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1.
Lancet Gastroenterol Hepatol ; 5(5): 507-514, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32277903

RESUMO

The survival of patients with alcohol-related liver disease who receive a liver transplant has steadily improved to reach 80-85% at 1 year post-transplantation. The standard requirement for liver transplant-abstinence from alcohol for 6 months before transplantation-has been applied widely, but few data support the use of this rule as the sole criterion for selecting candidates for liver transplantation. When determining the suitability of a patient for transplantation, many liver transplant programmes now try to balance the period of abstinence against the risk of death associated with the severity of liver damage. Data accumulated since 2011 suggest that early liver transplantation (ie, transplantation without a specific period of abstinence) in patients with severe alcoholic hepatitis who do not respond to medical therapy is an effective therapeutic strategy. Further studies are needed to help refine the selection of patients with alcohol-related liver disease who have been abstinent for less than 6 months as suitable liver transplant candidates, and to improve the treatment of alcohol use disorder in those patients who have received a liver transplant.


Assuntos
Hepatopatias Alcoólicas/cirurgia , Transplante de Fígado , Seleção de Pacientes , Abstinência de Álcool , Consumo de Bebidas Alcoólicas/psicologia , Alcoolismo/complicações , Alcoolismo/terapia , Aloenxertos/patologia , Hepatite Alcoólica/cirurgia , Humanos , Hepatopatias Alcoólicas/etiologia , Hepatopatias Alcoólicas/psicologia , Período Pós-Operatório
2.
Transplant Proc ; 52(3): 900-904, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32151390

RESUMO

INTRODUCTION: Distance from a liver transplant (LT) center does not affect post-transplant outcomes. Rural areas have lower rates of listing and receiving solid organ transplants. The aim of this study was to investigate trends in referral for LT based on physician-dependent variables. METHODS: An online survey was distributed to a cohort of physicians. Questions pertained to physician demographics, including age, specialty, practice location, and training at an LT center. Distances to the nearest transplant center was calculated based on zip code. Variables studied included length of sobriety, patient age, and body mass index required for transplant evaluation. Responses were analyzed using univariate ordinal logistic regression models and multivariable analyses. RESULTS: In the study, 299 physician respondents were analyzed. Physicians without LT center training were 2.05 (confidence interval [CI] 1.33-3.17) times more likely to require longer duration of sobriety. As distance increased from a transplant center, the odds of requiring longer sobriety increased by 1.43 (CI 1.11-1.83) times. Gastroenterologists (GIs) and transplant hepatologists (THs) showed significant differences in referral candidacy for patients with alcohol-related liver disease (P < .0001). When compared to GIs/THs, primary care physicians were 2.11 times (CI 0.97-4.58) more likely to require a longer duration of sobriety. No significant physician-dependent variables were found in respect to patient age or body mass index. DISCUSSION: Our study demonstrates that physician-dependent variables exist in referral for transplant evaluation. GIs and THs were more likely to refer higher-risk patients, which suggests a disparity in referral of patients with alcohol-related liver disease to transplantation depending on access to subspecialty care.


Assuntos
Hepatopatias Alcoólicas/cirurgia , Transplante de Fígado , Padrões de Prática Médica/estatística & dados numéricos , Encaminhamento e Consulta/estatística & dados numéricos , Adulto , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Inquéritos e Questionários , Adulto Jovem
3.
Dig Dis Sci ; 65(7): 2089-2103, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-31707529

RESUMO

BACKGROUND: Alcohol-related liver disease (ALD) is the leading indication for liver transplantation (LT) in the USA. Alcohol relapse post-LT can negatively impact long-term outcomes, and prognostic scoring systems are available for further study. AIMS: Our study aims were to: (1) evaluate the relationship between alcohol relapse and rejection and mortality, (2) investigate risk factors for relapse, and (3) assess predictive validity of the SIPAT (Stanford Integrated Psychosocial Assessment for Transplant) and SALT (Sustained Alcohol Use Post-Liver Transplant) scores on post-LT alcohol relapse. METHODS: We conducted a retrospective chart review of 155 patients transplanted for chronic ALD at a single transplant center. Cox proportional hazard models assessed the relationship between alcohol relapse and allograft rejection and psychosocial risk factors for relapse. RESULTS: 20% of patients met criteria for alcohol relapse. Alcohol relapse was associated with allograft rejection (HR 2.33, 95% CI 1.11-4.91, p = .03). Three variables most strongly associated with alcohol relapse: prior relapse, failure to engage in recommended alcohol treatment, and continued drinking with liver disease, which were combined into a psychosocial model. SIPAT score≥ 21 and SALT score ≥ 7 were associated with alcohol relapse (HR 6.40, 95% CI 1.36-30.18, p = .019 and HR 2.30, 95% CI 1.12-4.75, p = .024). Receiver operator characteristic analysis compared predictive ability of our psychosocial model to SIPAT (C-statistic .83 compared to .71) and SALT (C-statistic = .77 compared to .62). CONCLUSION: We identified important psychosocial predictors of post-LT alcohol relapse and validated SIPAT and SALT scores as pre-transplant risk factors for alcohol relapse.


Assuntos
Consumo de Bebidas Alcoólicas/epidemiologia , Alcoolismo/terapia , Rejeição de Enxerto/epidemiologia , Hepatopatias Alcoólicas/cirurgia , Transplante de Fígado , Participação do Paciente/estatística & dados numéricos , Adulto , Idoso , Consumo de Bebidas Alcoólicas/psicologia , Alcoolismo/psicologia , Feminino , Humanos , Hepatopatias Alcoólicas/psicologia , Masculino , Pessoa de Meia-Idade , Participação do Paciente/psicologia , Modelos de Riscos Proporcionais , Recidiva , Estudos Retrospectivos , Apoio Social
4.
Transplantation ; 104(2): 285-292, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31107823

RESUMO

BACKGROUND: Alcoholic liver disease (ALD) accounts for 15%-30% of transplants performed in the United States and Europe; however, the data on living donor liver transplantation (LDLT) for ALD remain sparse. The purpose of this study was to examine the outcomes following LDLT for ALD using data from the adult-to-adult living donor liver transplantation (A2ALL) study, which represents the largest Western experience with adult-to-adult LDLT. METHODS: A retrospective review of A2ALL data collected between 1998 and 2014 was performed. Patients were excluded if they received a deceased donor liver transplant. Demographic data, postoperative outcomes and complications, graft and patient survival, and predictors of graft and patient survival were assessed. RESULTS: Of the 1065 patients who underwent LDLT during the study time period, 168 (15.8%) were transplanted for a diagnosis of ALD. Comparing patients who underwent transplant for ALD with those who were transplanted for other etiologies of liver disease, there was no significant difference in graft survival at 1 (88% versus 84%), 5 (76% versus 74%), or 10 years following transplant (55% versus 61%, P = 0.29). Similarly, there was no difference in patient survival at 1 (94% versus 91%), 5 (83% versus 79%), or 10 years following transplant (61% versus 66%, P = 0.32). CONCLUSIONS: LDLT for ALD results in excellent 1-, 5-, and 10-year graft and patient survival. Patients with ALD and impaired renal function have a higher risk of graft loss and death. These findings support the notion that early LDLT for patients with ALD may help optimize outcomes.


Assuntos
Hepatopatias Alcoólicas/complicações , Falência Hepática/cirurgia , Transplante de Fígado/métodos , Doadores Vivos/estatística & dados numéricos , Medição de Risco/métodos , Adulto , Seguimentos , Sobrevivência de Enxerto , Humanos , Incidência , Hepatopatias Alcoólicas/cirurgia , Falência Hepática/epidemiologia , Falência Hepática/etiologia , Pessoa de Meia-Idade , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Fatores de Tempo , Estados Unidos/epidemiologia
5.
Dig Dis Sci ; 65(5): 1501-1511, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-31642005

RESUMO

BACKGROUND: Worse functional status correlates with increased mortality on the liver transplant (LT) waitlist. Whether functional status affects LT outcomes equally across cirrhosis etiologies is unclear. AIMS: We evaluate the impact of functional status on waitlist and post-LT mortality stratified by etiology and age. METHODS: Functional status among US adults from 2005 to 2017 United Network for Organ Sharing LT registry data was retrospectively evaluated using Karnofsky Performance Status Score (KPS-1 = functional status 80-100%, KPS-2 = 60-70%, KPS-3 = 40-50%, KPS-4 = 10-30%). Waitlist and post-LT survival were stratified by KPS and cirrhosis etiology, including alcoholic liver disease (ALD), nonalcoholic steatohepatitis (NASH), hepatitis C (HCV), and HCV/ALD, and evaluated using Kaplan-Meier and multivariate Cox proportional hazard models. RESULTS: Among 94,201 waitlist registrants (69.4% men, 39.5% HCV, 26.7% ALD, 23.2% NASH), ALD patients had worse functional status compared to HCV (KPS-4: 17.2% vs. 8.3%, p < 0.001). Worse functional status at time of waitlist registration was associated with higher 90-day waitlist mortality with the greatest effect in ALD (KPS-4 vs. KPS-1: ALD HR 2.16, 95% CI 1.83-2.55; HCV HR 2.17, 95% CI 1.87-2.51). Similar trends occurred in 5-year post-LT survival with ALD patients the most harmed. Compared to patients < 50 years, patients ≥ 65 years had increased waitlist mortality at 90-days if they had HCV or HCV/ALD, and 5-year post-LT mortality regardless of cirrhosis etiology with ALD patients most severely affected. CONCLUSIONS: In a retrospective cohort study of patients, US ALD patients had disparately worse functional status at time of LT waitlist registration. Worse functional status correlated with higher risk of waitlist and post-LT mortality, affecting ALD and HCV patients the most.


Assuntos
Fatores Etários , Avaliação de Estado de Karnofsky/estatística & dados numéricos , Hepatopatias Alcoólicas/mortalidade , Transplante de Fígado/mortalidade , Listas de Espera/mortalidade , Idoso , Feminino , Humanos , Estimativa de Kaplan-Meier , Hepatopatias Alcoólicas/patologia , Hepatopatias Alcoólicas/cirurgia , Testes de Função Hepática/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Sistema de Registros , Estudos Retrospectivos
6.
Transplantation ; 104(2): 293-298, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31283683

RESUMO

BACKGROUND: The morbidity and mortality from alcohol-related liver disease (ALD) is increasing in the United States. However, little is known about gender differences in evaluation and listing for liver transplantation (LT) in patients with ALD. METHODS: This is a retrospective review of adult patients with ALD evaluated for LT at a single transplant center from January 1, 2010, to March 1, 2017. Univariate, multivariate, and time-series analyses were performed. RESULTS: Among the 949 patients with ALD evaluated, mean age was 53 years, 84% were Caucasian, and 33% were women. The median model for end-stage liver disease score was similar between the genders. Women were less likely to be listed for LT (10% versus 19%; P < 0.05). The proportion of women not listed due to active substance use was significantly higher versus men (42% versus 35%; P < 0.05), while the frequency of medical contraindications was comparable between the genders. During a median follow-up of 416 days (range: 0-2784), listed women with ALD were less likely to undergo transplantation (42% versus 47%; P < 0.05). CONCLUSIONS: Men with ALD were 95% more likely to be listed and 105% more likely to be transplanted compared to women with ALD. While men had more lifetime substance use and related consequences, women had more psychiatric comorbidities and were less likely to be listed due to active alcohol and opioid use. Early detection and effective treatment of psychiatric and substance use disorders in women with ALD may improve their transplant eligibility.


Assuntos
Hepatopatias Alcoólicas/cirurgia , Transplante de Fígado/métodos , Transplantados/estatística & dados numéricos , Feminino , Seguimentos , Humanos , Hepatopatias Alcoólicas/epidemiologia , Masculino , Pessoa de Meia-Idade , Morbidade/tendências , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Distribuição por Sexo , Fatores Sexuais , Taxa de Sobrevida/tendências , Estados Unidos/epidemiologia
7.
Adicciones (Palma de Mallorca) ; 32(4): 243-254, 2020. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-198090

RESUMO

La enfermedad hepática alcohólica (EHA) es una de las causas más frecuentes de trasplante hepático en enfermedad hepática terminal. No hay evidencia del impacto de la detección regular de sustancias en orina (DRSO) sobre la supervivencia de los pacientes con EHA. Los objetivos de este estudio fueron comparar la sensibilidad de la DRSO, evaluar su impacto en la supervivencia y en el trasplante hepático, y evaluar el impacto de la adherencia a la DRSO. Realizamos un estudio retrospectivo (N = 84) con candidatos para trasplante hepático por EHA. Registramos las variables demográficas, bioquímicas y clínicas al inicio del estudio. Evaluamos la adherencia a la DRSO durante el seguimiento. Calculamos la sensibilidad tanto de la DRSO como de las declaraciones de los pacientes para todas las sustancias. Realizamos análisis multivariables (regresión logística) y de supervivencia para explorar los factores asociados y el impacto de la adherencia a la DRSO, y de los resultados positivos en la DRSO sobre la supervivencia. La DRSO tuvo una alta sensibilidad para identificar bebedores activos (76,9%), fumadores (78,9%) y consumidores de cannabis (83,3%). La alta adherencia a la DRSO tuvo una asociación inversa con la mortalidad durante el seguimiento. La presencia de trastornos de la personalidad tuvo un impacto negativo (RM ,29, IC 95% ,08-,97) sobre la adherencia a la DRSO. Tanto la DRSO como las declaraciones deben llevarse a cabo en este perfil de pacientes. Los profesionales que participan en programas de trasplante hepático deben promover el cumplimiento de la DRSO, principalmente en pacientes con trastornos de la personalidad


Alcohol Liver Disease (ALD) is one of the most prevalent conditions leading to liver transplantation for end-stage liver disease. There is lacking evidence of regular urine screening testing (RUST) impact on survival or liver transplantation of ALD patients. The aims of this study were to compare the sensitivity of RUST, to assess its impact on survival and liver transplantation, and to evaluate factors associated with adherence to RUST. We performed a single-centered retrospective study (N = 84) with ALD candidates for liver transplantation. Demographic, biochemical and clinical variables were recorded at baseline. Adherence to RUST was evaluated during follow-up. The sensitivity of both RUST and self-reports were calculated for all drugs. Multivariable logistic and survival regression analyses were performed to explore associated factors and the impact of adherence to RUST, and positive results on survival. RUST had high sensitivity for identifying active drinkers (76.9%), smokers (78.9%) and cannabis users (83.3%). High adherence to RUST was inversely associated with mortality during follow-up. Presence of personality disorders negatively impacted (OR 0.29, CI 95% 0.08-0.97) adherence to RUST. Both RUST and self-reports should be carried out in this setting. Professionals involved in liver transplantation programs must promote adherence to RUST, primarily in patients with personality disorders


Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Hepatopatias Alcoólicas/urina , Transplante de Fígado , Drogas Ilícitas/urina , Etanol/urina , Estudos Retrospectivos , Hepatopatias Alcoólicas/cirurgia , Período Pré-Operatório , Análise de Regressão , Alcoolismo/urina , Análise de Variância , Estatísticas não Paramétricas , Autorrelato , Fatores de Tempo
8.
Transplant Proc ; 51(10): 3369-3374, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31739988

RESUMO

INTRODUCTION: Post-transplant diabetes mellitus (PTDM) is a serious and frequent metabolic complication after the transplantation of solid organs. PTDM incidence 12 months after the transplantation is 2.5%-25%. MATERIALS AND METHODS: It is a retrospective analysis with 6-month follow-up of patients after liver transplantation without diabetes mellitus type 1 or 2 at the time of transplantation. We recorded all known risk factors for PTDM; however, only patients with tacrolimus in standard immunosuppression protocol were included in the analysis. RESULTS: The PTDM incidence in the group of 102 patients was 18.6%. We identified following independent risk factors for PTDM: alcohol-related liver disease (Hazard Ratio 1.8261 [1.2246-2.723], P = .0031) and average level of tacrolimus ≥ 10 ng/mL (2.5482 [1.1592-5.6019], P = .0199). PTDM was diagnosed in average 2.5 months after the liver transplantation. CONCLUSION: PTDM leads to infections, cardiovascular disease, and decreased survival. The mechanism by which alcohol-related liver disease influences the development of PTDM remains unclear.


Assuntos
Diabetes Mellitus Tipo 2/etiologia , Hepatopatias Alcoólicas/complicações , Transplante de Fígado/efeitos adversos , Complicações Pós-Operatórias/etiologia , Adulto , Feminino , Humanos , Imunossupressão/métodos , Imunossupressores/uso terapêutico , Incidência , Hepatopatias Alcoólicas/cirurgia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Tacrolimo/uso terapêutico
9.
Liver Transpl ; 25(11): 1611-1619, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31529607

RESUMO

Up to 50% of liver transplantation (LT) recipients with known or clandestine alcohol-use disorder (AUD) before surgery return to alcohol use after LT. However, only severe alcohol relapse, which varies in frequency from 11% to 26% of patients, has an impact on longterm survival and significantly decreases survival rates after 10 years. Therefore, it is crucial to identify patients with the highest risk of severe relapse in order to arrange specific, standardized monitoring by an addiction team before and after LT. The aims of this study were to describe the effects of combined management of AUD on the rate of severe alcohol relapse and to determine the risk factors before LT that predict severe relapse. Patients transplanted between January 2008 and December 2014 who had met with the LT team's addiction specialist were included in the study. Patients who exhibited alcohol-related relapse risk factors received specific addiction follow-up. A total of 235 patients were enrolled in the study. Most of them were men (79%), and the mean age at the time of the LT was 55.7 years. Severe relapse occurred in only 9% of the transplant recipients. Alcohol-related factors of severe relapse were a pretransplant abstinence of 6 months and family, legal, or professional consequences of alcohol consumption, whereas the nonalcohol-related factors were being single and being eligible for a disability pension. In conclusion, the integration of an addiction team in a LT center may be beneficial. The addiction specialist can identify patients at risk of severe relapse in the pretransplantation period and hence arrange for specific follow-up.


Assuntos
Abstinência de Álcool/estatística & dados numéricos , Alcoolismo/prevenção & controle , Transplante de Fígado , Equipe de Assistência ao Paciente/organização & administração , Prevenção Secundária/organização & administração , Medicina do Vício , Assistência ao Convalescente/métodos , Assistência ao Convalescente/organização & administração , Alcoolismo/diagnóstico , Alcoolismo/epidemiologia , Alcoolismo/reabilitação , Estudos de Coortes , Progressão da Doença , Doença Hepática Terminal/patologia , Doença Hepática Terminal/cirurgia , Feminino , Humanos , Hepatopatias Alcoólicas/patologia , Hepatopatias Alcoólicas/cirurgia , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Prevenção Secundária/métodos , Índice de Gravidade de Doença
10.
Transplant Proc ; 51(6): 1934-1938, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31399178

RESUMO

Excessive alcohol consumption has a negative impact on graft survival after liver transplantation (LT). However, it is difficult to predict alcohol relapse before LT. This study surveyed the alcohol consumption of LT recipients to identify the risk factors for harmful drinking. We surveyed the alcohol consumption of LT recipients by using the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C). AUDIT-C scores ≥ 5 points in men and ≥ 4 points in women indicated a high risk for harmful and hazardous drinking. Excessive alcohol consumption was considered to be > 20 g per day. Ninety-nine LT recipients completely filled out the questionnaire. Alcohol consumption after LT was detected in 26 recipients (26.5%); 4 of them had alcoholic liver disease before transplantation and 22 did not have alcoholic liver disease. The amount of alcohol consumption per day significantly decreased after LT (alcohol consumption per day: 49.6 g before LT vs 8.1 g after LT, P < .05). Fourteen recipients (14.1%) consumed alcohol excessively after LT. The AUDIT-C score before LT and smoking were risk factors for excessive alcohol consumption in the multivariate analysis. To properly manage post-transplant recipients, assessing the risk of excessive alcohol consumption by using the AUDIT-C is necessary.


Assuntos
Alcoolismo/diagnóstico , Hepatopatias Alcoólicas/cirurgia , Transplante de Fígado/efeitos adversos , Medição de Risco/métodos , Adulto , Alcoolismo/complicações , Feminino , Sobrevivência de Enxerto , Humanos , Hepatopatias Alcoólicas/etiologia , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Período Pós-Operatório , Recidiva , Fatores de Risco , Inquéritos e Questionários
11.
Transplant Proc ; 51(7): 2416-2419, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31402253

RESUMO

PURPOSE: Nonalcoholic steatohepatitis (NASH) is an increasing cause of liver transplantation (LT) worldwide, especially in Europe and North America. In this study, we aimed to investigate the changing pattern of etiologic causes of LT in our center for the past 15 years. MATERIALS AND METHODS: A cohort of 967 consecutive adult patients with history of LT between 2004 and 2018 in our center was reviewed regarding etiologies for LT. All patients who had a transplant during this time frame were divided into 3 time periods as follows: 2004 to 2009, 2010 to 2013, and 2014 to 2018. All explanted liver samples were sent to pathology for establishment of a definitive etiologic cause. RESULTS: Chronic hepatitis B virus (HBV) infection was the leading cause of LT in the overall cohort (37%), followed by hepatitis C virus (HCV) infection (11%), and alcoholic liver disease (9.5%). NASH accounted for 7.5% of the cases. While HBV decreased from 44% in 2004 to 2009 to 36% in 2014 to 2018, NASH increased from 1.1% to 9.4% in overall transplants during the same period, accounting for one-third of the etiologies for LT following HBV and HCV. CONCLUSIONS: There might be a global changing figure regarding etiology for LT in Turkey, especially NASH, which is the fastest growing cause of LT. However, this topic needs to be evaluated in large cohort series from collaborative multicenter studies from Turkey.


Assuntos
Hepatite B Crônica/epidemiologia , Hepatite C/epidemiologia , Hepatopatias Alcoólicas/epidemiologia , Transplante de Fígado/estatística & dados numéricos , Hepatopatia Gordurosa não Alcoólica/epidemiologia , Adulto , Estudos de Coortes , Feminino , Hepatite B Crônica/cirurgia , Hepatite C/cirurgia , Humanos , Hepatopatias Alcoólicas/cirurgia , Masculino , Pessoa de Meia-Idade , Hepatopatia Gordurosa não Alcoólica/cirurgia , Turquia
12.
Am J Transplant ; 19(10): 2678-2685, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31419015

RESUMO

Alcohol-related liver disease (ALD) is a common indication for liver transplantation. Reflecting growing consensus that early transplant (ie, prior to sustained abstinence) can be a viable option for acute alcoholic hepatitis, access to liver transplantation for ALD patients has increased. Prevention of alcohol relapse is critical to pretransplant stabilization and posttransplant survival. Behavioral interventions are a fundamental component of alcohol use disorder treatment, but have rarely been studied in the transplant context. This scoping review summarizes published reports of behavioral and psychosocial alcohol interventions conducted with ALD patients who were liver transplant candidates and/or recipients. A structured review identified 11 eligible reports (3 original research studies, 8 descriptive papers). Intervention characteristics and clinical outcomes were summarized. Interventions varied significantly in orientation, content, delivery format, and timing/duration. Observational findings illustrate the importance of situating alcohol interventions within a multidisciplinary treatment context, and suggest the potential efficacy of cognitive-behavioral and motivational enhancement interventions. However, given extremely limited research evaluating behavioral alcohol interventions among ALD patients, the efficacy of behavioral interventions for pre- and posttransplant alcohol relapse remains to be established.


Assuntos
Abstinência de Álcool/psicologia , Alcoolismo/complicações , Hepatopatias Alcoólicas/cirurgia , Transplante de Fígado/métodos , Reabilitação Psiquiátrica/métodos , Doadores de Tecidos/psicologia , Transplantados/psicologia , Terapia Comportamental/métodos , Humanos , Hepatopatias Alcoólicas/etiologia , Hepatopatias Alcoólicas/psicologia
13.
BMC Gastroenterol ; 19(1): 150, 2019 Aug 22.
Artigo em Inglês | MEDLINE | ID: mdl-31438857

RESUMO

BACKGROUND: Alcoholic liver disease (ALD) is the leading cause of liver transplantation (LT). The magnitude and risk factors of post-LT alcohol relapse are not well described. We conducted a meta-analysis to evaluate alcohol relapse rate and its predictors after LT. METHODS: Searches of MEDLINE and SCOPUS identified eligible published studies of alcohol relapse after LT published up to 31 March 2018. Alcohol relapse was defined as any alcohol consumption post-LT, and heavy alcohol relapse was defined as a relapse of alcohol consumption that was associated with a significant harm. Data for the proportion of alcohol relapse was pooled using a meta-analysis for pooling proportion. An odds ratio (OR) of the predictor of alcohol relapse was extracted and pooled using meta-analysis for the pooling risk factor. Data were analyzed using a random effect model if heterogeneity was presented; otherwise, a fixed effect model was applied. The study was registered at PROSPERO (CRD42017052659). RESULTS: Ninety-two studies with over 8000 cases were recruited for pooling proportion of alcohol relapse. The alcohol relapse rate and heavy alcohol relapse rate after LT during the mean follow-up time of 48.4 ± 24.7 months were 22% (95% confidence interval (CI): 19-25%) and 14% (95%CI: 12-16%). Psychiatric comorbidities (odds ratio (OR) 3.46, 95%CI: 1.87-6.39), pre-transplant abstinence of less than 6 months (OR 2.76, 95%CI: 2.10-3.61), unmarried status (OR 1.84, 95%CI: 1.39-2.43), and smoking (OR 1.72, 95%CI: 1.21-2.46) were associated with alcohol relapse after LT. However, we noticed publication bias of unpublished negative studies and high heterogeneity of results. CONCLUSIONS: Post-transplant alcohol relapse occurred in about one-fifth of patients who underwent alcohol-related LT. Psychiatric comorbidities represented the strongest predictor of alcohol relapse. Psychiatric comorbidities monitoring and pre-LT alcohol abstinence for at least 6 months may decrease alcohol relapse after LT.


Assuntos
Abstinência de Álcool , Consumo de Bebidas Alcoólicas , Hepatopatias Alcoólicas/cirurgia , Transplante de Fígado/efeitos adversos , Humanos , Transplante de Fígado/métodos , Recidiva , Medição de Risco
14.
Ann Transplant ; 24: 359-366, 2019 Jun 18.
Artigo em Inglês | MEDLINE | ID: mdl-31209197

RESUMO

BACKGROUND Alcohol use disorders affect 10% of the European population. Alcohol-related liver disease (ALD) is the most common indication for liver transplantation in Slovakia. The aim of this study was to determine the proportion of patients with ALD who received a liver transplant who had alcohol relapsed, and the risk factors for alcohol relapse, as well as to compare clinical outcomes according to relapse. MATERIAL AND METHODS A retrospective study of consecutive patients with ALD, who underwent liver transplantation in a single transplant center between May 2008 and December 2017. We included adult patients who received a liver transplant due to ALD and excluded those who died <1 month after liver transplantation. We recorded demographic and clinical characteristics, graft injury, and overall mortality and compared them between relapsers and abstainers. RESULTS During the study period, we reviewed 196 cases of liver transplantation in 191 patients. We excluded 87 patients for non-ALD etiology and 15 patients by predefined criteria. The final analysis was carried out in 89 patients, mean aged 55 years; 24.7% were female. We diagnosed relapse in 23 patients (26%) with harmful drinking in 52% and occasional drinking in 48% of relapsers. The independent risk factors associated with relapse were: smoking (OR=5.92, P=0.006), loss of social status (OR=7.61, P=0.002), and time after liver transplantation (OR=1.0008, P=0.015). Graft injury was more frequent in relapsers with 2 independent risk factors: occasional drinking (OR=12.7, P=0.0005), and harmful drinking (OR=36.6, P<0.0001); overall survival was unaffected. CONCLUSIONS We found relapse to alcohol drinking in 26% of patients who received a liver transplant for ALD. Risk factors associated with alcohol drinking relapse were time, cigarette smoking, and loss of social status. Graft injury was more frequent in relapsers, but mortality was similar between relapsers and non-relapsers.


Assuntos
Alcoolismo/cirurgia , Hepatopatias Alcoólicas/cirurgia , Alcoolismo/complicações , Feminino , Sobrevivência de Enxerto , Humanos , Hepatopatias Alcoólicas/etiologia , Transplante de Fígado , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Recidiva , Estudos Retrospectivos , Fatores de Risco
15.
Liver Transpl ; 25(9): 1310-1320, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31063642

RESUMO

Alcohol-associated liver disease (ALD) is the most common indication for liver transplantation (LT) in the United States and Europe. A 6-month alcohol abstinence period has been required by many transplant programs prior to listing, which may influence wait-list (WL) outcomes. Therefore, we examined WL events in patients with ALD versus non-ALD with a special interest in whether these outcomes differed by sex. All US adults listed for LT from January 2002 to December 2016 were eligible except status 1 patients, Model for End-Stage Liver Disease exceptions, retransplants and those with acute alcoholic hepatitis. The outcomes of interest were cumulative WL death or being too sick and WL removal for improvement within 2 years of listing. Competing risk regression models were used to evaluate recipient factors associated with the outcomes. Among the 83,348 eligible WL patients, 23% had ALD. Unadjusted cumulative WL removal within 2 years was 19.0% for ALD versus 21.1% for non-ALD (P < 0.001). In fully adjusted models, ALD was associated with a significantly lower risk of WL removal for death or being too sick (subhazard ratio [SHR], 0.84; 95% confidence interval [CI], 0.81-0.87; P < 0.001) and a higher risk of removal for improvement (SHR, 2.91; 95% CI, 2.35-3.61; P < 0.001) versus non-ALD patients. After adjusting for potential confounders, women with ALD had a higher risk of removal for death or being too sick (SHR, 1.09; 95% CI, 1.00-1.08; P < 0.001) and a higher chance for improvement (SHR, 2.91; 95% CI, 2.35-3.61; P < 0.001) than men with ALD. In conclusion, WL candidates with ALD have more favorable WL outcomes than non-ALD patients with a 16% lower risk of removal for deterioration and 191% higher risk of removal for improvement. This result likely reflects the benefits of alcohol abstinence, but it suggests that listing criteria for ALD may be too restrictive, with patients who might derive benefit from LT not being listed.


Assuntos
Abstinência de Álcool , Doença Hepática Terminal/mortalidade , Hepatopatias Alcoólicas/mortalidade , Transplante de Fígado/normas , Listas de Espera/mortalidade , Adolescente , Adulto , Idoso , Progressão da Doença , Doença Hepática Terminal/diagnóstico , Doença Hepática Terminal/patologia , Doença Hepática Terminal/cirurgia , Feminino , Humanos , Hepatopatias Alcoólicas/diagnóstico , Hepatopatias Alcoólicas/patologia , Hepatopatias Alcoólicas/cirurgia , Transplante de Fígado/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Estados Unidos/epidemiologia , Adulto Jovem
16.
World J Gastroenterol ; 25(13): 1628-1639, 2019 Apr 07.
Artigo em Inglês | MEDLINE | ID: mdl-30983822

RESUMO

BACKGROUND: Alcohol-related liver disease (ALD) is a leading cause of liver failure and indication for liver transplantation that arises in the setting of alcohol use disorder (AUD). Previous reviews of transplantation for ALD are limited in scope of outcomes and type of ALD studied. A comprehensive systematic review could improve use of transplantation in ALD and improve future research. We hypothesize that while transplanting ALD may improve mortality and relapse, findings will be limited by pre-specified causes of heterogeneity - assessment and treatment of AUD, definition of ALD, spectrum of ALD studied, assessment and rates of relapse, and study quality and bias. AIM: To optimize liver transplantation for ALD, understanding existing research to guide future research, we conducted a systematic review with meta-analysis. METHODS: We conducted a systematic review, comparing liver transplant to no-transplant in patients with ALD, with a primary outcome of both short- and long-term mortality and relapse. We performed a comprehensive search of MEDLINE, EMBASE, Web of Science, and The Cochrane Library databases for peer-reviewed journal articles comparing use of liver transplant in ALD to no-transplant. Two reviewers independently conducted screening, full text review, and data extraction according to the PRISMA guidelines. We report the quality of the evidence according to the GRADE criteria. RESULTS: We analyzed data from 10 studies. Of 1332 participants, 34.2% (456/1332) had undergone liver transplantation, while 65.8% (876/1332) had not. While random effects meta-analysis suggested transplant in comparison to no-transplant had an association of reduced mortality that did not reach statistical significance, relative risk (RR) = 0.51 (0.25-1.05), but not relapse risk, RR = 0.52 (0.18-1.53), significant heterogeneity limited these findings. When restricted to prospective data, transplant compared to no-transplant significantly reduced mortality, RR = 0.25 (0.13-0.46, P < 0.01), and relapse, RR = 0.25 (0.14-0.45, P < 0.01), with insignificant heterogeneity but persistent small-study effects. The overall quality of the evidence was Very Low. Heterogeneity analysis suggested that AUD assessment and treatment was often not reported while ALD, relapse assessment and rate, and data collection were institutionally rather than standardly defined. CONCLUSION: Systematic review of liver transplantation for ALD suggests reduced mortality and relapse in heterogeneous, institution-specific populations with inherent bias. To understand efficacy of transplanting ALD, our research approach must change.


Assuntos
Doença Hepática Terminal/cirurgia , Hepatopatias Alcoólicas/cirurgia , Transplante de Fígado/estatística & dados numéricos , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Progressão da Doença , Doença Hepática Terminal/mortalidade , Doença Hepática Terminal/patologia , Humanos , Hepatopatias Alcoólicas/mortalidade , Hepatopatias Alcoólicas/patologia , Avaliação de Resultados em Cuidados de Saúde/normas , Recidiva , Projetos de Pesquisa/normas , Resultado do Tratamento
17.
Scand J Gastroenterol ; 54(2): 233-239, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30999770

RESUMO

OBJECTIVES: Nonalcoholic steatohepatitis (NASH), which is a common and increasing indication for liver transplantation (LT), is known to recur after LT. Since the recurrence of NASH can lead to graft failure, the identification of predictive factors is needed and preventive strategies should be implemented. METHODS: We retrospectively examined 95 patients who had undergone LT for NASH or alcoholic liver disease (ALD) as a primary indication. We evaluated peritransplant characteristics and histological findings 1-year post LT among liver transplant patients due to NASH or ALD. RESULTS: Pre-LT body mass index (BMI) was higher and pre-LT diabetes was more prevalent in NASH patients than in ALD patients (p < .01). The difference of BMI persisted at 3 months and 1 year after LT. There were no differences between the groups regarding histopathological findings including the degree of steatosis and fibrosis in 1-year biopsy. In multivariate analysis, recipient age and 1-year BMI were independent risk factors for post-LT fatty liver disease development. Regarding predictive factors of NASH recurrence, the prevalence of pre-LT insulin-dependent diabetes was significantly higher in patients who developed NASH recurrence than those who did not. The increase of HbA1c at 1-year post-LT checkup was higher in patients who developed recurrence than those who did not, although the difference did not reach statistical significance. CONCLUSIONS: The results of this study suggest that insulin-dependent diabetes has detrimental effects on NASH recurrence following LT. Optimal glycemic control should be recommended, but studies are needed to prove its preventive effect on NASH recurrence.


Assuntos
Cirrose Hepática/etiologia , Transplante de Fígado , Hepatopatia Gordurosa não Alcoólica/complicações , Hepatopatia Gordurosa não Alcoólica/cirurgia , Adulto , Idoso , Índice de Massa Corporal , Diabetes Mellitus/epidemiologia , Feminino , Humanos , Cirrose Hepática/patologia , Hepatopatias Alcoólicas/complicações , Hepatopatias Alcoólicas/cirurgia , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Prevalência , Recidiva , Estudos Retrospectivos , Fatores de Risco , Suécia/epidemiologia
18.
Ann Transplant ; 24: 162-167, 2019 Mar 22.
Artigo em Inglês | MEDLINE | ID: mdl-30898994

RESUMO

BACKGROUND The classical cardiovascular risk factors and changes in the circulatory system secondary to end-stage liver disease (ESLD) are associated with an increased risk of cardiac abnormalities (CAs) in patients waiting for liver transplantation (LTx). The aim of this study was to assess the relationship between the etiology of liver disease and the presence of CAs in patients qualified for LTx. MATERIAL AND METHODS The study enrolled patients qualified to LTx due to ESLD at the Clinical Hospital of the Medical University of Warsaw between 2013 and 2016. Out of 396 patients: 65, 157, 117, and 57 had ESLD due to the alcoholic liver disease (ALD), viral infections (VIR), autoimmune disorders (AUTO), and different etiologies (OTHER), respectively. RESULTS An increased frequency of hypertension and diabetes mellitus were observed in ALD and VIR groups, while for hyperlipidemia, the highest rates were observed in ALD and AUTO groups. Significant differences in CAs rates were observed for resting tachycardia, prolonged QT interval, bradycardia, and left ventricular diastolic dysfunction. After adjustment for age, MELD, and Child-Pugh scores, hyperlipidemia (26% vs. 7-15%, p<0.048) was most frequently observed in the AUTO group, while poor aerobic capacity (49% vs. 21-34%, p<0.009) dominated in the OTHER group. CONCLUSIONS The frequency of hyperlipidemia, and poor aerobic capacity were directly related to the etiology of liver disease, while the remaining associations resulted from effects of age, MELD, and Child-Pugh score.


Assuntos
Doenças Cardiovasculares/etiologia , Doença Hepática Terminal/complicações , Transplante de Fígado , Listas de Espera , Adulto , Doenças Autoimunes/complicações , Doenças Autoimunes/cirurgia , Doença Hepática Terminal/etiologia , Doença Hepática Terminal/cirurgia , Feminino , Hepatite Viral Humana/complicações , Hepatite Viral Humana/cirurgia , Humanos , Hiperlipidemias/etiologia , Hepatopatias Alcoólicas/complicações , Hepatopatias Alcoólicas/cirurgia , Transplante de Fígado/efeitos adversos , Masculino , Pessoa de Meia-Idade , Escores de Disfunção Orgânica , Período Perioperatório/efeitos adversos , Fatores de Risco
19.
Medicine (Baltimore) ; 98(8): e14612, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30813187

RESUMO

While increased serum concentrations of CXCL9/10 are associated with acute cellular rejection (ACR) occurrence, the association between CXCL9/10 single nucleotide polymorphisms (SNPs) and ACR after liver transplantation (LT) remains unknown.In the present case-control study, polymorphisms of CXCL9 (rs10336) and CXCL10 (rs3921) were determined by polymerase chain reaction in 215 liver transplant recipients. ACR was defined as biopsy proven within 6 months after LT. As selected SNPs were in 3'-UTR region, their possible association with protein synthesis was assessed by measuring the plasma concentration of CXCL9/10 in a cohort of 40 new transplant patients using ELISA.There was no association between CXCL9/10 genotypes and overall incidence of ACR. However, patients with CXCL9 genotype AA developed ACR earlier than patients with GG genotype (P = .003), with similar results for CXCL10 gene (CC vs GG; P = .005). There was no statistically significant difference in plasma concentrations of CXCL9/10 between the rejectors and the non-rejectors. Of note, patients with AA CXCL9 genotype had significantly higher CXCL9 plasma concentrations than patients with AG (P = .01) or GG genotype (P = .045).In conclusion, the SNPs of CXCL9 (rs10336) and CXCL10 (rs3921) are not associated with the incidence of ACR. However, patients with CXCL9 genotype AA developed ACR earlier and the same genotype was associated with greater plasma concentrations suggesting the involvement of CXCL9 mediated processes in ACR development.


Assuntos
Quimiocina CXCL10/genética , Quimiocina CXCL9/genética , Rejeição de Enxerto/genética , Transplante de Fígado/efeitos adversos , Adulto , Idoso , Aloenxertos , Estudos de Casos e Controles , Quimiocina CXCL10/sangue , Quimiocina CXCL9/sangue , Ensaio de Imunoadsorção Enzimática , Feminino , Genótipo , Rejeição de Enxerto/epidemiologia , Humanos , Incidência , Fígado/patologia , Fígado/cirurgia , Hepatopatias Alcoólicas/cirurgia , Masculino , Pessoa de Meia-Idade , Polimorfismo de Nucleotídeo Único
20.
JAMA Intern Med ; 179(3): 340-348, 2019 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-30667468

RESUMO

Importance: Alcohol-associated liver disease (ALD) has emerged as the most common indication for liver transplant in the United States, but data on the reasons for this increase and long-term post-liver transplant outcomes among liver transplant recipients are sparse. Objective: To characterize trends and long-term outcomes of liver transplant for ALD in the United States between 2002 and 2016. Design, Setting, and Participants: This multicenter, prospective, national cohort study used data from the United Network for Organ Sharing database to evaluate all liver transplants performed in the United States between January 1, 2002, and December 31, 2016. Main Outcomes and Measures: National and regional trends in liver transplant for ALD, with a sensitivity analysis with hepatitis C virus (HCV) infection and hepatocellular carcinoma (HCC) included, and early (≤90 days after liver transplant) and late (>90 days after liver transplant) patient and graft survival. Results: The cohort consisted of 32 913 patients, including 9438 with ALD and 23 475 without ALD (patients who had HCV infection and HCC indications were excluded). Median age of patients with ALD was 54 years (interquartile range, 47-60 years) and of patients without ALD was 54 years (interquartile range, 44-61 years). Patients with ALD (vs non-ALD) were more frequently male (7197 of 9438 [76.2%] vs 11 767 of 23 475 [50.1%]; P < .001) and white (7544 [80.0%] vs 17 251 [73.5%]; P < .001). The proportion of liver transplants for ALD increased from 24.2% (433 of 1791) in 2002 to 27.2% (556 of 2044) in 2010 and 36.7% (1253 of 3419) in 2016. With HCV infection included, the proportions of liver transplant for ALD were 15.3% in 2002, 18.6% in 2010, and 30.6% in 2016, representing a 100% increase in liver transplant for ALD, of which 48% was associated with a decrease in HCV infection as an indication for liver transplant. The magnitude of increase in ALD was regionally heterogeneous and associated with changes in patient characteristics suggestive of alcoholic hepatitis: decreasing age (χ2 = 36.5; P = .005) and increasing model for end-stage liver disease score (χ2 = 69.1; P < .001). Cumulative unadjusted 5-year posttransplant survival was 79% (95% CI, 78%-80%) for ALD vs 80% (95% CI, 79%-80%) for non-ALD; cumulative unadjusted 10-year posttransplant survival was 63% (95% CI, 61%-64%) for ALD vs 68% (95% CI, 67%-69%) for non-ALD (P = .006). In multivariable analysis, ALD was associated with increased risk of late death after liver transplant (adjusted hazard ratio, 1.11; 95% CI, 1.03-1.20; P = .006). Conclusions and Relevance: The findings suggest that early liver transplant for alcoholic hepatitis may be leading to broader acceptance of ALD for liver transplant. Late survival among liver transplant recipients with ALD was inferior to that among recipients with non-ALD indications, suggesting a need for future studies to identify patient profiles associated with best outcomes. Regional differences suggest heterogeneity in policies toward liver transplant for ALD.


Assuntos
Hepatopatias Alcoólicas/cirurgia , Transplante de Fígado , Avaliação de Resultados em Cuidados de Saúde , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Taxa de Sobrevida , Estados Unidos
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