Dienstag Aryeh, Dienstag Penina, Mohan Kanwal, Mirza Omar, Schubert Elizabeth, Ford Laura, Edelman Margot, Im Gene, Shenoy Akhil
Department of Psychiatry, Hadassah Hebrew University School of Medicine, Jerusalem, Israel.
Department of Anesthesia, Hadassah Hebrew University School of Medicine, Jerusalem, Israel.
Subst Abuse. 2022 Aug 10;16:11782218221115659. doi: 10.1177/11782218221115659. eCollection 2022.
Severe acute alcoholic hepatitis (AAH) has an extremely poor prognosis with a high short term mortality rate. As a result, many centers, including our own, have allowed transplant patients to be listed for transplantation prior to achieving 6-months of sobriety. Several scoring systems, designed to target patients with a minimal period of sobriety, have been proposed to identify patients with alcohol use disorder (AUD), who would be predisposed to relapse after liver transplantation. We investigated whether these scoring systems corroborated the results of the non-structured selection criteria used by our center regarding decision to list for transplant.
We conducted a retrospective case-control study of 11 patients who underwent early liver transplantation for AAH matched with 11 controls who were declined secondary to low insight into AUD. Blinded raters confirmed the severity of the diagnosis of DSM-5 and scored the patients on a variety of structured psychometric scales used to predict alcohol relapse. These included the High Risk for Alcohol Relapse Scale (HRAR), Stanford Integrated Psychosocial Assessment Tool (SIPAT), Alcohol Relapse Risk Assessment (ARRA), Hopkins Psychosocial Scale (HPSS), Michigan Alcoholism Prognosis Score (MAPS), Alcohol Use Disorders Identification Test -Consumption (AUDIT-C), and Sustained Alcohol Use Post-Liver Transplant (SALT) scales. All patients who underwent transplantation were followed for harmful and non-harmful drinking until the end of the study period.
The transplant recipients had significantly favorable MAPS, HRAR, SIPAT, ARRA, and HPSS scores with cutoffs that matched their previous research. The SALT and AUDIT-C scores were not predictive of our selection of patients for transplantation. Despite an expedited evaluation and no significant period of sobriety, our case cohort had a 30% relapse to harmful drinking after an average of 6.6 years (5-8.5 years) of follow-up.
Despite the rapid assessment and the short to no period of sobriety, the patient cohort demonstrated a 30% relapse to harmful drinking, consistent with the 20% to 30% relapse to drinking rate reported after liver transplantation for all forms of alcoholic liver disease. Average scores from MAPS, HRAR, SIPAT, ARRA, and HPSS corroborated our current stratification procedures, with lower mean risk scores found in the transplanted group.
Patients with AUD and severe AAH who obtain new insight into their disease and posses other favorable psychosocial factors have low rates of AUD relapse post-liver-transplantation. The psychosocial selection criteria for patients with alcoholic hepatitis in our institution are consistent with 4 of the 5 scoring systems investigated in their prediction of sobriety post-transplant.
严重急性酒精性肝炎（AAH）预后极差，短期死亡率很高。因此，包括我们中心在内的许多机构允许移植患者在戒酒未满6个月时就被列入移植名单。已经提出了几种评分系统，旨在针对戒酒时间最短的患者，以识别酒精使用障碍（AUD）患者，这些患者在肝移植后易复发。我们调查了这些评分系统是否证实了我们中心用于决定列入移植名单的非结构化选择标准的结果。
我们对11例因AAH接受早期肝移植的患者进行了一项回顾性病例对照研究，并与11例因对AUD认识不足而被拒绝的对照患者进行了匹配。不知情的评估者确认了DSM-5诊断的严重程度，并使用多种用于预测酒精复发的结构化心理测量量表对患者进行评分。这些量表包括酒精复发高风险量表（HRAR）、斯坦福综合心理社会评估工具（SIPAT）、酒精复发风险评估（ARRA）、霍普金斯心理社会量表（HPSS）、密歇根酒精中毒预后评分（MAPS）、酒精使用障碍识别测试-消费量（AUDIT-C）以及肝移植后持续酒精使用量表（SALT）。所有接受移植的患者均被随访有害和无害饮酒情况，直至研究期结束。
移植受者的MAPS、HRAR、SIPAT、ARRA和HPSS评分显著优于对照组，其临界值与先前研究相符。SALT和AUDIT-C评分不能预测我们对移植患者的选择。尽管评估迅速且无明显戒酒期，但我们的病例队列在平均6.6年（5 - 8.5年）的随访后，有30%的患者复发至有害饮酒。
尽管评估迅速且戒酒期短或无戒酒期，但患者队列仍有30%的患者复发至有害饮酒，这与所有形式酒精性肝病肝移植后报告的20%至30%的饮酒复发率一致。MAPS、HRAR、SIPAT、ARRA和HPSS的平均评分证实了我们目前的分层程序，移植组的平均风险评分较低。
对疾病有新认识且具备其他有利心理社会因素的AUD和严重AAH患者肝移植后AUD复发率较低。我们机构中酒精性肝炎患者的心理社会选择标准与所研究的5种评分系统中的4种在预测移植后戒酒情况方面是一致的。
