Methadone maintenance therapy in liver transplantation.

Cirrhosis due to chronic infection with hepatitis C virus remains by far the most common reason for liver transplantation in North America. Currently, parenteral use of street drugs is the most common means of acquiring hepatitis C. Methadone maintenance therapy is an accepted form of treatment for chronic opiate (eg, heroin) addiction and, not surprisingly, a significant proportion of methadone-treated patients have chronic hepatitis C. The feasibility of liver transplant candidacy in hepatitis patients who require methadone maintenance therapy is controversial, and some transplant centers require patients to withdraw from such therapy in order for the transplant process to move forward. Thus stable patients with end-stage cirrhosis who are receiving methadone maintenance are left in a most difficult situation: discontinue methadone and accept the side effects of withdrawal with the risk of recidivism to use of street opiates, an absolute contraindication for transplantation, or continue methadone therapy and risk exclusion from the transplant process. The issue of methadone replacement therapy in end-stage cirrhosis and the posttransplant literature on the subject are explored in this paper.

Predictors of relapse to significant alcohol drinking after liver transplantation.

BACKGROUND: End-stage alcoholic liver disease is common, with many of these patients referred for liver transplantation (LT). Alcohol relapse after LT can have detrimental outcomes such as graft loss and can contribute to a negative public perception of LT. OBJECTIVE: To identify factors that predict the recurrence of harmful alcohol consumption after LT. METHODS: A total of 80 patients who underwent LT for alcoholic cirrhosis or had significant alcohol consumption in association with another primary liver disease, from July 1992 to June 2006 in British Columbia, were retrospectively evaluated by chart review. Several demographic-, psychosocial- and addiction-related variables were studied. Univariate and multivariate logistic regression analyses were used to test possible associations among the variables studied and a return to harmful drinking after LT. RESULTS: The relapse rate of harmful alcohol consumption post-liver transplant was 10%, with two patient deaths occurring directly as a result of alcohol relapse. Univariate analysis revealed relapse was significantly associated with pretransplant abstinence of less than six months (P=0.003), presence of psychiatric comorbidities (P=0.016), female sex (P=0.019) and increased personal stressors (P=0.044), while age at transplant of younger than 50 years approached significance (P=0.054). Multivariate logistic regression analysis revealed the following independent factors for relapse: pretransplant abstinence of less than six months (OR 77.07; standard error 1.743; P=0.013) and female sex (OR 18.80; standard error 1.451; P=0.043). CONCLUSION: The findings of the present study strongly support a required minimum of six months of abstinence before LT because duration of abstinence was found to be the strongest predictor of recidivism. Female sex, younger age at transplant and psychiatric comorbidities were also associated with relapse to harmful drinking.

Differences in psychosocial profiles between men and women living kidney donors.

BACKGROUND: The expansion of kidney transplantation by living donation has led to a disproportional increase in the women to men ratio among donors and this difference cannot be explained on the basis of medical exclusion. The present study was designed to test whether women donors are more likely to (i) display altruistic and gender-typed nurturing behaviour and (ii) be subtly influenced by family pressure to donate and less able to resist this pressure. METHODS: All 71 (61% women) individuals who had donated a kidney at our centre between 1995 and 2005 were sent a survey. Thirty-nine individuals (71% response rate; 64% female participation) filled out and returned the survey, which included standardized measures of altruism, self-esteem, family dynamics and endorsement of gender-stereotyped roles, as well as sociodemographic questions and questions about donation. RESULTS: Findings show no difference between women and men in terms of the psychological attributes measured. One woman and two men reported having felt pressure to donate, and 92% of women compared with 54% of men reported having felt free to change their mind. Men took longer than women to make the decision to donate. CONCLUSIONS: Results suggest that among individuals who have already donated, there is no evidence that women may be more inclined to donate than man because of differences in their psychosocial profiles or because they may be more vulnerable to family pressure. Future research may gain from focusing on men and women donors and non-donors in families where transplantation is being considered.

Liver transplant candidacy unsuitability: a review of the British Columbia experience.

BACKGROUND: Every centre has contraindications to liver transplantation and declares patients unsuitable for medical or nonmedical reasons. To date, there has been no published review of any centre's experience. METHODS: A retrospective chart review was completed from 1997 to 2001, inclusive of all patients referred for liver transplant to the British Columbia Transplant Society who were declared unsuitable for transplantation, as well as the reasons for unsuitability. RESULTS: One hundred fifty patients were considered to be unsuitable for transplantation. During this period, 167 transplants were performed and 737 patients were referred for candidacy. Data were missing on three patients; analysis was performed on the remaining 147. Patients' ages ranged from 15 to 72 years, and 33.3% were female. The most common primary liver disease was hepatitis C (n=53, 35%), followed by alcoholic liver disease (n=35, 24%) and autoimmune liver diseases (n=23, 16%). Medical contraindications constituted 74 patients (49.0%) and the most common reasons for unsuitability were no need of a liver transplant (29 patients [39%]), exclusion due to hepatoma or extrahepatic malignancy (20 patients [27%]) and multisystem failure (12 patients [16%]). Nonmedical contraindications constituted 73 patients. Failure to meet minimal alcohol criteria comprised the largest group (n=39, 53.4%) followed by inadequate social support (n=12, 16.4%), failure to follow up medical assessment (n=10, 13.7%) and drug abuse (n=6, 8.2%). CONCLUSIONS: Although many patients were declined for transplantation, the proportion is relatively small compared with the number of referred patients. Nonmedical reasons, including failure to meet alcohol criteria and lack of social support, remain a significant reason for unsuitability in British Columbia. Community intervention before transplant referral is recommended.

They talk the talk: Surveying attitudes and judging behavior about living anonymous kidney donation.

BACKGROUND: Over the past 30 years, numerous studies have reported that some individuals are willing to donate a kidney anonymously to a stranger; however, intentions are poor predictors of behavior. We surveyed individuals interested in being living anonymous donors (LADs), exposed them to an interview paralleling live-donor assessment, and measured their LAD commitment. Personality and donation decision factors were examined to corroborate cases of attitudinal and behavioral congruency. METHODS: A telephone survey of 1,002 randomly selected adults living in Vancouver, British Columbia, asked respondents how willing they were to donate a kidney, while alive, to particular individuals including a stranger. A subsample participated in a follow-up, which involved completing a mailed questionnaire and taking part in an in-depth interview. Expert raters judged respondents' commitment to being a LAD on the basis of the interviews. RESULTS: Two hundred fifty-eight (26%) of those surveyed stated they would probably or definitely be willing to donate a kidney to a stranger. Fifty-two completed the follow-up. Sixteen of the 52 (31%) were judged to be "committed LADs." No demographic differences were found between the committed LADs and the 33 remaining "noncommitted participants." The committed LADs differed significantly from the noncommitted participants on personality measures and donation decision factors. These differences underscore the latter group's anonymous donation commitment. CONCLUSIONS: This study brings into focus the potential for a significant number of individuals coming forward as potential LAD candidates if they are informed about the need and given unbiased information about the procedure. We believe there is ethical latitude in allowing the promotion of LAD donation by interested third parties such as patient advocacy groups and professional bodies. We advocate public awareness of LAD programs as a first step followed thereafter by more provocative measures to engage the public in this endeavor.

The living anonymous kidney donor: lunatic or saint?

Studies indicate that 11% to 54% of individuals surveyed would consider donating a kidney, while alive, to a stranger. The idea of 'living anonymous donors' (LADs) as a donor source, however, has not been embraced by the medical community. Reservations focus on the belief that LADs might be psychologically unstable and thus unsuitable donors. Our goal was to inform policy development by exploring the psycho-social make up and motivations of the LAD. Ninety-three unsolicited individuals contacted our center expressing interest in living anonymous donation. Of these, 43 participated in our study, completing two extensive inventories of psychopathology and personality disorder and taking part in the Comprehensive Psycho-Social Interview (CPSI). From the Personality Assessment Inventory (PAI), the revised NEO Personality Inventory (NEO PI-R), and the CPSI, coders assessed psychological health, psycho-social suitability, commitment, and motivations. Twenty-one participants passed the stringent criteria to be considered potential LADs. Content analysis of motivations showed that potential LADs were more likely than non-LADs (those who did not pass the criteria) to have a spiritual belief system and to be altruistic. Non-LADs were more likely than potential LADs to use donation to make a statement against their families. The authors conclude with a preliminary outline of eight policy recommendations.