- Email: [email protected]
Recommendations for alcohol-related liver disease
Comment
We thank Hilary Standing for her insights and contributions to this Comment. We are all involved in the Consortium. We declare that we have no other conflict of interest. 1
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International Women’s Health Coalition. The Cairo consensus: the right agenda for the right time: International Conference on Population and Development. 1995: http://www.iwhc.org/docUploads/ CAIROCONSENSUS.PDF (accessed May 19, 2006). Misra G, Chandiramani R. Sexuality, gender and rights. New Delhi: Sage, 2005. WHO. Gender and reproductive rights. 2005: http://www.who.int/ reproductive-health/gender/sexual_health.html (accessed May 15, 2006). Merali I. Advancing women’s reproductive and sexual health rights: using the international human rights system. Dev Pract 2000; 10: 609–24. Centre for Reproductive Law and Policy (CRLP). Beijing +5: assessing reproductive rights. November, 2000: http://www.crlp.org/pdf/pub_bp_ Beijing+5.pdf (accessed May 15, 2006).
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Nyamu-Musembi C. Towards an actor-oriented perspective on human rights: working paper 169. 2002: http://www.ntd.co.uk/idsbookshop/ details.asp?id=713 (accessed May 15, 2006). Silberschmidt M. Male sexuality in the context of socio-economic change in rural and urban East Africa. Sexual Africa Magazine 2005; 2: http://www.arsrc. org/resources/publications/sia/apr05/issue.htm (accessed May 15, 2006). Cornwall A, Welborne A. Realizing rights: transforming approaches to sexual and reproductive well being. London: Zed Books, 2002. UNFPA. Ensuring reproductive rights and implementing sexual and reproductive health programmes including women’s empowerment, male involvement and human rights: expert round table meeting, Kampala, June 22–25, 1998: http://www.unfpa.org/icpd5/meetings/kampala_rh/reports/ reportkampala.htm (accessed May 15, 2006). Realising Rights. Improving sexual and reproductive health in poor and vulnerable populations. 2005: http://www.realising-rights.org (accessed May 23, 2006).
Recommendations for alcohol-related liver disease Orthotopic liver transplantation for alcoholic liver disease is well established in the UK. Survival for patients and grafts is similar to that for other causes of liver disease, at least in the first 5 years. Evidence from the USA suggests that survival beyond 5 years is reduced, particularly in people who return to drinking.1 Prediction of who will return to drinking is challenging because few good studies have been published that identify reliable factors. In the UK, seven units undertake liver transplantations, with transplantation for alcoholic liver disease accounting for around 25% of all procedures although the proportion for each unit varies (17–34%). Because this disease continues to be (probably) the most controversial indication in terms of the attitude of the general public, all units should use a similar approach to assessment, listing for transplantation, and follow-up of patients, and they should standardise advice given about alcohol intake in the liver-transplant setting. The following recommendations were agreed by a working party including representatives from every unit and have been ratified by the UK Liver Advisory Group. Panel 1 summarises these recommendations. Patients admitted for assessment when alcohol has contributed to their liver disease should be reviewed by a specialist in substance misuse. This process should include careful attention to risk factors associated with prediction of relapse to drinking, and should provide advice for the transplant team on follow-up requirements to prevent relapse into drinking. At present, evidence that a fixed period of abstinence will predict patients’ adherence after transplantation www.thelancet.com Vol 367 June 24, 2006
is conflicting.2–8 However, we should recognise that, with abstinence, many potential patients will improve to such an extent that transplantation is no longer indicated. A period of abstinence is also required to allow the addiction team to assess the individual and organise any support measures that might be needed. The working party agreed on several factors that all precluded from listing for a liver transplant because a poor outcome for the graft was likely.2,4–6,9 Panel 2 outlines these factors. If the opinion of the multidisciplinary team is that a patient should be listed, that individual will be asked to sign an agreement that they will not drink after the operation and will adhere to follow-up requirements. The expectation is that all patients who undergo transplantation for alcoholic liver disease will remain abstinent after the procedure. To encourage this
Panel 1: Recommendations for liver transplantation in patients with alcoholic liver disease Assessment ● Alcohol specialist Contraindications ● Alcoholic hepatitis ● More than two episodes of medical non-adherence ● Return to drinking after full professional assessment ● Current illicit drug misuse Listing ● Sign agreement indicating intention of abstinence Follow-up ● Alcohol specialist and transplant clinician
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Comment
Panel 2: Factors precluding listing for liver transplantation ●
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Alcoholic hepatitis—clinical syndrome of jaundice, coagulopathy rather than histological diagnosis. Repetitive episodes (more than two) of non-adherence to medical care, for which there was satisfactory explanation. This factor should not be confined to management of the patient’s liver disease. Return to drinking after full professional assessment and advice (includes permanent removal from transfer list if found to be drinking while listed). Current or consecutive illicit drug misuse (except occasional cannabis use).
outcome, follow-up for alcohol use will be separate from and additional to transplant follow-up and should be undertaken by specialists in substance misuse. Ideally, these workers would be the same individuals involved in the patient’s assessment. As time from the liver transplantation increases, we anticipate that frequency of follow-up will fall and that shared-care arrangements with alcohol services in the patient’s locality will usually be appropriate. The type and frequency will depend on the patient’s needs. The same process of assessment and listing should be applied to patients for whom alcohol has contributed to the progression of another chronic liver disease. This is definitely the case if alcohol consumption is greater than 100 units a week and is very likely to be the case if consumption lies between 50 and 100 units. A separate agreement indicating alcohol as a cofactor should be used. As with all potential transplant patients, if a possible recipient is judged by the multidisciplinary team not to be a suitable candidate, the opportunity for a second opinion from a second liver-transplant unit should be offered. This appraisal should initially be in the form of a case-notes review, with full reassessment to follow if appropriate. Because alcohol contributes to progression of hepatitis C disease, we recommend that all recipients with
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chronic hepatitis C infection, irrespective of whether they have misused alcohol or not, should be advised to abstain from alcohol. Clinical experience suggests that a liver allograft is more susceptible to alcohol injury than a native liver. Therefore, in recipients not undergoing transplantation for alcoholic liver disease or hepatitis C infection, we recommend that a patient has 2 alcohol-free days a week and that men do not exceed three units in 1 day and women do not exceed two units in 1 day. A J Bathgate, on behalf of the UK Liver Transplant Units’ Working Party Scottish Liver Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh EH3 9YW, UK [email protected] Members of the working party are: A Bathgate, G Masterton (Scottish Liver Transplant Unit, Edinburgh); M Hudson (Freeman Hospital, Newcastle upon Tyne); C Millson (St James’ Hospital, Leeds); J Neuberger, Kerry Webb (Queen Elizabeth Hospital, Birmingham); M Allison (Addenbrooke’s Hospital, Cambridge); J O’Grady (Kings College Hospital, London); and A Burroughs, L Shepherd (Royal Free Hospital, London). We declare that we have no conflict of interest. 1
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Cuadrado A, Fabrega E, Casafont F, Pons-Romero F. Alcohol recidivism impairs long-term survival after orthotopic liver transplantation for alcoholic liver disease. Liver Transpl 2005; 11: 420–26. Gish RG, Lee AH, Keeffe EB, Rome H, Concepcion W, Esquivel CO. Liver transplantation for patients with alcoholism and end-stage liver disease. Am J Gastroenterol 1993; 88: 1337–42. Anand AC, Ferraz-Neto BH, Nightingale P, et al. Liver transplantation for alcoholic liver disease: evaluation of a selection protocol. Hepatology 1997; 25: 1478–84. Foster PF, Fabrega F, Karademir S, Sankary HN, Mital D, Williams JW. Prediction of abstinence from ethanol in alcoholic recipients following liver transplantation. Hepatology 1997; 25: 1469–77. Gish RG, Lee A, Books L, Leung J, Lau JYN, Moore DH. Long-term follow-up of patients diagnosed with alcohol dependence or alcohol abuse who were evaluated for liver transplantation. Liver Transpl 2001; 7: 581–87. DiMartini A, Day N, Dew MA, et al. Alcohol use following liver transplantation: a comparison of follow-up methods. Psychosomatics 2001; 42: 55–62. Jauhar S, Talwalkar JA, Schneekloth T, Jowsey S, Wiesner RH, Menon KV. Analysis of factors that predict alcohol relapse following liver transplantation. Liver Transpl 2004; 10: 408–11. Miguet M, Monnet E, Vanlemmens C, et al. Predictive factors of alcohol relapse after orthotopic liver transplantation for alcoholic liver disease. Gastroenterol Clin Biol 2004; 28: 845–51. Zibari GB, Edwin D, Wall L, et al. Liver transplantation for alcoholic liver disease. Clin Transplant 1996; 10: 676–79.
www.thelancet.com Vol 367 June 24, 2006
We thank Hilary Standing for her insights and contributions to this Comment. We are all involved in the Consortium. We declare that we have no other conflict of interest. 1
2 3 4 5
International Women’s Health Coalition. The Cairo consensus: the right agenda for the right time: International Conference on Population and Development. 1995: http://www.iwhc.org/docUploads/ CAIROCONSENSUS.PDF (accessed May 19, 2006). Misra G, Chandiramani R. Sexuality, gender and rights. New Delhi: Sage, 2005. WHO. Gender and reproductive rights. 2005: http://www.who.int/ reproductive-health/gender/sexual_health.html (accessed May 15, 2006). Merali I. Advancing women’s reproductive and sexual health rights: using the international human rights system. Dev Pract 2000; 10: 609–24. Centre for Reproductive Law and Policy (CRLP). Beijing +5: assessing reproductive rights. November, 2000: http://www.crlp.org/pdf/pub_bp_ Beijing+5.pdf (accessed May 15, 2006).
6
7
8 9
10
Nyamu-Musembi C. Towards an actor-oriented perspective on human rights: working paper 169. 2002: http://www.ntd.co.uk/idsbookshop/ details.asp?id=713 (accessed May 15, 2006). Silberschmidt M. Male sexuality in the context of socio-economic change in rural and urban East Africa. Sexual Africa Magazine 2005; 2: http://www.arsrc. org/resources/publications/sia/apr05/issue.htm (accessed May 15, 2006). Cornwall A, Welborne A. Realizing rights: transforming approaches to sexual and reproductive well being. London: Zed Books, 2002. UNFPA. Ensuring reproductive rights and implementing sexual and reproductive health programmes including women’s empowerment, male involvement and human rights: expert round table meeting, Kampala, June 22–25, 1998: http://www.unfpa.org/icpd5/meetings/kampala_rh/reports/ reportkampala.htm (accessed May 15, 2006). Realising Rights. Improving sexual and reproductive health in poor and vulnerable populations. 2005: http://www.realising-rights.org (accessed May 23, 2006).
Recommendations for alcohol-related liver disease Orthotopic liver transplantation for alcoholic liver disease is well established in the UK. Survival for patients and grafts is similar to that for other causes of liver disease, at least in the first 5 years. Evidence from the USA suggests that survival beyond 5 years is reduced, particularly in people who return to drinking.1 Prediction of who will return to drinking is challenging because few good studies have been published that identify reliable factors. In the UK, seven units undertake liver transplantations, with transplantation for alcoholic liver disease accounting for around 25% of all procedures although the proportion for each unit varies (17–34%). Because this disease continues to be (probably) the most controversial indication in terms of the attitude of the general public, all units should use a similar approach to assessment, listing for transplantation, and follow-up of patients, and they should standardise advice given about alcohol intake in the liver-transplant setting. The following recommendations were agreed by a working party including representatives from every unit and have been ratified by the UK Liver Advisory Group. Panel 1 summarises these recommendations. Patients admitted for assessment when alcohol has contributed to their liver disease should be reviewed by a specialist in substance misuse. This process should include careful attention to risk factors associated with prediction of relapse to drinking, and should provide advice for the transplant team on follow-up requirements to prevent relapse into drinking. At present, evidence that a fixed period of abstinence will predict patients’ adherence after transplantation www.thelancet.com Vol 367 June 24, 2006
is conflicting.2–8 However, we should recognise that, with abstinence, many potential patients will improve to such an extent that transplantation is no longer indicated. A period of abstinence is also required to allow the addiction team to assess the individual and organise any support measures that might be needed. The working party agreed on several factors that all precluded from listing for a liver transplant because a poor outcome for the graft was likely.2,4–6,9 Panel 2 outlines these factors. If the opinion of the multidisciplinary team is that a patient should be listed, that individual will be asked to sign an agreement that they will not drink after the operation and will adhere to follow-up requirements. The expectation is that all patients who undergo transplantation for alcoholic liver disease will remain abstinent after the procedure. To encourage this
Panel 1: Recommendations for liver transplantation in patients with alcoholic liver disease Assessment ● Alcohol specialist Contraindications ● Alcoholic hepatitis ● More than two episodes of medical non-adherence ● Return to drinking after full professional assessment ● Current illicit drug misuse Listing ● Sign agreement indicating intention of abstinence Follow-up ● Alcohol specialist and transplant clinician
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Comment
Panel 2: Factors precluding listing for liver transplantation ●
●
●
●
Alcoholic hepatitis—clinical syndrome of jaundice, coagulopathy rather than histological diagnosis. Repetitive episodes (more than two) of non-adherence to medical care, for which there was satisfactory explanation. This factor should not be confined to management of the patient’s liver disease. Return to drinking after full professional assessment and advice (includes permanent removal from transfer list if found to be drinking while listed). Current or consecutive illicit drug misuse (except occasional cannabis use).
outcome, follow-up for alcohol use will be separate from and additional to transplant follow-up and should be undertaken by specialists in substance misuse. Ideally, these workers would be the same individuals involved in the patient’s assessment. As time from the liver transplantation increases, we anticipate that frequency of follow-up will fall and that shared-care arrangements with alcohol services in the patient’s locality will usually be appropriate. The type and frequency will depend on the patient’s needs. The same process of assessment and listing should be applied to patients for whom alcohol has contributed to the progression of another chronic liver disease. This is definitely the case if alcohol consumption is greater than 100 units a week and is very likely to be the case if consumption lies between 50 and 100 units. A separate agreement indicating alcohol as a cofactor should be used. As with all potential transplant patients, if a possible recipient is judged by the multidisciplinary team not to be a suitable candidate, the opportunity for a second opinion from a second liver-transplant unit should be offered. This appraisal should initially be in the form of a case-notes review, with full reassessment to follow if appropriate. Because alcohol contributes to progression of hepatitis C disease, we recommend that all recipients with
2046
chronic hepatitis C infection, irrespective of whether they have misused alcohol or not, should be advised to abstain from alcohol. Clinical experience suggests that a liver allograft is more susceptible to alcohol injury than a native liver. Therefore, in recipients not undergoing transplantation for alcoholic liver disease or hepatitis C infection, we recommend that a patient has 2 alcohol-free days a week and that men do not exceed three units in 1 day and women do not exceed two units in 1 day. A J Bathgate, on behalf of the UK Liver Transplant Units’ Working Party Scottish Liver Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh EH3 9YW, UK [email protected] Members of the working party are: A Bathgate, G Masterton (Scottish Liver Transplant Unit, Edinburgh); M Hudson (Freeman Hospital, Newcastle upon Tyne); C Millson (St James’ Hospital, Leeds); J Neuberger, Kerry Webb (Queen Elizabeth Hospital, Birmingham); M Allison (Addenbrooke’s Hospital, Cambridge); J O’Grady (Kings College Hospital, London); and A Burroughs, L Shepherd (Royal Free Hospital, London). We declare that we have no conflict of interest. 1
2
3
4
5
6
7
8
9
Cuadrado A, Fabrega E, Casafont F, Pons-Romero F. Alcohol recidivism impairs long-term survival after orthotopic liver transplantation for alcoholic liver disease. Liver Transpl 2005; 11: 420–26. Gish RG, Lee AH, Keeffe EB, Rome H, Concepcion W, Esquivel CO. Liver transplantation for patients with alcoholism and end-stage liver disease. Am J Gastroenterol 1993; 88: 1337–42. Anand AC, Ferraz-Neto BH, Nightingale P, et al. Liver transplantation for alcoholic liver disease: evaluation of a selection protocol. Hepatology 1997; 25: 1478–84. Foster PF, Fabrega F, Karademir S, Sankary HN, Mital D, Williams JW. Prediction of abstinence from ethanol in alcoholic recipients following liver transplantation. Hepatology 1997; 25: 1469–77. Gish RG, Lee A, Books L, Leung J, Lau JYN, Moore DH. Long-term follow-up of patients diagnosed with alcohol dependence or alcohol abuse who were evaluated for liver transplantation. Liver Transpl 2001; 7: 581–87. DiMartini A, Day N, Dew MA, et al. Alcohol use following liver transplantation: a comparison of follow-up methods. Psychosomatics 2001; 42: 55–62. Jauhar S, Talwalkar JA, Schneekloth T, Jowsey S, Wiesner RH, Menon KV. Analysis of factors that predict alcohol relapse following liver transplantation. Liver Transpl 2004; 10: 408–11. Miguet M, Monnet E, Vanlemmens C, et al. Predictive factors of alcohol relapse after orthotopic liver transplantation for alcoholic liver disease. Gastroenterol Clin Biol 2004; 28: 845–51. Zibari GB, Edwin D, Wall L, et al. Liver transplantation for alcoholic liver disease. Clin Transplant 1996; 10: 676–79.
www.thelancet.com Vol 367 June 24, 2006