Journal Article Annotations
2021, 3rd Quarter
Annotations by Sarah R. Andrews, MD
This prospective pilot study, based in Canada, challenges the 6-month-rule of abstinence for transplant in patients with alcohol-associated liver disease. Between May 2018 and October 2020, 703 referrals were made for liver transplant. Of these referrals, 14% were listed and 6% received transplants. There was no significant difference in survival rate among patients who had six months of sobriety prior to transplant compared to those who did not. Length of abstinence was not a predictor for returning to alcohol use, but younger age and lower Model for End-Stage Liver Disease (MELD) scores were. There was no significant difference with non-pilot patients with greater than six months of abstinence versus alcohol-liver disease pilot patients in return to alcohol use.
Strength and weaknesses:
This study is one of the first to pilot early liver transplantation beyond acute alcohol-associated hepatitis to include alcohol-related liver disease. One notable weakness of the study is the need for ongoing follow-up data to assess for sustained abstinence.
As the rate for early transplantation in acute alcohol-associated hepatitis has increased, this study focuses on more equitable transplant care for all patients with alcohol-related liver disease and how relapse prevention therapy and monitoring biomarkers can assist in decreased relapse rates and improving survival. This study is relevant for consulting transplant psychiatrists to better understand how to evaluate patients for transplant: simply suggesting abstinence for six months may not be as predictive of good clinical outcomes as other markers, such as MELD score.
This prospective cohort study evaluated depressive symptoms and sleep patterns among 66 lung or heart transplant patients for several years post-transplant. At six months following transplantation, patients were more likely to be sedentary and over one-third had increased depressive symptoms. Impaired quality of sleep was associated with increased depressive symptoms while better sleep quality was associated with less risk of hospitalization or death.
Strength and weaknesses:
The strength of this study was identifying the importance of sleep quality and transplant outcomes. Objective outcome measures improved internal validity: sleep quality was assessed from actigraphy-based data, which has been shown to be comparable in validity and reliability to polysomnography. Depressive symptoms were measured using the Centers for Epidemiologic Study of Depression (CESD). However, one weakness is that these data rely on association and do not show causation. The sample size is small, and the investigators lacked sleep data for recipients prior to transplant. It remains unclear how interventions on sleep might correlate with clinical outcomes.
C-L psychiatrists managing patients pre- and post- heart or lung transplant should carefully assess sleep symptoms, which correlate with both psychiatric and medical outcomes. It may well be that improving patients’ sleep may not only improve quality of life but also prolong life.