3/2/01 ADD_MED listserv Post by Robin Room Apparently I can't send the 13 abstracts in the text, as they're too long, so I'm trying again with a selection of them. Robin 6. Glannon, W. Responsibility, alcoholism, and liver transplantation. Journal of Medicine and Philosophy, 23(1):31-49, 1998. (146117) This paper discusses medical and moral arguments offered in response to the question of whether patients with alcohol-related end-stage liver disease should be given lower priority for a liver transplant than those whose disease is not alcohol-related. Though moral considerations may be invoked in assigning priority to some people over others concerning liver transplantation, these moral considerations are not grounded in virtue or vice, nor are they punitive. Instead, they are grounded in control and responsibility. Insofar as a person's choices and actions are not compelled or coerced by addictions or adverse social circumstances like extreme poverty, and insofar as he is capable of foreseeing that his choices and actions likely will lead to cirrhosis of the liver, he has sufficient control over these events and their consequences to be responsible for this disease. In addition, if he is capable of foreseeing that his control over and responsibility for liver failure will give him lower priority for needed medical treatment, then it is fair to give him lower priority for that treatment. Retrospective as well as prospective factors must be considered when deciding whether to treat a person for a disease; how the person contracted the disease in the first place and whether he had sufficient control over antecedent events to prevent it needs to be examined. Because of scarce medical resources, a shift is necessary in emphasis from treatment to prevention of disease, presupposing that people are able to make choices and actions to take responsibility for their health. 40 Ref. 7. Neuberger, J. Transplantation for alcoholic liver disease: Perspective from Europe. Liver Transplantation and Surgery, 4(5):S51-S57, 1998. (154509) Studies are reviewed showing similar survival rates of patients who receive a liver transplant for alcohol-related liver disease and those who receive them for other conditions. Abstinence from alcohol before liver transplantation is important, because it might make transplantation unnecessary. In the author's retrospective analysis of 254 patients with alcoholic liver disease referred for transplantation, 19 improved with abstinence and supportive care and no longer needed a transplant. The period of abstinence needed before undertaking transplantation is uncertain, however. Prognostic models for assessing patients with alcoholic liver disease have been developed but they do not correlate well with each other. Although return to alcohol consumption after transplantation is not uncommon, failure of the graft or damage to it is infrequent. Increasingly, alcohol-related liver disease is becoming an indication for liver transplantation, but some form of rationing will be required as the number of potential candidates exceeds the supply of donors. The author states that those who allocate donated livers will need to consider public opinion surveys showing that the general public places a lower priority on transplantation for alcoholic liver disease than for other indications. It is difficult to reconcile this public opinion and the organ transplantation guidelines of the American Medical Association, which do not exclude patients with alcoholic liver disease. More public debate is needed to achieve a consensus. 28 Ref. 8. Pereira, S.P.; Howard, L.M.; Muiesan, P.; Rela, M.; Heaton, N.; Williams, R. Effect of alcohol relapse on quality of life after liver transplantation for alcoholic liver disease. Gut, 43(1):159, 1998. (145934) The frequency of alcohol relapse and its effect on quality of life indicators was assessed in patients transplanted for alcoholic liver disease (ALD) over the last 10 years. In 56 ALD transplant (Tp) survivors, alcohol relapse and quality of life indicators were assessed by outpatient and casenote review and by postal questionnaire. Forty-seven questionnaires were returned. The results of the study revealed that 13 of the respondents (28 percent), and 2 of the 9 nonrespondents (22 percent) had evidence of harmful drinking at some time post-Tp. A further 13 patients admitted to drinking alcohol at least once, corresponding to an overall relapse rate of 28/56 or 50 percent. Those with alcohol relapse were: (1) transplanted longer ago; (2) had shorter pre-Tp abstinence periods; (3) rated their general health post-Tp less well, and (4) had more difficulty with bathing or climbing stairs than abstinent patients. These differences were most marked in the subgroup with harmful drinking, who were also more likely to have high sleep problem scores and to take benzodiazepines regularly. Despite these differences, health dimension scores were similar between the groups and were only marginally lower than those of UK community controls. In the long-term, at least 50 percent of patients will drink again at some stage post-Tp, although at lower levels of alcohol intake than previously. Those who experience difficulties with activities of daily living and/or sleep post-TP are at greatest risk of a return to harmful drinking, and may be the group who would benefit from professional counseling. 11. Lucey, M.R.; Carr, K.; Beresford, T.P.; Fisher, L.R.; Shieck, V.; Brown, K.A.; Campbell, D.A.; Appelman, H.D. Alcohol use after liver transplantation in alcoholics: A clinical cohort follow-up study. Hepatology, 25(5):1223-1227, 1997. (138070) The purposes of this study were to determine among a cohort of long-term alcoholic survivors after liver transplantation (1) the incidence of alcohol use; (2) its effect on allograft integrity; and (3) the validity of pretransplant alcohol prognosis screening process. A retrospective clinical cohort study of all alcoholic patients (n=3D50), who underwent orthotopic liver transplantation at a single center from February 1987 until January 1991 and followed-up through December 1994, was conducted. Thirty three (66 percent) consistently denied any alcohol use throughout the posttransplantation follow-up, whereas 17 (34 percent) were identified as having consumed alcohol at least once since the transplant. The median interval from transplantation to alcohol relapse was 17 months, with a range of 3 to 45 months. Recurrent alcohol use was associated with significant medical complications sufficient to require admission to the hospital in 6 patients. Mild or progressive hepatitis, which was the most common abnormality in posttransplant liver biopsy findings, was equally distributed between both alcohol users and abstainers and sometimes occurred in the absence of antibody to hepatitis C virus antibodies. There was a similar frequency of biopsy-proven acute cellular rejection in alcohol users and abstainers. It is concluded that alcohol use by alcoholics is uncommon in the first 5 years after liver transplantation. Among a small subset of alcoholic transplant recipients, drinking behavior after liver transplantation is associated with considerable morbidity, requiring hospital admissions and occasionally leading to graft loss and death. 29 Ref. 14. Mioni, D.; Burra, P.; Cillo, U.; Zanus, G.; Targhetta, S.; Graziotto, A.; Fagiuoli, S.; Salvagnini, M.; Naccarato, R. Liver transplantation (OLT) in patients with alcoholic liver disease (ALD) with respect to recidivism to alcohol consumption. Gut, 41(suppl 3):A238, 1997. (142675) Liver transplantation (OLT) is an effective therapeutic option for end-stage liver disease, and survival rates are encouraging. However, many transplant centers are still reluctant to accept patients with alcoholic liver disease (ALD) because of the risk of recidivism after the operation. This study evaluated long-term results (recidivism to alcohol consumption, incidence of acute rejection, and survival) in patients transplanted for ALD. Thirty-four patients (26 males, 8 females, median age 46 years, range 30-60 years) who underwent OLT for ALD were studied and compared with 92 patients (56 males, 36 females, median age 43 years, range 24-61 years) who underwent OLT for non-ALD up to 6 years. Recidivism in ALD patients or alcohol consumption in non-ALD patients were proved by a semistructured interview and self-rating questionnaires to assess physical and psychiatric morbidity, abnormal liver function tests, and liver biopsy. Acute rejection was diagnosed using established histologic criteria. Patient survival was estimated using the Kaplan-Meier method. At 1-13 months after OLT recidivism occurred in 5 of 25 (20 percent) of surviving ALD patients, all of them with alcohol dependence diagnosis before OLT. Alcohol consumption was declared by 5 of 65 (8 percent) of non-ALD patients at 1-13 months after OLT. Incidence of acute rejection was lower in ALD than in non-ALD patients (56 percent versus 64 percent). Patient survival at 1, 3, and 6 years after OLT was respectively 72, 72, and 72 percent in the ALD group and 76, 71, and 64 percent in the non-ALD group.=20 Copyright 1997 - BMJ Publishing Group 17. Pereira, S.P.; Muiesan, P.; Howard, L.; Rela, M.; Heaton, N.; Williams, R. Long-term survival and quality of life after liver transplantation for alcoholic liver disease. Gut, 41(suppl 3):A78, 1997. (142666) The frequency of alcohol relapse and its effects on long-term survival and functional status after orthotopic liver transplantation (OLT) for alcoholic liver disease (ALD) were studied in 111 patients (mean age 51 years, range 33-69) who underwent OLT for ALD after alcohol abstinence of 6 months or less. Alcohol relapse and quality of life indicators were assessed by outpatient and case note review and by questionnaires sent to survivors. In the first 3 months, 19 deaths occurred, 14 from sepsis or cardiac complications (74 percent). Twelve more patients died in 0.9-7.5 years (median 1.6 years) post-OLT, most frequently due to hepatoma recurrence (N =3D 3) or other malignancies = (N =3D 4). Actuarial survival rates for the 111 patients were 79 and 64 percent at 1 and 5 years respectively, compared with figures of 76 percent and 69 percent in 700 patients transplanted for other liver diseases. Of the 92 patients who survived at least 3 months, 18 (20 percent) reported at least one episode of drinking more than 3 units daily, while a similar number admitted to "social" drinking, after a median abstinence of 9 months. Five patients developed recurrent alcoholic cirrhosis/graft failure within 5 years; two of them died at 10-24 months. Abstinent and nonabstinent patients did not differ significantly in functional status after OLT. Thus long-term survival after OLT for ALD is similar to that for other liver transplant recipients. Alcohol relapse occurs in a large minority of patients, though at lower levels of alcohol intake than previously. In those with problem drinking post-transplant, graft damage occurs rapidly. Overall, however, quality of life indicators after transplantation for ALD are similar to those of the general popultiven.