Effect of an Integrated Transplantation Mental Health Program on Alcohol Relapse After Liver Transplantation for Severe Alcoholic Hepatitis: A Single-Center Prospective Study.

BACKGROUND: Liver transplantation (LT) for severe alcohol-associated hepatitis (AH) remains controversial due to perceived increased recidivism risk after LT because of a lack of protracted abstinence before LT. Data on risk stratification for alcohol relapse after LT are limited. We sought to evaluate the utility of having a mental health program embedded in a transplantation center in risk assessment for alcohol relapse-free patient survival after LT. METHODS: We conducted a prospective analysis of all patients with a diagnosis of severe AH hospitalized at a single transplant center from April 2015 to April 2020. After a comprehensive mental health risk stratification, patients were either waitlisted for LT or declined for waitlisting. The primary endpoint was alcohol relapse-free patient survival rate for those who received LT. The secondary endpoint compared survival rates between patients who received LT and those who did not. The median follow-up was 10 months. RESULTS: Among the 83 patients included in the study, 54 patients were waitlisted for LT (65%, group 1) and 29 were declined (35%, group 2). Patient characteristics and median Model for End-Stage Liver Disease score on presentation were comparable for both cohorts (36 in group 1, 38 in group 2; P = .8). Group 1 had significantly better Stanford Integrated Psychosocial Assessment for Transplantation total scores (median 40 vs 57; P < .01), presence of social support (100% of patients in group 1 vs 76% in group 2; P < .01), and less prevalence of active tobacco smokers (30% in group 1 vs 66% in group 2; P < .01). For those who were not waitlisted, 72.5% experienced rapid deterioration of hepatic function. Among the 54 patients waitlisted, 29 patients received LT (54%), whereas 19 died while on the waiting list (35%). One- and 3-year patient survival after LT were 92.5% and 92.5%, respectively. The overall and sustained alcohol relapse rates after LT were 10.3% and 3.5%, respectively. CONCLUSION: Severe AH is a complex medical and mental health disease and requires an intense risk assessment for recidivism after LT. Our study shows that an integrated transplantation mental health program provides an accurate risk stratification for alcohol relapse after LT, a successful intervention to mitigate recidivism risk, and optimal short-term alcohol relapse-free patient survival. Future studies should focus on enhancing the guidelines for broader application.

Outcome analysis of continuous intraoperative renal replacement therapy in the highest acuity liver transplant recipients: A single-center experience.

BACKGROUND: Orthotopic liver transplantation is the definitive treatment modality for patients with end-stage liver disease. Pre-orthotopic liver transplantation renal dysfunction has a significant negative influence on outcomes post-orthotopic liver transplantation. Intraoperative renal replacement therapy is an adjunctive therapy to address the metabolic challenges during orthotopic liver transplantation in patients with a high acuity of illness. The impact of intraoperative renal replacement therapy on post-orthotopic liver transplantation outcomes, however, is unclear. METHODS: From October of 2012 to April of 2016, 96 adult patients underwent orthotopic liver transplantation for end-stage liver disease. Three groups were identified: (1) Group I: patients with pre-orthotopic liver transplantation renal dysfunction who underwent intraoperative renal replacement therapy, (2) Group II: patients with pre-orthotopic liver transplantation renal dysfunction who did not receive intraoperative renal replacement therapy, and (3) Group III: patients with orthotopic liver transplantation without evidence of pretransplant renal dysfunction. RESULTS: At 17.7 months follow-up, there was no difference in survival among the study groups. Physiologic model for end-stage liver disease at the time of orthotopic liver transplantation was significantly higher in both groups with renal dysfunction (I = 43, II = 39) than in Group III (18). Post-orthotopic liver transplantation, 12-month patient survival in Group II was 100%. While the model for end-stage liver disease score at orthotopic liver transplantation was significantly different between Group I and Group III, the 12-month, post-orthotopic liver transplantation patient survival was comparable at 78% vs 88%, respectively. CONCLUSION: Intraoperative renal replacement therapy is a safe adjunctive therapy during liver transplantation of critically ill patients with renal dysfunction. Identifying patients who require intraoperative renal replacement therapy would improve intraoperative and post-liver transplant survival and may facilitate recovery of native kidney function after transplant.

Parental live liver donation: psychosocial considerations in the decision to donate.

PURPOSE OF REVIEW: Live donor liver transplantation is a treatment option for patients in need of orthotopic liver transplantation to mitigate the organ shortage from deceased donors. The long-term outcomes for pediatric recipients from live liver donors are excellent, and parents commonly are the ones seeking donation to save their child from irreversible liver failure. Although live donors go through a careful medical and psychosocial evaluation to ensure the benefits of donation outweigh the risks, parental live liver donation poses unique challenges due to the biological and emotional relationships with the child. This article highlights specific psychosocial considerations for parental live liver donors. RECENT FINDINGS: There is limited research regarding the psychosocial evaluation and outcomes for live liver donors. Some literature suggests the need for standard criteria regarding the psychosocial evaluation of donors because of the risks. However, there are positive benefits with donation, such as improved emotional quality of life for adult to pediatric donors, and the possible benefits should be considered. SUMMARY: Live liver donation is an appealing alternative treatment option, particularly in the pediatric population, in which outcomes are generally positive and medical risk to donor is less than adult-to-adult donation. For parental donors, special consideration should be given to the informed consent and the decision-making process, psychological health, and presence of substance use when weighing the risk versus protective factors for donors.