of these conditions.
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Affiliation(s)
- Ka-Kit Li
- Liver Unit, Queen Elizabeth Hospital, Birmingham, B15 2TH, UK
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Abstract
Understanding alcohol addiction and abstinence is key to treating alcoholic liver disease, since abstinence leads to improvement in all forms of alcoholic liver damage. Although pharmacotherapy for alcoholism, using agents such as naltrexone, acamprosate, topiramate, and baclofen, is an exciting field, few studies have included patients with liver disease or cirrhosis. To treat alcoholic liver injury, corticosteroids have become the standard of care in patients with severe alcoholic hepatitis. In contrast, the role of pharmacotherapy to treat alcoholic fibrosis is unclear, with failure to observe a benefit in randomized, placebo-controlled clinical trials of colchicine, S-adenosylmethionine (SAMe), or phosphatidylcholine. Liver transplantation remains an option in selected patients with life-threatening alcoholic liver disease.
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Addolorato G, Russell M, Albano E, Haber PS, Wands JR, Leggio L. Understanding and treating patients with alcoholic cirrhosis: an update. Alcohol Clin Exp Res 2009; 33:1136-44. [PMID: 19389182 DOI: 10.1111/j.1530-0277.2009.00956.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Alcoholic cirrhosis represents the terminal stage of alcoholic liver disease (ALD) and one of the main causes of death among alcohol abusers. The aim of this review was to provide an update on alcoholic cirrhosis, with an emphasis on recent findings. Increased alcohol consumption in developing countries is expected to increase cirrhosis mortality. There is a need, therefore, to develop new approaches to the prevention of ALD, including more attention to co-factors that may increase risk of ALD (i.e., obesity and diabetes, chronic HCV infection, and smoking). Furthermore, a better understanding of the pathological mechanisms on the basis of alcohol cirrhosis represents a cornerstone in order to develop new pharmacological treatments. Inflammatory and immune responses along with oxidative stress and alterations in adipokine secretion might contribute in different ways to the evolution of alcohol-induced fibrosis/cirrhosis. As of this date, patients with severe alcoholic hepatitis with a Maddrey Discriminant Factor (MDF) 32 should be offered pentoxifylline and/or corticosteroids unless contraindications exist. For ambulatory patients, S-adenosylmethionine (SAMe) may be considered in a motivated patient with nutritional support. Current studies do not support use of anti-tumor necrosis factor (TNF)-alpha antibody. Finally, achieving total alcohol abstinence should represent the main aim in the management of patients affected by any stage of cirrhosis. In the last decades, several drugs able to increase abstinence and prevent alcohol relapse have been evaluated and some of them have obtained approval for alcohol dependence. Patients with alcoholic cirrhosis; however, are usually excluded from such treatments. A recent study demonstrated the efficacy and safety of baclofen in inducing and maintaining alcohol abstinence in cirrhotic alcohol-dependent patients with cirrhosis. All together the information available suggests the need of a multimodal approach in the clinical management of these patients.
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Affiliation(s)
- Giovanni Addolorato
- Institute of Internal Medicine, Catholic University of Rome (GA, LL), Rome, Italy
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Kotlyar DS, Burke A, Campbell MS, Weinrieb RM. A critical review of candidacy for orthotopic liver transplantation in alcoholic liver disease. Am J Gastroenterol 2008; 103:734-43; quiz 744. [PMID: 18081918 DOI: 10.1111/j.1572-0241.2007.01691.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The majority of candidates with end-stage alcoholic liver disease (ESALD) in the United States who are eligible for referral for liver transplantation (LT) are not being referred. There is a lack of firm consensus for the duration of abstinence from alcohol as well as what constitutes good psychosocial criteria for listing for LT. Evidence shows that the general public and the practicing physicians outside the transplant community perceive that patients with a history of alcohol abuse will make poor transplant candidates. However, physicians in the transplant community perceive selected patients with ESALD as good candidates. When considering patients for listing for LT, 3 months of alcohol abstinence may be more ideal than 6 months. Patients with a lack of social support, active smoking, psychotic or personality disorders, or a pattern of nonadherence should be listed only with reservation. Those who have a diagnosis of alcohol abuse as opposed to alcohol dependence may make better transplant candidates. Patients who have regular appointments with a psychiatrist or psychologist in addictions treatment training also seem to do more favorably.
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Affiliation(s)
- David S Kotlyar
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA
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