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Alcohol relapse score predicts early liver transplant eligibility

SAN FRANCISCO — A novel prognostic score using four objective pretransplant variables identified patients with alcoholic hepatitis who were candidates for early liver transplantation with a low risk for sustained alcohol use posttransplant, according to data presented at The Liver Meeting 2018.

“Severe alcoholic hepatitis portends high mortality and there’s still no effective therapy for long-term survival,” Brian Lee, MD, from University of California in San Francisco, said in his presentation. “Early liver transplant, meaning without minimum curative abstinence, can be life-saving.”

To further define alcohol use after liver transplantation, Lee and colleagues categorized patients as having “non-sustained use” — in which they had stopped drinking at last follow-up — or “sustained use” from last follow-up.

“To differentiate between true sustained alcohol use and a recent slip, the minimum duration of alcohol use had to be at least 100 days,” Lee noted.

The study comprised 134 patients who underwent liver transplantation for alcoholic hepatitis with no specific sobriety period. Most patients were abstinent from last follow-up (74%) with 16% who “had slips only,” and 10% who had sustained alcohol use after a median of 1.6 years.

While sustained alcohol use was more rare than non-sustained use both at 1 year (10% vs. 26%) and 3 years (16% vs. 33%), sustained alcohol use correlated with a 4.6-fold higher risk for mortality compared with no significant risk among those with non-sustained use (P = .01).

“Given the impact to long-term outcomes, there is need for objective tools to guide patient selection, with the goal to minimize risk of sustained alcohol use after transplant,” Lee said.

The four variables that defined the Sustained Alcohol use post-LT score (SALT) included more than 10 drinks per day at initial hospitalization (4 points), multiple prior rehabilitation attempts (4 points), prior alcohol-related legal issues (2 points) and prior illicit substance abuse (1 point). SALT scores of 5 or higher had a positive predictive value of (95% CI, 10-47) and a negative predictive value of 95% (CI, 89-98) for sustained alcohol use posttransplant. The SALT score demonstrated a higher c-index (0.76; 95% CI, 0.68-0.83) than the High-Risk Alcoholism Relapse scale (0.56; 95% CI, 0.39-0.72).

“SALT may assist in selection of early LT candidates or to guide risk-based interventions posttransplant,” Lee said. “Given the low positive predictive value, high SALT should not preclude considerations of early transplant. Our next steps need to address external validation and strategies to prevent and intervene in patients with alcohol after transplant.” – Talitha Bennett

Reference:

Lee B, et al. Abstract 0012. Presented at: The Liver Meeting 2018; Nov. 9-13, 2018; San Francisco.

Disclosure: Lee reports no relevant financial disclosures.