DAY 2 - Post Liver Transplantation Management of Alcohol Use Disorder Lowers Mortality and Risk of Relapse

Patients with alcohol-related liver disease (ALD) face alarmingly high relapse rates of 30-50% and a 5-year mortality rate of 20% after liver transplantation (LT). These concerning statistics underscore the critical need for effective interventions to prevent alcohol use disorder (AUD) relapse and improve long-term outcomes. ALD has emerged as a leading indication for LT worldwide, presenting significant challenges in post-transplant management and emphasizing the importance of developing strategies for this vulnerable patient population. However, knowledge of optimal management of AUD post-transplantation remains limited.

At the American College of Gastroenterology (ACG) 2024 Annual Scientific Meeting in Philadelphia, Pennsylvania, Dr. Himsikhar Khataniar, an Internal Medicine Resident at Allegheny General Hospital in Pittsburgh, reported findings from published data on interventions for LT recipients to reduce relapse and decrease mortality. 

The research method involved a systematic search of PubMed, MEDLINE, and Embase databases from their inception to September 2023, identifying studies reporting on post-LT interventions to prevent alcohol relapse. The study encompassed behavioral and pharmacological interventions, providing a comprehensive view of available treatment options.

766 patients (80.1% male, mean age 50.54±6.5 years) exposed to post-LT interventions for AUD were studied. Following continued treatment with either intervention, pharmacological or behavioral, the combined risk of relapse post-LT was 19% compared to the previously reported 30-50%. The aggregated mortality risk was 6%, a remarkable improvement from the 20% reported in earlier literature. A subgroup analysis of pharmacological interventions showed a 17% relapse risk and 7% mortality risk. Interestingly, no significant differences were found between pharmacological and behavioral approaches, suggesting both can be effective treatment plans.

"This is the first meta-analysis examining post-liver transplantation interventions for alcohol use disorder," said Dr. Khataniar. He acknowledged some research limitations, "Concomitant substance use disorders, such as opioid use disorders, were not thoroughly addressed, and we think the need for long-term studies on intervention efficacy is important." Post-LT AUD management is multifaceted and involves neurobiological, psychosocial, and socioeconomic factors. Dr. Khataniar concluded, "AUD management post-liver transplant reduces both relapse and mortality, and both pharmacological and behavioral interventions are effective." He stressed the importance of establishing specialized teams at transplant centers for extended post-transplant follow-up, mentioning that such an initiative has been started at Allegheny General Hospital.

In response to audience questions on whether AUD treatment generally stops after transplant and why that happens, Dr. Khataniar explained that post-transplant treatment primarily focuses on behavioral modifications rather than medications. Naltrexone is the most commonly used medication, and baclofen was used in one randomized control trial. Apart from these, no other medications were reportedly used post-transplant, possibly due to concerns about adverse effects.".

This research raises further questions about effective intervention combinations, implementation of long-term AUD management programs, strategies for addressing co-occurring substance use disorders, and potential biomarkers for relapse risk. The study underscores the need for a multidisciplinary approach to care, combining pharmacotherapy with behavioral therapy for effective management.