Protocolized screening and detection of occult alcohol use before and after liver transplant: Lessons learned from a quality improvement initiative

Abstract

Introduction: Detection of alcohol (ETOH) use with biomarkers provides an opportunity to intervene and treat patients with alcohol use disorder before and after liver transplant (LT). We describe our center's experience using urine ethyl glucuronide (EtG) and serum phosphatidylethanol (PEth) in alcohol screening protocols.Methods: Single-center, retrospective review of patients presenting for LT evaluation, patients waitlisted for LT for alcohol-associated liver disease (ALD), and patients who received a LT for ALD over a 12-month period, from October 1, 2019 through September 30, 2020. Patients were followed from waitlisting to LT, or for up to 12 months post-LT. We monitored protocol adherence to screening for ETOH use-defined as completion of all possible tests over the follow-up period-at the initial LT visit, while on the LT waitlist and after LT.Results: During the study period, 227 patients were evaluated for LT (median age 57 years, 58% male, 78% white, 54.2% ALD). Thirty-one patients with ALD were placed on the waitlist, and 38 patients underwent LT for ALD during this time period. Protocolized adherence to screening for alcohol use was higher for PEth for all LT evaluation patients (191 [84.1%] vs. 146 [67%] eligible patients, p < .001), in patients with ALD waitlisted for LT (22 [71%] vs. 14 (48%] eligible patients, p = .04) and after LT for ALD, 20 (33 [86.8%] vs. 20 [52.6%] eligible patients, p < .01). Few patients with a positive test in any group completed chemical dependency treatment. Conclusions:When screening for ETOH use in pre-and post-LT patients, protocol adherence is higher using PEth compared to EtG. While protocolized biomarker screening can detect recurrent ETOH use in this population, engagement of patients into chemical dependency treatment remains challenging.

The Impact of Metabolic Health and Obesity on Liver Transplant Candidates and Recipients

“…Simple screening tools, such as the AUDIT score or the more abbreviated version, AUDIT-C, may be utilized to capture high-risk patients [ 65 , 66 ]. Biomarkers for the detection of alcohol consumption, including urine ethyl glucuronide and phoshatidylethanol, can help identify intermittent and chronic alcohol intake, respectively [ 67 ]. Patients who are identified as having MetALD should be offered a multidisciplinary approach to help them achieve long-term sobriety in addition to their metabolic health management.…”

Management of alcohol-associated liver disease and alcohol use disorder in liver transplant candidates and recipients: Challenges and opportunities

“…[82] PEth is a lipid species formed by phospholipase D on the surface of red blood cells and has a detection window of 2 to 4 weeks with up to 100% specificity for alcohol ingestion. [83][84][85][86] Concerns for false positives with blood transfusions have been raised; low-positive PEth results in patients who have received blood transfusions and had no access to alcohol should be carefully considered within the clinical perspective as it could represent a false positive, especially when urine ethyl glucuronide is negative. [87] PEth test validity extends to chronic liver disease and can distinguish between various levels of alcohol use: <20 ng/mL (little or no drinking), 20-200 ng/mL (moderate consumption), and > 200 ng/mL (heavy consumption), making it possible to estimate the degree of daily alcohol intake within the detection window.…”

“…PEth is the most sensitive direct biomarker for alcohol intake and has been studied in pre-LT and post-LT populations 82 . PEth is a lipid species formed by phospholipase D on the surface of red blood cells and has a detection window of 2 to 4 weeks with up to 100% specificity for alcohol ingestion 83–86 . Concerns for false positives with blood transfusions have been raised; low-positive PEth results in patients who have received blood transfusions and had no access to alcohol should be carefully considered within the clinical perspective as it could represent a false positive, especially when urine ethyl glucuronide is negative 87…”