Contemporary Policies Regarding Alcohol and Marijuana Use Among Liver Transplant Programs in the United States

Zhu, Jiaming; Chen, Ping‐Yu; Frankel, Marla; Selby, Rick; Fong, Tse‐Ling

doi:10.1097/tp.0000000000001969

Cited by 59 publications

(78 citation statements)

References 34 publications

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“…In a recent survey of 49 United Network for Organ Sharing-approved transplant programs, 43% of programs required a period of abstinence before transplantation. (23) Second, we found a small reduction in unhealthy drinking after DAA treatment in the overall cohort and all subgroups by SVR and cirrhosis status. In the pegylated interferon era, the data have been mixed regarding patterns of alcohol use after therapy.…”

Section: Discussionmentioning

confidence: 65%

Alcohol Use and Long‐Term Outcomes Among U.S. Veterans Who Received Direct‐Acting Antivirals for Hepatitis C Treatment

et al. 2020

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Outcomes related to alcohol use after hepatitis C virus (HCV) treatment are unknown in the direct-acting antiviral (DAA) era. We assessed levels of alcohol use before and after HCV treatment and their association with long-term outcomes in a cohort of U.S. veterans. In this retrospective cohort analysis, 29,037 patients who initiated DAA regimens between 2013 and 2015 were followed for a mean of 3.04 years. We categorized alcohol use into three categories (nondrinking, low-level drinking, and unhealthy drinking) using Alcohol Use Disorders Identification Test-Consumption questionnaires administered within 1 year before (baseline) and after treatment. Multivariable Cox proportional hazards regression was used to determine the associations between alcohol use and mortality or liver-related outcomes. Before DAA treatment, 68% of veterans reported nondrinking, 22.9% reported low-level drinking, and 9.1% reported unhealthy drinking. Compared to patients with baseline non-drinking, those with unhealthy drinking had a higher risk of mortality (adjusted hazard ratio [HR] 1.53, 95% confidence interval [CI]: 1.34-1.75) and decompensated cirrhosis (adjusted HR 1.30, 95% CI: 1.06-1.59) and lower likelihood of liver transplantation (adjusted HR 0.24, 95% CI: 0.06-0.92). These associations were greater in patients without sustained virologic response than in those with sustained virologic response. When alcohol use before and after treatment was modeled as a time-varying covariate, similar associations were observed. Survival analysis also found that unhealthy drinking was significantly associated with a lower probability of survival compared with nondrinking. Low-level alcohol use was not associated with increased risk of adverse outcomes. Conclusion: In this large cohort of U.S. veterans with HCV who received DAAs, unhealthy drinking was common and associated with a higher risk of posttreatment mortality. Interventions to achieve alcohol cessation before and during antiviral treatment should be encouraged. (Hepatology Communications 2020;4:314-324).

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Section: Discussionmentioning

confidence: 65%

Alcohol Use and Long‐Term Outcomes Among U.S. Veterans Who Received Direct‐Acting Antivirals for Hepatitis C Treatment

et al. 2020

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“…Further, to evaluate the outcomes of early liver transplant for alcoholic hepatitis, patients with a listing or transplant diagnosis of hepatocellular carcinoma (HCC) were excluded because HCC is typically an exclusion criterion in policies concerning early liver transplant. 3,12,15,16 We then performed sensitivity analyses with HCV infection and HCC included. In the sensitivity analysis involving HCC, patients with a secondary listing diagnosis of alcoholic cirrhosis or alcoholic hepatitis were categorized as having ALD if the primary listing diagnosis was HCC.…”

Section: Methodsmentioning

confidence: 99%

National Trends and Long-term Outcomes of Liver Transplant for Alcohol-Associated Liver Disease in the United States

et al. 2019

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IMPORTANCE Alcohol-associated liver disease (ALD) has emerged as the most common indication for liver transplant in the United States, but data on the reasons for this increase and long-term post-liver transplant outcomes among liver transplant recipients are sparse. OBJECTIVE To characterize trends and long-term outcomes of liver transplant for ALD in the United States between 2002 and 2016. DESIGN, SETTING, AND PARTICIPANTS This multicenter, prospective, national cohort study used data from the United Network for Organ Sharing database to evaluate all liver transplants performed in the United States between January 1, 2002, and December 31, 2016. MAIN OUTCOMES AND MEASURES National and regional trends in liver transplant for ALD, with a sensitivity analysis with hepatitis C virus (HCV) infection and hepatocellular carcinoma (HCC) included, and early (≤90 days after liver transplant) and late (>90 days after liver transplant) patient and graft survival. RESULTS The cohort consisted of 32 913 patients, including 9438 with ALD and 23 475 without ALD (patients who had HCV infection and HCC indications were excluded). Median age of patients with ALD was 54 years (interquartile range, 47–60 years) and of patients without ALD was 54 years (interquartile range, 44–61 years). Patients with ALD (vs non-ALD) were more frequently male (7197 of 9438 [76.2%] vs 11767 of 23 475 [50.1%]; P < .001) and white (7544 [80.0%] vs 17 251 [73.5%]; P < .001). The proportion of liver transplants for ALD increased from 24.2% (433 of 1791) in 2002 to 27.2% (556 of 2044) in 2010 and 36.7% (1253 of 3419) in 2016. With HCV infection included, the proportions of liver transplant for ALD were 15.3% in 2002,18.6% in 2010, and 30.6% in 2016, representing a 100% increase in liver transplant for ALD, of which 48% was associated with a decrease in HCV infection as an indication for liver transplant. The magnitude of increase in ALD was regionally heterogeneous and associated with changes in patient characteristics suggestive of alcoholic hepatitis: decreasing age (χ2 = 36.5; P = .005) and increasing model for end-stage liver disease score (χ2 = 69.1; P < .001). Cumulative unadjusted 5-year posttransplant survival was 79% (95% CI, 78%−80%) for ALD vs 80% (95% CI, 79%−80%) for non-ALD; cumulative unadjusted 10-year posttransplant survival was 63% (95% CI, 61%−64%) for ALD vs 68% (95% CI, 67%−69%) for non-ALD (P = .006). In multivariable analysis, ALD was associated with increased risk of late death after liver transplant (adjusted hazard ratio, 1.11; 95% CI, 1.03–1.20; P = .006). CONCLUSIONS AND RELEVANCE The findings suggest that early liver transplant for alcoholic hepatitis may be leading to broader acceptance of ALD for liver transplant. Late survival among liver transplant recipients with ALD was inferior to that among recipients with non-ALD indications, suggesting a need for future studies to identify patient profiles associated with best outcomes. Regional differences suggest heterogeneity in policies toward liver transplant for AL...

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“…These issues reflect the importance of reducing biases by having a hospital‐wide screening process, while acknowledging the potential need to develop individualized treatment recommendations and action plans for acute or emergent illnesses. As a next step, the workgroup has developed a nationwide survey using a similar approach applied by Zhu et al to understand substance use guidelines or policies used by other pediatric centers and investigate differences in perspectives among the types of providers and across organ teams across the United States, including those transplant centers that also perform lung transplantation. Key findings from this current study coupled with the nationwide survey findings will help to inform the development of guidelines that can be applied to transplantation centers nationwide.…”

Section: Discussionmentioning

confidence: 99%

“…There is some inconsistency, even among adult transplant populations, regarding whether and how much substance use plays a role in transplant candidacy, regardless of the legality of the substance . Indeed, a study examining substance use policies among adult liver transplant programs in the United States found considerable variation in policies across programs, including discrepancies in periods of alcohol abstinence required and inconsistency in accepting patients who used medical and/or recreational marijuana …”

Section: Introductionmentioning

confidence: 99%

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Providers’ perspectives on substance use among solid organ transplant candidates in a pediatric hospital

Christofferson

Burgers

Buchanan

et al. 2020

Pediatric Transplantation

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Introduction: Substance use is prevalent among youth and often leads to impairment in multiple domains. Additionally, substance use may pose adverse health issues posttransplant. Yet, practices related to substance use among pediatric patients who require organ transplant remain inconsistent. In this study, providers were surveyed for their perspectives on substance use among solid organ transplant candidates within a pediatric hospital.Methods: An online survey was administered to providers on the heart, kidney, and liver transplant teams at one tertiary pediatric care center located in the intermountain region of the United States (N = 50, 42% response rate). Providers answered questions about the need for a hospital-wide policy across heart, liver, and kidney transplant teams within this transplant center, timing of substance use evaluation, types of substances eliciting concerns based on organ, and recommended interventions. Data were analyzed using descriptive statistics. Results:Providers felt strongly about the need for a policy to guide recommendations for substance use among transplant candidates. Providers wanted a hospitalwide substance use policy (84%) and a standardized measure for assessing substance use (98%). Respondents (98%) indicated that substance use should be assessed during the pretransplant evaluation. Respondents expressed varied concerns based on substance and organ type, and recommended interventions for patients to cease substance use prior to transplant listing. Conclusions:This study highlights the need for a clear, directive, hospital-wide policy and standardized procedure for evaluating substance use among adolescent solid organ transplant candidates nationally across pediatric transplant centers.

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Contemporary Policies Regarding Alcohol and Marijuana Use Among Liver Transplant Programs in the United States

Abstract: Policies regarding alcohol use have become more flexible particularly toward patients with AAH. Marijuana use is also more accepted. Although policies regarding alcohol and marijuana have changed significantly in the last decade, they remain highly variable among programs.

Cited by 59 publications

References 34 publications

Alcohol Use and Long‐Term Outcomes Among U.S. Veterans Who Received Direct‐Acting Antivirals for Hepatitis C Treatment

Alcohol Use and Long‐Term Outcomes Among U.S. Veterans Who Received Direct‐Acting Antivirals for Hepatitis C Treatment

National Trends and Long-term Outcomes of Liver Transplant for Alcohol-Associated Liver Disease in the United States

Providers’ perspectives on substance use among solid organ transplant candidates in a pediatric hospital

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