Risk Factors for Alcohol Relapse Following Orthotopic Liver Transplantation: A Systematic Review

• Published in: Psychosomatics (Washington, D.C.) D.C.), 2015-01, Vol.56 (1), p.21-35
• Main Authors: Rustad, James K., M.D, Stern, Theodore A., M.D, Prabhakar, Maithri, M.B.B.S, Musselman, Dominique, M.D., M.S
• Format: Article
• Language: English
• Subjects: Humans; Internal Medicine; Liver Diseases, Alcoholic - diagnosis; Liver Diseases, Alcoholic - epidemiology; Liver Diseases, Alcoholic - surgery; Liver Transplantation; Postoperative Complications - diagnosis; Postoperative Complications - epidemiology; Psychiatry; Recurrence; Risk Factors
• ISSN: 0033-3182; 1545-7206
• DOI: 10.1016/j.psym.2014.09.006

Background Each year, 5000–6000 individuals undergo orthotopic liver transplantation (OLT) in the United States, and of these, nearly 18% have alcoholic liver disease. Relapse to alcohol occurs in more than 40% of patients with OLT for alcoholic liver disease. Objectives We sought to identify factors that predict relapse to alcohol or medication nonadherence following OLT in patients with alcoholic liver disease and to review what randomized clinical interventions have addressed these factors following OLT. Our hypothesis was that there would be factors before and after OLT that predict relapse to alcohol following OLT, and that these, if targeted, might improve sobriety and associated outcomes of adherence with medications and appointments. Methods We performed a review (focusing on articles published since 2004) with PubMed and MEDLINE searches using the following search terms: liver transplantation, recidivism, alcohol relapse, and predictors of alcohol relapse. We supplemented the online searches with manual reviews of article reference lists and selected relevant articles for further review by author consensus. Results In largely white populations, prospective studies document that shorter length of pretransplantation sobriety is a significant predictor of time to first drink and time to binge use. Presence of psychiatric comorbidity, high score on standardized High-risk Alcoholism Relapse Scale, and diagnosis of Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) alcohol dependence are predictive of posttransplantation alcohol relapse. Pretransplantation alcohol use history variables (e.g., family history of alcoholism) reliably discriminate between complete abstainers and those who drink, while medical and psychosocial characteristics at early post–liver transplantation period (e.g., more bodily pain) maximally discriminate patterns of alcohol use. Alcoholic individuals with early-onset, rapidly accelerating moderate use and early-onset, continuously increasing heavy use have more than double the prevalence of steatohepatitis or rejection on biopsy and graft failure and more frequent mortality resulting from recurrent alcoholic liver disease than late-onset (i.e., peak of heaviest drinking at 6 y posttransplantation) alcohol users do. Fortunately, pretransplantation screening combined with a structured pretransplantation management program and a 12-step program attendance reduced recidivism. No randomized clinical trials have been