Abstinence from alcohol and alcohol rehabilitation therapy in alcoholic liver disease: a population-based study.

Objective: Abstinence from alcohol is recommended in patients diagnosed with alcoholic hepatitis (AH) and alcoholic cirrhosis (AC). We aimed to determine the impact of alcohol abstinence on prognosis of patients with AC and AH.Methods: All incident AC and AH patients in Iceland 2001-2016 were identified. Cirrhosis was confirmed clinically, biochemically, with imaging and histologically. Abstinence, alcohol rehabilitation and survival were analyzed.Results: Overall, 169 patients with AC and/or AH were identified. Eleven died during index hospitalization, leaving 158 patients for final analysis, median (IQR) age 56 years (48-65), 72% males. Over all 61 patients (39%) had AC, 40 (25%) AH and 57 (36%) features of both. Thirty-nine percent of patients remained abstinent during follow-up and 63% underwent alcohol rehabilitation. Moderate to severe ascites at diagnosis (odds ratio (OR): 3.05, 95% confidence interval (CI): 1.37-7.02) and lack of alcoholic rehabilitation (OR: 5.28, 95% CI: 2.24- 14.11) were independent predictors of abstinence. Abstinence at one year of follow-up was not related to increased survival. Patients surviving one year, abstinence during follow-up was related to increased survival for both groups.Conclusion: Abstinence from alcohol following AC/AH diagnosis was achieved in 39% of patients. Abstinence was not related to increased survival for alcoholic liver disease patients at one-year, which might partly indicate that this might be a marker that some patients were 'too sick to drink'. AC and AH patients who survived one year and remained abstinent had a favorable long-term prognosis.

Enfermedad de injerto contra huésped como complicación después de un trasplante hepático: una asociación rara pero grave / Graft versus host disease as a complication after liver transplantation: a rare but serious association

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[Alcoholic liver disease: possibilities of diagnosis, treatment and rehabilitation in multidisciplinary hospital].

Tactics of alcoholic liver disease treatment is defined in accordance with lesion level. Differentiated approach to these patients can significantly improve the efficiency of diagnosis, treatment and rehabilitation. At the stage of cirrhosis it is necessary to focus on prevention and treatment of complications. Patients with compensated cirrhosis and subcompensated improved survival achievable Propafenone S-ademetionine (geptral, Geptor). The article presents the results of our study demonstrating a significant decrease in serum bilirubin in patients on background intravenous S-ademetionine. Practicability of stage system creation of medical rehabilitation of patients with alcoholic cirrhosis is approved.

Rehabilitation for cirrhotic patients discharged after hepatic encephalopathy improves survival.

INTRODUCTION: The 1-year mortality of cirrhotic patients with hepatic encephalopathy (HE) is approximately 60-80% in recent studies. We aimed to establish a rehabilitation out-patient clinic (RC) for alcoholic cirrhotic patients sur-viving HE. MATERIAL AND METHODS: Prospectively, patients surviving HE were offered participation in the RC and were seen by a nurse for a one-hour interview with 1-3 weeks' interval after discharge and by a physician, if needed. Clinical, psychological and social problems were identified and addressed. Alcohol consumption was recorded and alcohol cessation was encouraged at each visit. Minimal or overt HE prompted referral to the Liver Unit. The patients were compared with HE patients discharged in 2008 (the control group). RESULTS: A total of 19 patients were included in the RC group and compared with the 14 patients of the control group. The Child-Pugh score was higher in the RC group (median 13; range 8-14) than in the control group (median 11; range 7-13) (p = 0.033), whereas other clinical, demographic and biochemical parameters did not differ between the two groups. One-year survival was higher in the RC group (16/19; 84%) than in the control group versus (5/14; 36%) (p = 0.012). The log-rank test confirmed an improved survival for the RC group (p = 0.008). The economic costs of subsequent hospital admissions did not differ between the two groups. In the RC group, alcohol consumption was reduced in all but two patients. CONCLUSION: Survival was significantly improved for patients in the rehabilitation clinic. The improved survival did not subsequently cause higher hospital admission costs. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

Chronic liver disease--an increasing problem: a study of hospital admission and mortality rates in England, 1979-2005, with particular reference to alcoholic liver disease.

AIMS: To determine time trends in hospital admissions for chronic liver disease in England between 1989/1990 and 2002/2003, mortality rates in England and Wales between 1979 and 2005, and the influence of alcohol-related disease on these trends. METHODS: Hospital episode statistics for admissions in England were obtained from the Information Center for Health and Social Care and mortality data for England and Wales from the Office for National Statistics. RESULTS: Hospital admission rates for chronic liver disease increased by 71% in males and 43% in females over the study period. This increase was largely due to alcoholic liver disease, admission rates for which more than doubled between 1989/1990 and 2002/2003. While there was a smaller rise for chronic viral hepatitis B and C, admission rates declined for hepatitis A, autoimmune hepatitis, and primary biliary cirrhosis. Mortality rates for chronic liver disease more than doubled between 1979 and 2005. Two thirds of these deaths were attributable to alcohol-related liver disease in 2005. The highest rate of alcoholic liver disease mortality was in the 45-64 age group, and the largest percentage increase between 1979 and 2005 occurred in the 25-34 age group. CONCLUSIONS: Hospital admissions and mortality in England from chronic liver disease are increasing. The underlying reasons are complex, but alcohol-induced liver disease makes a major contribution. There are clear social and health implications if the trend continues and addressing alcohol-related liver disease should be a public health priority.

[Stabilisation of abstinence by means of psychoeducation for patients with alcoholic liver disease awaiting liver transplantation]. / Stabilisierung der Abstinenz durch Psychoedukation für alkoholabhängige Patienten vor Lebertransplantation.

BACKGROUND: A manualised six-month psychoeducational intervention was conducted in patients with alcoholic liver disease and abstinence problems who were waiting for a transplantation. OBJECTIVES: In a naturalistic design it was investigated whether the intervention could improve patients' alcohol abstinence. METHODS: Between January 2002 and November 2003, 72 patients were enrolled in the therapeutic intervention, 48 of whom participated in group therapy. Health-related quality of life (SF-12), anxiety and depression (HADS-D), symptom strain (BSI) and social support (F-SOZU) were measured. Alcohol abstinence was examined in each group session by measuring the alcohol concentration in breath. RESULTS: At the beginning and end of the group therapy patients showed subsyndromal measures of anxiety and depression and minor symptoms of psychopathology. Physical quality of life was reduced (t = -8.694; df = 44; p < .001). Mental quality of life was in the range of the normative sample and was correlated with depression (r = -0.400; p = .009). Patients perceived high social support (t = 8.213; df = 45; p < .001). During the course of therapy four patients had relapses but the remaining patients stayed abstinent. Physical quality of life improved (t = -2.275; df = 27; p = .031), mental quality of life and symptom strain remained stable. CONCLUSIONS: The therapy presented here facilitated a stabilisation of mental well-being in patients with alcoholic liver disease who were waiting for organ transplantation. The relapse rate measured by alcohol concentration in breath remained low.

Indication of liver transplantation in severe alcoholic liver cirrhosis: quantitative evaluation and optimal timing.

BACKGROUND/AIMS: The aim of our study was to evaluate the proportion of patients with severe alcoholic cirrhosis who would need orthotopic liver transplantation (OLT) and to determine the optimal delay to evaluate an abstinent patient for transplantation. METHODS: Survival without OLT, improvement in liver function and need for OLT were studied in all patients admitted in 1997 for a first episode of Child-Pugh C alcoholic cirrhosis. RESULTS: Twenty-six percent (19/74) of patients died during the initial hospitalization. The cumulative survival rates after 6 months and 1, 2 and 3 years were 56, 36, 35 and 24%, respectively. One liver transplantation (1.3%, 95% confidence interval 0.0-3.9) was performed for persisting liver failure despite abstinence. Improvement of the Child-Pugh score was observed within 3 months in 66% of the abstinent patients. OLT was indicated in four patients without liver improvement despite abstinence, but was contraindicated in three. CONCLUSIONS: Only a few patients with severe alcoholic cirrhosis undergo OLT, since most of them do not stop drinking and/or die soon, and those becoming abstinent often improve their liver function. OLT should be considered when improvement in liver function is lacking after 3 months of abstinence.

Alcoholic cirrhosis is a good indication for liver transplantation, even for cases of recidivism.

BACKGROUND/AIMS: Alcoholic cirrhosis remains a controversial indication for liver transplantation, mainly because of ethical considerations related to the shortage of donor livers. The aim of this study was to review experience to date, focusing on survival rates and complications, and the effect of alcohol relapse on outcome and alterations in marital and socioprofessional status. METHODS: The results for 53 patients transplanted for alcoholic cirrhosis between 1989 and 1994 were compared with those for 48 patients transplanted for non-alcoholic liver disease. The following variables were analysed: survival, rejection, infection, cancer, retransplantation, employment and marital status, alcoholic recurrence. The same variables were compared between alcohol relapsers and non-relapsers. RESULTS: Recovery of employment was the only significantly different variable between alcoholic (30%) and non-alcoholic patients (60%). Two factors influenced survival in the absence of alcohol recidivism: age and abstinence before transplantation. For all other variables, there were no differences between alcoholic and non-alcoholic patients, and, within the alcoholic group, between relapsers and non-relapsers. The recidivism rate was 32%. CONCLUSION: The data indicate that liver transplantation is justified for alcoholic cirrhosis, even in cases of recidivism, which did no affect survival and compliance with the immunosuppressive regimen. These good results should help in educating the general population about alcoholic disease.

Changes in liver cirrhosis death rates in different countries in relation to per capita alcohol consumption and Alcoholics Anonymous membership.

OBJECTIVE: This study examines how trends in liver cirrhosis relate to per capita alcohol consumption and Alcoholics Anonymous (AA) membership in 33 countries between 1965 and 1991. It was expected that reductions in liver cirrhosis deaths seen in many countries would be related to both decreased consumption and increased AA membership. METHOD: Data on liver cirrhosis death rates, alcohol consumption and AA membership were gathered from a variety of international sources. The data were analyzed with regression analyses (Ordinary Least Squares). RESULTS: Cirrhosis deaths and alcohol consumption levels were positively related in all analyses. In two of the four analyses, the negative relationship between cirrhosis deaths and AA group rates was marginally significant. CONCLUSIONS: Liver cirrhosis rates were strongly related to alcohol consumption and showed some relationship to AA group rates. The modest impact of AA may be due to the weakness of the true relationship but also to incompleteness in the cirrhosis and AA data in some countries.

A model to examine the validity of the 6-month abstinence criterion for liver transplantation.

Six months of abstinence from alcohol is a commonly used criterion for liver transplantation eligibility for patients with alcoholic cirrhosis. There is limited evidence to document the validity of this criterion with regard to risk of alcoholism relapse. Ninety-one patients with alcoholic cirrhosis were interviewed for relapse risk using the High Risk Alcoholism Relapse (HRAR) Scale. The HRAR model can be used to predict relapse risk independent of duration of sobriety and therefore can be used to examine the validity of the 6 months of abstinence criteria in this clinical population. The two methods demonstrated poor to fair agreement. Agreement was highest with a cutoff allowing a 5% 6-month relapse risk when 79% agreement (c = 0.56) was demonstrated between the two methods. Using the 6-month abstinence criterion alone disallows a significant number of candidates who have a low relapse risk based on their HRAR score. The validity of the 6-month abstinence criterion is supported somewhat by comparison with the HRAR model. However, use of the 6-month abstinence criterion alone forces a significant number of patients with a low relapse risk by HRAR to wait for transplant listing. A relapse risk model based on an estimate of alcoholism severity in addition to duration of sobriety may more accurately select patients who are most likely to benefit from liver transplantation.

[Treatment of alcoholic liver diseases and psychiatric and psychosocial problems]. / Behandlung der alkoholischen Lebererkrankungen und ihrer psychiatrischen und psychosozialen Probleme.

Only about 15% of the subjects abusing ethanol will eventually develop cirrhosis of the liver, suggesting that other factors in addition to the consumption of large quantities of ethanol play a role in the pathogenesis of alcoholic cirrhosis. Important contributors may be infection with hepatitis viruses, in particular HCV, protein-calorie malnutrition and immunologic factors. Abstinence improves the prognosis of patients with alcoholic cirrhosis, provided that the liver disease is not too far advanced. No pharmacotherapeutic intervention has shown a convincing improvement of the prognosis of alcoholic liver disease, so that the therapeutic efforts should be mainly directed towards abstinence. The patient with alcoholic liver disease needs support and guidance by the treating physicians. Supportive treatment with Disulfiram, Acamprosate or Naltrexon can help with achieving durable abstinence.

Hepatic and other medical disorders of alcoholism: from pathogenesis to treatment.

The medical risks of moderate and excessive alcohol consumption are reviewed. Current knowledge of metabolism of alcohol, including effects of moderate amounts, on hepatic metabolism and toxicity is summarized, with an evaluation of the relationship between the level of consumption and its effects on nutrients (including retinoids, carotenoids and folate), liver disease and other medical complications of alcoholism, including cardiovascular diseases and cancer. Putative benefits are also considered. Promising therapeutic approaches evolving from newly gained insight in the pathogenesis of medical complications of alcoholism are outlined.

[Rehabilitation of patients with alcoholic liver cirrhosis after orthotopic liver transplantation: a 7-year follow-up]. / Rehabilitation von Patienten mit alkoholischer Leberzirrhose nach orthotoper Lebertransplantation: ein 7jähriges Follow-up.

Alcoholic liver cirrhosis is the main indication for orthotopic liver transplantation. Since 1988, 52 patients with alcoholic liver cirrhosis have been transplanted at the Department of Surgery of the University of Heidelberg. The survival rates are as follows: 73% of the patients survived for 1 year, 68% for 2 and 3 years, 64% for 4 years, and 57% survived for 5 years. After transplantation, recidivism occurred in 6 patients. Remarkable in this case was the fact that all 6 patients had a relatively short period of abstention prior to surgery (2 to 5 months). In 12 patients, a small carcinoma was found in the cirrhotic liver. This had neither been seen previously by ultrasound nor by computer tomography. In summary, orthotopic liver transplantation is an excellent mode of treatment in end-stage alcoholic liver cirrhosis. However, the patients have to be carefully selected in order to avoid recidivism following transplantation.

Fatty acid composition of liver total lipids in alcoholic patients with and without liver damage.

Alcohol ingestion may promote lipid peroxidation, and the presence of polyunsaturated fatty acids in liver lipids may be essential for the generation of liver damage through this mechanism. The aim of this study is to examine fatty acid composition of liver lipids in chronic alcoholics with and without histological liver damage. A percutaneous liver biopsy was performed to 28 patients hospitalized for treatment of their alcoholism. Liver total lipids were extracted from a portion of the tissue sample and fatty acid composition was measured by gas chromatography. Another piece of the sample was sent for histological study. Six patients had histological cirrhosis or alcoholic hepatitis in their biopsies, the rest of the patients had minimal changes. Patients with liver damage had higher levels of oleic acid and total monoenoic fatty acids, a higher 18:1/18:0 ratio, lower levels of polyunsaturated fatty acids, a lower 20:4/18:2 ratio, and a lower peroxidability index in liver total lipids, than patients without liver damage. Alcoholic patients with asymptomatic liver damage have less unsaturated fatty acids in liver total lipids than their counterparts with normal livers.

[Is the new guardianship law regarding alcoholic patients therapeutically useful? A case example]. / Ist das neue Betreuungsrecht bei Alkoholabhängigen therapeutisch nutzbar? Ein Fallbeispiel.

Although treatment outcome in alcoholism is good and well documented, many patients are not sufficiently motivated for participating in a treatment program. The following case-report illustrates the example of a young male alcoholic suffering from decompensated liver cirrhoses without motivation for a long-term treatment. The positive effects of the new guidelines of the laws regulating custody and civil commitment are shown and discussed.

Acetaminophen metabolism in patients with different cytochrome P-4502E1 genotypes.

Cytochrome P-450 (CYP) 2E1 is the major ethanol-oxidizing enzyme of the nonalcohol dehydrogenase metabolic pathway in the liver. Recently, the presence of genetic polymorphisms of this enzyme was confirmed. In this study, to clarify the influence of CYP2E1 genotype on alcohol metabolism, we analyzed acetaminophen metabolism in subjects with different CYP2E1 genotypes. In normal subjects, a half-life of acetaminophen from blood was the longest in type A (c1/c1) and was the shortest in type C (c2/c2). The elimination rate in type C was more than twice that of type A and type B (c1/c2). In type A, both half-life and elimination rate of acetaminophen were not different between patients with noncirrhotic alcoholic liver disease within 1 week after abstinence and in normal subjects. In one patient with minimal change, there were no differences in both half-life and elimination rate within 1 and 6 weeks after abstinence. On the other hand, in type B, half-life was shorter and the elimination rate was greater in alcoholic noncirrhotic patients within 1 week after abstinence than in alcoholic patients with type A and in normal subjects with type B. In type B, half-lives were shorter, and the elimination rates were greater in patients with alcoholic liver disease within 1 week after abstinence than 4 to 6 weeks after abstinence. These results suggest the possibility that alcohol metabolism in individuals with the c2 gene may be greater than those with the c1 gene, and that the induction of CYP2E1 by ethanol in type B may occur more markedly than that in type A, although the sample number is too small to obtain final conclusions.

Predictors of mortality in alcoholic men: a 20-year follow-up study.

This study investigates the predictors of mortality in 156 male alcoholics who were psychiatrically hospitalized between 1967 and 1968 and followed for > 20 years. The findings showed that an older age, liver cirrhosis, and separation or divorce at intake were all associated with a shorter time to death. These results corroborate those of other follow-up studies that have identified age, health, and social support as independent correlates of mortality in alcoholics. From a therapeutic standpoint, the most alterable predictor is social support. Thus, the establishment of a salutary social network and social support system should be an integral part of the alcoholic's treatment plan.