Detection of alcohol prior to liver transplant, recurrence or continued use?

Londoño-Ramirez, Ana Carolina; Pérez-Martínez, Enrique; van-der Hofstadt-Román, Carlos J.; Rodríguez-Marín, Jesús
doi:10.1016/j.medcle.2016.05.009
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Alcoholic liver cirrhosis is one of the most common and accepted liver transplant &#40;LT&#41; indications&#44; but there are still many unresolved issues&#58; there are no internationally accepted criteria for the selection of these patients&#44; there is no agreement on techniques for quantifying alcohol consumption and there is a lack of consensus on the aspects of mental health to be considered in post-transplant monitoring&#44; in addition to the clinical and psychological assessments establishing the risk of a relapse of alcohol consumption that stems from before the LT&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Although there are mixed results on the effects of abstinence on morbidity and mortality in this population&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> some authors stress that a relapse of alcohol consumption can lead to liver damage and increased mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Post-transplant alcoholism rates in the US fluctuate from between 28 and 50&#37;&#44; and there are no controlled clinical trials on the treatment of alcoholism in this population&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> In some studies relapses of alcohol consumption are associated with a poorer survival rate 5 years after the LT&#44; despite alcohol not being the primary reason for the transplant&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Death is primarily due to the recurrence of liver disease&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> and the appearance of other non-hepatic malignancies&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Thus&#44; transplant teams agree that any alcohol consumption should be considered a contraindication for LT&#44; and that abstinence is necessary when a patient is being evaluated for LT&#44; when they have been included on the waiting list and after transplant surgery&#46; Most groups have enforced a minimum of 6 months total abstinence protocol for transplant candidates&#59; however&#44; it has not been proven that a period of 6 months of abstinence before transplantation is an indicator of the ability of these patients to control their alcoholism<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> &#8211; which would help to prevent long-term complications related to alcohol consumption &#8211; nor whether it is sufficient to predict the risk of relapse&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">As a rule&#44; data on the consumption of alcohol pre-LT and post-LT is obtained by interview or self-reporting instruments&#44; although there are several biological markers that detect alcohol consumption such as blood-alcohol and breath tests&#44; measuring methanol in serum&#44; ethyl glucuronide urine test&#44; toxicological analysis of hair and skin devices that analyse sweat continuously&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Alcohol consumption rates for patients on the waiting list for LT are high&#44; they exceed 25&#37;&#46; In most cases patients who have denied consuming alcohol during the evaluation period are found to have consumed it&#44; when they are given a breathalyser test&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#44;7</span></a> In these contexts&#44; the pre-LT evaluation by mental health professionals is not part of a therapeutic relationship&#44; but only intended to be a judgement of the patient&#39;s suitability to receive an organ that they need&#59; so patients can hide behaviours they know might negatively affect their acceptance for a transplant&#44; both during the pre-LT&#44; evaluation period and their time on the waiting list&#46; However&#44; we consider that these patients have not voluntarily decided to stop drinking but that a health complication has imposed this demand on them&#46; Therefore&#44; many do not see the need to stop consuming&#44; especially when they do not consider themselves addicts and&#44; above all&#44; once the LT has proved successful and&#44; for them&#44; the health problem has disappeared&#46; Thus&#44; abstinence must be made a central objective of therapy&#44; and rehabilitation with a multidisciplinary approach must be part of that therapeutic process&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In our LT programme at the Hospital General de Alicante&#44; patients and family undergo a structured interview that assesses aspects related to alcohol and other substance addictions&#44; and which detects severe mental and emotional illness and cognitive and family support problems that may interfere with the continuity of medical treatment and the transplant process&#46; If tests detect alcohol or psychotoxic drug consumption within the last 6 months&#44; the patient is referred to the addiction control unit to ensure appropriate treatment&#59; and the case is monitored&#44; establishing an abstinence or more than 6 months&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">On one occasion&#44; alcohol consumption was identified in a patient&#44; prior to his operation&#59; the smell of ethanol on his breath was casually detected and later confirmed by a plasma test&#46; After this finding&#44; a routine plasma ethanol test was conducted on 31 patients&#44; upon their admission on the day of transplant&#44; and before their operation&#44; having been called by surprise &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Despite our selection&#44; monitoring and management of addictive behaviours programme&#44; when we measured the plasma concentration of ethanol &#40;Cp ethanol&#41; in these patients we identified active alcohol consumption on the day of the transplant in 5 people &#40;35&#46;7&#37; of subjects with alcohol aetiology&#41;&#46; Given that under normal circumstances&#44; individuals do not show any Cp ethanol at all&#44; this test was considered positive when it showed a range over zero&#44; in our index case the sample was extracted intraoperatively with an Cp ethanol of 112<span class="elsevierStyleHsp" style=""></span>mg&#47;l&#59; it was also detected on the other 4 patients when they were admitted preoperatively with Cp ethanol of 131&#44; 8&#44; 296 and 144<span class="elsevierStyleHsp" style=""></span>mg&#47;l&#44; respectively&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In a context of a shortage of organs&#44; such as the context of LT&#44; a strict selection of transplant candidates must necessarily be enforced&#44; and alcoholics should be denied LT on the grounds that is an often self-inflicted and recurrent disease with harmful post-transplant consequences&#44; which could also negatively affect organ donation&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> Therefore&#44; transplant programmes should include a multidisciplinary team that uses reliable techniques to ensure that all patients meet a minimum abstinence period and which considers the psychotherapeutic management of addictions before and after being processed by mental health teams&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Alcohol consumption occurs both before and after LT&#44; and approximately 20&#37; of patients resume a dangerous level of alcohol consumption after their LT&#44; causing liver damage and reducing survival rates&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> Since random drug analysis obtains more positive results than clinical interviews&#44; including family interviews&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> we believe that&#44; rather than speaking of a relapse&#44; the process can be called a continuity in consumption&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Monitoring of patients during the evaluation phase and during the waiting period through clinical interviews&#44; reports from caregivers and biochemical tests ensure the best results in terms of detecting positive cases&#46; Therefore we think that all patients&#44; regardless of their alcohol or drug history&#44; should undergo a toxicology screening&#44; at least during the initial evaluation for transplant&#44; it would be more equitable and less stigmatising than signalling out those patients who honestly admit to substance abuse and more positive results would be obtained&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Some researchers believe that medical and psychological care in the post-transplant monitoring phase could be much more effective than a mere pre-transplant selection&#44; and suggest the need to expand the role of the mental health team in post-transplant monitoring protocols and determination of possible relapse into alcoholism&#44; which would facilitate detecting the need for early treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Finally&#44; it seems quite clear that&#44; on the basis of the considerations made&#44; the problem of alcoholism in LT patients should be treated specifically in terms of addiction&#44; both before and after transplant&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Londo&#241;o-Ramirez AC&#44; P&#233;rez-Mart&#237;nez E&#44; van-der Hofstadt-Rom&#225;n CJ&#44; Rodr&#237;guez-Mar&#237;n J&#46; Detecci&#243;n del consumo de alcohol inmediatamente antes del trasplante hep&#225;tico&#44; &#191;reca&#237;da o continuidad del consumo&#63; Med Clin &#40;Barc&#41;&#46; 2016&#59;146&#58;279&#8211;280&#46;</p>"
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          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:10 [
            0 => array:3 [
              "identificador" => "bib0055"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Liver transplantation for patients with alcoholic liver disease&#58; an open question"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46; Gramenzi"
                            1 => "S&#46; Gitto"
                            2 => "F&#46; Caputo"
                            3 => "M&#46; Biselli"
                            4 => "S&#46; Lorenzini"
                            5 => "M&#46; Bernardi"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.dld.2011.03.011"
                      "Revista" => array:6 [
                        "tituloSerie" => "Dig Liver Dis"
                        "fecha" => "2011"
                        "volumen" => "43"
                        "paginaInicial" => "843"
                        "paginaFinal" => "849"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21550324"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0060"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Negative outcomes after liver transplantation in patients with alcoholic liver disease beyond the fifth post-transplant year"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46; Gr&#261;t"
                            1 => "Z&#46; Lewandowski"
                            2 => "K&#46; Gr&#261;t"
                            3 => "K&#46;M&#46; Wronka"
                            4 => "M&#46; Krasnod&#281;bski"
                            5 => "K&#46; Barski"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Clin Transpl"
                        "fecha" => "2014"
                        "volumen" => "28"
                        "paginaInicial" => "1112"
                        "paginaFinal" => "1120"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0065"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Excessive alcohol consumption after liver transplantation impacts on long-term survival&#44; whatever the primary indication"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "S&#46; Faure"
                            1 => "A&#46; Herrero"
                            2 => "B&#46; Jung"
                            3 => "Y&#46; Duny"
                            4 => "J&#46;P&#46; Daures"
                            5 => "T&#46; Mura"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jhep.2012.03.014"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Hepatol"
                        "fecha" => "2012"
                        "volumen" => "57"
                        "paginaInicial" => "306"
                        "paginaFinal" => "312"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22521352"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0070"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A randomized&#44; controlled study of treatment for alcohol dependence in patients awaiting liver transplantation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "R&#46;M&#46; Weinrieb"
                            1 => "D&#46;H&#46; Van Horn"
                            2 => "K&#46;G&#46; Lynch"
                            3 => "M&#46;R&#46; Lucey"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/lt.22259"
                      "Revista" => array:6 [
                        "tituloSerie" => "Liver Transpl"
                        "fecha" => "2011"
                        "volumen" => "17"
                        "paginaInicial" => "539"
                        "paginaFinal" => "547"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21506242"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0075"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Abusive drinking after liver transplantation is associated with allograft loss and advanced allograft fibrosis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "J&#46;P&#46; Rice"
                            1 => "J&#46; Eickhoff"
                            2 => "R&#46; Agni"
                            3 => "A&#46; Ghufran"
                            4 => "R&#46; Brahmbhatt"
                            5 => "M&#46;R&#46; Lucey"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/lt.23762"
                      "Revista" => array:6 [
                        "tituloSerie" => "Liver Transpl"
                        "fecha" => "2013"
                        "volumen" => "19"
                        "paginaInicial" => "1377"
                        "paginaFinal" => "1386"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24115392"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0080"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Challenges in transplantation for alcoholic liver disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "G&#46;A&#46; Berlakovich"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3748/wjg.v20.i25.8033"
                      "Revista" => array:6 [
                        "tituloSerie" => "World J Gastroenterol"
                        "fecha" => "2014"
                        "volumen" => "20"
                        "paginaInicial" => "8033"
                        "paginaFinal" => "8039"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25009374"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0085"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Detection of alcohol consumption in patients with alcoholic liver cirrhosis during the evaluation process for liver transplantation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "J&#46;M&#46; Hempel"
                            1 => "G&#46; Greif-Higer"
                            2 => "T&#46; Kaufmann"
                            3 => "M&#46;E&#46; Beutel"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/lt.23468"
                      "Revista" => array:6 [
                        "tituloSerie" => "Liver Transpl"
                        "fecha" => "2012"
                        "volumen" => "18"
                        "paginaInicial" => "1310"
                        "paginaFinal" => "1315"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22577089"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0090"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Controversies in the management of alcoholic liver disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "H&#46;H&#46; Tan"
                            1 => "S&#46; Virmani"
                            2 => "P&#46; Martin"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/msj.20135"
                      "Revista" => array:6 [
                        "tituloSerie" => "Mt Sinai J Med"
                        "fecha" => "2009"
                        "volumen" => "76"
                        "paginaInicial" => "484"
                        "paginaFinal" => "498"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19787655"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0095"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ethical considerations regarding early liver transplantation in patients with severe alcoholic hepatitis not responding to medical therapy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "V&#46; Donckier"
                            1 => "V&#46; Lucidi"
                            2 => "T&#46; Gustot"
                            3 => "C&#46; Moreno"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jhep.2013.11.015"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Hepatol"
                        "fecha" => "2014"
                        "volumen" => "60"
                        "paginaInicial" => "866"
                        "paginaFinal" => "871"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24291238"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
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                      "titulo" => "Detection of alcohol consumption in patients with alcoholic liver cirrhosis during the evaluation process for liver transplantation"
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                          "autores" => array:4 [
                            0 => "J&#46;M&#46; Hempel"
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                      "doi" => "10.1002/lt.23468"
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                        "tituloSerie" => "Liver Transpl"
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                        "paginaInicial" => "1310"
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      ]
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