Factors associated with a positive phosphatidylethanol test during liver transplantation evaluation.

BACKGROUND: Early identification of alcohol use is crucial for informing recommendations of appropriate follow-up treatment pre-liver transplant and optimizing post-liver transplant outcomes. The purpose of the study was to investigate whether there are psychosocial factors associated with a positive PEth test. METHODS: All patients who underwent a routine pre-surgical psychological evaluation for liver transplant listing (all etiologies, including acute liver failure, dual organ, and re-transplantation) at a single health care system in 2020 were included in a retrospective chart review. Data extraction included results from PEth testing and information from the psychological evaluation (i.e., demographic, psychiatric symptoms, and cognitive functioning). RESULTS: There were 158 patients (73.8%) who had a PEth test, of whom 21.5% had a positive result (n = 34). Younger age was associated with a positive PEth (p < .001). ALD status and type of ALD (hepatitis vs. cirrhosis) were also associated with a positive PEth test. Other demographic characteristics and psychiatric symptoms were not associated with a positive PEth result (p > .05). CONCLUSION: Younger age was the only significant demographic variable associated with a positive PEth test. Given the difficulty of predicting who may be using alcohol, it may be useful to use PEth testing for all patients during the pre-liver transplant evaluation and while patients are listed for liver transplant. Early identification of alcohol use through routine PEth testing will help identify patients who are using alcohol and need further treatment for alcohol use to optimize health and post-transplant outcomes.

Availability of PEth testing is associated with reduced eligibility for liver transplant among patients with alcohol-related liver disease.

BACKGROUND: Serum phosphatidylethanol (PEth) is a highly sensitive test to detect alcohol use. We evaluated whether the availability of PEth testing impacted rates of liver transplant evaluation terminations and delistings. METHODS: Medical record data were collected for patients who initiated transplant evaluation due to alcohol-related liver disease in the pre-PEth (2017) or PEth (2019) eras. Inverse probability weighting (IPW) was used to balance baseline patient characteristics. Outcomes included termination of evaluation or delisting due to alcohol use; patients were censored at receipt of transplant; death was considered a competing risk. The Fine-Gray method was performed to determine whether PEth testing affected risk of evaluation termination/ delisting due to alcohol use. RESULTS: Three hundred and seventy-five patients with alcohol-related indications for transplant (157 in 2017; 210 in 2019) were included. The final IPW-adjusted model for the composite outcome of terminations/delisting due to alcohol use retained two significant variables (P < .05): PEth era and BMI category. Patients evaluated during the PEth era were almost three times more likely to experience an alcohol-related termination/delisting than those in the pre-PEth era (sHR = 2.86; 95%CI 1.67-4.97) CONCLUSION: We found that availability of PEth testing at our institution was associated with a higher rate of exclusion of patients from eligibility for liver transplant. Use of PEth testing has significant potential to inform decisions regarding transplant candidacy for patients with alcohol-related liver disease.

Acceptance of Illness Among Patients Pursuing Transplantation or Left Ventricular Assist Device.

Acceptance of illness is related to better mental health among patients with chronic illness; however, this construct has not been evaluated as part of routine transplantation evaluations. The purpose of this study was to create a brief measure of acceptance of illness for patients pursuing organ transplantation and examine how acceptance is related to distress. Retrospective medical record reviews were conducted for 290 patients who completed a routine psychosocial evaluation prior to transplant listing which included the Illness Acceptance Scale (IAS). Internal consistency for the IAS was excellent (Cronbach's alpha = .92). Illness acceptance was negatively correlated with depression, anxiety, and catastrophizing and was not related to health literacy or health numeracy. The IAS is a reliable and valid measure for patients who are pursuing thoracic transplant or left ventricular assist device. Clinicians may want to screen transplant candidates for illness acceptance and refer those with lower levels to psychological interventions.

Posttransplant Complications Predict Alcohol Relapse in Liver Transplant Recipients.

Alcohol relapse after liver transplantation (LT) in patients with alcohol-related liver disease (ALD) is a major challenge. Although its association with pretransplant psychosocial factors was extensively studied, the impacts of posttransplant courses on alcohol relapse have not been well investigated. The aim of this study is to analyze peritransplant factors associated with posttransplant alcohol relapse in patients with ALD. This study evaluated 190 adult LT patients with ALD from 2013 to 2019. Risk factors for alcohol relapse were analyzed, focusing on posttransplant chronic complications, which were classified as Clavien-Dindo classification 3a or higher that lasted over 30 days. The posttransplant alcohol relapse rate was 13.7% (26/190) with a median onset time of 18.6 months after transplant. Multivariate Cox regression analysis revealed that posttransplant chronic complications were an independent risk factor for posttransplant alcohol relapse (hazard ratio [HR], 5.40; P = 0.001), along with psychiatric comorbidity (HR, 3.93; P = 0.001), history of alcohol relapse before LT (HR, 3.00; P = 0.008), and an abstinence period <1.5 years (HR, 12.05; P = 0.001). A risk prediction model was created using 3 pretransplant risk factors (psychiatric comorbidity, alcohol relapse before LT, and abstinence period <1.5 years). This model clearly stratified the risk of alcohol relapse into high-, moderate-, and low-risk groups (P < 0.001). Of the 26 patients who relapsed, 11 (42.3%) continued drinking, of whom 3 died of severe alcoholic hepatitis, and 13 (50.0%) achieved sobriety (outcomes for 2 patients were unknown). In conclusion, posttransplant chronic complications increased the risk of alcohol relapse. Recognition of posttransplant chronic complications in conjunction with the risk stratification model by pretransplant psychosocial factors would help with the prediction of posttransplant alcohol relapse.

Access to robotic assisted kidney transplant for recipients: a systematic review and call for reporting standards.

Robot-assisted kidney transplantation (RAKT) is a relatively novel, minimally invasive option for kidney transplantation. However, clarity on recipient selection in the published literature is lacking thereby significantly limiting interpretation of safety and other outcomes. This systematic review aimed to identify and synthesize the data on selection of RAKT recipients, compare the synthesized data to kidney transplant recipients across the USA, and explore geographical clusters of availability of RAKT. Systematic literature review, in accordance with PRISMA, via OVID MEDLINE, Embase, and Web of science from inception to March 5, 2023. All data entry double blinded and quality via Newcastle Ottawa Scale. 44 full-text articles included, encompassing approximately 2402 kidney transplant recipients at baseline but with considerable suspicion for overlap across publications. There were significant omissions of information across studies on patient selection for RAKT and/or analysis. Overall, the quality of studies was very low. Given suspicion of overlap across studies, it is difficult to determine how many RAKT recipients received living (LD) versus deceased donor (DD) organs, but a rough estimate suggests 89% received LD. While the current RAKT literature provides preliminary evidence on safety, there are significant omissions in reporting on patient selection for RAKT which limits interpretation of findings. Two recommendations: (1) international consensus is needed for reporting guidelines when publishing RAKT data and (2) larger controlled trials consistently reporting recipient characteristics are needed to clearly determine selection, safety, and outcomes across both LD and DD recipients.

It Is Not All About Pretransplant Factors: Posttransplant Complications Alter the Risk of Alcohol Relapse.

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