Alcoholic Liver Disease and Transplantation : Psychiatric Evaluation

by National Institute of Health

(Page 4 of 7)

For OLT to be successful in alcoholic patients it is essential that the patients remain abstinent after the transplant and comply with the demanding medical regimen (consistently take the necessary antirejection medications). Routinely conducting psychiatric evaluations before patients are included on the list of candidates for transplantation may identify those who are most likely to fail these criteria. (Currently, ALD patients get on transplant lists later than patients with nonalcoholic liver disease because of the requirement for an evaluation of future abstinence.) In a survey using a five-point questionnaire, staff at 93 percent of transplant centers felt that a psychiatric evaluation was an important component in the pretransplant workup, and staff at 83 percent of the centers reported routinely using a psychiatrist or addiction specialist during the pretransplant evaluation. In most cases, the psychiatric evaluation includes assessments of the patient's socioeconomic condition as well as of underlying psychiatric disorders, job status, number and duration of prior attempts at abstinence, and use of other drugs. During this evaluation, the psychiatrist routinely interviews both the patient and one or more family members, and estimates the risk of post-transplant alcohol relapse.

One measure that has been proposed to predict post-transplant sobriety is the University of Michigan Alcoholism Prognosis Scale, which assesses a variety of factors, including: the patient's and family's recognition and acceptance of alcoholism. Four prognostic factors indicating sobriety, including involvement in activities that can substitute for drinking (sports), negative behavioral consequences of alcoholism, presence of hope/self-esteem, and availability of social relationships. Social stability factors, such as a stable job, residence, and marriage, or living with another person.

Data on the effectiveness of the MAPS are equivocal, however. In a prospective study, patients identified as suitable OLT candidates based on their MAPS scores had a low incidence of pathological drinking 3 years after liver transplantation. Conversely, a retrospective study conducted 5 years after ALD patients had received transplants showed that their pretransplant scores did not predict continued sobriety.

Some researchers consider an abstinence period of 6 months prior to OLT a predictor of long-term abstinence. Some transplant programs and insurance companies insist on an absolute 6-month period of abstinence before a patient with ALD can be listed for liver transplantation. This 6-month rule remains controversial, however, and appears to be arbitrary. Some studies favoring the 6-month rule have demonstrated that patients who are abstinent for less than 6 months have a greater relapse rate, but these studies only examined short periods of time, included only a small number of patients, and did not include control subjects. In contrast, many retrospective and prospective studies have demonstrated that the 6-month rule does not predict long-term sobriety after OLT. As a result, the current minimal listing criteria for liver transplantation proposed by UNOS do not require a 6-month period of abstinence before listing ALD patients for liver transplantation.

As an alternative to the 6-month abstinence requirement for predicting abstinence after OLT, Yates and colleagues proposed a High Risk Alcoholism Relapse scale, which is based on the patient's history of heavy drinking, usual number of drinks, and number of prior alcoholism inpatient treatment episodes. Initial studies have demonstrated that patients with low HRAR scores had a low relapse rate and could be deemed eligible for transplant without a pre-OLT 6-month period of abstinence. A subsequent study by the same research group, however, showed that the HRAR scale had little ability to predict continued sobriety after OLT.

Outcomes for ALD Patients After OLT

When assessing the long-term outcome for patients receiving OLT or any other kind of transplant, researchers and clinicians evaluate numerous factors in addition to the survival of the patient, including how long the transplanted organ continues to function (graft survival) and the patient's quality of life. Out of concerns that ALD patients may resume drinking after OLT and thereby damage the transplanted liver, investigators frequently assess graft survival in these patients. These assessments have found that the graft-survival rate in patients with ALD is comparable to that of patients with non-ALD. This finding suggests that the ALD patients are not more likely to relapse (or that their alcohol consumption may not be likely to damage the transplanted liver). In fact, the 1- and 3-year graft-survival rates in patients with ALD are above the average graft-survival rates for all diagnoses for which OLTs are performed. Moreover, the presence of a concurrent HCV infection does not appear to alter the 1-, 3-, and 5-year graft-survival rates in patients with ALD. However, a study by Neuberger and colleagues demonstrated that patients undergoing OLT for combined ALD and HCV infection were more likely to develop hepatic fibrosis than were patients with either ALD or HCV infection alone.

A few retrospective studies have been performed in abstinent patients who underwent OLT for ALD. These patients' livers subsequently were removed and examined for the presence of hepatitis caused by alcohol. Again, the presence of hepatitis appeared to have no impact on outcome, with the survival and relapse rates of these patients comparable to those of patients with alcoholic cirrhosis alone. No specific studies have assessed OLT survival rates and sobriety in patients with acute alcoholic hepatitis.

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