Long-term medical and psycho-social evaluation of patients undergoing orthotopic liver transplantation for alcoholic liver disease

Orthotopic liver transplantation for patients with end-stage alcohol-related liver disease and severe acute alcohol-related hepatitis

Worldwide, cirrhosis due to alcohol-related liver disease (ALD) is responsible for 0.9% of global deaths and 47.9% of cirrhosis-related deaths. End-stage ALD (ESALD) is the final condition of alcohol-related cirrhosis, and severe acute alcohol-related hepatitis (SAAH) is a distinct clinical syndrome associated with the consumption of large amounts of alcohol. In some cases, ESALD, and SAAH may need liver transplantation (LT). The severity of ESALD can improve after a few months (three months) of abstinence from alcohol, avoiding or delaying the need for LT. Conversely, patients with ESALD with a poor prognosis (MELD≥15) may be candidates for LT after three months of abstinence; in these patients, the 6 months rule needs to be revised. In addition, in non-responders to steroid therapy, the indication for early LT in patients with SAAH and acute on chronic liver failure (ACLF) due to alcohol use find indication in carefully selected patients (those with good insight into their alcohol problems and good social support). Thus, the role of a multi-disciplinary team of experts in the management of alcohol use disorder, ESALD and SAAH working in the same institution, the support of the patient's family and self-help groups represent a crucial approach in the reinforcement of motivation to abstain from alcohol, and in helping patients to avoid relapses in heavy drinking when entered in an LT program.

Management of end-stage alcohol-related liver disease and severe acute alcohol-related hepatitis: position paper of the Italian Society on Alcohol (SIA)

Worldwide, the prevalence of alcohol use disorder (AUD) is 20-30% in men and 10-15% in women, and cirrhosis due to alcohol-related liver disease (ALD) is responsible for 0.9% of global deaths and 47.9% of cirrhosis-related deaths. End-stage ALD (ESALD) is the final condition of alcohol-related cirrhosis, and severe acute alcohol-related hepatitis (SAAH) is a distinct clinical syndrome associated with the consumption of large amounts of alcohol. In some cases, ESALD, and SAAH may need liver transplantation (LT). Thus, the management of ESALD and SAAH in patients affected by AUD may be an essential part of the clinical skills for hepatologists. For these reasons, the national board of the Italian Society on Alcohol have reviewed the most recent data on the management of ESALD, SAAH and LT for ALD in patients with AUD, formulating a position paper with related recommendations regarding four issues of specific clinical interest in this field: (a) the management of hepatic encephalopathy in patients with AUD, and LT in patients with ESALD; (b) the management of SAAH; (c) the management of AUD in patients with ESALD and SAAH; (d) special populations: polydrug addicts.

Alkolik karaciğer hastalığı nedeniyle karaciğer nakli yapılan hastalarda psikiyatrik eştanı ve yeniden alkol kullanımı: Bir ön çalışma

Amaç: Alkolik karaciğer hastalığı, karaciğer naklinin önde gelen endikasyonlarından biridir. Karaciğer nakli sonrasında olumlu sonuçlar elde edilmekle birlikte, bazı olgularda alkol alımının tekrar ortaya çıktığı bildirilmiştir. Çalışmamızın amacı bu hastalarda psikiyatrik eş tanıları ve karaciğer nakli sonrasındaki izlem döneminde yeniden alkol kullanımını incelemektir. Gereç ve Yöntem: Kurumumuzda alkolik karaciğer hastalığı nedeniyle karaciğer nakli yapılan 14 hastanın bir yıllık tıbbi kayıtları retrospektif olarak incelenmiştir. Bulgular: On dört hastadan beşinde (%35,7) geçmişte psikiyatri başvurusu, dördünde (%28,6) psikiyatrik tedavi öyküsü saptanmıştır. Psikiyatrik görüşme sırasında halen psikiyatrik hastalığı devam eden ve psikiyatrik tedavi gören hasta sayısı ikidir (%14,3). Bu hastalarda gözlenen tanılar alkol kullanım bozukluğu, depresyon ve anksiyete bozukluğudur. İzlemde bir hasta kaybedilmiş, kalan 13 hastadan hiçbirinde alkol kullanımında yineleme gözlenmemiştir. Sonuç: Alkolik karaciğer hastalığı karaciğer nakli için ideal bir endikasyondur ve yakın izlemle alkol kullanımında yineleme önlenebilir. Psikiyatri hem nakil öncesi hem nakil sonrası dönemde organ nakli ekibinin vazgeçilmez bir üyesi olmalıdır.

Predicting and preventing alcohol relapse in alcohol-related liver disease

BACKGROUND

despite a 450% increase in UK alcohol-related liver disease mortality over the past 30 years, little evidence-based guidance exists regarding preventing recidivism post-liver transplant for alcohol-related liver disease.

METHOD

a systematic literature review was conducted to identify demographic variables predictive of alcohol relapse and effective psychosocial interventions for alcohol-related liver disease patients post-liver transplant.

RESULTS

variables most significantly predictive of alcohol relapse post-transplant were-less than 12 months pre-liver transplant abstinence; patients with children; poor pre-liver transplant psychosomatic evaluation; non-compliance with post-liver transplant treatment plan; and patients with active insurance policies. Structured management was the most effective psychosocial intervention in preventing alcohol relapse.

CONCLUSION

findings should be interpreted cautiously, due to limited and poor-quality evidence. Rigorously designed further research of the psychosocial interventions targeting predictive demographic variables is recommended.

Alcohol relapse and its predictors after liver transplantation for alcoholic liver disease: a systematic review and meta-analysis

BACKGROUND

Alcoholic liver disease (ALD) is the leading cause of liver transplantation (LT). The magnitude and risk factors of post-LT alcohol relapse are not well described. We conducted a meta-analysis to evaluate alcohol relapse rate and its predictors after LT.

METHODS

Searches of MEDLINE and SCOPUS identified eligible published studies of alcohol relapse after LT published up to 31 March 2018. Alcohol relapse was defined as any alcohol consumption post-LT, and heavy alcohol relapse was defined as a relapse of alcohol consumption that was associated with a significant harm. Data for the proportion of alcohol relapse was pooled using a meta-analysis for pooling proportion. An odds ratio (OR) of the predictor of alcohol relapse was extracted and pooled using meta-analysis for the pooling risk factor. Data were analyzed using a random effect model if heterogeneity was presented; otherwise, a fixed effect model was applied. The study was registered at PROSPERO (CRD42017052659).

RESULTS

Ninety-two studies with over 8000 cases were recruited for pooling proportion of alcohol relapse. The alcohol relapse rate and heavy alcohol relapse rate after LT during the mean follow-up time of 48.4 ± 24.7 months were 22% (95% confidence interval (CI): 19-25%) and 14% (95%CI: 12-16%). Psychiatric comorbidities (odds ratio (OR) 3.46, 95%CI: 1.87-6.39), pre-transplant abstinence of less than 6 months (OR 2.76, 95%CI: 2.10-3.61), unmarried status (OR 1.84, 95%CI: 1.39-2.43), and smoking (OR 1.72, 95%CI: 1.21-2.46) were associated with alcohol relapse after LT. However, we noticed publication bias of unpublished negative studies and high heterogeneity of results.

CONCLUSIONS

Post-transplant alcohol relapse occurred in about one-fifth of patients who underwent alcohol-related LT. Psychiatric comorbidities represented the strongest predictor of alcohol relapse. Psychiatric comorbidities monitoring and pre-LT alcohol abstinence for at least 6 months may decrease alcohol relapse after LT.

The multidisciplinary support in preventing alcohol relapse after liver transplantation: A single-center experience

BACKGROUND AND AIM

Alcoholic liver disease (ALD) represents a frequent indication for liver transplantation (LT). Since 2004, we have adopted a program of multidisciplinary support(MS) to assist patients undergoing LT for ALD. We aimed at analyzing the relapse rate and the risk factors for relapse. The relapse rate was also compared with that of a historical group of patients who underwent transplantation. Their survival rate was also analyzed.

PATIENTS AND METHODS

Consecutive patients with ALD transplanted from 2004 were included. The most important demographic, psychosocial, and clinical characteristics known to be associated with alcohol relapse were recorded.

RESULTS

Sixty-nine patients underwent MS: 8.7% presented alcohol relapse. At multivariate analysis female gender (sHR 9.02, 95% CI 1.71-47.56, P = .009), alcohol withdrawal syndrome (sHR 5.89, 95% CI 1.42-24.46, P = .015) and a shorter time of MS program before LT (sHR 0.928 per month, 95% CI 0.870-0.988, P = .021) were identified as independent risk factors for relapse. The rate of alcohol relapse was significantly lower than that of the historical group who did not undergo MS (sHR 0.21, 95% CI: 0.06-0.68; P = .009).

CONCLUSION

This study shows that a MS program may contribute to alcohol relapse prevention after LT in ALD patients. However, the relevance of this support needs to be confirmed by clinical trials.

Liver Transplantation for Alcoholic Liver Disease and Hepatocellular Carcinoma

Hepatocellular carcinoma is one of the main important causes of cancer-related death and its mortality is increasingly worldwide. In Europe, alcohol abuse accounts for approximately half of all liver cancer cases and it will become the leading cause of hepatocellular carcinoma in the next future with the sharp decline of chronic viral hepatitis. The pathophysiology of alcohol-induced carcinogenesis involves acetaldehyde catabolism, oxidative stress and chronic liver inflammation. Genetic background plays also a significant role and specific patterns of gene mutations in alcohol-related hepatocellular carcinoma have been characterized. Survival is higher in patients who undergo specific surveillance programmes than in patients who do not. However, patients with alcohol cirrhosis present a significantly greater risk of liver decompensation than those with cirrhosis due to other aetiologies. Furthermore, the adherence to screening program can be suboptimal. Liver transplant for patients with Milan-in hepatocellular carcinoma represents the best possible treatment in case of tumour recurrence/progression despite loco-regional or surgical treatments. Long-term result after liver transplantation for alcohol related liver disease is good. However, cardiovascular disease and de novo malignancies can significantly hamper patients' survival and should be carefully considered by transplant team. In this review, we have focused on the evolution of alcohol-related hepatocellular carcinoma epidemiology and risk factors as well as on liver transplantation in alcoholic patients with and without hepatocellular carcinoma.

Role of liver transplantation in severe alcoholic hepatitis

Severe alcoholic hepatitis has very high short term mortality and corticosteroids have been the mainstay of treatment for decades. Patients with Lille score >0.45 are considered non-responders to steroids and have poor outcome. Recently Orthotopic Liver Transplantation (OLT) is being increasingly used as rescue treatment for these patients, without waiting for 6 months of abstinence. Liver transplant is the only rescue treatment which can potentially provide long term benefit for patients who are steroid non-responders. However, with scarcity of organs being a concern, all patients of severe alcoholic hepatitis cannot be chosen for transplantation in an arbitrary way. There is a need for development of predictive tools and objective protocols to select patients who can justify the use of precious liver grafts. With a stringent criteria for selection of patients receiving the graft, liver transplantation in severe alcoholic hepatitis can become a viable rescue therapeutic option conferring significant survival advantage of both short- and long-term basis. The optimal criteria for selection will also prevent misuse of the liver donor pool as well as to prevent mortality in salvageable patients. Further research needs to be done to identify subset of patients which are at low risk of recidivism and also cannot be managed with pharmacotherapy alone. We reviewed the current knowledge on role of OLT in patient with acute severe alcoholic hepatitis in the present review.

Substance abuse in Heart Transplant Recipients: A 10-Year Follow-up Study

Context—

Active substance abuse is widely accepted as a contraindication for heart transplantation because of the theory that relapse would occur after transplantation and result in compromise of graft function, lowering long-term survival. Listing “recovering” substance abusers for heart transplantation has been controversial.

Objective—

To determine if substance abuse plays an unfavorable role in the outcome of heart transplantation.

Methods—

The medical records of all patients at our center who received a heart transplant more than 10 years ago were retrospectively reviewed for history of substance abuse.

Results—

From a pool of 189 transplant recipients, 47 patients had a definite history of substance abuse (group 1) and were considered in recovery, whereas 142 patients were clearly without any history of substance abuse (group 2). Group 1 had a significantly greater percentage of patients with a pretransplantation diagnosis of idiopathic cardiomyopathy ( P=.003), a higher occurrence of heart-related cause of death ( P=.017), and a significant prevalence of noncompliance ( P=.0001) and death because of noncompliance ( P=.0004). In contrast, group 2 surprisingly had a significantly higher incidence of death related to infection ( P=.0062), which is unexplained. Despite higher incidence of noncompliance in group 1, there was no significant difference in the overall survival rate between the 2 groups.

Conclusion—

These results suggest that patients with a history of substance abuse can undergo successful heart transplantation with acceptable long-term survival, though they are at greater risk for substance abuse relapse and resulting noncompliance with the treatment regimen. The extent to which relapse of substance abuse and its consequences affect the cost of posttransplantation care remains to be determined.

Controversies in the management of alcoholic liver disease

Alcohol is a risk factor for chronic disease burden in developed countries. Alcoholic liver disease affects 1% of the North American population and is the second most frequent indication for liver transplantation in the United States. It is a spectrum that ranges from simple hepatic steatosis to alcoholic hepatitis to steatohepatitis and eventually cirrhosis. The clinical spectrum of alcoholic hepatitis is wide and ranges from the asymptomatic patient to overt liver failure and death. Liver biopsy as a means of prognostication in alcoholic hepatitis has mostly been replaced with less invasive scoring systems. The management of alcoholic liver disease is challenging. Abstinence is the cornerstone of therapy and should include rehabilitation with a multidisciplinary approach. No specific treatment is required in mild to moderate alcoholic hepatitis. In patients with severe hepatitis, there appears to be a moderate survival benefit from the use of either corticosteroids or pentoxifylline in the absence of contraindications to their use. Nonresponders should have steroid therapy withdrawn by day 7, as persistence with therapy is not beneficial. Orthotopic liver transplantation remains the definitive therapy for decompensated alcoholic cirrhosis despite alcohol abstinence. More studies are needed to define the optimal timing of orthotopic liver transplantation and patients at risk of alcohol relapse post-transplant. Mt Sinai J Med 76:484-498, 2009. (c) 2009 Mount Sinai School of Medicine.

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

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

A critical review of candidacy for orthotopic liver transplantation in alcoholic liver disease

The majority of candidates with end-stage alcoholic liver disease (ESALD) in the United States who are eligible for referral for liver transplantation (LT) are not being referred. There is a lack of firm consensus for the duration of abstinence from alcohol as well as what constitutes good psychosocial criteria for listing for LT. Evidence shows that the general public and the practicing physicians outside the transplant community perceive that patients with a history of alcohol abuse will make poor transplant candidates. However, physicians in the transplant community perceive selected patients with ESALD as good candidates. When considering patients for listing for LT, 3 months of alcohol abstinence may be more ideal than 6 months. Patients with a lack of social support, active smoking, psychotic or personality disorders, or a pattern of nonadherence should be listed only with reservation. Those who have a diagnosis of alcohol abuse as opposed to alcohol dependence may make better transplant candidates. Patients who have regular appointments with a psychiatrist or psychologist in addictions treatment training also seem to do more favorably.

Single-center experience on liver transplantation for hepatocellular carcinoma arising in alcoholic cirrhosis: results and ethical issues

BACKGROUND

Liver transplantation is currently recognized as the optimal treatment for both early hepatocellular carcinoma in the setting of cirrhosis (HCC) as well as for alcoholic liver disease (ALD). The purpose of this study was to evaluate the outcome of patients with HCC and ALD in the absence of viral hepatitic infections.

METHODS

Twelve recipients were transplanted with a diagnosis of HCC and ALD in the absence of viral hepatitis during a 6-year period. Nine received deceased donor livers, and 3 live donor grafts. Our results were compared to those obtained by a search of the world literature.

RESULTS

The postoperative course was uneventful in all but one patient. All recipients experienced a good quality of life postoperatively. Three-year overall and recurrence-free survival rates were 82 and 73%, respectively. Nine patients are currently alive, after a median follow-up of 29 months.

CONCLUSION

This is the first study to evaluate liver transplantation for HCC in ALD. Although outcomes are excellent, the evaluation of patients with ALD and HCC constitutes a challenging topic in transplantation surgery, especially when live liver donation is considered. An interdisciplinary structured approach is recommended, with special emphasis on ethical considerations.

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.