Scoring methods inaccurately predict who will relapse to alcohol post LT

SAN FRANCISCO — Current methods for predicting harmful alcohol relapse after liver transplantation accurately predict who will not relapse but have low positive predictive values, according to data presented at The Liver Meeting 2018.

“Cirrhosis due to alcohol is increasing in incidence and alcoholic hepatitis is an increasingly common indication for transplant,” Michael D. Voigt, MD, from the University of Iowa School of Medicine, said in his presentation. “Standard approach to selecting patients with alcohol use disorder for transplant is to use predictive factors to stratify the risk of alcohol relapse following transplant and then exclude those at the highest risk. Our aim was to evaluate the accuracy of clinical and objective scoring systems in predicting this relapse to harmful drinking.”

Voigt and colleagues selected the Stanford Integrated Psychosocial Assessment for Transplant (SIPAT) and High Risk for Alcohol Relapse score (HRAR) for the study.

The retrospective cohort comprised 269 patients with alcohol use disorder (AUD) who underwent evaluation for liver transplantation between 2008 and 2015. All patients had at least 2 years of follow-up. Forty-three patients underwent transplantation and 38 remained listed.

At follow-up, 26 patients relapsed and 127 patients remained abstinent. The researchers found no significant difference between those who relapsed and those who did not regarding age, sex, stable partner, history of drug use, or treatment.

Patients who relapsed were more likely to continue to drink after the initial diagnosis of liver disease than those who did not relapse (77% vs. 43%; P = .002) and were more likely employed (42% vs. 24%).

Factors that correlated with relapse included receipt of transplant (HR = 2.32; 95% CI, 1.11-4.86), continued alcohol use after liver disease diagnosis (HR = 5.07; 95% CI, 1.99-12.88), duration of drinking (HR = 0.95; 95% CI, 0.91-0.99), and sobriety duration prior to evaluation (HR = 0.833; 95% CI, 0.75-0.92).

Additionally, high risk for relapse to harmful alcohol use by a social work assessment (HR = 13.31; 95% CI, 2.84-62.28) and by psychologist assessment (HR =7.08; 95% CI, 1.52-32.89) correlated with an increased risk. Denial for waitlisting was the most significant factor correlated with relapse (HR = 11.371; 95% CI, 1.12-1,115.45).

Based on these results, HRAR scores between 4 and 6 had a positive predictive value of 23% and negative predictive value of 81%, and SIPAT scores less than 40 had a positive predictive value of 0% and negative predictive value of 97%.

High risk based on social work assessment had a positive predictive value of 27% and negative predictive value of 97%. High risk based on psychological assessment had a 21% positive predictive value and 97% negative predictive value.

“If clinical or objective scores are unfavorable, these alone should not rule out listing for liver transplant,” “Therefore, an alternative approach to preventing posttransplant relapse to harmful drinking is needed. Patients with high risk scores should be considered for transplant, but targeted for posttransplant management of AUD.” – by Talitha Bennett

Reference:

Voigt MD, et al. Abstract 0247. Presented at: The Liver Meeting 2018; Nov. 9-13, 2018; San Francisco.

Disclosure: Voigt reports no relevant financial disclosures.