Alcoholic Liver Disease and Transplantation : Quality of Life, Alcohol Use

by National Institute of Health

(Page 5 of 7)

Quality of Life

The term "quality of life" encompasses various factors that influence a patient's subjective well-being, such as medical status, social status, employment status, or relationships. Overall, the physical and psychological outcomes for ALD patients after OLT appear similar to those of non-ALD patients. However, patients who relapse to alcohol use after receiving transplants have poorer post-transplant scores on quality-of-life measures than patients who do not relapse.

ALD patients in general have problems keeping a job and fulfilling their job requirements. OLT can ameliorate these problems to a certain extent. Nevertheless, an analysis combining the findings of several studies demonstrated that the employment status of ALD patients both before and after transplantation is dismal. Before transplantation, 29 percent of ALD patients and 59 percent of non-ALD patients were employed. At 3 years after the OLT, employment rates for non-ALD patients had increased substantially, whereas employment rates for ALD patients had increased only marginally. Furthermore, no associations were found between alcohol use and employment status after OLT or between pre- and post-transplant employment and sobriety. With all these findings it is important to note, however, that the employment status reported in many studies is based on self-reports, which have substantial limitations.

Relapse to Alcohol Use

As mentioned previously, an important concern in selecting alcoholic candidates for OLT and evaluating the outcome of the procedure is the likelihood of a relapse to alcohol use after the transplant. The definition of an alcohol relapse is controversial, varying from any use of alcohol after OLT to alcohol abuse resulting in physical and social consequences or rehospitalization for alcoholism. Although any alcohol use after OLT should be viewed as serious because it is the earliest indicator of high risk for the long-term viability of the graft, not all relapses may be harmful to the transplanted liver and the patient. The occasional use of small amounts of alcohol (a "slip") is not considered harmful and should not be treated punitively. These slips may not progress to an overt relapse that is potentially harmful to the new liver.

Because of the differing definitions of relapse, the reported relapse rates vary widely across studies, whereas the rates of graft dysfunction resulting from alcohol relapses are more consistent regardless of the definition of relapse used. Furthermore, the transplanted liver is rejected at a similar rate in both abstinent and nonabstinent alcoholic patients. This rejection reaction can occur if the patient does not consistently take necessary antirejection medications. Studies have found that among patients receiving OLT for ALD, the overall rate of noncompliance with the antirejection medications is as high as 16 percent. However, alcohol relapses per se do not appear to influence the patients' compliance with their medication regimen.

Interestingly, a meta-analysis found that ALD and non-ALD patients reported similar rates of alcohol use at 6 months and 12 months (17 percent and 16 percent, respectively) after OLT, although heavy drinking was more common in patients who had undergone liver transplantation for ALD. At 7 years after OLT, 32 percent of ALD patients reported drinking some alcohol. As previously mentioned, continued alcohol use after OLT puts the patient at risk for renewed ALD. Studies have found, however, that from a purely biological perspective, recurrent ALD is less prevalent and less severe after OLT than recurrent liver disease from other causes (reinfection with a hepatitis virus).

The reported relapse rate is influenced not only by the different definitions of relapse but also by the method used to identify a relapse. The most useful identification method appears to be a clinical interview conducted by a transplant psychiatrist or a questionnaire interview by an assistant. Biochemical markers (alcohol levels in the blood, urine, or breath, or tests for the presence of certain enzymes) as well as regular liver biopsies are less effective at identifying relapses. Relapse rates are highest during the initial 6 months after the transplant and decline after this period. About 95 percent of all relapses occur in the first 2 years after OLT.

Predictors of Relapse After OLT

Most patients with ALD are less severely dependent on alcohol than patients attending alcohol clinics, possibly because patients who do not exhibit symptoms of severe alcohol dependence are at greater risk of developing ALD because they can sustain continuous alcohol consumption over many years. The patient's premorbid social stability and Alcoholics Anonymous attendance record before OLT are important determinants of sustained abstinence after the procedure. Such factors can be assessed prior to a transplant using measures such as the Strauss-Bacon and Skinner indices, but few transplant centers report using these indices.

Another factor influencing relapse risk is the presence of other psychiatric disorders. The prevalence of preexisting psychiatric disorders in ALD patients is unknown. The few studies conducted in this patient population appear to show a higher rate of major psychiatric disorders among ALD patients than in the general population. However, major depressive disorders or schizophrenic conditions, which would indicate a greater risk of relapse after OLT, occur only rarely. The presence of post-traumatic stress disorder also increases the risk of alcohol relapse.

Coexisting dependence on drugs other than alcohol also is associated with higher rates of alcohol relapse. Studies have found that although 30 to 50 percent of patients who are dependent only on alcohol achieve sustained abstinence after alcoholism treatment, only 10 percent of patients who used more than one drug achieved abstinence. (The failure of investigators to distinguish between alcohol dependence and multiple-drug dependence in patients with ALD is one of the reasons for the variable relapse rates after OLT.) A prolonged period of documented abstinence from all drugs can indicate a low risk of relapse. Conversely, multiple failed attempts at alcohol abstinence before OLT are considered an indication that the prognosis for sustained sobriety after the transplant is poor.

About the Author

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