A Review of Behavioral Alcohol Interventions for Transplant Candidates and Recipients With Alcohol-Related Liver Disease

Hera E. Schlagintweit; Marie-Josée Lynch; Christian S. Hendershot

Disclosures

American Journal of Transplantation. 2019;19(10):2678-2685. 

In This Article

Abstract and Introduction

Abstract

Alcohol-related liver disease (ALD) is a common indication for liver transplantation. Reflecting growing consensus that early transplant (ie, prior to sustained abstinence) can be a viable option for acute alcoholic hepatitis, access to liver transplantation for ALD patients has increased. Prevention of alcohol relapse is critical to pretransplant stabilization and posttransplant survival. Behavioral interventions are a fundamental component of alcohol use disorder treatment, but have rarely been studied in the transplant context. This scoping review summarizes published reports of behavioral and psychosocial alcohol interventions conducted with ALD patients who were liver transplant candidates and/or recipients. A structured review identified 11 eligible reports (3 original research studies, 8 descriptive papers). Intervention characteristics and clinical outcomes were summarized. Interventions varied significantly in orientation, content, delivery format, and timing/duration. Observational findings illustrate the importance of situating alcohol interventions within a multidisciplinary treatment context, and suggest the potential efficacy of cognitive-behavioral and motivational enhancement interventions. However, given extremely limited research evaluating behavioral alcohol interventions among ALD patients, the efficacy of behavioral interventions for pre- and posttransplant alcohol relapse remains to be established.

Introduction

Alcohol-related liver disease (ALD), including alcoholic cirrhosis and acute alcoholic hepatitis, represents the majority of liver disease cases[1,2] and is a primary indication for liver transplant.[3] Despite evidence for positive transplant outcomes,[4–6] ALD patients have historically faced considerable barriers to transplant access, including the common prerequisite of 6 months of continuous abstinence prior to transplant listing.[7–9] More recently, developments such as growing consensus that early transplant (ie, prior to sustained abstinence) is a viable option for acute alcoholic hepatitis,[3,6,10] and improvements in the treatment of hepatitis C infection, have contributed to increased transplant access for ALD patients.[11]

Because posttransplant resumption of alcohol use can compromise long-term survival,[12–14] comprehensive alcohol use disorder (AUD) treatment is a crucial element of pre- and posttransplantation procedures.[15,16] While select pharmacotherapies (eg, acamprosate, baclofen) may be safely prescribed to ALD patients to help maintain abstinence,[17] the extent to which behavioral alcohol interventions (a critical element of evidence-based alcohol treatment approaches) are effective for ALD patients is uncertain. ALD patients represent a unique subpopulation of those with AUD, often presenting with a chronic and severe history of alcohol addiction and variable insight and motivation into alcohol problems.[18,19] These considerations may call into question the generalizability of conventional AUD interventions to ALD patients.[19]

Randomized, prospective research on behavioral alcohol interventions in the transplant context is scant, leaving providers to make decisions about AUD treatments without ample research evidence. Nonetheless, several teams internationally have reported information on behavioral interventions for ALD patients, including some novel innovations.[20] Given that there have been few efforts to summarize this literature, this scoping review aims to summarize characteristics and clinical outcomes of behavioral alcohol interventions for ALD patients in the transplant context. Reviews of AUD treatment in ALD more broadly, including pharmacological treatment approaches, are available elsewhere.[18,17]

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