Annotations by Sarah R. Andrews, MD and Gregory Nikogosyan, DO
July, 2025
PUBLICATION #1 — Transplant Psychiatry
FDG PET of the brain to screen for neurodegenerative disease in older liver transplant candidates.
Natalie Jones, Trent M Schwartz, Steven Bishay, W Hudson Robb, Amanda Sams, Josh Kogan, Monica Nable, Sydney Nelson, Oliver S Zhao, Timothy Hohman, Steven Huang, Felipe Martinez, Ba Nguyen, Clifford Shin, Ming Yang, Holly Westervelt, Sarah M Szymkowicz, Lesley T Omary, Bashar A Aqel, Rolland Dickson, Blanca Lizaola, Amit Mathur, Manhal Izzy, Mary Ellen I Koran
Abstract: Eur J Nucl Med Mol Imaging. 2025 Jun 5. doi: 10.1007/s00259-025-07382-0. Online ahead of print.
Purpose The aging liver transplant population presents new challenges in distinguishing irreversible, age-related causes of dementia from hepatic encephalopathy (HE), given their overlapping clinical presentations. Dementia is often assessed through neuropsychological testing (NPT), but imaging utilizing biomarkers like Fluorodeoxyglucose (FDG) Positron Emission Tomography/Computed Tomography (PET/CT) has been considered as an alternative. This preliminary investigation aims to assess FDG PET/CT in screening for irreversible causes of dementia in older liver transplant candidates. Methods Eighteen patients with clinical suspicion for dementia during transplant evaluation were assessed using FDG PET/CT of the brain. Demographic data, FDG PET/CT and NPT results, and time between date of order and interpretation of FDG PET/CT and NPT were collected. Concordance between and time-to-diagnosis of FDG PET/CT and NPT were calculated. FDG PET/CT of these patients were compared to healthy, age-matched controls to determine altered patterns of FDG uptake in the brains of these patients. Results 40% of patients were diagnosed with an irreversible cause of dementia on FDG PET/CT. There was moderate agreement (K = 0.44) between NPT and FDG PET/CT. FDG PET/CT had a sensitivity and specificity of 100% and 50%, respectively. Time-to-diagnosis was significantly shorter with FDG PET/CT (12.4 days) compared to NPT (73.1 days). Voxel-wise analysis showed statistically significant diffuse cortical and basal ganglia hypometabolism in patients being evaluated for liver transplant versus age-matched healthy controls. Conclusion FDG PET/CT is helpful in screening for irreversible causes of dementia in older liver transplant candidates, but a positive PET indicates that further evaluation is required before denying a patient a potentially life-saving treatment. Efficient workup for these patients is crucial, and FDG PET/CT could provide a sensitive first screening test for dementia in older patients undergoing liver transplant evaluation which can be confirmed with NPT or with more specific biomarkers of neurodegenerative disease.
The finding:
Fluorodeoxyglucose (FDG) Positron Emission Tomography/Computed Tomography (FDG PET/CT) showed 100% sensitivity and 75% specificity for diagnosing dementia, using neuropsychological testing (NPT) as the reference standard. Moderate agreement between FDG PET/CT and NPT (Cohen’s Kappa = 0.44, 95% CI [0.074,0.82]). FDG PET/CT results were available much faster than NPT (mean of 12.4 days vs 73.1 days, p = 0.016). Patients exhibited diffuse hypometabolism in cortical and basal ganglia regions compared to healthy controls, particularly in frontal, temporal, parietal, and occipital lobes, potentially complicating specific dementia diagnoses.
Strengths and weaknesses:
This study addresses a critical need in transplant medicine to differentiate reversible cognitive impairments from irreversible neurodegenerative disease in older liver transplant candidates. FDG PET/CT appears to have high sensitivity and positions itself as a valuable initial screening tool for neurodegenerative diseases. The study was only 18 patients, with just 10 receiving both FDG PET/CT and NPT, limiting the findings’ generalizability. The predominantly white cohort may not represent diverse populations. Furthermore, it is not clear which 10 patients received NPT to determine the specificity of FDG PET/CT.
Relevance:
Rapid and accurate screening of neurodegenerative disorders pre-transplant is essential, given the increased morbidity and mortality. At the time of diagnosis, Alzheimer’s disease, for instance, may have a life expectancy of anywhere from 3 to 10 years. With proactive FDG PET/CT, there is a greater likelihood of capturing neurodegenerative disorders earlier, possibly leading to longer life expectancy after diagnosis. Although the article did not explore this, there is a possibility FDG PET/CT may capture a cohort of patients with an earlier stage or pre-stage of a neurodegenerative disease who may do well during the life of the newly transplanted organ. Careful studies and evaluation of the impact of early screening with FDG PET/CT should be studied prior to utilization for transplant risk assessment.
PUBLICATION #2 — Transplant Psychiatry
Liver Transplant Provider Perspectives on Posttransplant Management of Alcohol Use Disorder.
Maria P Cote, Daniel Cloonan, Sienna Li, Shahaan Razak, Ruby Singh, Taylor Coe, Paula C Zimbrean, Sarah Andrews, Ana Ivkovic, Stephen Bartels, Ryan Chadha, Emily Bethea, Heidi Yeh, Nicholas Lim, Leigh Anne Dageforde
Abstract: Transplant Direct. 2025 Mar 10;11(4):e1766. doi: 10.1097/TXD.0000000000001766. eCollection 2025 Apr.
Background:
Liver transplantation (LT) is the standard treatment for liver failure secondary to alcohol-associated liver disease, but limited literature and best practices exist for post-LT treatment of alcohol use disorder (AUD). This study explores current AUD management practices and providers’ perceived barriers to effective post-LT AUD management.
Methods:
A 45-item survey on post-LT AUD treatment practices was distributed to members of the American Society of Transplant Surgeons, the Association of Consult/Liaison Psychiatry Transplant Special Interest Group, and both the American Society of Transplantation’s Liver and Intestine Community of Practice and Psychosocial and Ethics Community of Practice discussion boards, between December 2021 and April 2022. Univariate analysis of categorical variables was performed using the chi-square test. Data were analyzed using center volume tertiles, country region, and provider professional activity.
Results:
Two hundred thirty-two respondents from 70 LT centers across all 11 United Network for Organ Sharing regions completed the survey. Half of the them were attending physicians and 16.4% were nurse coordinators. Most centers (84%) aimed for alcohol abstinence for all post-LT patients. Perceived barriers to AUD treatment efficacy included ongoing desire to drink (18%), denial about alcohol misuse (14.9%), and lack of posttransplant support (14%). Additionally, 62.1% of centers had no policy for prescribing medication-assisted therapy to treat AUD, and 32.7% of centers reported no center-level changes in AUD care. Providers identified primary needs as hiring additional mental health professionals (30.8%), dedicating specific staff to AUD care (24.7%), and standardizing psychiatric/psychological care in transplant clinics (17.2%).
Conclusions:
Despite the increasing volume of LT for alcohol-associated liver disease, significant perceived barriers to effective AUD treatment remain.
The Finding:
The study found that in those with alcohol associated liver disease, 45% were liver transplant cases, with 10% of those cases having severe alcohol-associated hepatitis (SAH). Furthermore, 88.1% of centers performed liver transplants on individuals with SAH. Furthermore, for management, 84% of centers aimed for complete alcohol abstinence for all post-LT patients, although screening for alcohol use is inconsistent, with only 25.3% of centers performing routine verbal screenings at all visits. The majority of centers, 76.9%, used biochemical screenings. In the treatment of AUD, it was found that 62.1% of centers lacked protocols for prescribing MAUD (medications for alcohol use disorder), and 33.5% were unsure who prescribed such treatments. Most common treatments were found to be acamprosate at 27.4% and naltrexone at 26.5%. Medication fatigue was reported to be a barrier to compliance in 49.3% of cases. Desired interventions by providers included mental health-related changes (62%), hiring more mental health professionals (30.8%), dedicating staff to AUD care (24.7%), and standardizing psychiatric care (17.2%). There was low within-center agreement on screening and MAUD prescribing, highlighting a lack of standardization. Finally, 63.9% of respondents note that patient relapse to alcohol use negatively affects team morale.
Strengths and weaknesses:
This study had a broad representation of 232 respondents from 59% of U.S. liver transplant centers, containing sites in all 11 United Network for Organ Sharing (UNOS) regions. The study included a range of providers such as physicians, nurses, coordinators, social workers, etc. The survey consisted of 45 items, which underwent iterative review and piloting to ensure validity. There is a possibility of selection bias due to low response rates, for example, four UNOS regions contributed 60.8% of responses. There was also variable center representation with some having only one respondent while others having over 10 respondents. Furthermore, this study does not integrate the patient perspective to factor in personal motivations or socioeconomic challenges in liver transplant.
Relevance:
The study highlights the urgent need for standardized AUD management protocols in liver transplant centers particularly given the high prevalence of ALD and the significant relapse rates seen within five years post-transplant. It underscores gaps in mental health resources and screening practices, informing strategies to improve patient outcomes. This study also focuses on resource inadequacies and provider-perceived barriers critical for developing targeted interventions to reduce relapse and improve graft survival. This may lead to policy implications such as national guidelines through professional bodies tailored to the post-LT population.
PUBLICATION #3 — Transplant Psychiatry
From embedded interprofessional clinics to expanded alcohol-associated liver disease programs.
Gerald Scott Winder, Juan Pablo Arab, Arpita Goswami Banerjee, Kelly Bryce, David C Fipps, Filza Hussain, Gene Im, Lesley Omary, Arpan A Patel, Shivali Patel, Susan Rubman, Marina Serper, Akhil Shenoy, Joji Suzuki, Paula Zimbrean, Kimberly Brown, Marwan Abouljoud, Jessica L Mellinger.
Abstract: Liver Transpl. 2025 May 13. doi: 10.1097/LVT.0000000000000638. Online ahead of print.
Hazardous alcohol use remains a major contributor to acute and chronic liver disease, while alcohol-associated liver disease (ALD) is a leading indication for liver transplantation. In recent years, embedded, interprofessional ALD clinics have improved access to alcohol use disorder care within hepatology and liver transplantation, but more work is needed to meet this challenge. The literature is lacking regarding scaling procedures to provide services for increasingly large ill patient populations. This article begins to fill this gap by describing “expanded ALD care”: broad, innovative, longitudinal, interprofessional care delivery strategies surpassing standalone clinics. Drawing from analogous patient populations served by collaborative models in primary care and comprehensive eating disorder treatment, the expanded ALD care framework proposes practical strategies toward specific innovations: equipoise between biomedical and psychosocial care elements, increased clinician number and reach, long-term patient relationships, harm reduction and palliative care, outreach to external agencies and clinicians, and enhanced support for patients and families. The article also defines attributes of innovative healthcare systems that support expanded ALD care.
The findings:
The article explores the importance of addressing hazardous alcohol use, which is a primary cause of liver disease, necessitating increased liver transplants. It discusses the necessity for better care integration for those with alcohol use disorders within liver healthcare settings. Recent efforts have seen the introduction of interprofessional clinics embedded within hepatology and liver transplant services to enhance access to care, but challenges remain in adequately expanding these programs to accommodate the growing number of affected patients. The article proposes an “expanded ALD (alcohol liver disease) care” model which goes beyond conventional clinic structures by integrating a wider, innovative range of long-term, interprofessional care strategies. It emphasizes a balanced approach between biomedical treatments and psychosocial interventions, improving the scope and capabilities of healthcare providers, and developing sustainable patient relationships including harm reduction and palliative care approaches, alongside effective collaboration with external bodies to support patients and families comprehensively.
Strengths and Weaknesses:
The strength of the proposed model lies in its comprehensive approach to integrating and extending care through a multi-disciplinary team, offering a longitudinal framework that encompasses a spectrum of care services from clinical treatment to psychosocial support. This model not only addresses the immediate needs of patients but also fosters longer-term therapeutic relationships and community integration. However, the article’s weaknesses include a lack of specific data on the efficacy of such models and possible challenges in practitioner training, funding, and resource allocation necessary to implement expanded ALD care at a larger scale.
Relevance to a CL Psychiatrist:
As experts at the intersection of physical health and psychiatric care, CL psychiatrists are uniquely positioned to contribute to comprehensive, multidisciplinary care model proposed for ALD patients. Their expertise in managing psychosocial aspects of chronic illnesses can significantly enhance the effectiveness of treatments by addressing both the psychological and physical aspects of alcohol use disorders, particularly within the context of liver disease and transplantation settings.
