Interpreting the significance of drinking by alcohol-dependent liver transplant patients: fostering candor is the key to recovery

A randomized, controlled study of treatment for alcohol dependence in patients awaiting liver transplantation

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.

Liver transplantation for alcoholic liver disease

Alcoholic liver disease (ALD) is the second commonest indication for liver transplantation after viral hepatitis in the United States and Europe. Controversies surround the indications and allocation of scarce and expensive resource for this so called self inflicted disease. Controversies stem from the apprehension that alcoholic recipients are likely to relapse and cause damage to the graft. There is a need to select those candidates with lower risk for relapse with the available predictive factors and scores. Substance abuse specialist and psychiatrists are mandatory in the pre-transplant evaluation and in the post-transplant follow-up. There is conflicting evidence to support a fixed period of pretransplant abstinence, although most units do follow this. Alcoholic hepatitis (AH) continues to be a contraindication for transplantation, however there is a need for further research in this field as a subset of patients with AH who do not respond to medical treatment, have high early mortality and could benefit from transplantation. One year, 3-year, and 5-year survival post-transplant is similar for both ALD and non-ALD recipients. The incidence of post-transplant rejection and retransplantation is also similar to other recipients. ALD with viral hepatitis especially hepatitis C virus leads to a more aggressive liver disease with early presentation for transplantation. ALD patients are more prone to develop de-novo malignancy; this is attributed to the long term effect of alcohol, tobacco combined with immunosuppression. Post-transplant surveillance is important to detect early relapse to alcoholism, presence of de-novo malignancy and treat the same adequately.

Hair analysis versus conventional methods of drug testing in substance abusers seeking organ transplantation

As substance abusers need to demonstrate abstinence prior to transplant, valid/reliable drug tests are needed. Patients may deny use, fearing surgery will be delayed. Breath, blood and urine tests have brief detection windows that allow patients to evade detection. Routine laboratory tests do not include all substances of abuse. Hair analysis overcomes these barriers, increasing the likelihood that active users will be identified. This study compared results for alcohol, opioids and cocaine based on 445 self-report, breath, urine and hair samples from 42 patients who had been denied a transplant due to recent substance abuse. Compared to hair toxicology, sensitivity for conventional drug tests was moderate for cocaine and opioids, but poor for alcohol. Of positive hair tests, only half were corroborated through other tests. In contrast, specificity was high across tests and substances, with positive findings from conventional tests confirmed through hair toxicology. Based on a 90-day detection window for hair analysis, two negative tests suggest 6 months of continuous abstinence. Hair testing should be considered as an alternative approach for monitoring substance use in the transplant population, either as a routine procedure or when the veracity of findings from conventional tests is in doubt.

The place of liver transplantation in the treatment of severe alcoholic hepatitis

Although most patients with alcoholic liver disease experience positive outcomes following liver transplantation, data on the outcome after liver transplantation in patients with severe alcoholic hepatitis are limited. Furthermore, predicting which patients with severe alcoholic hepatitis will maintain sobriety after transplantation is especially difficult. We review the arguments in favour and against extending liver transplantation to selected patients with severe alcoholic hepatitis. In conclusion, we propose that liver transplantation should be a rescue option for occasional patients with severe alcoholic hepatitis who meet the following criteria: those with severe alcoholic hepatitis that has failed medical management, who fulfil all other standard criteria for transplantation, including a thorough psychosocial assessment, yet who are unlikely to survive a mandatory 6-month abstinence period.

Management of alcoholic liver disease

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.

Predictors of relapse to alcohol and illicit drugs after liver transplantation for alcoholic liver disease

BACKGROUND

Alcoholic liver disease (ALD) is a common indication for transplantation worldwide. This study identifies factors predicting posttransplant recidivism.

METHODS

Clinical and laboratory data were reviewed. Uni- and multivariate analyses for survival and relapse to alcohol and illicit drugs were performed.

RESULT

Between July 1995 and November 2007, 387 patients underwent liver transplantation at our institution. Of these, 147 patients (38%) were found to have ALD. Five patients (3.4%) were excluded because of perioperative mortality. Overall survival was 96.2%, 89.6%, and 84.4% at 1, 3, and 5 years, respectively, with a median follow-up of 41.2 months. Twenty-seven patients (19%) returned to alcohol after transplantation. By univariate analysis, depression was the only significant factor affecting survival (P=0.01), whereas posttransplant relapse to alcohol trended toward significance (P=0.059). Multivariate analysis showed both factors to be independently associated with poor survival (P=0.008 and 0.017, respectively). Factors associated with relapse included less than 12 months of abstinence before transplant (P=0.019) and participation in rehabilitation (P=0.026). Multivariate analysis showed pretransplant abstinence less than 12 months as the only independent factor (P=0.037) associated with alcohol relapse after transplantation. Twenty-five patients (17.2%) had documented drug use after transplantation. Drug abuse before transplantation was the only independent predictor of drug abuse after transplantation (P=0.017).

CONCLUSIONS

Excellent results can be obtained in patients undergoing liver transplantation for ALD, though depression and recidivism adversely impact survival. In our series, abstinence less than 12 months was associated with relapse to alcohol. Similarly, those with prior drug abuse are more likely to continue drug use after transplantation.

Detecting lifetime alcohol problems in individuals referred for liver transplantation for nonalcoholic liver failure

Transplantation for alcoholic liver disease is becoming increasingly common, and with adequate screening, short- to medium-term outcomes are very good. However, while conducting a prospective study of the outcome of liver transplantation in Birmingham, United Kingdom, we observed that a research diagnosis of alcohol abuse or dependence was made in a number of cases in which no reference to alcohol problems had been made by the referring agency. This article explores the characteristics of these "missed" cases and highlights key patient characteristics that might prompt a more detailed assessment of alcohol consumption. Two hundred eight individuals completed the research interview, and 80 (39%) met Diagnostic and Statistical Manual of Mental Disorders IV criteria for a lifetime diagnosis of either alcohol abuse (n = 29) or dependence (n = 51). When the initial referral details were reviewed, the possibility of alcohol problems had not been raised in 10 (12.5%) of these cases. Hepatitis C was the most common primary diagnosis in the missed cases, but there was no difference between diagnosed and missed cases in terms of demographic factors, severity of liver disease, or the number or degree of lifetime problems associated with alcohol. However, members of the missed group were more likely to have drunk alcohol in the past 6 months and in a greater volume and were more likely to have used illicit drugs such as opiates, amphetamines, hallucinogens, and cannabis. These findings point to the need to take an adequate history of lifetime alcohol problems in all patients being considered for liver transplantation.

Hepatitis infection in the treatment of opioid dependence and abuse

Many new and existing cases of viral hepatitis infections are related to injection drug use. Transmission of these infections can result directly from the use of injection equipment that is contaminated with blood containing the hepatitis B or C virus or through sexual contact with an infected individual. In the latter case, drug use can indirectly contribute to hepatitis transmission through the dis-inhibited at-risk behavior, that is, unprotected sex with an infected partner. Individuals who inject drugs are at-risk for infection from different hepatitis viruses, hepatitis A, B, or C. Those with chronic hepatitis B virus infection also face additional risk should they become co-infected with hepatitis D virus. Protection from the transmission of hepatitis viruses A and B is best achieved by vaccination. For those with a history of or who currently inject drugs, the medical management of viral hepatitis infection comprising screening, testing, counseling and providing care and treatment is evolving. Components of the medical management of hepatitis infection, for persons considering, initiating, or receiving pharmacologic therapy for opioid addiction include: testing for hepatitis B and C infections; education and counseling regarding at-risk behavior and hepatitis transmission, acute and chronic hepatitis infection, liver disease and its care and treatment; vaccination against hepatitis A and B infection; and integrative primary care as part of the comprehensive treatment approach for recovery from opioid abuse and dependence. In addition, participation in a peer support group as part of integrated medical care enhances treatment outcomes. Liver disease is highly prevalent in patient populations seeking recovery from opioid addiction or who are currently receiving pharmacotherapy for opioid addiction. Pharmacotherapy for opioid addiction is not a contraindication to evaluation, care, or treatment of liver disease due to hepatitis virus infection. Successful pharmacotherapy for opioid addiction stabilizes patients and improves patient compliance to care and treatment regimens as well as promotes good patient outcomes. Implementation and integration of effective hepatitis prevention programs, care programs, and treatment regimens in concert with the pharmacological therapy of opioid addiction can reduce the public health burdens of hepatitis and injection drug use.

Meta-analysis of risk for relapse to substance use after transplantation of the liver or other solid organs

For patients receiving liver or other organ transplants for diseases associated with substance use, risk for relapse posttransplantation is a prominent clinical concern. However, there is little consensus regarding either the prevalence or risk factors for relapse to alcohol or illicit drug use in these patients. Moreover, the evidence is inconsistent as to whether patients with pretransplantation substance use histories show poorer posttransplantation medical adherence. We conducted a meta-analysis of studies published between 1983 and 2005 to estimate relapse rates, rates of nonadherence to the medical regimen, and the association of potential risk factors with these rates. The analysis included 54 studies (50 liver, 3 kidney, and 1 heart). Average alcohol relapse rates (examined only in liver studies) were 5.6 cases per 100 patients per year (PPY) for relapse to any alcohol use and 2.5 cases per 100 PPY for relapse with heavy alcohol use. Illicit drug relapse averaged 3.7 cases per 100 PPY, with a significantly lower rate in liver vs. other recipients (1.9 vs. 6.1 cases). Average rates in other areas (tobacco use, immunosuppressant and clinic appointment nonadherence) were 2 to 10 cases per 100 PPY. Risk factors could be examined only for relapse to any alcohol use. Demographics and most pretransplantation characteristics showed little correlation with relapse. Poorer social support, family alcohol history, and pretransplantation abstinence of < or =6 months showed small but significant associations with relapse (r = 0.17-0.21). Future research should focus on improving the prediction of risk for substance use relapse, and on testing interventions to promote continued abstinence posttransplantation.

The impact of acute alcoholic hepatitis in the explanted recipient liver on outcome after liver transplantation

Patients with clinical acute alcoholic hepatitis (AAH) are not considered suitable candidates for orthotopic liver transplantation (OLT). The histological correlates of AAH are often seen in the explanted liver at the time of transplantation. The importance of these findings remains inconclusive regarding their role as a prognostic marker for patient or allograft health. Our aim was to examine the explanted liver of patients with purely alcoholic liver disease (ALD) for findings of histologic AAH and to correlate these to patient and graft outcomes. We compared patients with and without histological AAH with patients transplanted for non-ALD. Of 1,097 liver transplant recipients, 148 had ALD and 125 were non-ALD control patients with similar demographics. Thirty-two of 148 ALD patients had histologic AAH, and 116 had bland alcoholic cirrhosis (BAC). Twenty-eight percent of the ALD patients reported <6 months abstinence, and 54% reported <12 months abstinence. There was a statistically significant relationship between the presence of histologic AAH and abstinence durations<12 months (P=0.009), but not <6 months. Overall, posttransplantation patient and graft survival between the ALD and non-ALD groups was not significantly different (P=0.53). Furthermore, patient and graft survival between ALD patients with histologic AAH and BAC were similar (P=0.13 and P=0.11, respectively). The rate of posttransplantation relapse among ALD patients was 16%; however, there was no increase in graft loss, nor was there decreased survival compared with controls. The patients with histologic AAH and those with BAC had no differences in posttransplantation relapse (P=0.13). In multivariate analysis, patient and graft survival was not influenced by pretransplantation abstinence or posttransplantation relapse. In conclusion, histological alcoholic hepatitis in the explant did not predict worse outcome regarding relapse, and allograft or patient survival for liver transplant recipients. Caution should be exercised when liver histology is used to discriminate among suitable candidates for OLT concerning alcoholic patients.

"I'll never touch it again, doctor!"--harmful drinking after liver transplantation

BACKGROUND

Alcohol relapse can negatively influence the outcome after liver transplantation (LT). The aim of our study was to identify factors that could be associated with the recurrence of harmful alcohol consumption after LT.

METHODS

A total of 387 consecutive patients (23.8% women) who underwent LT for alcoholic cirrhosis in Geneva, Switzerland, and Lyon, France, between 1989 and 2005 were evaluated. Mean +/- SD age was 51.3 +/-7.5 years. Follow-up time was 61.2 +/- 47.5 months. Alcohol consumption relapse and potential factors associated with it were studied.

RESULTS

The relapse rate of harmful alcohol consumption after LT was 11.9%. In univariate analysis, alcohol relapse was significantly associated with age greater than 50 years (P = .04), year of LT 1995 or earlier (P<.05), duration of abstinence less than 6 months (P = .02), presence of psychiatric comorbidities (P<.001), presence of a life partner (P<.05), and a high score on the High-Risk Alcoholism Relapse (HRAR) scale (P<.001). Multivariate logistic regression disclosed the following independent factors of relapse: duration of abstinence of less than 6 months (odds ratio [OR], 3.3; 95% confidence interval [CI], 1.2-9.3) (P = .02); presence of psychiatric comorbidities (OR, 7.8; 95% CI, 3.1-20.0) (P<.001); and HRAR score higher than 3 (OR, 10.7; 95% CI, 3.8-30.0) (P = .001). In patients with none of these factors, alcohol relapse was 5%, while the presence of 1, 2, or 3 factors was associated with relapse rates of 18%, 64%, and 100% of the patients, respectively.

CONCLUSIONS

In a large cohort of patients undergoing LT for alcoholic cirrhosis, a duration of abstinence of less than 6 months before wait-listing for LT, the presence of psychiatric comorbidities, or an HRAR score higher than 3 was associated with relapse into harmful drinking. The presence of more than 1 factor dramatically increased this risk over 50%. In the pre-LT evaluation in this setting, these factors should be accurately determined.

Liver transplantation: an update 2007

PURPOSE OF REVIEW

Recent attention in liver transplantation has focused on equity in organ allocation and management of posttransplant complications.

RECENT FINDINGS

Adoption of the model for end-stage liver disease for liver allocation has been successful in implementing a system based on medical urgency rather than waiting time. Refinements are being studied in improving the prediction of mortality and improving transplant benefit by balancing pretransplant mortality and posttransplant survival. Emerging literature is examining expansion of the current criteria for transplantation of hepatocellular carcinoma and the role of neoadjuvant therapy. Chronic renal dysfunction after liver transplantation is a source of considerable morbidity. Nephron-sparing immunosuppression regimens are emerging with encouraging results. Hepatitis C virus infection is difficult to differentiate histologically from rejection, although newer markers are being developed. Antiviral and immunosuppressive strategies for reducing the severity of hepatitis C virus recurrence are discussed. Alcohol relapse is common after liver transplant in alcoholic liver disease patients and can lead to worse outcomes.

SUMMARY

Organ allocation tends to evolve under the model for end-stage liver disease with a focus on maximizing transplant benefit. Hepatitis C virus, hepatocellular carcinoma, chronic renal dysfunction and alcohol relapse are major challenges, and continued research in these areas will undoubtedly lead to better outcomes for transplant recipients.

Liver transplantation for alcoholic liver disease

Alcoholism is a disease of remission and relapse. A lapse in abstinence tends to be viewed as a failure to commit to abstinence, and an acknowledged relapse may lead to the patient's removal from the liver transplant list; however, such a relapse may actually offer insight into alcoholism. Liver transplant physicians should consider recognizing lapses in abstinence as slips that indicate a need for treatment of alcoholism. Further research should address which alcoholic liver patients suffer relapses and how alcohol relapse affects the ability to maintain abstinence before or after transplantation.

Urinary ethyl glucuronide testing detects alcohol consumption in alcoholic liver disease patients awaiting liver transplantation

This study compared measurement of urinary ethyl glucuronide (EtG), a conjugated minor ethanol metabolite with a longer detection window than ethanol itself, with breath alcohol testing and self-report as ways to disclose recent drinking by 18 liver transplant candidates with an alcoholic liver disease diagnosis that underwent an addiction group therapy program. At each therapy session, patients were questioned about any alcohol consumption in the intervening time, and they also performed a mandatory breath alcohol test, while observed urine samples for measurement of EtG were delivered on a voluntary basis. None of the patients ever admitted to intake of alcohol, and only 1 of 127 breath alcohol tests turned out positive. However, 9 patients showed positive EtG results in 24 (49%) of 49 urine samples. The individual frequency of urine samples being positive for EtG ranged from 22% to 100% with a mean value of 57%. Because 6 patients refused to provide urine on a total of 18 occasions, alcohol use might have been even more common. These results underscore the uncertainty of self-report data and the low sensitivity of breath alcohol testing as ways to disclose recent drinking, and underline the necessity of introducing sensitive and specific objective measures of recent alcohol consumption, such as EtG, in the transplantation setting.

Long-term survival and predictors of relapse after orthotopic liver transplantation for alcoholic liver disease

The relevance of sobriety for outcome after orthotopic liver transplantation (OLT) for alcoholic liver disease (ALD) is still discussed controversially. We conducted a retrospective analysis of 300 patients transplanted for ALD with regard to recurrent alcohol consumption, risk factors for drinking after OLT, and long-term survival. The 300 patients underwent OLT for ALD between 1989 and 2002. Median follow-up was 89 months. Incidence and severity of drinking, survival rates, and causes of death were assessed. Age, gender, duration of pretransplant sobriety, social support, presence of children, and the results of psychosomatic evaluation were analyzed for their impact on recurrent alcohol consumption after OLT. Drinking of various degrees was observed in 19% of ALD patients after OLT. Pretransplant sobriety of less than 6 months, absence of companion in life, presence of young children, and a predicted poor psychosomatic prognosis were associated with an increased risk of recurrent alcohol consumption, whereas age and gender were not independent risk factors. Survival rates of patients who resumed abusive drinking were significantly lower than survival rates of abstinent patients or patients with minor lapses. Recurrent alcoholic liver disease accounted for the vast majority of deaths among patients who resumed abusive drinking after OLT, whereas malignant tumors, infections, and cardiovascular disease were the most common causes of death among abstinent patients. In conclusion, abusive drinking after OLT is associated with poor long-term survival. Analysis of risk factors may help to identify patients with a high risk for recurrent alcohol abuse after OLT.

Liver transplantation for alcoholic liver disease: a systematic review of psychosocial selection criteria

AIMS

To examine the evidence base for psychosocial selection criteria for liver transplant candidates with alcoholic liver disease.

METHOD

Systematic review using three electronic databases supplemented by hand searches.

RESULTS

Out of 96 published studies, 22 were included. All but one were cohort design, most were retrospective, single centre, and small sample. Methodology varied considerably, such that meta-analysis was not feasible.

CONCLUSIONS

Social stability, no close relatives with an alcohol problem, older age, no repeated alcohol-treatment failures, good compliance with medical care, no current polydrug misuse, and no co-existing severe mental disorder have all been associated with future abstinence in more studies than not, in those that examined these variables. Duration of preoperative abstinence was a poor predictor. We recommend that, if predicting future abstinence is considered necessary by transplant teams, a standardized approach is agreed and deployed amongst transplant units, then audited and reviewed.

Prevalence, severity and correlates of alcohol use in adult renal transplant recipients

BACKGROUND

Severe alcohol use is recognized as a major public health concern, even though light to moderate alcohol use might have beneficial effects on health. Alcohol use has been studied to some extent in solid organ transplant populations, yet evidence is lacking on alcohol use and its correlates in the renal transplant population. The aim of this study was therefore to determine the prevalence, severity and correlates of alcohol use in renal transplant recipients.

METHODS

This cross-sectional study is a secondary analysis of the Supporting Medication Adherence in Renal Transplantation (SMART) study. Alcohol use was assessed by patient's self-report. At risk and binge drinkers were classified using World Health Organization criteria. The following correlates of alcohol use were explored: adherence with immunosuppression (Siegal questionnaire; electronic monitoring), smoking, coping style (UCL), depressive symptomatology (BDI) and busyness/routine in life style (ACQ Busyness Scale).

RESULTS

Two hundred and eighty-four patients were included in this analysis, 58.1% male, with a mean age of 54 yr (range 20-84) and a median of seven (interquartile ranges [IQR] 8) yr post-transplantation. A total of 52.8% of study participants reported to drink alcohol at least once a week. Two hundred and eighty of 284 subjects (98.5%) were drinking at low risk, four at moderate risk (1.5%). None of the participants were drinking severely. Correlates of alcohol use were male gender and being professionally active.

CONCLUSION

Alcohol use is less prevalent in renal transplant recipients than in the general population. Severe alcohol use does not seem to represent a serious problem in renal transplant patients.

Predictors of relapse to harmful alcohol after orthotopic liver transplantation

BACKGROUND

End-stage alcoholic liver disease (ALD) is a common indication for liver transplantation. Outcomes may be limited by return to harmful drinking. Previous studies have identified few predictors of drinking relapse.

AIM

This study examined novel postulated predictors of relapse to drinking.

METHOD

The case notes of all patients transplanted for ALD at the Royal Prince Alfred Hospital from 1987-2004 were reviewed. Pre-transplant characteristics were rated by a psychiatrist independent of the transplant team, blind to the outcome. Outcomes were rated by a second independent alcohol treatment specialist also blind to the pre-transplant ratings.

RESULTS

Of 100 patients, 6 died before discharge from hospital, 4 had <6 months follow-up, 18 relapsed to harmful drinking, 10 drank below harmful levels, and 62 remained abstinent after a mean of 5.6 years follow-up. Univariate analyses identified six potential pre-transplant predictors of return to harmful drinking. These were a diagnosis of mental illness (of which all cases were of depression), the lack of a stable partner, grams per day consumed in the years before assessment for transplant, reliance on 'family or friends' for post-transplant support, tobacco consumption at time of assessment, and lack of insight into the alcohol aetiology. Duration of pre-transplant abstinence and social class by occupation did not predict relapse. A multivariate model based on the above characteristics correctly predicted 89% of the outcomes.

CONCLUSION

A model based on readily defined behaviours and psychosocial factors predicted relapse to harmful drinking after transplant for ALD. This model may improve assessment and post-transplant management of patients with advanced ALD.

Liver transplantation for alcoholic liver disease

Patients with end-stage alcoholic liver disease should be considered for liver transplantation. A careful pretransplant evaluation must be undertaken to assess for both medical and psychiatric factors that will continue to require attention following transplantation. Although most programs require at least 6 months of ethanol abstinence before consideration of liver transplantation, there is little evidence that this conclusively predicts a reduction in recidivism. Most programs continue to exclude those with alcoholic hepatitis. Postoperatively, attention to psychiatric issues, recidivism, compliance, and assessment for tumors, especially squamous cell carcinomas, should be undertaken.

Pretransplant screening of sobriety with carbohydrate-deficient transferrin in patients suffering from alcoholic cirrhosis

Sufficient assessment of potential candidates for orthotopic liver transplantation (OLT) is the most important factor for a low alcohol relapse rate after transplantation in patients suffering from alcoholic cirrhosis. In the current study the efficiency of pretransplant screening with carbohydrate-deficient transferrin (CDT) was analysed in patients on the waiting list for OLT. A prospective study was performed in 44 patients who had undergone OLT for alcoholic cirrhosis. All patients had had pretransplant assessment by a specialist psychologist and were found to have no problems with alcohol. Pre- and post-transplant CDT monitoring was performed. Overall, 790 CDT values were measured in the study population. The median observation period was 2.1 months before and 41.2 months after transplantation, respectively. In 35 patients (80%) pretransplant CDT values were found to be above the reference value, but only one patient suffered an alcohol relapse after transplantation. Of the nine patients (20%) who demonstrated normal CDT before transplantation, two suffered an alcohol relapse after transplantation. CDT is a very useful marker for the monitoring of an alcohol relapse in patients following OLT for alcoholic cirrhosis, as has been previously indicated. However, CDT does not appear to be useful as a pretransplant screening marker for selection of potential transplant candidates suffering from alcoholic cirrhosis.

Analysis of factors that predict alcohol relapse following liver transplantation

Alcoholic liver disease has become a major indication for liver transplantation in the United States. Factors that predict alcohol relapse after liver transplantation are poorly defined. The aim of our study was to identify predictors of alcohol relapse in patients undergoing liver transplantation for alcoholic liver disease. One hundred and eleven patients undergoing liver transplantation for alcoholic liver disease between 1985 and 1999 were identified from our database. Patients were selected for liver transplantation if their risk of relapse was felt to be low by the transplant team. A chart review was conducted to determine if relapse had occurred, the presence or absence of factors that were thought to predict relapse, and survival. Demographic and psychosocial variables were analyzed using univariate and multivariate logistic regression to identify independent predictors of relapse. The median duration of abstinence before liver transplantation was 15 months (range: 1-120). Hepatitis C virus was present in 64% of patients. A family history of alcoholism in a first-degree relative was identified in 38%, and 78% received treatment for alcoholism before liver transplantation. The mean duration of follow-up was 44.1 +/- 3.7 months. There were 29 deaths (26%) overall. Seventeen patients (15%) returned to alcohol use. On multivariate analysis a family history of alcoholism was found to be an independent predictor of alcohol relapse (P=.03). Further prospective studies are needed to examine this association in greater detail to provide targeted treatment for alcoholism both before and after liver transplantation.

Influence of superimposed alcoholic hepatitis on the outcome of liver transplantation for end-stage alcoholic liver disease

BACKGROUND/AIMS

Alcoholic cirrhosis is a common indication for liver transplantation. The present study was aimed to assess the influence of superimposed alcoholic hepatitis on the outcome of liver transplantation in patients with alcoholic cirrhosis.

METHODS

Survival rates of 68 patients transplanted for alcoholic cirrhosis were compared with those of 101 patients transplanted for miscellaneous causes. Within the alcoholic group, explanted livers were searched for data of acute alcoholic hepatitis. The survival rate of patients with alcoholic hepatitis superimposed on liver cirrhosis was compared to that of patients with liver cirrhosis alone. Clinical severity of alcoholic hepatitis was assessed with Maddrey's score.

RESULTS

Survival was similar in alcoholics and patients with other causes of liver disease. Among patients transplanted for alcoholic cirrhosis, survival was similar in patients with superimposed alcoholic hepatitis (n=36) and in cases with liver cirrhosis alone (n=32). There was no difference in survival between patients with mild (n=26) and severe (n=10) alcoholic hepatitis. Seven alcoholics (10%) returned to ethanol consumption. Recidivism was not associated with either alcoholic hepatitis in the explanted liver or graft loss.

CONCLUSIONS

Survival after liver transplantation in patients with alcoholic cirrhosis plus alcoholic hepatitis detected in the explanted liver is similar to that of patients transplanted for other reasons. Even the presence of severe alcoholic hepatitis does not worsen the outcome of liver transplantation for end-stage alcoholic liver disease.

Liver transplantation in patients with alcohol and other substance use disorders

It is unfortunate that LT is not the ultimate sobering experience. LT patients can and do relapse; however, relapse to alcohol or substance use should no more be considered a failure of LT than the recurrence of HCV after LT. It is a phenomenon of their addiction. As a group, the survival and outcomes of patients undergoing LT for ALD are not significantly different from those undergoing LT for other causes. The fact that few patients return to heavy and deleterious alcohol or substance use attests to the success of programs in selecting patients capable of caring for themselves and their livers after LT. In the pre-LT phase, establishing the correct addiction diagnosis is essential so that those at highest risk can be carefully monitored. Although information is emerging about other risk factors for relapse, the authors caution against considering patients with these characteristics as being categorically unfit for LT. Each individual is unique, and such factors should guide clinical decision making rather than being absolute contraindications. After LT, clinical interviews, preferably by a trained psychiatric physician or clinician, are essential to monitoring alcohol and substance use, and surveillance early on is required. Much work needs to be done with respect to substance use and relapse after LT because few studies have explored these issues. In addition, the special treatment needs of those who relapse has not been addressed. Treatment research is underway but has relied on traditional strategies that are not always applicable to LT recipients. Further areas to improve clinical care include improving health behaviors, specifically, smoking cessation. The authors anticipate that, in the near future, the ongoing work in this area will provide information and guidance to physicians and clinicians caring for these unique patients.

Liver transplantation for chronic liver disease: advances and controversies in an era of organ shortages

Since liver transplantation was first performed in 1968 by Starzl et al, advances in case selection, liver surgery, anaesthetics, and immunotherapy have significantly increased the indications for and success of this operation. Liver transplantation is now a standard therapy for many end stage liver disorders as well as acute liver failure. However, while demand for cadaveric organ grafts has increased, in recent years the supply of organs has fallen. This review addresses current controversies resulting from this mismatch. In particular, methods for increasing graft availability and difficulties arising from transplantation in the context of alcohol related cirrhosis, primary liver tumours, and hepatitis C are reviewed. Together these three indications accounted for 42% of liver transplants performed for chronic liver disease in the UK in 2000. Ethical frameworks for making decisions on patients' suitability for liver transplantation have been developed in both the USA and the UK and these are also reviewed.

[Study of the health education process in liver transplant recipients]

We present the results of a study carried out in Bellvitge University Hospital in Barcelona (Spain) in patients who underwent orthotopic liver transplantation and who are the subject of a health education program. Throughout the years, the structure of this program has undergone several changes. Initially, only verbal information supplied by a nurse on the knowledge required for patient self-care was envisaged. Through continuous evaluation, different forms of written and audiovisual information on patient self-care were introduced. The aim of this study was to evaluate patient knowledge on self-care by comparing compliance with recommendations at discharge among the patients who received verbal information only with that among patients who received verbal as well as written and/or audiovisual information. The study population comprised 434 patients who underwent liver transplantation from February 1984 to December 31, 1998. A retrospective cohort study was designed with two groups of patients. The first group was composed by 117 patients who received verbal, written and audiovisual information. The second group comprised 107 patients who received verbal information only. Data collection was through a telephone survey. Telephone interview was possible with only 98 patients in the first group and 60 in the second.In the overall evaluation of health education level, the score obtained by the first group was 8.3 (SD = 2.2) and that obtained by the second group was 6.8 (SD = 1.8). The possible score was between 0 and 11. The differences between groups were statistically significant (p < 0.001). In general, patients who received verbal information only showed lower compliance with recommendations at discharge than those also received written and/or audiovisual information.