Clinical

Score predicts recidivism after liver transplantation for alcoholic liver disease

Last Updated: 2007-06-15 9:40:11 -0400 (Reuters Health)

By Karla Gale

NEW YORK (Reuters Health) - Among patients who undergo liver transplantation because of alcoholic cirrhosis, three factors independently predict the risk of relapse into harmful drinking -- duration of abstinence, presence of depression or anxiety, and the High-Risk Alcoholism Relapse (HRAR) scale score -- physicians in Switzerland and France report.

"Abstinence remains crucial," Dr. Jerome Dumortier and associates emphasize in their report. However, they note in the Archives of Internal Medicine for June 11, the common practice of selecting candidates for liver transplantation based on duration of sobriety fails to account for other factors known to influence alcoholic behavior.

The investigators analyzed outcomes for all 387 patients who underwent liver transplantation for alcoholic liver disease at University Hospital, Geneva and at Edouard Herriot Hospital in Lyon, between 1989 and 2005.

Mean duration of abstinence at the time of placement on the waiting list was 20 months; mean duration spent on the waiting list was 5 months; and mean follow-up after liver transplantation was 61 months. Anxiety or depression were documented among 21% of patients, and 93% had HRAR score < 4.

The authors explain that HRAR is scored from 0 to 6 according to years of heavy drinking, daily alcohol consumption, and number of prior alcoholism inpatient treatments. They define "harmful alcohol consumption" as drinking more than 40 grams of alcohol per day, and evidence of alcohol-related damage.

At 1 year after liver transplantation, 95.5% of patients were free from alcohol relapse. Corresponding rates at 3, 5, and 10 years following transplantation were 89.8%, 85.4%, and 77.8%, respectively.

In univariate analysis, factors linked to alcohol relapse were presence of an anxiety or depressive disorder, absence of a life partner, elevated HRAR score, duration of sobriety < 6 months, liver transplantation performed before 1996, and age > 50 years.

Multivariate analysis revealed that significantly increased risk for recidivism was associated with a diagnosis of a psychiatric disorder prior to liver transplantation (odd ratio 7.8, p < 0.001), HRAR score of 4 or more (OR 10.7, p < 0.005), and a period of abstinence less than 6 months when placed on the transplant waiting list (OR 3.3, p = 0.02).

Dr. Dumortier and associates observed that in the absence of any of these three factors, only 18 of 272 patients (5%) relapsed. If one factor was present, the proportion increased to 16 of 92 (18%). With two factors, the relapse rate was 14 of 22 patients (64%), and for the three patients with all three factors, the rate was 100%.

The corresponding time from transplantation to relapse averaged 45, 30, 32, and 23 months, respectively.

"The results of the present study warrant further consideration, not only because 3 parameters ... were associated with alcohol relapse, but also because the combination thereof assumed a particular importance," the authors write, noting the risk of recidivism was < 20% in the presence of one factor alone, while the combination of two or three factors resulted in a risk exceeding 60%.

Moreover, the individual parameters are of great consequence, they add. They point out that psychiatric disorders are amenable to treatment, which could therefore reduce the risk of relapse of alcohol abuse.

Additionally, duration of sobriety "is crucial to know at the time of placement on the waiting list because this is an important element of decision-making before the liver transplantation, not at the moment of the liver transplantation."

A high HRAR score is notable for its strong, 10-fold increased risk of relapse. The research team comments that the HRAR score "applies equally to men and women."

They recommend that evaluation before liver transplantation for alcoholic liver disease should include these three parameters, and that a patient with two or three of them should be considered at very high risk of alcohol relapse.

Arch Intern Med 2007;167:1183-1188.