Journal Club Alcohol, Other Drugs, and Health: Current Evidence September-October 2007

Featured Article A simple score for predicting alcohol relapse after liver transplantation: results from 387 patients over 15 years De Gottardi A, et al. Arch Intern Med. 2007;167(11): 1183–1188.

Study Objective To identify risk factors for alcohol use after liver transplantation (LT) for alcoholic liver disease

Study Design 387 patients who underwent LT for alcoholic liver disease were retrospectively enrolled in this study. Pre-LT alcohol use was assessed with the High-Risk Alcoholism Relapse (HRAR) scale. –The HRAR assesses chronicity of heavy drinking, prior alcohol consumption, and prior alcohol treatment history. Post-LT alcohol use was assessed at regular intervals over an average of 61 months. –Harmful use was defined as about >3.5 drinks of alcohol per day plus alcohol-related physical or mental consequences.

Assessing Validity of an Article about Prognosis Are the results valid? What are the results? How can I apply the results to patient care?

Are the Results Valid? Was the sample representative? Were the subjects sufficiently homogeneous with respect to prognostic risk? Was follow-up sufficiently complete? Were objective and unbiased outcome criteria used?

Was the sample representative? Patients included all those who received LT in 2 European hospitals between 1989 and 2005 (n=387). Indication for LT was based on... –the presence of end-stage liver disease, in which LT was the only option for survival; –the absence of medical or surgical contraindications, and –a period of abstinence (a minimum of 3 months was considered necessary).

Were the subjects sufficiently homogeneous with respect to prognostic risk?  High-Risk Alcoholism Relapse (HRAR) scores:  0–3 in 356 (93%) of subjects  4–6 in 27 (7%) of subjects

Was follow-up sufficiently complete?  Average follow-up after LT was 61 months (range of 0–192 months).

Were objective and unbiased outcome criteria used? Alcohol relapse was determined by self-report and thus could have been under-reported. Uniform criteria were used to define the outcome of relapse. No information about adherence to post LT follow- up visits was provided, raising a concern about selective reporting.

What are the Results? How likely are the outcomes over time? How precise are the estimates of likelihood?

How likely are the outcomes over time? Results: During an average follow-up of 61 months after LT, 12% had harmful alcohol use. In adjusted analyses, the following were significantly associated with harmful alcohol use after LT: –a score of >3 on the HRAR scale (odds ratio [OR], 10.7) –psychiatric comorbidity (OR, 7.8) –pre-LT abstinence from alcohol for ≤6 months (OR, 3.3)

How likely are the outcomes over time? (cont.) Harmful alcohol use after LT occurred in… –5% of patients with none of the above factors, –18% with 1 factor, –64% with 2 factors, and –100% with all 3 factors.

How precise are the estimates of likelihood? The 95% Confidence Intervals (CIs) are wide: –For a score of >3 on the HRAR scale: OR, 10.7; 95% CI, 3.8–30.0 –For psychiatric comorbidity: OR, 7.8; 95% CI, 3.1–20.0 –For pre-LT abstinence from alcohol for <6 months: OR, 3.3; 95% CI, 1.2–9.3

How Can I Apply the Results to Patient Care? Were the study patients and their management similar to those in my practice? Was the follow-up sufficiently long? Can I use the results in the management of patients in my practice?

Were the study patients similar to those in my practice? 76% were male. Average age at transplantation was 51 years. 57% were “blue collar” workers. 21% had an anxiety or depressive disorder. 93% had low scores (0–3) on the HRAR scale.

Was the follow-up sufficiently long? Average follow-up after LT was 61 months.

Can I use the results in the management of patients in my practice? This observational study provides data indicating that LT patients are more likely to relapse if they have the following: –more chronic heavy drinking –greater daily alcohol consumption –extensive prior treatment histories –psychiatric comorbidity –shorter durations of abstinence Knowledge of these factors can help predict the likelihood of relapse to harmful drinking.