“But I didn’t drink!”: What to do with discordant phosphatidylethanol results

Abstract

Liver transplantation (LT) teams must be adept at detecting, evaluating, and treating patients’ alcohol use given its prominence among psychological and behavioral phenomena which cause and contribute to liver diseases. Phosphatidylethanol (PEth) is a highly useful alcohol biomarker increasingly recommended for routine use in hepatology and LT. PEth is unique among alcohol biomarkers because of its wide detection window, high sensitivity and specificity, and the correlation of its numerical value with different patterns of alcohol use. Alongside myriad clinical opportunities in hepatology and LT, PEth also confers numerous challenges: little guidance exists about its clinical use; fearing loss of LT access and the reactions of their clinicians and families, candidates and recipients are incentivized to conceal their alcohol use; and liver clinicians report lack of expertise diagnosing and treating substance-related challenges. Discordance between patient self-reported alcohol use and toxicology is yet another common and particularly difficult circumstance. This article discusses the general toxicological properties of PEth; explores possible scenarios of concordance and discordance among PEth results, patient history, and self-reported drinking; and provides detailed clinical communication strategies to explore discordance with liver patients, a key aspect of its use.

Making the best use of testing for blood phosphatidylethanol

“…In the right circumstances, PEth testing fosters open communication between patients with AUD/ALD and their providers while serving as motivation for and a signpost of sobriety on the pathway to lifelong abstinence. Utilizing the communication strategies laid out by Winder et al [3] in this issue can be a practical first step on this journey.…”

“…In the current issue of Liver Transplantation , Winder et al 3 explore the possible scenarios that may arise with the use of this highly reliable alcohol biomarker, whether providing concordant or discordant results in relation to patient self-reported alcohol use. As more clinicians utilize PEth testing and find themselves having to navigate these scenarios, understanding the ways to approach these challenging situations clearly and compassionately is imperative.…”

Liver transplant evaluation redux: Hope for reconsidering previously declined candidates with alcohol-associated liver disease

“…Therapeutic discussion of positive toxicology with patients with LT, uniquely motivated to conceal alcohol use, is an art. [9] Third, 9 re-evaluated patients were transplanted during the study period, with an additional 10 actively listed at the time of writing, showing previously declined patients with ALD can become successful candidates and recipients. With a median post-LT follow-up of 1.3 years, no recipient relapsed to alcohol, a finding underscoring the importance of integrated care at this institution and the efficacy of integrated AUD care in LT. [10] Given the need for integrated programs like the authors', [6] revenue generated from additional LT could represent the financial means by which LT centers expand their embedded psychosocial expertise.…”