[Stabilisation of abstinence by means of psychoeducation for patients with alcoholic liver disease awaiting liver transplantation]

[Control and care structures at transplant centers for patients with ethyltoxic cirrhosis while waiting for a liver transplant: A qualitative survey of practitioners.]

OBJECTIVE

The aim of this study was to record the current care and control structures in place for patients with ethyltoxic liver cirrhosis while being prepared for a liver transplant (LTX) at German transplant centers. In addition, it was also intended to analyze the associated barriers as well as the view of the practitioners on ways to improve care of this patient group.

METHODS

In an exploratory descriptive qualitative design, 11 interviews with practitioners from 10 of the 22 German LTX centers were conducted and analyzed using qualitative content analysis.

RESULTS

There were considerable differences in the care and control structures in place at the LTX centers. Addiction therapy counseling or treatment were not integrated into the treatment concept at all centers. Structural barriers arose from insufficient funding and staffing. Practitioners recommended expansion of treatment options as well as standardizing treatment concepts.

DISCUSSION

The results of our study point to a need for action both in the area of the structures of the individual LTX centers and overall at the system level. Taking into account current standards of addiction medicine, our results could serve as a basis for the development of treatment concepts and recommendations for optimizing standard care before LTX.

A review of behavioral alcohol interventions for transplant candidates and recipients with alcohol-related liver disease

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.

Risk factors and outcomes associated with alcohol relapse after liver transplantation

Alcoholic liver disease (ALD) is the second most common indication for liver transplantation (LT) in the United States and Europe. Unlike other indications for LT, transplantation for ALD may be controversial due to the concern for alcohol relapse and non-compliance after LT. However, the overall survival in patients transplanted for ALD is comparable or higher than in patients transplanted for other etiologies of liver disease. While the rate of alcohol use after liver transplantation does not differ among various etiologies of liver disease, alcohol relapse after transplantation for ALD has been associated with complications such as graft rejection, graft loss, recurrent alcoholic cirrhosis and reduced long-term patient survival. Given these potential complications, our review aimed to discuss risk factors associated with alcohol relapse and the efficacy of various interventions attempted to reduce the risk of alcohol relapse. We also describe the impact of alcohol relapse on post-transplant outcomes including graft and patient survival. Overall, alcohol liver disease remains an appropriate indication for liver transplantation, and long-term mortality in this group of patients is primarily attributed to cardiovascular disease or de novo malignancies rather than alcohol related hepatic complications, among those who relapse.

Non-invasive separation of alcoholic and non-alcoholic liver disease with predictive modeling

Background & Objective

Currently, a major clinical challenge is to distinguish between chronic liver disease caused by metabolic syndrome (non-alcoholic fatty liver disease, NAFLD) from that caused by long term or excessive alcohol consumption (ALD). The etiology of severe liver disease affects treatment options and priorities for liver transplantation and organ allocation. Thus we compared physiologically similar NAFLD and ALD patients to detect biochemical differences for improved separation of these mechanistically overlapping etiologies.

Methods

In a cohort of 31 NAFLD patients with BMI below 30 and a cohort of ALD patient with (ALDC n = 51) or without cirrhosis (ALDNC n = 51) serum transaminases, cell death markers and (adipo-)cytokines were assessed. Groups were compared with One-way ANOVA and Tukey's correction. Predictive models were built by machine learning techniques.

Results

NAFLD, ALDNC or ALDC patients did not differ in demographic parameters. The ratio of alanine aminotransferase/aspartate aminotransferase - common serum parameters for liver damage - was significantly higher in the NAFLD group compared to both ALD groups (each p<0.0001). Adiponectin and tumor necrosis factor(TNF)-alpha were significantly lower in NAFLD than in ALDNC (p<0.05) or ALDC patients (p<0.0001). Significantly higher serum concentrations of cell death markers, hyaluronic acid, adiponectin, and TNF-alpha (each p<0.0001) were found in ALDC compared to ALDNC. Using machine learning techniques we were able to discern NAFLD and ALDNC (up to an AUC of 0.9118±0.0056) or ALDC and ALDNC (up to an AUC of 0.9846±0.0018), respectively.

Conclusions

Machine learning techniques relying on ALT/AST ratio, adipokines and cytokines distinguish NAFLD and ALD. In addition, severity of ALD may be non-invasively diagnosed via serum cytokine concentrations.

Liver transplantation in alcoholic patients: impact of an alcohol addiction unit within a liver transplant center

BACKGROUND

Many concerns about liver transplantation in alcoholic patients are related to the risk of alcohol recidivism. Starting from 2002, an Alcohol Addiction Unit (AAU) was formed within the liver transplant center for the management of alcoholic patients affected by end-stage liver disease and included in the waiting list for transplantation. We evaluated retrospectively the impact of the AAU on alcohol recidivism after transplantation. The relationship between alcohol recidivism and the duration of alcohol abstinence before transplant was evaluated as well.

METHODS

Between 1995 and 2010, 92 cirrhotic alcoholic patients underwent liver transplantation. Clinical evaluation and management of alcohol use in these patients was provided by psychiatrists with expertise in addiction medicine not affiliated to the liver transplant center before 2002 (n = 37; group A), or by the clinical staff of the AAU within the liver transplant center starting from 2002 (n = 55; group B).

RESULTS

Group B, as compared with group A, showed a significantly lower prevalence of alcohol recidivism (16.4 vs. 35.1%; p = 0.038) and a significantly lower mortality (14.5 vs. 37.8%; p = 0.01). Furthermore, an analysis of group B patients with either ≥6 or <6 months of alcohol abstinence before transplantation showed no difference in the rate of alcohol recidivism (21.1 vs. 15.4%; p = ns).

CONCLUSIONS

The presence of an AAU within a liver transplant center reduces the risk of alcohol recidivism after transplantation. A pretransplant abstinence period <6 months might be considered, at least in selected patients managed by an AAU.

Management of alcohol dependence in patients with liver disease

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.

[Stress symptoms and health-related quality of life in patients after orthotopic liver transplantation]

OBJECTIVES

The study explored the presence of stress symptoms among orthotopic liver transplantation (OLT) recipients and investigated how stress symptoms are linked to health-related quality of life (HRQOL). A new concept of adjustment disorder as a stress response syndrome according to Maercker was considered.

METHODS

We recruited 76 OLT recipients, all of whom had been treated in the Department of Surgery, Division of Transplantation Surgery, University of Medicine of Graz, Austria. A self-rating scale was administered to evaluate stress symptoms (PTSS-10). The data on health-related quality of life were obtained from the SF-36 (Health Status Questionnaire).

RESULTS

Following OLT 30.3 % (n = 23) of the sample suffered from stress symptoms. In the group of patients suffering from stress symptoms there were significant impairments in health related quality of life in the SF-36 health-related domains physical functioning, role physical, pain, general health, vitality, social functioning, role emotional, and mental health.

CONCLUSIONS

OLT recipients may face a major risk of OLT-related postoperative stress symptoms in the sense of adjustment disorders according to Maercker. Stress symptoms are highly associated with impairments in quality of life.

[Psychiatric assessment of alcoholic patients on a waiting list for liver transplantation: which prognostic criteria are empirically proven?]

Liver disorders are the most frequent somatic complications of alcoholism. As 10‑20% of alcoholic patients will develop liver cirrhosis, this is the most frequent reason for premature death in alcoholic patients. Liver transplantation is now an accepted therapy for alcoholic liver cirrhosis but psychiatric assessment is usually required for patients entering a waiting list for transplantation. Prognostic criteria are controversially discussed, especially the so-called 6-month rule. Numerous studies and recent meta-analyses have indicated that duration of alcoholism, family history, age, sex, comorbid substance use and psychiatric disorders, noncompliance and social instability are outcome predictors. The 6-month criterion is not well proven but some studies are indicative. Possible therapeutic interventions for alcoholic patients on a waiting list are discussed.

Validierung der türkischen Version des Screenings für Somatoforme Störungen (SOMS) 1Wir danken Frau Z. Subasi für ihre Hilfe in der Begleitung der Patienten in der ersten Einsatzphase des türkischen SOMS

Bei türkischstämmigen Migranten ist die Inanspruchnahme psychotherapeutischer Behandlung häufig mit somatoformen Beschwerden verknüpft. Zur besseren Objektivierung dieser Beschwerden wurde das Screening für Somatoforme Störungen (SOMS), das körperliche Beschwerden nicht organischer Genese erfasst, in die türkische Sprache übersetzt und anhand einer Stichprobe von 114 türkischsprachigen Patienten einer muttersprachlichen psychosomatischen Ambulanz sowie einer Gruppe von 105 psychisch unauffälligen türkischen Migranten validiert. Die türkische Version des SOMS wies eine hohe interne Konsistenz (von α = 0.78 bis α = 0.93), eine hohe konkurrente und divergente Validität (von r = .37 bis r = –.48) anhand von Depressivitätsscores nach dem Beck-Depressions-Inventar und dem Gesamtscore des Kohärenzgefühls nach der Sense of Coherence Scale sowie eine hohe diskriminante Validität auf. Mit der türkischen Version des SOMS wird ein verständliches, reliables und valides Instrument zur Erfassung somatoformer Symptome bei türkischen Migranten vorgelegt.

[Subjective experiences following organ transplantation--a qualitative study of 120 heart, lung, liver, and kidney recipients]

OBJECTIVES

The communication with patients who have undergoned transplantation is greatly influenced by their subjective experience. This paper deals with this subjective transplant-specific experience six months after surgery.

METHODS

Following their heart, lung, liver, or kidney transplantation, 120 patients were questioned concerning their experiences regarding the transplantation, the organ itself, and changes in their personal life. Their statements were investigated by qualitative content analysis.

RESULTS

Generally, the statements concerning the transplantation were positive. Interpersonal contact with the medical staff and or family members was perceived as very helpful. Two-thirds of the patients spoke openly about their organ. For the most part, their statements about changes in their personal life were positive, expressed in the sense of personal growth. Fears and insecurities occurred as negative changes.

CONCLUSIONS

On the whole, the majority of the patients expressed positive experiences regarding their transplantation. Interpersonal and supportive relationships played a significant role.