Identification of Quantifiable Predictors of Relapse in Patients with Alcohol‐Associated Liver Disease

Abstract

Abstinence in patients with alcohol-associated liver disease (ALD) reduces mortality. Most predictors of relapse are not quantifiable, preventing objective analysis of relapse risk and targeted intervention to improve clinical outcomes. We prospectively enrolled patients with ALD from November 2016 to December 2019 and administered a survey with two previously published scales to assess insight into alcohol-use disorder (Hanil Alcohol Insight Scale [HAIS]) and social support (Community Assessment Inventory Scale [CAIS]). Relapse was assessed using surveys and metabolite testing. Unadjusted and prespecified adjusted regression analyses identified predictors of relapse. We enrolled 81% of eligible patients (n = 136), of whom 58 had follow-up data available at the time of analysis. Over a median follow-up of 1 year (interquartile range: 0.5-1.4), 10 patients relapsed (17%). Patients who relapsed were more likely to continue drinking despite either a diagnosis of liver disease or a decompensating event, and were less likely to have been transplanted (all P < 0.05). In unadjusted regression, the HAIS and the "support inside the home" subcategory of the CAIS were predictive of relapse, with odds ratio (OR) = 0.84 (95% confidence interval 0.72-0.97) and 0.85 (0.74-0.97). In adjusted regression, the HAIS was no longer significant, with adjusted OR = 0.70 (0.49-1.00, P = 0.05), whereas the "support inside the home' subcategory of CAIS remained significant, with adjusted OR = 0.69 (0.51-0.92, P = 0.01). Conclusions: Risk factors for relapse in patients with ALD were identified and quantified prospectively, suggesting opportunities to objectively identify patients at risk for relapse as well as to intervene to prevent relapse. (Hepatology Communications 2021;0:1-9).A lcohol-associated liver disease (ALD) is the leading cause of gastrointestinal-related death among women and men, with a crude mortality rate of 6.8 per 100,000. (1) ALD can be defined clinically as evidence of liver damage that occurs in the setting of high-risk drinking. The NIAAA has defined high-risk drinking to include the consumption of four or more drinks on any day or eight or more drinks per week for women (five or more drinks on any day or 15 or more drinks per week for men), (2,3) but these thresholds are not particular to ALD. The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) defines alcohol addiction by the diagnosis of alcohol use disorder (AUD), which is often co-morbid with ALD and predicts high-risk drinking. (4,5

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

“…[23] It measures AAI in the non-LT ALD population [56][57][58] associating with alcohol relapse in unadjusted analysis (OR = 0.84 [0.72-0.97]), an association no longer significant after adjusted regression (OR = 0.70 [0.49-1.00]). [58] In non-ALD populations, insight measured by a modified HAIS correlated with the early success of outpatient SUD treatment. [59] HAIS-measured AAI interacted with a person's implicit alcohol preferences to predict alcohol relapse.…”

“…The Hanil Alcohol Insight Scale (HAIS) is the most used AAI scale 23 . It measures AAI in the non-LT ALD population 56–58 associating with alcohol relapse in unadjusted analysis (OR = 0.84 [0.72–0.97]), an association no longer significant after adjusted regression (OR = 0.70 [0.49–1.00]) 58 . In non-ALD populations, insight measured by a modified HAIS correlated with the early success of outpatient SUD treatment 59 .…”

Social support and transplantation

“…Another study found the level of social support and level of adherence decreased in tandem with time elapsed from transplant [12 ▪ ], suggesting decreased social support may contribute to poorer adherence over time. Social support and alcohol relapse were also correlated, as patients who relapsed after transplant reported decreased social support within their home compared with patients who abstained posttransplant [13 ▪ ].…”

Development and validation of the Schedule for the Assessment of Insight in Alcohol Dependence (SAI-AD): Dimensions and correlates of insight in alcohol use disorder

“…Poor insight is strongly associated with avoidance of treatment (Probst et al, 2015), less successful quit attempts (Willems et al, 1973) and more premature dropouts (Ball et al, 2006) during treatment programs, less time of abstinence after discharge (Kim et al, 2007), and a higher risk of relapse (Dandaba et al, 2020, Shen et al, 2021.…”