Liver transplantation in patients with alcohol and other substance use disorders
Section snippets
EPIDEMIOLOGY
The need for transplantable human organs far exceeds current organ availability in the United States. As of April 2001, 17,520 Americans were awaiting liver transplantation (LT), whereas only 4934 received a liver in the previous year.4 Of the many antecedent causes of end-organ damage, heavy alcohol and illicit drug use are more likely to result in the need for LT compared with other organs. The lifetime prevalence of alcohol dependence in the United States is approximately 13%,24 and of those
PHYSICAL VERSUS PSYCHIATRIC DIAGNOSES: THE IMPORTANCE OF IDENTIFYING THE PRESENCE OF AN ADDICTION
It is often assumed that individuals referred for LT evaluation because of ALD carry the diagnosis of an alcohol addiction related to the cause of their liver disease; however, substance abuse diagnoses should be established by a professional experienced in addictions. A recent survey of 69 US LT programs found that 83% of centers have a psychiatrist or addiction medicine specialist routinely see each patient with ALD during the evaluation phase.20 Despite this, in the LT literature,
MONITORING ALCOHOL USE BEFORE AND AFTER LIVER TRANSPLANTATION
Few data regarding alcohol or drug use before LT are available. This may be because of a powerful disincentive for patients on an LT waiting list to admit to alcohol or drug use for fear that they will be removed from the list for their disclosure.41 Nonetheless, clinical experience and research studies have shown that alcohol and drug use does occur among patients awaiting LT. Therefore, the authors advocate that LT programs strive for an atmosphere in which patients can feel safe when asking
RATES OF RETURN TO ALCOHOL CONSUMPTION (RELAPSE VERSUS “SLIP”)
Clarifying the rates of alcohol and substance use are essential to identifying factors that predict relapse and associating these drinking episodes with subsequent medical morbidity and mortality. The identification and definition of drinking episodes as either a relapse or a “slip” are crucial but depend on the methods and frequency of post-LT patient monitoring. While there is a lack of consistency in defining drinking rates in the LT population, the results of studies can be roughly
PREDICTORS OF THOSE AT HIGH RISK FOR RELAPSE
For the general alcoholic population, investigations have attempted to identify those at risk for drinking by looking at a variety of behavioral and psychologic factors acting concurrently with or as antecedents to the alcohol use.30 Unfortunately, studies performed in the non-LT, alcoholic population have not found reliable predictors of relapse by 1 year after addiction treatment.30 Given the complexities in predicting drinking in non-LT alcoholics, it is not surprising that no single factor
PATIENTS WITH SUBSTANCE USE AND RELAPSE
There are few published outcome studies regarding outcome of LT in patients with histories of significant drug use. Coffman et al12 examined the outcome of 99 patients who had undergone LT for ALD. Patients who had habitually used other substances in addition to alcohol demonstrated similar alcohol-relapse rates as did those without a prior drug use history. The investigators speculated that this outcome was related to the fact that these patients had stopped their use of drugs other than
THE PORTLAND VETERANS AFFAIRS MEDICAL CENTER EXPERIENCE
The LT program at the Portland Veterans Administration Medical Center (VAMC) and Oregon Health Sciences University (OHSU) is one of two regional VA transplant centers serving the Veterans Health Administration System for the entire United States. Since 1988, the combined program has evaluated over 1200 candidates for LT, and nearly 600 have undergone LT. Similar to most programs in the United States, it is estimated that nearly 50% of the OHSU patients have histories of alcohol and/or other
Alcohol Use Disorders
Research has shown that alcoholic LT candidates differ from non-LT alcoholics in some clinically significant ways. For example, most quit drinking on their own, without sensing the need for working on their recovery.39, 43 In fact, many patients undergoing LT evaluation for ALD have had no formal alcoholism treatment or even attended an Alcoholics Anonymous (AA) meeting (< 50% at some centers).18, 43 That 30% to 50% of patients undergoing LT for ALD return to some drinking after LT,29 and that
SUMMARY
It is unfortunate that LT is not the ultimate sobering experience. LT patients can and do relapse; however, relapse to alcohol or substance use should no more be considered a failure of LT than the recurrence of HCV after LT. It is a phenomenon of their addiction. As a group, the survival and outcomes of patients undergoing LT for ALD are not significantly different from those undergoing LT for other causes. The fact that few patients return to heavy and deleterious alcohol or substance use
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Cited by (38)
Alcohol and other substance use after liver transplant
2020, Best Practice and Research: Clinical GastroenterologyCalcineurin signaling as a target for the treatment of alcohol abuse and neuroinflammatory disorders
2019, Progress in Molecular Biology and Translational ScienceCitation Excerpt :Liver transplant for AD patients is controversial because of the concern that the patients may relapse and not only reject the organ, but also exhaust medical and financial resources.15 However, over the past 15 years, AD liver graft recipients have been noted as a clinically distinct group with much higher abstinence rates than AUD individuals taking FDA approved treatment.16–22 Most transplant patients 1 year following transplant showed about 90% abstinence rate and about 75–80% after 3 years.23
Psychiatric Assessment of Liver Transplant Candidates
2015, Transplantation of the Liver: Third EditionLiver transplantation for patients with alcoholic liver disease: An open question
2011, Digestive and Liver DiseaseCitation Excerpt :Thus, indications and contra-indications for OLT in ALD are similar to transplant for other aetiologies, but additional evaluations are needed for alcohol-induced co-morbidities and to gauge the probability of alcohol relapse [36,42–44]. In particular, it was reported that drinking relapse after OLT was low if patients had successfully completed conventional alcohol rehabilitation programmes before OLT [45]. Transplant specialists agree that pre-OLT abstinence is helpful to ration organs and assure an adequate OLT outcome, but setting a fixed time frame of abstinence remains controversial [10,46,47].
Recurrence of Nonviral Diseases
2007, Clinics in Liver DiseaseCitation Excerpt :Treatment is supportive. The use of agents, such as naltrexone or acamprosate, is used in selected patients but the effect is as yet uncertain [68]. The diagnosis of recurrent recurrence of nonalcoholic fatty liver disease (NAFLD) is suggested by the characteristic ultrasound pattern, showing an echo bright liver and confirmed by liver histology.
Management of Recurrent Non-Viral Conditions
2006, Zakim and Boyer's Hepatology