Substance use by liver transplant candidates: An anonymous urinalysis study

Abstract

Toxicological urinalysis is a highly sensitive and specific test that detects recent substance use. It has been established for substance misuse treatment but has not been routinely used at liver transplantation (LT) centers. Patients with a history of substance misuse are required to be abstinent from alcohol and illicit drugs before they are listed for LT. In this cross-sectional study, we sought to determine the prevalence of recent substance use in LT candidates via toxicological urinalysis. One hundred nine adults who were admitted for an LT assessment provided data, and they were categorized by the etiology of their liver disease [alcohol-related liver disease (ALD), hepatitis C virus (HCV), or other liver diseases]. Urine was toxicologically screened for drugs and their metabolites as well as the urinary alcohol metabolites ethyl glucuronide and ethyl sulfate. The prevalence of alcohol metabolites in patients with ALD was 20%. Licit and illicit substances together provided a positive toxicological result in 30% of the patients. Positive results were more common among patients with HCV (40%) and ALD (38%) versus patients with other liver diseases (18%). During the clinical assessment, 4% of the patients with ALD or HCV self-reported current alcohol or illicit drug use. These results correspond to the findings of other studies and emphasize the uncertainty of self-reported substance use data for LT candidates. Liver transplantation (LT) for end-stage liver disease is a well-established lifesaving treatment option that provides recipients with improved quality of life and longevity.1,2 The success of LT has traditionally been related to survival. Survival rates have continuously improved; across the United States, the United Kingdom, and Ireland, the 1-, 5-, 10-, and 20-year patient survival rates are 90%, 70%, 65%, and 50%, respectively.2-4 Furthermore, longitudinal data have shown remarkable improvements in quality-of-life domains after LT. The consideration of candidates for LT whose liver disease etiology is related to substance misuse remains controversial. Surveys of public and professional attitudes toward organ allocation to patients with different causes of liver disease have demonstrated that abstinent patients with a history of alcohol dependence or injecting drug use are considered a low priority in comparison with other patient groups. 5,6 There is also evidence suggesting that patients with chronic alcohol-related liver disease (ALD) are not being referred for an LT assessment even though they are considered good candidates within the transplant community. 5,7 In practice, patients with a history of substance misuse who are assessed for LT must currently be abstaining from alcohol and illicit drugs (except for occasional cannabis use, which is not contraindicated in the UK guidelines 8,9 ); after the LT assessment, alcohol or illicit drug use is a contraindication for transplantation.Abbreviations: ALD, alcohol-related liver disease; HCV, hepatitis C virus; LT, liver transplantation. James Bell...

Assessing the drinking status of liver transplant patients with alcoholic liver disease

“…Among the reasons for monitoring and encouraging abstinence in ALD patients are the stabilization of their medical condition before surgery and the improvement of their prospects for long‐term sobriety afterward . Unfortunately, the recurrence of drinking is common even in ALD patients who have committed to abstinence and who have already been selected for liver transplantation . It has also been argued that with consistent abstinence, a candidate for ALD‐related transplantation might in fact no longer require a graft .…”

Application of Prescription Drug Monitoring Program to detect underreported controlled substance use in patients evaluated for liver transplant

“…To date, most studies have focused on the use of UDS in screening patients for LT. 5 There are several limitations to our study including the fact that it is retrospective and from a single center, so the results may not reflect the practice or patient population at another center. As dis- In conclusion, we have shown PDMP to be a useful screening tool when used in conjunction with the UDS for detecting underreported CS use in LT candidates.…”

“…5 In recent years, statewide Prescription Drug Monitoring Programs (PDMP) have been employed to track the dispensing of CS so that providers can identify excessive use and abuse among patients. Webzell et al found that the prevalence of alcohol metabolites in patients with alcohol-related liver disease was 20%.…”

Ethyl glucuronide

“…58 In a cross-sectional study of 109 adult patients undergoing assessment for liver transplantation, 20% of subjects with alcohol-related liver disease had positive urine EtG and EtS results, but only 4% self-reported alcohol use. 59 In a larger study of 141 liver transplant candidates in Germany, urinary EtG had a positive predictive value of 89.3% and a negative predictive value of 98.9% for detecting alcohol consumption and was superior to CDT, MCV and GGT. 60 Theoretically, end-stage liver disease could result in reduced production of EtG and EtS, although as these are minor pathways of alcohol metabolism, there is no evidence that such a reduction occurs.…”