An Assessment of the Psychosocial Evaluation for Early Liver Transplantation in Patients With Acute Alcoholic Hepatitis in the Context of Alcohol Use Disorder, a Case-Control Study

Abstract

Background: 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. Methods: 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. Results: 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. Discussion: 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. Conclusion: 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.

Assessment and Evaluation of Alcohol Use Disorder in Liver Transplant

“…The SIPAT has demonstrated good interrater reliability and predictive validity for transplant candidacy. 13 Other research has found that SIPAT and Sustained Alcohol Use Post-LT scores were predictive of relapse following transplant. 49 However, research in this area contains few studies with limited statistical power or methodological errors confounding results.…”

“…9 Although numerous scoring systems have proposed to aid in candidate selection, there is not 1 criterion that has been shown to reliably predict post-LT relapse, which is often precipitated by unpredictable stressors which are unknown at time of evaluation. [10][11][12][13][14] The "6-mo sobriety rule" allowed for identification of individuals that would recover spontaneously without need for undergoing LT, and also provided a seemingly equitable and objective standard to identify patients who are likely to remain abstinent after LT. It was previously widely adopted by 85% of transplant centers in 1996 as well as many insurance policies.…”

ACG Clinical Guideline: Alcohol-Associated Liver Disease

“…Selection of patients with severe AH for LT requires a rigorous psychosocial evaluation by a multidisciplinary team including social workers and addiction counselors and psychiatrists. Tools such as Stanford Integrated Psychosocial Assessment Tool (261,263), High Risk for Alcohol Relapse Score, Michigan Alcoholism Prognostics Score, Hopkins Psychosocial Score, and SALT score may be used to determine risk of recurrent alcohol use after LT (100,264,265). However, most of these scores are not accurate in identifying patients who are at high risk for recurrent alcohol use but rather are accurate in predicting a low likelihood of relapse.…”

Liver transplantation for alcohol-associated hepatitis

“…Although these models may aid in the assessment of risk of alcohol relapse and can guide patient selection for transplant, there is no consensus on their use. Additional research and discussion needed to determine their role in conjunction with professional assessments by specialists for patient selection for liver transplantation [72 ▪ ,80 ▪ ,81,82].…”

“…Several scoring systems have also been developed to better risk-stratify patients with ALD with regards to posttransplant alcohol use in addition to psychosocial assessments for transplant and traditional screening tools for AUD (Table 2) [32,52,55,56 ▪ ,68–71,72 ▪ ,73 ▪ ,74–79]. A recent retrospective case–control study found that patients who underwent early liver transplantation compared with controls declined secondary to low insight into AUD had significantly more favorable Michigan Alcoholism Prognostic Scale (MAPS), High-Risk Alcoholism Relapse (HRAR), Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT), Alcohol Relapse Risk Assessment (ARRA), and Hopkins Psychosocial Scale (HPSS) scores, but Sustained Alcohol Use Post-LT (SALT) and Alcohol Use Disorders Identification Test (AUDIT-C) scores were not predictive [72 ▪ ]. Although these models may aid in the assessment of risk of alcohol relapse and can guide patient selection for transplant, there is no consensus on their use.…”