Alcohol relapse after liver transplantation (LT) in patients with alcohol‐related liver disease (ALD) is a major challenge. Although its association with pretransplant psychosocial factors was extensively studied, the impacts of posttransplant courses on alcohol relapse have not been well investigated. The aim of this study is to analyze peritransplant factors associated with posttransplant alcohol relapse in patients with ALD. This study evaluated 190 adult LT patients with ALD from 2013 to 2019. Risk factors for alcohol relapse were analyzed, focusing on posttransplant chronic complications, which were classified as Clavien‐Dindo classification 3a or higher that lasted over 30 days. The posttransplant alcohol relapse rate was 13.7% (26/190) with a median onset time of 18.6 months after transplant. Multivariate Cox regression analysis revealed that posttransplant chronic complications were an independent risk factor for posttransplant alcohol relapse (hazard ratio [HR], 5.40; P = 0.001), along with psychiatric comorbidity (HR, 3.93; P = 0.001), history of alcohol relapse before LT (HR, 3.00; P = 0.008), and an abstinence period <1.5 years (HR, 12.05; P = 0.001). A risk prediction model was created using 3 pretransplant risk factors (psychiatric comorbidity, alcohol relapse before LT, and abstinence period <1.5 years). This model clearly stratified the risk of alcohol relapse into high‐, moderate‐, and low‐risk groups (P < 0.001). Of the 26 patients who relapsed, 11 (42.3%) continued drinking, of whom 3 died of severe alcoholic hepatitis, and 13 (50.0%) achieved sobriety (outcomes for 2 patients were unknown). In conclusion, posttransplant chronic complications increased the risk of alcohol relapse. Recognition of posttransplant chronic complications in conjunction with the risk stratification model by pretransplant psychosocial factors would help with the prediction of posttransplant alcohol relapse.
Background
Serum phosphatidylethanol (PEth) is a highly sensitive test to detect alcohol use. We evaluated whether the availability of PEth testing impacted rates of liver transplant evaluation terminations and delistings.
Methods
Medical record data were collected for patients who initiated transplant evaluation due to alcohol‐related liver disease in the pre‐PEth (2017) or PEth (2019) eras. Inverse probability weighting (IPW) was used to balance baseline patient characteristics. Outcomes included termination of evaluation or delisting due to alcohol use; patients were censored at receipt of transplant; death was considered a competing risk. The Fine‐Gray method was performed to determine whether PEth testing affected risk of evaluation termination/ delisting due to alcohol use.
Results
Three hundred and seventy‐five patients with alcohol‐related indications for transplant (157 in 2017; 210 in 2019) were included. The final IPW‐adjusted model for the composite outcome of terminations/delisting due to alcohol use retained two significant variables (P < .05): PEth era and BMI category. Patients evaluated during the PEth era were almost three times more likely to experience an alcohol‐related termination/delisting than those in the pre‐PEth era (sHR = 2.86; 95%CI 1.67–4.97)
Conclusion
We found that availability of PEth testing at our institution was associated with a higher rate of exclusion of patients from eligibility for liver transplant. Use of PEth testing has significant potential to inform decisions regarding transplant candidacy for patients with alcohol‐related liver disease.
One of the major challenges in liver transplantation (LT) in patients with alcohol-related liver disease (ALD) is posttransplant alcohol relapse. It was reported that incidence rate ranges from 8.7% to 42%. [1][2][3][4][5][6] Alcohol relapse, especially "harmful relapse," could lead to allograft dysfunction or failure because of alcohol toxicity. 2 Many studies are investigating pretransplant factors to determine an association with posttransplant alcohol relapse (Table 1). Psychosocial factors and drinking patterns are closely associated with posttransplant relapse. [1][2][3][4][6][7][8][9] Strong social support is protective against alcohol relapse. 9 Abstinence period has been extensively investigated as well. Most transplant centers in the United States require 6 months of abstinence before accepting patients with ALD as LT candidates, which may allow them to improve their condition or identify patients who could remain abstinent after LT. 10 However, there are reports showing conflicting results suggesting that the length of abstinence was not associated with posttransplant alcohol relapse. 1,9 Hence the rationale of the "6-month rule" in patient selection for LT to predict relapse remains controversial. 1,2,8 POsTTransPlanT COMPliCaTiOns as a nOvel PreDiCTOr FOr alCOHOl relaPseThe impact of posttransplant courses on alcohol relapse has not been well investigated. Our group recently conducted a retrospective study to investigate possible effects Abbreviations: ALD, alcohol-related liver disease; CI, confidence interval; GVDH, graft-versus-host disease; HR, hazard ratio; HRAR, high-risk alcoholism relapse; LT, liver transplantation.
BackgroundEarly identification of alcohol use is crucial for informing recommendations of appropriate follow‐up treatment pre‐liver transplant and optimizing post‐liver transplant outcomes. The purpose of the study was to investigate whether there are psychosocial factors associated with a positive PEth test.MethodsAll patients who underwent a routine pre‐surgical psychological evaluation for liver transplant listing (all etiologies, including acute liver failure, dual organ, and re‐transplantation) at a single health care system in 2020 were included in a retrospective chart review. Data extraction included results from PEth testing and information from the psychological evaluation (i.e., demographic, psychiatric symptoms, and cognitive functioning).ResultsThere were 158 patients (73.8%) who had a PEth test, of whom 21.5% had a positive result (n = 34). Younger age was associated with a positive PEth (p < .001). ALD status and type of ALD (hepatitis vs. cirrhosis) were also associated with a positive PEth test. Other demographic characteristics and psychiatric symptoms were not associated with a positive PEth result (p > .05).ConclusionYounger age was the only significant demographic variable associated with a positive PEth test. Given the difficulty of predicting who may be using alcohol, it may be useful to use PEth testing for all patients during the pre‐liver transplant evaluation and while patients are listed for liver transplant. Early identification of alcohol use through routine PEth testing will help identify patients who are using alcohol and need further treatment for alcohol use to optimize health and post‐transplant outcomes.
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