Definition and measurement of alcohol-associated insight in early liver transplantation for acute alcohol-associated hepatitis: A systematic review

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.

“But I didn’t drink!”: What to do with discordant phosphatidylethanol results

“…Obtaining and discussing PEth results can help clinicians determine the level of AUD care patients require according to established criteria 49 . These encounters can also provide information regarding patient’s alcohol-associated insight, a key parameter LT teams deem highly important and useful in ALD treatment planning and organ allocation 50 . As indicated by patients’ alcohol recovery status and overall clinical risk, teams should determine how PEth fits into recommended “routine” and “robust” monitoring pre- and post-LT for alcohol slips and relapses 23 …”

“…[49] These encounters can also provide information regarding patient's alcohol-associated insight, a key parameter LT teams deem highly important and useful in ALD treatment planning and organ allocation. [50] As indicated by patients' alcohol recovery status and overall clinical risk, teams should determine how PEth fits into recommended "routine" and "robust" monitoring preand post-LT for alcohol slips and relapses. [23] Despite clinicians' best communication efforts, some patients will continue to produce positive PEth while consistently denying alcohol use leaving clinicians with persistent discordant information and a simultaneous need to make decisions regarding treatment and organ allocation.…”