New Tool Can Predict Patients at Low Risk for Return to Sustained Alcohol Use Following Early Liver Transplantation

Among patients with alcohol-related liver disease receiving early liver transplantation (e.g., without a specific period of abstinence), a return to sustained alcohol use post liver-transplant is associated with a 5-fold increased risk of death compared with abstinence. Researchers sought to develop a predictive tool to identify patients pre-transplant with low risk for sustained alcohol use post-transplant using retrospective data on 134 patients with severe alcohol-related hepatitis who received early liver transplantation. Alcohol use in the post-transplant period was obtained primarily through self-report and categorized.*

• Of 134 patients, 72% were male and 82% were Caucasian. The median time of abstinence pre-liver transplant was 54 days, and the median Model for End-Stage Liver Disease-Sodium (MELD-Na) score was 34.
• 129 patients survived to home discharge post-transplant and were followed for a median of 1.6 years. Of this group, 26% self-reported any alcohol use post-transplant; 21 individuals had a “slip” while 13 had sustained alcohol use.
• 4 variables were associated with sustained alcohol use post-liver transplant and comprise the SustainedAlcohol Use Post-Liver Transplant (SALT) score (range 0–11):
  • >10 drinks per day at initial hospitalization (+4 points);
  • >2 prior “failed” rehabilitation attempts (+4 points);
  • Any history of prior alcohol-related legal issues (+2 points);
  • History of non-tetrahydrocannabinol illicit substance use (+1 point).
• A SALT score >5 demonstrated a positive predictive value of 25%; a SALT score <5 demonstrated a 95% negative predictive value for sustained alcohol use post liver transplant.

* No alcohol use; a “slip” (defined as any alcohol use with recovered sobriety); or sustained alcohol use (defined as a minimum duration of 100 days).

Comments: Using 4 objective pre-transplant variables, the SALT score can identify candidates with severe alcohol-related hepatitis who are at low risk for sustained alcohol use following early liver transplantation. Utilization of this tool may not only inform appropriate patient selection for early transplantation among individuals with severe alcohol-related hepatitis, but can also guide risk-based interventions in the post-transplant period.

Seonaid Nolan, MD

Reference: Lee BP, Vittinghoff E, Hsu C, et al. Predicting low risk for sustained alcohol use after early liver transplant for acute alcoholic hepatitis: the Sustained Alcohol Use Post-Liver Transplant score. Hepatology. 2019;69(4):1477–1487.