Scientific letter
Detection of alcohol prior to liver transplant, recurrence or continued use?
Detección del consumo de alcohol inmediatamente antes del trasplante hepático, ¿recaída o continuidad del consumo?
Ana Carolina Londoño-Ramirez, Enrique Pérez-Martínez, Carlos J. van-der Hofstadt-Román
, Jesús Rodríguez-Marín
Corresponding author
Unidad de Psicología Clínica de la Salud, Hospital General Universitario de Alicante, Alicante, Spain
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"tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "279" "paginaFinal" => "280" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Ana Carolina Londoño-Ramirez, Enrique Pérez-Martínez, Carlos J. van-der Hofstadt-Román, Jesús Rodríguez-Marín" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Ana Carolina" "apellidos" => "Londoño-Ramirez" ] 1 => array:2 [ "nombre" => "Enrique" "apellidos" => "Pérez-Martínez" ] 2 => array:4 [ "nombre" => "Carlos J." "apellidos" => "van-der Hofstadt-Román" "email" => array:1 [ 0 => "hofstadt_car@gva.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 3 => array:2 [ "nombre" => "Jesús" "apellidos" => "Rodríguez-Marín" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad de Psicología Clínica de la Salud, Hospital General Universitario de Alicante, Alicante, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Detección del consumo de alcohol inmediatamente antes del trasplante hepático, ¿recaída o continuidad del consumo?" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Alcoholic liver cirrhosis is one of the most common and accepted liver transplant (LT) indications, but there are still many unresolved issues: there are no internationally accepted criteria for the selection of these patients, 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, in addition to the clinical and psychological assessments establishing the risk of a relapse of alcohol consumption that stems from before the LT.<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,<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.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Post-transplant alcoholism rates in the US fluctuate from between 28 and 50%, and there are no controlled clinical trials on the treatment of alcoholism in this population.<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, despite alcohol not being the primary reason for the transplant.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Death is primarily due to the recurrence of liver disease,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> and the appearance of other non-hepatic malignancies.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Thus, transplant teams agree that any alcohol consumption should be considered a contraindication for LT, and that abstinence is necessary when a patient is being evaluated for LT, when they have been included on the waiting list and after transplant surgery. Most groups have enforced a minimum of 6 months total abstinence protocol for transplant candidates; however, 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> – which would help to prevent long-term complications related to alcohol consumption – nor whether it is sufficient to predict the risk of relapse.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">As a rule, data on the consumption of alcohol pre-LT and post-LT is obtained by interview or self-reporting instruments, although there are several biological markers that detect alcohol consumption such as blood-alcohol and breath tests, measuring methanol in serum, ethyl glucuronide urine test, toxicological analysis of hair and skin devices that analyse sweat continuously.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Alcohol consumption rates for patients on the waiting list for LT are high, they exceed 25%. In most cases patients who have denied consuming alcohol during the evaluation period are found to have consumed it, when they are given a breathalyser test.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4,7</span></a> In these contexts, the pre-LT evaluation by mental health professionals is not part of a therapeutic relationship, but only intended to be a judgement of the patient's suitability to receive an organ that they need; so patients can hide behaviours they know might negatively affect their acceptance for a transplant, both during the pre-LT, evaluation period and their time on the waiting list. However, we consider that these patients have not voluntarily decided to stop drinking but that a health complication has imposed this demand on them. Therefore, many do not see the need to stop consuming, especially when they do not consider themselves addicts and, above all, once the LT has proved successful and, for them, the health problem has disappeared. Thus, abstinence must be made a central objective of therapy, and rehabilitation with a multidisciplinary approach must be part of that therapeutic process.<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, patients and family undergo a structured interview that assesses aspects related to alcohol and other substance addictions, 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. If tests detect alcohol or psychotoxic drug consumption within the last 6 months, the patient is referred to the addiction control unit to ensure appropriate treatment; and the case is monitored, establishing an abstinence or more than 6 months.</p><p id="par0035" class="elsevierStylePara elsevierViewall">On one occasion, alcohol consumption was identified in a patient, prior to his operation; the smell of ethanol on his breath was casually detected and later confirmed by a plasma test. After this finding, a routine plasma ethanol test was conducted on 31 patients, upon their admission on the day of transplant, and before their operation, having been called by surprise (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Despite our selection, monitoring and management of addictive behaviours programme, when we measured the plasma concentration of ethanol (Cp ethanol) in these patients we identified active alcohol consumption on the day of the transplant in 5 people (35.7% of subjects with alcohol aetiology). Given that under normal circumstances, individuals do not show any Cp ethanol at all, this test was considered positive when it showed a range over zero, in our index case the sample was extracted intraoperatively with an Cp ethanol of 112<span class="elsevierStyleHsp" style=""></span>mg/l; it was also detected on the other 4 patients when they were admitted preoperatively with Cp ethanol of 131, 8, 296 and 144<span class="elsevierStyleHsp" style=""></span>mg/l, respectively.</p><p id="par0045" class="elsevierStylePara elsevierViewall">In a context of a shortage of organs, such as the context of LT, a strict selection of transplant candidates must necessarily be enforced, and alcoholics should be denied LT on the grounds that is an often self-inflicted and recurrent disease with harmful post-transplant consequences, which could also negatively affect organ donation.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> Therefore, 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.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Alcohol consumption occurs both before and after LT, and approximately 20% of patients resume a dangerous level of alcohol consumption after their LT, causing liver damage and reducing survival rates.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> Since random drug analysis obtains more positive results than clinical interviews, including family interviews,<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> we believe that, rather than speaking of a relapse, the process can be called a continuity in consumption.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Monitoring of patients during the evaluation phase and during the waiting period through clinical interviews, reports from caregivers and biochemical tests ensure the best results in terms of detecting positive cases. Therefore we think that all patients, regardless of their alcohol or drug history, should undergo a toxicology screening, at least during the initial evaluation for transplant, 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.</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, 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, which would facilitate detecting the need for early treatment.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Finally, it seems quite clear that, on the basis of the considerations made, the problem of alcoholism in LT patients should be treated specifically in terms of addiction, both before and after transplant.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Londoño-Ramirez AC, Pérez-Martínez E, van-der Hofstadt-Román CJ, Rodríguez-Marín J. Detección del consumo de alcohol inmediatamente antes del trasplante hepático, ¿recaída o continuidad del consumo? Med Clin (Barc). 2016;146:279–280.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">HCC, hepatocellular carcinoma; FHF, fulminant hepatic failure; PH, portal hypertension; 95% CI, 95% confidence interval; MELD, MELD scale.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patients<br>(n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>31) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">95% CI \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Age</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">55.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">52.2–57.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Sex (M/F) (%)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">88/12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">MELD</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16–22 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Diagnosis</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>HCC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Cirrhosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Ascitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hepatorenal polycystic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>PH gastropathy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Budd-Chiari \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>FHF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Aetiology related to alcohol consumption</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">45.5% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1393888.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Descriptive data of the population under study.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "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: an open question" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. 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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" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack278020" "titulo" => "Acknowledgements" "texto" => "<p id="par0070" class="elsevierStylePara elsevierViewall">Our thanks to the Liver Transplant Team at the Hospital General Universitario de Alicante.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000014600000006/v3_201704140441/S2387020616302091/v3_201704140441/en/main.assets" "Apartado" => array:4 [ "identificador" => "43311" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000014600000006/v3_201704140441/S2387020616302091/v3_201704140441/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020616302091?idApp=UINPBA00004N" ]
