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Winder GS, Clifton EG, Fernandez AC, MacEachern M, Andrews S, Perumalswami P, DiMartini AF, Mellinger JL. Definition and measurement of alcohol-associated insight in early liver transplantation for acute alcohol-associated hepatitis: A systematic review. Liver Transpl 2023; 29:757-767. [PMID: 37016758 DOI: 10.1097/lvt.0000000000000144] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 03/27/2023] [Indexed: 04/06/2023]
Abstract
BACKGROUND Alcohol accounts for a large disease burden in hepatology and liver transplantation (LT) and across the globe. Clinical evaluations and decisions about LT candidacy are challenging because they rely on detailed psychosocial assessments and interpretations of psychiatric and substance use disorder data, which often must occur rapidly according to the acuity of end-stage liver disease. Such difficulties commonly occur during the process of candidate selection and liver allocation, particularly during early LT (eLT) in patients with acute alcohol-associated hepatitis (AAH). Patients with AAH commonly have very recent or active substance use, high short-term mortality, psychiatric comorbidities, and compressed evaluation and treatment timetables. LT clinicians report that patients' alcohol-associated insight (AAI) is among the most relevant psychosocial data in this population, yet no studies exist examining how LT teams define and use AAI in eLT or its effect on clinical outcomes. In April 2022, we searched Ovid MEDLINE, Elsevier Embase, EBSCOhost PsycInfo and CINAHL, and Wiley Cochrane Central Register of Controlled Trials for reports describing AAH populations who underwent eLT, which also described psychosocial evaluation parameters. The searches retrieved 1603 unique reports. After eligibility screening, 8 were included in the qualitative analysis. This systematic review reveals that AAI is a poorly defined construct that is not measured in a standardized way. Yet it is a commonly cited parameter in articles that describe the psychosocial evaluation and decision-making of patients undergoing eLT for AAH. This article also discusses the general challenges of assessing AAI during eLT for AAH, existing AAI definitions and rating scales, how AAI has been used to date in the broader hepatology and LT literature, and future areas for clinical and research progress.
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Affiliation(s)
- Gerald Scott Winder
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
| | - Erin G Clifton
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Anne C Fernandez
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Mark MacEachern
- Taubman Health Sciences Library, University of Michigan, Ann Arbor, Michigan, USA
| | - Sarah Andrews
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ponni Perumalswami
- Gastroenterology Section, Veterans Affairs, Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Andrea F DiMartini
- Departments of Psychiatry, Surgery, and Translational Science, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jessica L Mellinger
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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2
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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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3
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Liver transplantation in alcohol-associated liver disease: ensuring equity through new processes. Liver Transpl 2023; 29:539-547. [PMID: 36738082 DOI: 10.1097/lvt.0000000000000088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 12/14/2022] [Indexed: 02/05/2023]
Abstract
Worsened by the COVID-19 pandemic, alcohol use is one of the leading causes of preventable death in the US, in large part due to alcohol-associated liver disease. Throughout history, liver transplantation for this population has been controversial, and many policies and regulations have existed to limit access to lifesaving transplant for patients who use alcohol. In recent years, the rates of liver transplantation for patients with alcohol-associated liver disease have increased dramatically; however, disparities persist. For instance, many criteria used in evaluation for transplant listing, such as social support and prior knowledge of the harms of alcohol use, are not evidence based and may selectively disadvantage patients with alcohol use disorder. In addition, few transplant providers have adequate training in the treatment of alcohol use disorder, and few transplant centers offer specialized addiction treatment. Finally, current approaches to liver transplantation would benefit from adopting principles of harm reduction, which have demonstrated efficacy in the realm of addiction medicine for years. As we look toward the future, we must emphasize the use of evidence-based measures in selecting patients for listing, ensure access to high-quality addiction care for all patients pretransplant and posttransplant, and adopt harm reduction beliefs to better address relapse when it inevitably occurs. We believe that only by addressing each of these issues will we be able to ensure a more equitable distribution of resources in liver transplantation for all patients.
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Zanowski SC, Price JS, Selim MA, Schumann V, Durazo F, Hong JC. Effect of an Integrated Transplantation Mental Health Program on Alcohol Relapse After Liver Transplantation for Severe Alcoholic Hepatitis: A Single-Center Prospective Study. Transplant Proc 2022; 54:2627-2633. [DOI: 10.1016/j.transproceed.2022.09.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 09/19/2022] [Accepted: 09/20/2022] [Indexed: 11/21/2022]
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Dienstag A, Dienstag P, Mohan K, Mirza O, Schubert E, Ford L, Edelman M, Im G, Shenoy A. An Assessment of the Psychosocial Evaluation for Early Liver Transplantation in Patients With Acute Alcoholic Hepatitis in the Context of Alcohol Use Disorder, a Case-Control Study. Subst Abuse 2022; 16:11782218221115659. [PMID: 35966615 PMCID: PMC9373124 DOI: 10.1177/11782218221115659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 07/07/2022] [Indexed: 11/25/2022]
Abstract
Background: Severe acute alcoholic hepatitis (AAH) has an extremely poor prognosis with a
high short term mortality rate. As a result, many centers, including our
own, have allowed transplant patients to be listed for transplantation prior
to achieving 6-months of sobriety. Several scoring systems, designed to
target patients with a minimal period of sobriety, have been proposed to
identify patients with alcohol use disorder (AUD), who would be predisposed
to relapse after liver transplantation. We investigated whether these
scoring systems corroborated the results of the non-structured selection
criteria used by our center regarding decision to list for transplant. Methods: We conducted a retrospective case-control study of 11 patients who underwent
early liver transplantation for AAH matched with 11 controls who were
declined secondary to low insight into AUD. Blinded raters confirmed the
severity of the diagnosis of DSM-5 and scored the patients on a variety of
structured psychometric scales used to predict alcohol relapse. These
included the High Risk for Alcohol Relapse Scale (HRAR), Stanford Integrated
Psychosocial Assessment Tool (SIPAT), Alcohol Relapse Risk Assessment
(ARRA), Hopkins Psychosocial Scale (HPSS), Michigan Alcoholism Prognosis
Score (MAPS), Alcohol Use Disorders Identification Test -Consumption
(AUDIT-C), and Sustained Alcohol Use Post-Liver Transplant (SALT) scales.
All patients who underwent transplantation were followed for harmful and
non-harmful drinking until the end of the study period. Results: The transplant recipients had significantly favorable MAPS, HRAR, SIPAT,
ARRA, and HPSS scores with cutoffs that matched their previous research. The
SALT and AUDIT-C scores were not predictive of our selection of patients for
transplantation. Despite an expedited evaluation and no significant period
of sobriety, our case cohort had a 30% relapse to harmful drinking after an
average of 6.6 years (5-8.5 years) of follow-up. Discussion: Despite the rapid assessment and the short to no period of sobriety, the
patient cohort demonstrated a 30% relapse to harmful drinking, consistent
with the 20% to 30% relapse to drinking rate reported after liver
transplantation for all forms of alcoholic liver disease. Average scores
from MAPS, HRAR, SIPAT, ARRA, and HPSS corroborated our current
stratification procedures, with lower mean risk scores found in the
transplanted group. Conclusion: Patients with AUD and severe AAH who obtain new insight into their disease
and posses other favorable psychosocial factors have low rates of AUD
relapse post-liver-transplantation. The psychosocial selection criteria for
patients with alcoholic hepatitis in our institution are consistent with 4
of the 5 scoring systems investigated in their prediction of sobriety
post-transplant.
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Affiliation(s)
- Aryeh Dienstag
- Department of Psychiatry, Hadassah Hebrew University School of Medicine, Jerusalem, Israel
| | - Penina Dienstag
- Department of Anesthesia, Hadassah Hebrew University School of Medicine, Jerusalem, Israel
| | - Kanwal Mohan
- Department of Psychiatry, University of Calgary, Calgary, Canada
| | - Omar Mirza
- Department of Psychiatry, Harlem Hospital Center, New York, NY, USA
| | - Elizabeth Schubert
- Recanati-Miller Transplantation Institute, Mount Sinai Hospital, New York, NY, USA
| | - Laura Ford
- Recanati-Miller Transplantation Institute, Mount Sinai Hospital, New York, NY, USA
| | - Margot Edelman
- Recanati-Miller Transplantation Institute, Mount Sinai Hospital, New York, NY, USA
| | - Gene Im
- Recanati-Miller Transplantation Institute, Mount Sinai Hospital, New York, NY, USA
| | - Akhil Shenoy
- Department of Psychiatry, Columbia University Medical Center, New York, NY, USA
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6
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Scoring systems to assess relapse risk in alcohol use disorder presenting for early liver transplantation: A systematic review. Gen Hosp Psychiatry 2021; 72:23-30. [PMID: 34229280 DOI: 10.1016/j.genhosppsych.2021.06.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 06/14/2021] [Accepted: 06/24/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Early liver transplantation (LT) is considered for patients with alcohol use disorder (AUD) despite limited sober time when acute mortality risk from liver disease is high. The objective of this paper is to find psychosocial tools that do not rely on extended sober time and predict alcohol relapse post-LT. METHODS We conducted a systematic review of Pubmed, Embase, and Scopus for studies testing psychosocial tools that used numeric scoring to predict post-LT alcohol relapse. Tools that afforded points for length of sobriety were excluded. Each study was analyzed for its clinical context, post-LT relapse outcomes and predictive validity. RESULTS Five scoring systems across fourteen samples showed varied validity in predicting post-LT alcohol relapse. Relapse to any alcohol use after LT revealed an average relapse rate of 23%. Most scoring systems were understudied but four of five provided cut-off scores with high negative predictive values for relapse. CONCLUSION Scoring systems may have a place in candidate selection but the data on cut-off scores and predictability are still lacking for their use alone in high stakes LT selection. Larger studies with prospective scoring and standardized follow ups for relapse post-LT will better allow the predictive validity of these psychosocial tools to be compared.
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7
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Liver Transplantation for Alcohol-Related Liver Disease (ARLD): An Update on Controversies and Considerations. Can J Gastroenterol Hepatol 2020; 2020:8862152. [PMID: 33014915 PMCID: PMC7519455 DOI: 10.1155/2020/8862152] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 08/27/2020] [Accepted: 08/29/2020] [Indexed: 12/15/2022] Open
Abstract
According to the recent data from the United Network for Organ Sharing database, alcohol-related liver disease (ARLD) accounts to be the most common indication of liver transplantation (LT) waiting lists in the United States among men without hepatocellular carcinoma (HCC). Severe alcoholic hepatitis (AH) is serious and the life-threatening form of ARLD and should be treated timely. However, the LT for severe AH remained to be controversial among the transplant community because of marked interests about the constrained organ supply and the hazard that the AH liver recipient will return to risky drinking. Early LT for ARLD refers for a patient with severe AH undergoing LT who are non-responder to medical treatments. These patients are generally on the existing waiting list but usually followed by 6-month duration of alcohol abstinence. However, the rule of 6-month alcohol abstinence need before the LT is ambiguous. The 6-month alcohol abstinence was consistently defended in light of the compelling fact that it would enable patients to recoup from the intense impacts of alcohol to the liver. In routine, however, the purported "6-month abstinence rule" turned into a surrogate for the forecast of future drinking by ARLD patients for the LT. Careful consideration should be given to the alcohol use disorder of craving and the hazard for recidivism after the LT. As for the current situation, there, urgently, is a specific need of standardized criteria for the evaluation of patients with severe AH for earlier LT. Moreover, further studies are required precisely to develop an accurate prediction model for posttransplant alcohol recidivism. Additionally, development of a standardized protocol for post-LT follow-up and management is further needed. We carefully outlined the published experience with the LT for ARLD in this review.
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8
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Crabb DW, Im GY, Szabo G, Mellinger JL, Lucey MR. Diagnosis and Treatment of Alcohol-Associated Liver Diseases: 2019 Practice Guidance From the American Association for the Study of Liver Diseases. Hepatology 2020; 71:306-333. [PMID: 31314133 DOI: 10.1002/hep.30866] [Citation(s) in RCA: 450] [Impact Index Per Article: 112.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 05/31/2019] [Indexed: 12/12/2022]
Affiliation(s)
- David W Crabb
- Indiana University School of Medicine, Indianapolis, IN
| | - Gene Y Im
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - Gyongyi Szabo
- University of Massachusetts Medical School, Worcester, MA
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9
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Beresford TP, Lucey MR. Towards Standardizing the Alcoholism Evaluation Of Potential Liver Transplant Recipients. Alcohol Alcohol 2018; 53:135-144. [PMID: 29211831 DOI: 10.1093/alcalc/agx104] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 11/28/2017] [Indexed: 12/12/2022] Open
Abstract
Aims For teams around the world, alcoholic liver disease patients comprise the largest, and clinically most controversial, group applying for liver transplant. And yet evaluation decisions for them remain highly variable by locale. Methods Targeting standardized assessment, we provide guidelines on what information the transplant team should seek, from what sources, and how best to make use of it. This report focuses on 'what to do and how to do it' in providing appropriate assessments for this complex patient group. Results Proper evaluation includes (a) taking the clinical history from the patient and a required, corroborating third person, (b) assessing patient cognition, (c) establishing alcohol/substance use diagnosis to differentiate alcohol dependence, abuse and polysubstance dependence, (d) assessing ambivalence in primary alcohol addiction, (e) measuring social stability and (f) using Vaillant's factors for abstinence prognosis. Conclusions Properly applied, these six factors will allow standardized selection in most cases taken across programs despite differences in resources, available expertise and decision practices. Short Summary This report focuses on the essentials of the psychiatric/behavioral evaluation for 'alcoholic' persons referred for liver transplant. Attention to those essentials offers clinical standardization across transplant programs in different locales.
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Affiliation(s)
- Thomas P Beresford
- Department of Veterans Affairs Medical Center and School of Medicine, University of Colorado Denver, (116), 1055 Clermont Street, Denver, CO 80220-0116, USA
| | - Michael R Lucey
- Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792, USA
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10
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Marroni CA, Fleck Jr ADM, Fernandes SA, Galant LH, Mucenic M, de Mattos Meine MH, Mariante-Neto G, Brandão ABDM. Liver transplantation and alcoholic liver disease: History, controversies, and considerations. World J Gastroenterol 2018; 24:2785-2805. [PMID: 30018475 PMCID: PMC6048431 DOI: 10.3748/wjg.v24.i26.2785] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 05/23/2018] [Accepted: 06/16/2018] [Indexed: 02/06/2023] Open
Abstract
Alcohol consumption accounts for 3.8% of annual global mortality worldwide, and the majority of these deaths are due to alcoholic liver disease (ALD), mainly alcoholic cirrhosis. ALD is one of the most common indications for liver transplantation (LT). However, it remains a complicated topic on both medical and ethical grounds, as it is seen by many as a “self-inflicted disease”. One of the strongest ethical arguments against LT for ALD is the probability of relapse. However, ALD remains a common indication for LT worldwide. For a patient to be placed on an LT waiting list, 6 mo of abstinence must have been achieved for most LT centers. However, this “6-mo rule” is an arbitrary threshold and has never been shown to affect survival, sobriety, or other outcomes. Recent studies have shown similar survival rates among individuals who undergo LT for ALD and those who undergo LT for other chronic causes of end-stage liver disease. There are specific factors that should be addressed when evaluating LT patients with ALD because these patients commonly have a high prevalence of multisystem alcohol-related changes. Risk factors for relapse include the presence of anxiety or depressive disorders, short pre-LT duration of sobriety, and lack of social support. Identification of risk factors and strengthening of the social support system may decrease relapse among these patients. Family counseling for LT candidates is highly encouraged to prevent alcohol consumption relapse. Relapse has been associated with unique histopathological changes, graft damage, graft loss, and even decreased survival in some studies. Research has demonstrated the importance of a multidisciplinary evaluation of LT candidates. Complete abstinence should be attempted to overcome addiction issues and to allow spontaneous liver recovery. Abstinence is the cornerstone of ALD therapy. Psychotherapies, including 12-step facilitation therapy, cognitive-behavioral therapy, and motivational enhancement therapy, help support abstinence. Nutritional therapy helps to reverse muscle wasting, weight loss, vitamin deficiencies, and trace element deficiencies associated with ALD. For muscular recovery, supervised physical activity has been shown to lead to a gain in muscle mass and improvement of functional activity. Early LT for acute alcoholic hepatitis has been the subject of recent clinical studies, with encouraging results in highly selected patients. The survival rates after LT for ALD are comparable to those of patients who underwent LT for other indications. Patients that undergo LT for ALD and survive over 5 years have a higher risk of cardiorespiratory disease, cerebrovascular events, and de novo malignancy.
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Affiliation(s)
- Claudio Augusto Marroni
- Graduate Program in Medicine: Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre 90430-080, RS, Brazil
- Liver Transplant Adult Group, Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre 90035-072, RS, Brazil
| | - Alfeu de Medeiros Fleck Jr
- Liver Transplant Adult Group, Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre 90035-072, RS, Brazil
| | - Sabrina Alves Fernandes
- Graduate Program in Medicine: Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre 90430-080, RS, Brazil
- Liver Transplant Adult Group, Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre 90035-072, RS, Brazil
- Nutrition at the Centro Universitário Metodista (IPA), Porto Alegre 90420-060, RS, Brazil
| | - Lucas Homercher Galant
- Graduate Program in Medicine: Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre 90430-080, RS, Brazil
- Liver Transplant Adult Group, Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre 90035-072, RS, Brazil
| | - Marcos Mucenic
- Liver Transplant Adult Group, Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre 90035-072, RS, Brazil
| | - Mario Henrique de Mattos Meine
- Liver Transplant Adult Group, Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre 90035-072, RS, Brazil
| | - Guilherme Mariante-Neto
- Graduate Program in Medicine: Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre 90430-080, RS, Brazil
- Liver Transplant Adult Group, Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre 90035-072, RS, Brazil
| | - Ajacio Bandeira de Mello Brandão
- Graduate Program in Medicine: Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre 90430-080, RS, Brazil
- Liver Transplant Adult Group, Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre 90035-072, RS, Brazil
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11
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Nahas J, Im GY. Early liver transplantation for severe alcoholic hepatitis. Clin Liver Dis (Hoboken) 2018; 11:69-72. [PMID: 30992792 PMCID: PMC6385942 DOI: 10.1002/cld.693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 12/11/2017] [Accepted: 12/15/2017] [Indexed: 02/04/2023] Open
Affiliation(s)
- Jonathan Nahas
- Division of Liver Diseases, Icahn School of Medicine at Mount SinaiRecanati/Miller Transplantation InstituteNew YorkNY
| | - Gene Y. Im
- Division of Liver Diseases, Icahn School of Medicine at Mount SinaiRecanati/Miller Transplantation InstituteNew YorkNY
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12
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Ronan PJ, Strait SA, Palmer GM, Beresford TP. Central Administration of Cyclosporine A Decreases Ethanol Drinking. Alcohol Alcohol 2018; 53:193-199. [PMID: 29281037 DOI: 10.1093/alcalc/agx102] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 11/13/2017] [Indexed: 01/08/2023] Open
Abstract
Aims Abstinence among alcohol dependent liver graft recipients is remarkably high. The routine use of anti-immune agents in these patients led to rodent studies showing that immunosuppressants acting through inhibition of calcineurin (CLN) are highly effective in decreasing alcohol consumption. It remained unclear, however, whether the decreased alcohol consumption in rodent models is mediated through peripheral suppression of immune response or centrally through direct inhibition of cyclophilin-CLN in the brain. We tested the hypothesis that direct brain inhibition of CLN with intracerebroventricular (ICV) injections of the immunosuppressant cyclosporine A (CsA) is sufficient to decrease ethanol consumption in a rodent model of binge-like drinking. Methods Male C57BL/6NHsd mice were put through a modified 'drinking in the dark' (DID) paradigm. Effects of both peripheral (IP) and central (ICV) injections of CsA on ethanol consumption were assessed. Results Here, as in earlier work, IP CsA administration significantly decreased alcohol consumption. Supporting our hypothesis, central administration of CsA was sufficient to decrease alcohol consumption in a dose-dependent manner. There was no significant effect of CsA on water or sucrose consumption. Conclusions These results clearly implicate a CLN-mediated mechanism in brain in the inhibitory effects of CsA on ethanol consumption and provide novel targets for investigation of treatment for Alcohol Use Disorders (AUD). These results also add to the growing body of literature implicating neuroimmune mechanisms in the etiology, pathophysiology and behaviors driving AUD. Short Summary The unusually high abstinence rate and routine use of immunosuppressants in AUD liver graft recipients led us to rodent studies showing that immunosuppressants acting through inhibition of calcineurin (CLN) are highly effective in decreasing drinking. Here we demonstrate that this effect is mediated by brain rather than peripheral immune mechanisms.
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Affiliation(s)
- Patrick J Ronan
- Laboratory for Clinical and Translational Research in Psychiatry, Research Service and Psychiatry, Denver VA Medical Center, 1050 Clermont Street, Denver, CO 80220-0116, USA.,Sioux Falls VA Research Service, 2501 W. 22nd St., Sioux Falls, SD 57105, USA.,Department of Psychiatry and Division of Basic Biomedical Sciences, Sanford USD School of Medicine, MC151, 2501 W. 22nd St., Sioux Falls, SD 57105, USA
| | - Sydney A Strait
- Sioux Falls VA Research Service, 2501 W. 22nd St., Sioux Falls, SD 57105, USA
| | - Geralyn M Palmer
- Sioux Falls VA Research Service, 2501 W. 22nd St., Sioux Falls, SD 57105, USA
| | - Thomas P Beresford
- Laboratory for Clinical and Translational Research in Psychiatry, Research Service and Psychiatry, Denver VA Medical Center, 1050 Clermont Street, Denver, CO 80220-0116, USA.,Department of Psychiatry, University of Colorado Denver School of Medicine, Anschutz Medical Campus, 13001 East 17th Place, Aurora, CO 80045, USA
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13
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Beresford TP, Lucey MR. Introduction to the Special Issue on Alcohol and Liver Transplantation. Alcohol Alcohol 2018. [DOI: 10.1093/alcalc/agx125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Thomas P Beresford
- Department of Veterans Affairs Medical Center and School of Medicine, University of Colorado Denver (116), 1055 Clermont Street, Denver, CO 80220-0116, USA
| | - Michael R Lucey
- Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave # K4212, Madison, WI 53792, USA
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14
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Dew MA, Switzer GE, DiMartini AF, Matukaitis J, Fitzgerald MG, Kormos RL. Psychosocial Assessments and Outcomes in Organ Transplantation. Prog Transplant 2016; 10:239-59; quiz 260-1. [PMID: 11232552 DOI: 10.1177/152692480001000408] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A qualitative review was conducted to define the term psychosocial as applied to transplant patients and to summarize evidence regarding the role and impact of psychosocial assessments and outcomes across the transplant process. English-language case series and empirical studies from January 1970 through April 1990 that were abstracted in Medline and Psychological Abstracts or listed in publications' bibliographies were used as data sources. A qualitative analysis was performed to determine the depth of the case reports and whether the empirical reports obtained statistically reliable, clinically significant findings. The authors conclude that psychosocial assessments differ in content and application to candidate selection depending on the transplant program. Psychosocial status before transplant does not consistently affect medical outcomes after transplant. Psychosocial status generally improves with transplant, although difficulties are prevalent in psychological adjustment and in compliance with medical regimens. Psychiatric history can predict psychological outcomes after transplant but does not consistently predict compliance. Social supports and coping strategies strengthen psychosocial outcomes. Posttransplant psychosocial outcomes may predict physical morbidity and mortality.
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Affiliation(s)
- M A Dew
- University of Pittsburgh School of Medicine and Medical Center, Pittsburgh, Pa., USA
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Abstract
Two experiments document one basis of patient stereotyping: the relative frequency of people’s contact with medical patients. Experiment 1 demonstrated that illusory correlations formed based on the infrequency of target patients and their non-cooperative behaviors. Participants read about two groups of patients with two similar diseases (labelled A and B). One group appeared less often than the other and performed fewer non-cooperative behaviors; however, the proportion of non-cooperative and cooperative behaviors was the same for both groups. Participants overestimated the number of non-cooperative behaviors performed by the infrequently appearing group, evaluated the group negatively and believed that these patients would be unlikely to cooperate in the future. Experiment 2 attempted to address the relationship between illusory correlations and memory for the infrequent group’s non-cooperative behaviors. Implications for how people perceive medical non-adherence in patients with stigmatized medical conditions were discussed.
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16
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Im GY, Kim-Schluger L, Shenoy A, Schubert E, Goel A, Friedman SL, Florman S, Schiano TD. Early Liver Transplantation for Severe Alcoholic Hepatitis in the United States--A Single-Center Experience. Am J Transplant 2016; 16:841-9. [PMID: 26710309 DOI: 10.1111/ajt.13586] [Citation(s) in RCA: 174] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 08/16/2015] [Accepted: 08/31/2015] [Indexed: 01/25/2023]
Abstract
Early liver transplantation (LT) in European centers reportedly improved survival in patients with severe alcoholic hepatitis (AH) not responding to medical therapy. Our aim was to determine if a strategy of early LT for severe AH could be applied successfully in the United States. We reviewed 111 patients with severe AH at our center from January 2012 to January 2015. The primary end point was mortality at 6 months or early LT, with a secondary end point of alcohol relapse after LT. Survival was compared between those receiving early LT and matched patients who did not. Using a process similar to the European trial, 94 patients with severe AH not responding to medical therapy were evaluated for early LT. Overall, 9 (9.6%) candidates with favorable psychosocial profiles underwent early LT, comprising 3% of all adult LT during the study period. The 6-month survival rate was higher among those receiving early LT compared with matched controls (89% vs 11%, p<0.001). Eight recipients are alive at a median of 735 days with 1 alcohol relapse. Early LT for severe AH can achieve excellent clinical outcomes with low impact on the donor pool and low rates of alcohol relapse in highly selected patients in the United States.
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Affiliation(s)
- G Y Im
- Recanati/Miller Transplantation Institute, Division of Liver Diseases, Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - L Kim-Schluger
- Recanati/Miller Transplantation Institute, Division of Liver Diseases, Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - A Shenoy
- Department of Psychiatry, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - E Schubert
- Social Work Services, The Mount Sinai Medical Center, New York, NY
| | - A Goel
- Division of Liver Diseases, Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - S L Friedman
- Division of Liver Diseases, Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - S Florman
- Recanati/Miller Transplantation Institute, Division of Liver Diseases, Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - T D Schiano
- Recanati/Miller Transplantation Institute, Division of Liver Diseases, Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY
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Alcoholism: diagnosis, prognosis, epidemiology, and burden of the disease. HANDBOOK OF CLINICAL NEUROLOGY 2014; 125:3-13. [PMID: 25307565 DOI: 10.1016/b978-0-444-62619-6.00001-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
To the clinician, alcoholism can appear as an amorphous entity that is confusing with respect to diagnosis, treatment prognosis, and the role of the health professional, despite its high incidence and associated morbidities and mortality when unrecognized or untreated. This chapter focuses on the clinical application of current knowledge, with the aim of being useful to the practitioner in working directly with patients for whom alcoholism may or may not be an already identified problem. It briefly reviews large-scale studies and then focuses on diagnosis and prognosis assessment and decision making. Also considered are current controversies in nomenclature and the chapter ends with an economic perspective with respect to healthcare and cost to society. As the introductory chapter, the goal is to provide a context of the scope of alcoholism and attendant problems for the rest of the chapters.
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Beresford T, Fay T, Serkova NJ, Wu PH. Immunophyllin ligands show differential effects on alcohol self-administration in C57BL mice. J Pharmacol Exp Ther 2012; 341:611-6. [PMID: 22375069 DOI: 10.1124/jpet.111.188169] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
High abstinence rates characterize alcohol-dependent liver graft recipients. The immunosuppressants cyclosporine A (CsA) and tacrolimus (TRL) also inhibit calcineurin (CLN) in the brain. Previously, we found that CsA reduces alcohol consumption in C57BL/6J mice. The goals of the present study were: 1) to compare the ethanol preference effects of CsA against TRL, as well as sirolimus (SRL), an immunosuppressant without CLN inhibition and 2) to establish that reduction of alcohol consumption is not caused by caloric reinforcement from these ligands. C57BL/6J mice trained to imbibe ethanol consumed ethanol or sucrose in a modified limited-access drinking-in-the-dark paradigm; test groups received vehicle or doses of CsA (5-50 mg/kg), TRL (0.5-2.5 mg/kg), or SRL (1.0-5.0 mg/kg) for 5 consecutive days, 30 min before each 2-h limited-access session. Brain CsA, TRL, and SRL concentrations were measured. CsA (p < 0.001) and TRL (p < 0.01) each decreased ethanol consumption, whereas SRL showed no significant effects at any dose. Effective doses included CsA at 10 mg/kg and above and TRL at 2.5 mg/kg. CsA (50 mg/kg) did not reduce sucrose consumption. Both CsA and TRL reached significant brain concentrations compared with very low values of SRL. These data suggest that CsA and TRL may reduce alcohol preference through central CLN inhibition rather than by immunosuppression.
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Affiliation(s)
- Thomas Beresford
- Psychiatry and Research Services, Department of Veterans Affairs Medical Center, Denver, Colorado, USA.
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19
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Abstract
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.
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20
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Madey SF, DePalma MT, Bahrt AE, Beirne J. The Effect of Perceived Patient Responsibility on Characterological, Behavioral, and Quality-of-Care Assessments. BASIC AND APPLIED SOCIAL PSYCHOLOGY 2010. [DOI: 10.1207/s15324834basp1402_5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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21
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Alcohol abstinence criteria for living liver donors and their organ recipients. Curr Opin Organ Transplant 2008; 13:207-10. [DOI: 10.1097/mot.0b013e3282f4cb03] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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22
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Liver Transplantation. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_86] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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23
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Methadone maintenance and chronic opioid analgesia in liver transplantation. Curr Opin Organ Transplant 2006. [DOI: 10.1097/01.mot.0000218936.50267.e9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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24
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Perney P, Bismuth M, Sigaud H, Picot MC, Jacquet E, Puche P, Jaber S, Rigole H, Navarro F, Eledjam JJ, Blanc F, Larrey D, Pageaux GP. Are preoperative patterns of alcohol consumption predictive of relapse after liver transplantation for alcoholic liver disease? Transpl Int 2005; 18:1292-7. [PMID: 16221161 DOI: 10.1111/j.1432-2277.2005.00208.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Predictive factors for alcoholic relapse after liver transplantation (LT) performed for alcoholic liver disease (ALD) have been assessed in numerous studies, often with contradictory results. The aim of the study was to assess pretransplantation alcohol consumption characteristics on alcoholic relapse after LT. Patients transplanted for ALD for at least 6 months were included. An anonymous questionnaire assessed socio-demographic characteristics, medical history, and alcohol consumption before and after LT. Relapse was defined as any alcohol use after LT. Severe relapse was defined by heavy drinking: more than 21 units/week for males and 14 units/week for females. A total of 61 patients were studied. The mean follow up after LT was 49 +/- 34 months. Alcoholic relapse occurred in 32 of 61 patients (52%) and severe relapse in eight of 61 patients (13%). Risk factors for severe relapse were: length of abstinence before LT (P = 0.0001), more than one alcohol withdrawal before LT (P = 0.001), alcohol dependence (P = 0.05), alcohol abuse in first relatives (P = 0.05), and younger age (P = 0.05). Information on previous alcohol consumption (dependence, number of withdrawals, family history) helps to predict severe relapse after LT in patients with ALD, allowing early awareness and specific postoperative care.
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Affiliation(s)
- Pascal Perney
- Service de Médecine Interne E, Hôpital Saint Eloi, Montpellier cedex, France
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25
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DiMartini A, Dew MA, Javed L, Fitzgerald MG, Jain A, Day N. Pretransplant psychiatric and medical comorbidity of alcoholic liver disease patients who received liver transplant. PSYCHOSOMATICS 2005; 45:517-23. [PMID: 15546829 DOI: 10.1176/appi.psy.45.6.517] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The authors examined the pretransplant prevalence of comorbid physical and psychological disorders in 112 alcoholic liver disease patients who received liver transplant. Fifty-six percent of the patients had comorbid hepatitis C or hepatitis B virus, 40% had used other substances in addition to alcohol, 25% met the criteria for a lifetime DSM-IV nonalcohol substance use disorder, 36% for a lifetime depressive disorder, and 12% for a lifetime anxiety disorder. The findings suggest the need for pretransplant psychiatric evaluation of alcoholic liver disease patients to identify nonalcohol substance use disorders and other psychiatric disorders that may require treatment.
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Affiliation(s)
- Andrea DiMartini
- Department of Psychiatry and Transplantation Surgery, University of Pittsburgh Medical Center, Starzl Transplant Institute, Pittsburgh, PA, USA.
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26
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Berlakovich GA, Soliman T, Freundorfer E, Windhager T, Bodingbauer M, Wamser P, Hetz H, Peck-Radosavljevic M, Muehlbacher F. Pretransplant screening of sobriety with carbohydrate-deficient transferrin in patients suffering from alcoholic cirrhosis. Transpl Int 2004. [DOI: 10.1111/j.1432-2277.2004.tb00395.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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27
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Berlakovich GA, Soliman T, Freundorfer E, Windhager T, Bodingbauer M, Wamser P, Hetz H, Peck-Radosavljevic M, Muehlbacher F. Pretransplant screening of sobriety with carbohydrate-deficient transferrin in patients suffering from alcoholic cirrhosis. Transpl Int 2004; 17:617-21. [PMID: 15517171 DOI: 10.1007/s00147-004-0765-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2003] [Revised: 11/12/2003] [Accepted: 03/19/2004] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Gabriela A Berlakovich
- Department of Transplant Surgery, University of Vienna, Waehringer-Guertel 18-20, 1090 Vienna, Austria.
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28
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Affiliation(s)
- Santiago Tome
- Liver Unit, Internal Medicine Department, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain
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29
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Abstract
The purpose of this retrospective survey was to describe post-liver transplant work outcomes for female liver transplant recipients with histories of alcohol-related liver disease. The theoretical framework guiding the study was Laffrey's conception of health. The Short Michigan Alcohol Screening Test was used to measure alcohol-related liver disease. Forty-seven female liver transplant recipients whose Short Michigan Alcohol Screening Test scores were indicative of alcohol-related liver disease comprised the convenience sample. Using a mailed questionnaire, post-transplant work and daily activities were assessed. Work was operationally defined as including either employment or household work. Results revealed that 59% of the female recipients were working post-transplant and that working recipients had higher conception of health scores than did non-working recipients.
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Affiliation(s)
- S E Newton
- Oakland University School of Nursing, Rochester, MI 48309, USA.
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30
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Abstract
The authors review the psychosocial aspects of transplantation. They first review psychosocial risk factors that place transplant patients at higher risk for noncompliance and negative outcomes. They then discuss what assessments should be included in a pretransplantation psychosocial evaluation. Goals of the psychosocial evaluation include selection of candidates most likely to benefit from transplantation and identification of areas for psychosocial intervention, both before and after transplantation. The assessment should address the patient's premorbid psychiatric state, past adaptation to stressors, history of compliance with treatment, substance abuse history, and level of social support, including community and faith-based support systems. Results of psychometric assessments may be helpful when considered in conjunction with a clinical interview and other sources of information about the patient. It may also be helpful to use a screening tool developed specifically to evaluate psychosocial factors relevant to transplantation, such as the Psychological Assessment of Candidates for Transplantation (PACT) scale and the Transplantation Evaluation Rating Scale (TERS). The authors then review issues related to psychopharmacologic interventions in transplant patients, including the use of antidepressant medication pre- and post-transplant, strategies for avoiding delirium associated with immunosuppressive medications immediately post-transplantation, neuropsychiatric symptoms associated with interferon alpha therapy for hepatitis C, and interactions between over-the-counter and herbal agents (e.g., St. John's Wort) and immunosuppressive agents. Although limited research has been done on nonpharmacologic interventions, such as transplant support groups, it appears that certain types of group therapy, in particular, cognitive-behavioral groups that target specific risk factors such as depression, distress, and compliance, may also offer promising approaches for dealing with the problems of transplant patients. The authors then focus on two special situations that create particular problems for transplantation teams: liver transplantation in patients with alcoholic liver disease (ALD) and obesity in transplant patients. The authors conclude that the prognosis for patients with ALD who receive liver transplantation is similar to that of non-alcoholics and that alcoholism is not a contraindication for liver transplantation. However, careful preliminary psychosocial assessment is essential to review candidates for factors that are predictive of relapse, while close follow-up post-transplantation can help improve outcomes. It appears that obesity can increase the risk of negative outcomes in transplant patients, although there is currently no consensus on the use of obesity as an exclusion criteria. Interventions that take into account the special psychological and medical needs of transplant patients need to be developed for treating obesity both pre- and post-transplantation. Improved strategies for identifying high-risk patients and finding ways to intervene both pre- and post-transplantation can not only help lengthen transplant recipients' life spans, but also improve their adaptation to transplantation and lead to improved quality of life.
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Affiliation(s)
- S G Jowsey
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN 55905, USA
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31
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Abstract
Although increasing numbers of alcoholic patients are being referred to liver transplant centres, liver transplantation for alcoholic liver disease still remains controversial, essentially because we are in an era of organ shortage. In fact, the main issue is the likelihood of relapse and its influence on outcome, because it is the possibility of returning to alcohol use that separates patients with alcoholic liver disease from those with other forms of chronic liver disease. In all proposed clinical guidelines of indications for referral and assessment for liver transplantation for alcoholic liver disease, the authors emphasize the risk of alcoholism recurrence and, thus, a multidisciplinary approach is required to select patients who are likely to comply with follow-up and not return to a damaging pattern of alcohol consumption after transplantation. It emerges from all clinical studies that when we take into account the usual criteria of success for liver transplantation, i.e. patient and graft survival, rejection rate and infection rate, alcoholic liver disease is a good indication for liver transplantation. Predictive factors for alcoholic relapse after liver transplantation have been assessed in numerous studies, often with contradictory results making these difficult to analyse and compare. Several predictive factors for alcoholic relapse have been studied: length of abstinence before transplantation, associated psychiatric problems, social conditions, associated drug addiction, age. Abstinence after transplantation is the goal, but the necessary treatment for alcoholic disease can result in considerable improvement, even when complete abstinence is not achieved. Finally, the good results obtained with liver transplantation for alcoholic liver disease should help us to educate the general population about alcoholic disease.
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32
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Bellamy CO, DiMartini AM, Ruppert K, Jain A, Dodson F, Torbenson M, Starzl TE, Fung JJ, Demetris AJ. Liver transplantation for alcoholic cirrhosis: long term follow-up and impact of disease recurrence. Transplantation 2001; 72:619-26. [PMID: 11544420 PMCID: PMC2963946 DOI: 10.1097/00007890-200108270-00010] [Citation(s) in RCA: 143] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Alcoholic liver disease has emerged as a leading indication for hepatic transplantation, although it is a controversial use of resources. We aimed to examine all aspects of liver transplantation associated with alcohol abuse. METHODS Retrospective cohort analysis of 123 alcoholic patients with a median of 7 years follow-up at one center. RESULTS In addition to alcohol, 43 (35%) patients had another possible factor contributing to cirrhosis. Actuarial patient and graft survival rates were, respectively, 84% and 81% (1 year); 72% and 66% (5 years); and 63% and 59% (7 years). After transplantation, 18 patients (15%) manifested 21 noncutaneous de novo malignancies, which is significantly more than controls (P=0.0001); upper aerodigestive squamous carcinomas were overrepresented (P=0.03). Thirteen patients had definitely relapsed and three others were suspected to have relapsed. Relapse was predicted by daily ethanol consumption (P=0.0314), but not by duration of pretransplant sobriety or explant histology. No patient had alcoholic hepatitis after transplantation and neither late onset acute nor chronic rejection was significantly increased. Multiple regression analyses for predictors of graft failure identified major biliary/vascular complications (P=0.01), chronic bile duct injury on biopsy (P=0.002), and pericellular fibrosis on biopsy (P=0.05); graft viral hepatitis was marginally significant (P=0.07) on univariate analysis. CONCLUSIONS Alcoholic liver disease is an excellent indication for liver transplantation in those without coexistent conditions. Recurrent alcoholic liver disease alone is not an important cause of graft pathology or failure. Potential recipients should be heavily screened before transplantation for coexistent conditions (e.g., hepatitis C, metabolic diseases) and other target-organ damage, especially aerodigestive malignancy, which are greater causes of morbidity and mortality than is recurrent alcohol liver disease.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Anthony J. Demetris
- Address reprint requests to: A.J. Demetris, MD, 1548 BMST, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA 15213.
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33
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Karman JF, Sileri P, Kamuda D, Cicalese L, Rastellini C, Wiley TE, Layden TJ, Benedetti E. Risk factors for failure to meet listing requirements in liver transplant candidates with alcoholic cirrhosis. Transplantation 2001; 71:1210-3. [PMID: 11397951 DOI: 10.1097/00007890-200105150-00005] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The majority of liver transplant centers require a 6-month abstinence period before listing candidates for liver transplantation with alcoholic cirrhosis and a persistent sobriety thereafter. We attempted to identify risk factors for failure to comply with these requirements. METHODS Ninety-nine consecutive patients with alcoholic cirrhosis were referred for liver transplant evaluation between September 1996 and May 1998. The mean age was 49 years, 74% were male, and 54% were hepatitis C virus positive. To be listed, patients had to meet the following requirements. All patients received extensive psychosocial evaluations and were frequently monitored with random urine and blood alcohol tests; patients found positive were excluded or removed from the liver transplant waiting list. Detailed patient information was entered into a computerized database, and 36 discreet variables were analyzed in relation to success (patient listed and remained on the list) or failure (not listed or removed from the list based on noncompliance). RESULTS Forty-nine patients were successfully listed. Nineteen received a transplant, with a 95% 1-year patient and graft survival rate and 21% alcohol relapse rate after transplantation. Twenty-two patients had either medical contraindication and/or died before transplant listing. Twenty-four patients were never listed and four were removed from the list due to recurrent alcoholism, for a total of 28 failures. Our statistical analysis identified five significant risk factors for failure: (I) living arrangement (alone/family versus community/friend), P=0.006; (II) history of suicide ideation, P=0.03; (III) history of previous alcohol-related hospitalization, P=0.01; (IV) lack of previous alcoholic rehabilitation before transplant evaluation, P=0.001; and (V) failure to accept further alcoholic rehabilitation before orthotopic liver transplantation, P=0.01. CONCLUSIONS Our experience confirms that transplantation can be extremely successful in properly selected patients with alcoholic cirrhosis. We identified several predictive psychosocial factors of early alcoholic recidivism in transplant candidates.
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Affiliation(s)
- J F Karman
- Department of Medical Social Work, University of Illinois at Chicago Medical Center, 60612, USA
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34
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Transplantation of the Liver and Intestine. Surgery 2001. [DOI: 10.1007/978-3-642-57282-1_67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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35
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DiMartini A, Day N, Dew MA, Lane T, Fitzgerald MG, Magill J, Jain A. Alcohol use following liver transplantation: a comparison of follow-up methods. PSYCHOSOMATICS 2001; 42:55-62. [PMID: 11161122 DOI: 10.1176/appi.psy.42.1.55] [Citation(s) in RCA: 85] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Alcoholic cirrhosis is one of the most common indications for liver transplantation. Previous researchers have studied rates of return to drinking following transplantation, however, few have employed prospective measures of alcohol use. The authors prospectively studied the alcohol use of patients transplanted for alcoholic liver disease. The authors improved the accuracy of monitoring alcohol use by using various methods for tracking patient's alcohol consumption, and we report on the time to first alcohol use after transplantation comparing these different methods. The authors found that alcohol use can occur very early after transplantation, even within the first 3 months posttransplant. Thirty-eight percent of the patients consumed any alcohol after transplantation. The clinical interviews by the psychiatrist were the most successful method for identifying posttransplant alcohol use. Posttransplant alcohol use was significantly associated with prior nonalcohol substance use (P < 0.025), family history of alcoholism in a first-degree relative (P < 0.025), and prior alcohol rehabilitation experience (P < 0.05) but not with a prior psychiatric history or less than 6 months of pretransplant sobriety. The authors indicate that prospective monitoring, using a combination of methods, is the most accurate approach to identify alcohol consumption. With this type of accuracy, risk factors can be identified and alcohol use can be compared with alcohol-related morbidity posttransplant.
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Affiliation(s)
- A DiMartini
- Department of Psychiatry, University of Pittsburgh Medical Center, PA, USA
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36
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DiMartini A, Magill J, Fitzgerald MG, Jain A, Irish W, Khera G, Yates W. Use of a high-risk alcohol relapse scale in evaluating liver transplant candidates. Alcohol Clin Exp Res 2000. [PMID: 10968657 DOI: 10.1111/j.1530-0277.2000.tb02083.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Methods to improve assessment, selection, and monitoring of patients with alcoholic cirrhosis who pursue liver transplantation are sought continuously. We chose to investigate the use of the High-Risk Alcohol Relapse (HRAR) scale in our transplant population in the hope that it would improve our ability to identify and follow patients at highest risk for alcohol relapse. METHODS Detailed alcohol histories of 207 patients evaluated for liver transplantation were collected and graded for severity by using the HRAR. The HRAR provides information on the duration of alcohol use (a measure of chronicity), daily quantity of alcohol use, and rehabilitation experiences (treatment responsiveness). Posttransplant alcohol use was monitored through clinical follow-up in the transplant clinic. RESULTS Although men and women had similar years of heavy drinking pretransplant, women's daily alcohol consumption was significantly less than men's. HRAR scores did not distinguish those listed for transplant from those not listed or those who drank posttransplant from those who did not. Transplant patients were predominantly in the low-risk group (83% had an HRAR score <4). CONCLUSIONS The HRAR did not have predictive ability in our transplant population. Few of our patients were rated as high risk, and few drank posttransplant. Nevertheless, identifying patients at high risk may improve clinical care and decrease the rate of posttransplant alcohol consumption.
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Affiliation(s)
- A DiMartini
- Department of Psychiatry and the Thomas E Starzl Transplant Institute at the University of Pittsburgh Medical Center, Pennsylvania, USA.
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37
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Dew MA, Switzer GE, DiMartini AF, Matukaitis J, Fitzgerald MG, Kormos RL. Psychosocial assessments and outcomes in organ transplantation. Prog Transplant 2000. [PMID: 11232552 DOI: 10.7182/prtr.10.4.0543372h622k2j45] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
A qualitative review was conducted to define the term psychosocial as applied to transplant patients and to summarize evidence regarding the role and impact of psychosocial assessments and outcomes across the transplant process. English-language case series and empirical studies from January 1970 through April 1990 that were abstracted in Medline and Psychological Abstracts or listed in publications' bibliographies were used as data sources. A qualitative analysis was performed to determine the depth of the case reports and whether the empirical reports obtained statistically reliable, clinically significant findings. The authors conclude that psychosocial assessments differ in content and application to candidate selection depending on the transplant program. Psychosocial status before transplant does not consistently affect medical outcomes after transplant. Psychosocial status generally improves with transplant, although difficulties are prevalent in psychological adjustment and in compliance with medical regimens. Psychiatric history can predict psychological outcomes after transplant but does not consistently predict compliance. Social supports and coping strategies strengthen psychosocial outcomes. Posttransplant psychosocial outcomes may predict physical morbidity and mortality.
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Affiliation(s)
- M A Dew
- University of Pittsburgh School of Medicine and Medical Center, Pittsburgh, Pa., USA
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38
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Beresford TP, Everson GT. Liver transplantation for alcoholic liver disease: bias, beliefs, 6-month rule, and relapse--but where are the data? Liver Transpl 2000; 6:777-8. [PMID: 11084067 DOI: 10.1053/jlts.2000.19027] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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39
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Mori DL, Gallagher P, Milne J. The Structured Interview for Renal Transplantation--SIRT. PSYCHOSOMATICS 2000; 41:393-406. [PMID: 11015625 DOI: 10.1176/appi.psy.41.5.393] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Despite the fact that the demand for psychiatric evaluations of organ transplant recipients is increasing, there is not a commonly agreed upon protocol that can guide clinicians. A standard psychiatric interview, although necessary, is not sufficient when interviewing transplant candidates. In addition, it is important to acquire information specific to the medical regimen associated with renal disease and renal transplantation. The purpose of this paper is to present the Structured Interview for Renal Transplantation (SIRT). The SIRT was developed as a tool to guide clinicians through the interview process by providing a comprehensive structure while still allowing for flexibility. There are many advantages of using the SIRT--it is a tool that facilitates a clinician's ability to conduct a thorough evaluation in a time-efficient manner. It is also an excellent instrument for training clinicians, and the structure of the interview is appropriate for use in research.
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Affiliation(s)
- D L Mori
- Psychology Service, Boston VA Medical Center, MA 02130, USA
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40
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Abstract
The implementation of the presumptive donor law in Brazil is expected to increase the availability of organs for transplantation. As medical management of end-stage organ dysfunction continues to improve, increasing numbers of potential transplant recipients will be available to meet this supply. There is mounting evidence that supports the involvement of skilled psychiatric practitioners in the selection of transplant candidates. Data supporting the influence of psychosocial factors on compliance and therefore medical outcomes continues to grow. The literature review allows delineating the components and rationale for comprehensive psychosocial evaluations as a component of preoperative transplantation evaluation.
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Affiliation(s)
- E Messias
- Department of Psychiatry, University of Maryland, Baltimore, MD, USA.
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41
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Stilley CS, Miller DJ, Gayowski T, Marino IR. Psychological characteristics of candidates for liver transplantation: differences according to history of substance abuse and UNOS listing. United Network for Organ Sharing. J Clin Psychol 1999; 55:1287-97. [PMID: 11045777 DOI: 10.1002/(sici)1097-4679(199910)55:10<1287::aid-jclp9>3.0.co;2-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Liver transplantation for patients with a history of substance abuse remains controversial. Resumption of heavy alcohol use postoperatively is a threat to long-term survival, but recidivism among transplanted alcoholics is reportedly low. An argument against psychological evaluation prior to transplantation revolves around the speculation that candidates will attempt to portray themselves as more desirable prior to listing with UNOS (United Network for Organ Sharing). This study measured psychological distress, coping styles, optimism, selected personality features, and perception of family environment among 73 U.S. military veterans who were candidates for liver transplantation. Candidates with positive histories of substance abuse revealed significantly more distress, less adaptive coping styles, and more character pathology than their counterparts. The only significant difference according to UNOS listing was on one measure of family environment. Results support preoperative psychological assessment and intervention on a more extensive level for substance abusers and raise questions for future research.
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Affiliation(s)
- C S Stilley
- University of Pittsburgh and VA Pittsburgh Healthcare System, PA 15261, USA
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42
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Newton SE. Recidivism and return to work posttransplant. Recipients with substance abuse histories. J Subst Abuse Treat 1999; 17:103-8. [PMID: 10435257 DOI: 10.1016/s0740-5472(98)00059-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The purpose of this retrospective survey was to describe posttransplant recidivism and return to work rates for adult liver transplant recipients with histories of alcohol-related liver disease (ARLD) or ARLD and polysubstance use. Recidivism from alcohol was the primary substance analyzed. One hundred and twenty-two adult liver transplant recipients comprised the convenience sample; 98 had histories of ARLD and 24 had both ARLD and polysubstance use. Using a mailed survey, the recipients were asked about their drug and alcohol use (both prior to and following the transplant); family and social issues; and whether they were working posttransplant. The two subgroups of recipients differed with respect to the variables gender, age, and years posttransplant with the ARLD/polysubstance using recipients more likely to be male, younger, and more recent transplant recipients than those with ARLD, alone. Recidivism and return to work rates differed for the two subgroups.
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Affiliation(s)
- S E Newton
- University of Michigan, Rackham School of Graduate Studies, Ann Arbor, USA.
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44
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45
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Madey SF, Ondrus SA. Illusory Correlations in Perceptions of Obese and Hypertensive Patients' Noncooperative Behaviors1. JOURNAL OF APPLIED SOCIAL PSYCHOLOGY 1999. [DOI: 10.1111/j.1559-1816.1999.tb02036.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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46
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Schluger LK, Klion FM. Analytic Reviews : The Indications for and Timing of Liver Transplantation. J Intensive Care Med 1999. [DOI: 10.1177/088506669901400301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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47
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Affiliation(s)
- S Kaur
- Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois, USA
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48
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Yates WR, LaBrecque DR, Pfab D. Personality disorder as a contraindication for liver transplantation in alcoholic cirrhosis. PSYCHOSOMATICS 1998; 39:501-11. [PMID: 9819950 DOI: 10.1016/s0033-3182(98)71282-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Severe personality disorder has been proposed as a contraindication for liver transplantation. Seventy-three subjects with alcoholic-related liver disease were evaluated for personality disorder and followed for 6 months. The subjects with severe personality disorder had higher rates of divorce, higher rates of comorbid drug abuse or dependence, lower Weschler Adult Inventory Scale IQ estimates, and higher scores on indicators of emotional impairment. Personality disorder was not associated with a higher rate of return to alcohol use during the follow-up period. Three subjects with personality disorder underwent liver transplantation without behavioral or substance abuse complications. This study does not support routine exclusion of subjects based solely on a diagnosis of a severe personality disorder.
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Affiliation(s)
- W R Yates
- Department of Psychiatry, University of Oklahoma College of Medicine, Tulsa Campus 74129-1077, USA
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49
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DiMartini A, Jain A, Irish W, Fitzgerald MG, Fung J. Outcome of liver transplantation in critically ill patients with alcoholic cirrhosis: survival according to medical variables and sobriety. Transplantation 1998; 66:298-302. [PMID: 9721796 DOI: 10.1097/00007890-199808150-00004] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND At our center from August 1989 to December 1992, 834 adults underwent orthotopic liver transplantation (OLT) using tacrolimus as the primary immunosuppressive agent. A total of 183 adults (22%) had alcohol-related liver disease. Patients with alcoholic cirrhosis had a better though not statistically significant 5-year survival rate compared with all other patients. We were interested in specific predictors of survival, particularly for alcoholic cirrhotics who were gravely ill at the point of transplantation. METHODS For the 78 patients with alcohol-related liver disease who were United Network for Organ Sharing status IIA (critically ill) at the point of transplantation, variables of length of sobriety, alcohol rehabilitation, and medical variables (ventilator support, dialysis, vasopressor support, degree of encephalopathy, and infection) were assessed for contribution to survival. RESULTS Although there was a trend toward poorer survival in patients with the shortest length of sobriety (< or =1 month), pre-OLT length of sobriety or alcohol rehabilitation did not predict survival. However, these patients tended to be in multiorgan failure and encephalopathic. Nevertheless, pre-OLT dialysis requirement was the only variable that predicted poorer survival (P < 0.002). This study was not designed to evaluate recidivism. However, we know that 24% of these patients have used alcohol at some point after OLT. CONCLUSIONS Short pre-OLT length of sobriety may not predict which patients are likely to resume alcohol consumption after OLT, but it may identify patients in whom there will exist a variety of poor outcome variables. In our study, in these patients, post-OLT survival was associated with medical rather than alcohol history variables.
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Affiliation(s)
- A DiMartini
- Department of Psychiatry, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pennsylvania 15213, USA
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50
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Yates WR, Martin M, LaBrecque D, Hillebrand D, Voigt M, Pfab D. A Model to Examine the Validity of the 6-Month Abstinence Criterion for Liver Transplantation. Alcohol Clin Exp Res 1998. [DOI: 10.1111/j.1530-0277.1998.tb03681.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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