Predictive factors of abstinence in patients undergoing liver transplantation for alcoholic liver disease

Transcription

1 ORIGINAL ARTICLE Abstinence in ptients undergoing liver trnsplnttion., 2012; 11 (2): Mrch-April, Vol. 11 No.2, 2012: Predictive fctors of bstinence in ptients undergoing liver trnsplnttion for lcoholic liver disese José Altmirno,* Rmón Btller,* Andres Crdens,*** Jvier Michelen,* Neus Freix,** Miquel Monrás,** José Ríos,**** Alexndre Liccioni,* Jun Cbllerí,* Antoni Gul,** Ann Lligoñ** * Liver Unit. Hospitl Clínic. Institut d Investigcions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBER de Enfermeddes Hepátics y Digestivs (CIBERehd), Brcelon, Spin. ** Alcohology Unit. Psychitry Deprtment, Neurosciences Institute, Hospitl Clínic, Brcelon, Spin. *** GI Unit. Hospitl Clínic, Brcelon, Spin. **** Lbortory of Biosttistics & Epidemiology (Universitt Autònom de Brcelon); Sttistics nd Methodology Support Unit (Hospitl Clínic). Institut d Investigcions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBER de Enfermeddes Hepátics y Digestivs (CIBERehd), Brcelon, Spin. ABSTRACT Introduction. Alcoholic cirrhosis is one of the most common indictions for liver trnsplnttion (LT) in western countries. A mjor concern bout trnsplnt ptients due to lcoholic liver disese (ALD) is lcoholic recidivism. Dt concerning psycho-socil chrcteristics of ptients with 6 months of bstinence t initil evlution for LT is scrce. Objectives. The ims of this study were 1) To evlute the psycho-socil profile of cohort of ptients with lcoholic cirrhosis being evluted for LT. 2) Determine fctors ssocited with bstinence from lcohol t initil psycho-socil evlution for LT nd 3) To evlute the potentil impct of lcohol-free beer consumption on 6-month bstinence. Mteril nd methods. Ninety ptients referred to the Alcohol Unit of the Hospitl Clínic of Brcelon (Jnury 1995-December 1996) were included. Univrite nd multivrite logistic regression nlyses were used to identify the fctors ssocited with cesstion in lcohol consumption nd with 6-month bstinence. Results. Fctors ssocited with cesstion in lcohol consumption were wreness of lcohol toxicity (OR = 5.84, CI , p = 0.02) nd fmily recognition (OR = 3.81, CI , p = 0.01). Cesstion of lcohol consumption t knowledge of ALD (OR = 5.50, CI , p = 0.009), wreness of lcohol toxicity (OR = 2.99, CI , p = 0.05) nd fmily recognition (OR = 5.21, CI , p = 0.03) were the independent fctors ssocited with 6-month bstinence previous to psycho-socil evlution for LT. Conclusion. In conclusion wreness of lcohol toxicity nd fmily recognition re the independent fctors tht influence cesstion in lcohol consumption nd 6-month bstinence in ptients evluted for LT. The use of lcohol-free beer ws ssocited with higher rte of bstinence in ptients without lcohol cesstion. Key words. Alcoholic liver disese. Liver trnsplnttion. Abstinence. Predictive fctors. Alcohol-free beer. INTRODUCTION Correspondence nd reprint request: Ann Lligoñ, M.D. Alcohol Unit. Addictions & Psychitry Deprtment. Neurosciences Institute. Hospitl Clínic Villrroel 170, Brcelon 08036, Spin Ph.: Fx: E mil: lligon@clinic.ub.es Mnuscript received: August 05, Mnuscript ccepted: October 03, Alcohol buse is one of the min cuses of preventble morbidity nd mortlity worldwide. 1-5 Alcoholic liver disese (ALD) is the mjor cuse of mortlity mong dult ptients with lcohol buse. Alcohol buse is responsible for up to 50% of the cses of cirrhosis. 4,6 As consequence, lcoholic cirrhosis is one of the most common indictions for liver trnsplnttion (LT) in Europe nd in North Americ. 7-8 The workup of ptients with ALD nd cirrhosis undergoing evlution of for LT is extensive nd requires severl steps nd involves proper evlution by multidisciplinry tem in order to determine ppropriteness of the procedure in ny given cndidte. 9 Psychologicl ssessment is key element in the evlution of ptients with ALD nd cirrhosis nd is importnt for the trnsplnt committee in deciding dequcy for LT. 10,11 However, despite ll these evlutions, some type of lcoholic recidivism fter trnsplnttion my occur in pproximtely 20-30% of ptients, thus plcing the ptient nd grft t risk of subsequent rejection or liver disese

2 214 Altmirno J, et l., 2012; 11 (2): The mjority of liver trnsplnt centers in the United Sttes nd Europe require 6-month period of bstinence from lcohol s well s psychosocil clernce before cceptnce in the LT list. Although this 6-month rule of bstinence is considered rbitrry, it is ssocited with better post- LT outcomes in terms of less hrmful-drinking nd less relpse mong ptients who meet this criterion t initil evlution. 15,16 Other risk fctors tht identify those ptients with high risk of post-lt lcohol relpse re presence of mentl illness, lck of fmily support, tobcco consumption, nd lck of insight of lcohol s the cuse of their disese t initil ssessment Currently, risk fctors ssocited with filure to meet bstinence requirements for listing hve not been dequtely studied. In ddition, informtion bout the psycho-socil chrcteristics of ptients with 6 months of bstinence t initil evlution for LT is scrce. Thus, the im of this study ws to evlute the psycho-socil profile of cohort of ptients with lcoholic cirrhosis being evluted for LT nd determine fctors ssocited with bstinence from lcohol t the initil psycho-socil evlution for LT. Other im ws to evlute the potentil impct of lcohol-free beer consumption on 6-month bstinence. MATERIAL AND METHODS Ptients nd dt collection Ptients referred to the Alcohol Unit (AU) of the Hospitl Clinic of Brcelon, between Jnury 1995 nd December 1996, were prospectively included. All ptients hd dignosis of lcoholic cirrhosis nd were in the process for evlution for LT. All psycho-socil dt were collected in the first visit to the AU s prt of the psychitric evlution before LT. Ptients with other cuses of liver disese nd ddiction to other type of substnces (i.e. cnnbis, cocine, heroin, etc.) were excluded. Clinicl, epidemiologicl, nlyticl nd psychologicl prmeters were collected. For the purpose of the study, different prmeters t the initil psychitric evlution prior to listing were ssessed. The AU hs extensive experience in the field of psychology nd psychitry of liver trnsplnt ptients. Dt bout prior lcohol consumption, consumption of psychotropic drugs, lcohol bstinence, time since lst lcohol consumption, lcohol-free beer consumption nd the number of previous lcohol detoxifying tretments were crefully collected. Ptient informtion ws obtined through systemtic clinicl interview. This interview is divided into different sections nd ws dministered by trined professionl. The section of demogrphic nd socil dt explores the personl nd fmilir, orgnic, psychitric nd toxicology bckground. Another section exmines the current disese ccording to the DSM-IV criteri for dignosis of dependence nd psychitric impirment ssocited with lcohol consumption. 24 Alcohol intke ws evluted by the Systemtic Interview of Alcohol Consumption (SIAC). 25 Ptient s ttitude during the first psychitric visit ws evluted cliniclly ccording to the Minnesot Multiphsic Personlity Inventory (MMPI) questionnire. 26 All collected informtion (from ptient nd reltives) ws lwys compred with the informtion provided to other medicl stff of the LT progrm of our center. Clinicl, psychitric nd socil evlution The dignosis of ALD ws bsed on history of routine nd risk lcohol consumption ssocited with clinicl, histologicl nd lbortory findings of lcohol buse (lcohol serum levels, elevted liver enzymes nd/or typicl histologicl fetures on liver biopsy). Before listing, ll ptients underwent stndrd medicl, socil nd psychitric workup. Bsed on the experience with this workup we hve recently published the clinicl guidelines of our center for the evlution of LT cndidtes with ddictions. 27 For ptients with lcoholic cirrhosis, the listing policy of our center requires t lest 6 months of bstinence from lcohol long with persistent sobriety nd positive follow-up for psychitric nd psychologicl evlutions. Finlly, before nd fter being ccepted on the LT witing list, ptients were subjected to ongoing lcohol bstinence monitoring with urine nd blood lcohol tests every week. In our centre ptients re not disqulified for LT cndidcy if they report to drink lcohol free-beer. Thus, they re considered to be dmitted to the witing list. Definitions Cesstion in lcohol consumption ws defined s the complete cesstion of lcoholic beverges t the first knowledge of lcohol-relted liver disese. 6-month bstinence ws defined s the bsence of

3 Abstinence in ptients undergoing liver trnsplnttion., 2012; 11 (2): lcoholic beverges consumption 6 months prior to the AU psycho-socil evlution. Alcohol-free beer consumption ws llowed in ptients undergoing LT evlution nd ws not considered n lcoholic beverge. Durtion of bstinence previous to AU visit ws evluted by self-reporting nd by confronttion questionnires with the ptients ner reltives. Ptients were defined s fsting lcohol consumers if the first consumption of n lcoholic beverge ws previous to their first mel of the dy. Awreness of lcohol toxicity ws defined s the bility of the ptient to understnd nd ccept the existence of negtive consequence (physicl, behviorl, legl, socil, nd/or fmilir) directly relted with his/her lcohol consumption. Alcohol dependence (AD) ws defined ccording to the DSM-IV criteri. The wreness of AD ws defined s the cpcity of ptient to understnd nd recognize his/her filure to control lcohol intke. In those ptients with AD wreness the presence of lcohol toxicity wreness ws ssumed. The ptients ttitude ws evluted during the first visit to the AU. We strtified ptients into three different subgroups: Honest ttitude. Those ptients with the cpcity to understnd nd fce the existence of medicl nd socil problems relted with the mount or frequency of lcohol consumption. Denil-defensive ttitude. Ptients with tendency to minimize, deny or present defensive behvior towrds the evlution of the different spects of his/her medicl problems, nd Impired ttitude. Those with denying/defensive ttitude cused by neuropsychologicl sitution ble to impir memory nd cognitive functions ffecting the understnding of problems relted with lcohol consumption. Detiled ptient informtion bout their fmily bckground nd fmily ctive support were crefully mesured by both socil worker nd the AU tem. The min end-points for the study were cesstion of lcohol consumption nd lcohol bstinence 6 months prior to the psycho-socil evlution for LT. Sttisticl nlysis Continuous vribles were described s medin (25-75 interqurtile rnge). Ctegoricl vribles were described by mens of counts nd percentges. Comprisons between groups were performed using the Student s t test or Mnn-Whitney U test, depending on vrible distribution. Differences between ctegoricl vribles were ssessed by the chi-squre test or Fisher s exct test, when necessry. To investigte vribles with prognostic informtion for cesstion of lcohol consumption nd 6 months of bstinence t the psychitrist s pre-trnsplnt evlution, those vribles tht were sttisticlly significnt (p 0.10), nd those tht were considered cliniclly relevnt t the univrite nlysis were entered into bckwrd stepwise elimintion vrible selection procedure (multivrite logistic regression) nd then confirmed using forwrd stepwise elimintion vrible selection procedure. The p-vlues for the univrite tests were not corrected for multiple testing, becuse those tests were tken s explortory. The results of the multivrite logistic regression nlysis (odds rtio OR ) were considered to be the min result, s it determined those vribles independently ssocited with the min outcome (fter djusting for time nd the contributions of other vribles). A p-vlue < 0.05 ws required for significnce. The SPSS sttisticl pckge (SPSS Inc., version 15.0, Chicgo, IL.) ws used for ll nlysis. RESULTS Ptients chrcteristics During the study period 90 ptients were included. The bseline clinicl, demogrphicl nd biochemicl chrcteristics of the study cohort re depicted in tble ptients (37%) stopped their lcohol consumption t the moment of ALD dignosis. 60% (55 out of 90 ptients) rrived to first AU visit with 6 months of bstinence; mong these, 58% (32 out of 55 ptients) hd t lest 1-yer bstinence. Regrding the chrcteristics of lcohol buse nd consumption pttern, 66% of the cohort were fsting lcohol consumers, 42% ccepted to lose control when drinking nd 30% were incpble to mintin 48 h of bstinence. Importntly, the medin time between dignosis of ALD nd derivtion to AU ws 40 (12-97) months. 45 ptients (50%) were successfully listed nd trnsplnted. Hlf of the ptients were not trnsplnted due to n inbility to comply with listing requirements. Among these, 73% (33 out of 45 ptients) hd either medicl contrindiction nd/or died before LT listing. Four ptients were not listed due to mentl illness or psychitric contrindiction.

4 216 Altmirno J, et l., 2012; 11 (2): Tble 1. Bseline clinicl nd psychitric chrcteristics of ptients. n = 90 Gender (mle) n (%) 79 (88) Age (yers) 49 (44-57) Stop in lcohol consumption t ALD dignosis n (%) 34 (37) Alcohol bstinence < 6 months, n (%) 35 (39) 6-12 months, n (%) 23 (25) > 12 months, n (%) 32 (36) Biochemicl prmeters Bilirubin (mg/dl) 2.8 ( ) INR 1.3 ( ) Cretinine (mg/dl) 0.9 ( ) MELD 14 (10-16) Prmeters t psychitric evlution Awreness of lcohol dependence n (%) 15 (17) Awreness of lcohol toxicity n (%) 54 (60) Ptient s ttitude, n (%) Honest 24 (27) Denil-Defensive 52 (58) Other 14 (15) Fmily recognition, n (%) 59 (66) Fmily ctive support, n (%) 59 (66) Fmily history of lcoholism, n (%) 17 (19) Previous tretments for lcohol buse, n (%) 10 (11) Alcohol-free beer users, n (%) 26 (29) Time to lcohologist visit (months) 40 (12-97) ALD: lcoholic liver disese. INR: interntionl normlized rtio. MELD: model for end-stge liver disese. Fctors ssocited with cesstion of lcohol consumption We first investigted the prmeters ssocited with lcohol cesstion fter the dignosis of ALD. Tble 2 shows the results of the univrite nlysis performed in order to identify the vribles ssocited with cesstion of lcohol consumption. The fctors significntly ssocited with lcohol cesstion were: Awreness of AD (OR = 4.25, CI , p = 0.01). Awreness of lcohol toxicity (OR = 2.58, CI , p = 0.04). The ptient s honest ttitude towrds lcohol dependence nd relted toxicity (OR = 4.16, CI , p = 0.05) nd fmily recognition of the problem (OR = 2.80, CI , p = 0.02). When including the MELD score in the univrite nlysis we did not find ny ssocition to cesstion in lcohol consumption. After entering those vribles tht were sttisticlly significnt in the univrite model nd those cliniclly relevnt in multivrite nlysis, only wreness of lcohol toxicity (OR = 5.84, CI , p = 0.02) nd fmily recognition (OR = 3.81, CI , p = 0.01) remined sttisticlly significnt (Tble 3). Awreness of lcohol dependence, previous lcohol buse tretments nd ptient s ttitude were not significntly ssocited with cesstion of lcohol consumption. Fctors ssocited with 6 months of bstinence previous to psycho-socil evlution for LT A univrite nlysis ws performed In order to identify the fctors ssocited with 6-months of bstinence previous to the psycho-socil evlution (Tble 2). Cesstion in lcohol consumption t knowledge of lcohol-relted liver disese (OR = 9.32, CI , p < 0.001), wreness of lcohol toxicity (OR = 3.25, CI , p = 0.009), ptient s honest ttitude (OR = 4.42, CI , p = 0.01) nd fmily recognition (OR = 3.23, CI , p = 0.02) were significntly ssocited with mintennce of bstinence. When including the MELD score in the univrite nlysis we did not find ny ssocition to 6-months bstinence. To further nlyze the vribles predicting 6-months of bstinence, sttisticlly significnt nd cliniclly relevnt vribles were entered in multivrite model. Cesstion of lcohol consumption t knowledge of lcohol-relted liver disese (OR = 5.50, CI , p = 0.009), wreness of lcohol toxicity (OR = 2.99, CI , p = 0.05) nd fmily recognition (OR = 5.21, CI , p = 0.03) were the only vribles tht showed sttisticlly significnt ssocition (Tble 3). Awreness of lcohol dependence, ptient s ttitude nd lcohol-free beer consumption did not significntly predict mintennce of bstinence. Importntly, ptients who stopped lcohol consumption t ALD dignosis showed higher rtes of 6 months of bstinence compred to those who did not stop lcohol (88 vs. 44%, respectively; p < 0.001) (Figure 1A).

5 Abstinence in ptients undergoing liver trnsplnttion., 2012; 11 (2): Tble 2. Fctors ssocited with stop in lcohol consumption* nd 6-month bstinence in the univrite nlysis. OR 95% CI p vlue Stop in lcohol consumption* Age Awreness of lcohol dependence Awreness of lcohol toxicity Honest Denil-Defensive Other Fmily ctive support Fmily recognition Previous lcohol buse tretments History of fmily lcoholism Alcohol-free beer consumption MELD month bstinence Age Awreness of lcohol dependence Cesstion in lcohol consumption* < Awreness of lcohol toxicity Ptient s ttitude Honest Denil-Defensive Other Fmily ctive support Fmily recognition Previous lcohol buse tretments Time to derivtion History of fmily lcoholism Alcohol-free beer consumption MELD OR: odds rtio. CI: confidence intervl. *Cesstion in lcohol consumption t first knowledge of lcohol relted liver disese. Tble 3. Fctors ssocited with stop in lcohol consumption* nd 6-month bstinence in the multivrite nlysis. OR 95% CI p vlue Stop in lcohol consumption* Awreness of lcohol toxicity Fmily recognition month bstinence Cesstion in lcohol consumption* Awreness of lcohol toxicity Fmily recognition OR: Odds rtio. CI: confidence intervl. *Cesstion in lcohol consumption t first knowledge of lcohol relted liver disese. Role of lcohol-free beer consumption mong ptients undergoing evlution for LT A totl of 26 ptients (29%) begn using lcoholfree beer fter knowledge of their ALD. 34% of ptients (19 out of 55) with 6 months of bstinence nd 20% (7 out of 35) without 6 months of bstinence were lcohol-free beer consumers (p = 0.12). Among ptients tht reched 6-month bstinence t initil AU evlution the proportion of lcohol-free beer consumption ws significntly higher in those who

6 218 Altmirno J, et l., 2012; 11 (2): A 100 p < Percentge of 6-month bstinence t AU evlution for LT No (n = 56) Yes (n = 34) Stop in lcohol consumption B C P = 0.05 Percentge of 6-month bstinence t AU evlution for LT P = 0.04 No (n = 38) Yes (n = 18) Alcohol-free beer consumption Alcohol-free beer users (%) No (n = 25) Yes (n = 30) Stop in lcohol consumption since ALD dignosis Figure 1. A. 6-month bstinence ccording to the presence of stop in lcohol consumption since ALD dignosis. B. Rte of lcohol free-beer use ccording to the presence of stop in lcohol consumption fter ALD mong ptients who rrive with 6-month bstinence to LT evlution. C. 6-month bstinence rte ccording to the presence of lcohol-free beer consumption mong ptients without stop in lcohol consumption. did not stop lcohol consumption t dignosis of ALD (Figure 1B). We next compred the use of lcohol-free beer nd the rte of 6 months of bstinence in both, ptients with nd without cesstion of lcohol consumption t dignosis of ALD. Among those who did not stop lcohol consumption, the use of lcoholfree beer ws ssocited with higher rte of 6-month bstinence (67 vs. 34%, p = 0.04) (Figure 1C). This ssocition ws not observed mong ptients tht quit lcohol consumption t ALD dignosis. DISCUSSION ALD is one of the commonest cuses of cirrhosis nd is lso frequent indiction for LT. After erly uncertinty, it is now widely ccepted tht the overll clinicl outcomes of LT for crefully selected ptients with ALD re similr to other cuses of liver disese. 28 A period of 6 months of bstinence hs been widely dopted s it provides dequte time to demonstrte cesstion of lcohol use nd lso provides the opportunity for mny ptients to recover dequtely so s to no longer require LT. In ddition, ptients tht chieve this 6-month rule re less likely to incur in problem drinking fter LT nd it is stndrd requisite in the vst mjority, if not ll, LT progrms. 14,27,29 On the other hnd, the ssessment of the psycho-socil sttus of ptients with ALD undergoing LT identifies those ptients t prticulr risk to return to hrmful consumption of lcohol post-lt. 14,29,30 The psycho-socil fctors relted with relpse re insight into lcohol etiology, fmily or friends ctive support, lck of mentl illness, nd stble reltionship ,22,23,31

7 Abstinence in ptients undergoing liver trnsplnttion., 2012; 11 (2): However, less hs been described bout the fctors ssocited to 6-month bstinence t first evlution for LT. The results of our study demonstrte tht more thn 50% of ptients were ctegorized s hving toxicity wreness nd only 17% were wre of their dependence on lcohol. As expected, lmost 60% of ptients showed defensive-denil ttitude. This type of ttitude is not surprising nd expected in ptients with ALD since the ppernce of the negtive physicl consequences ssocited with lcohol use usully triggers mbivlent situtions bout such consumption nd defensive nd negtive position towrds medicl nd fmily wrnings. 32 Moreover, these ttitudes could lso be explined by the fct tht during the course of LT psycho-socil evlution ptients my find themselves living two distressing situtions: sense of imminent deth; or rebirth through the trnsplnt. During this phse, ptients often doubtful feel nxiety, mbivlence, fers nd frustrtion, ll of these potentil cuses of the ptient s chllenging ttitude. In our series, lmost 70% of the ptient s fmilies recognized the problem nd were ctively supporting the ptient. These figures re in keeping with previous studies ,33 Additionlly, we found medin of 40 (IQR 12-97) months between first dignosis of ALD nd first visit to AU. This lst observtion leds us to rise the concern on the urgent need for better cre nd better lgorithms for referrl to specilized AU centers not only when OLT is the lst option for their tretment. This men time to first visit to AU cn be mostly explined due to the lck of consciousness of most of the first ttention units in the opportune derivtion of ptients with ALD no mtter wht stge of the disese re the ptients coursing. We think tht erly derivtion of ptients with ALD to AU could positively impct in their long term prognosis. An interesting finding of our study ws the recognition of fctors relted to stopping lcohol nd 6 months of bstinence prior to LT evlution. We found the presence of lcohol toxicity wreness nd fmily recognition s the independent fctors ssocited with cesstion of lcohol consumption (Figure 1). These re importnt observtions in order to identify those ptients with high probbility of meeting the lcohol bstinence criteri needed for listing t the first AU visit. Vribles independently ssocited with 6-month bstinence were cesstion of lcohol consumption, lcohol toxicity wreness nd fmily recognition. Thus, these results indicte such ptients (e.g. ptients without lcohol cesstion fter ALD dignosis) could benefit from erly interventions in specilized ddictions units. These results lso support the notion tht the process, by which person trnsitions from ctive ddiction to sustined recovery, is ctully bsed on progressive wreness process. 34 Finlly, we focused on the potentil ssocition of the use of lcohol-free beer nd 6 months of bstinence. Among ptients without cesstion of lcohol consumption t first knowledge of lcohol-relted liver disese, we found tht the use of lcohol-free beer consumption ws significntly ssocited with higher rtes of 6-months of bstinence (Figure 1C). Importntly, when nlyzing those ptients who rrive t LT evlution with 6 months of bstinence we found tht the rte of lcohol-free beer use ws more frequent mong those ptients tht did not stop lcohol since ALD dignosis (Figure 1B). Although interesting, these lst observtions should be tken with cution for severl resons. First, lthough lcohol-free beer use my not hve deleterious impct from strictly orgnic nd toxicologicl point of view given the low lcohol component of the beverge, it does hve gret impct from the psychologicl perspective. The existing psychologicl component of ddiction tkes specil importnce in this cse. The consumption of drink with identicl stimultion fetures (e.g. similr tste, presenttion, color, nd drinking sitution) my led to similr expecttions, thus disble the ptient to cquire lcohol dependence wreness which is mjor contributor to sustined bstinence. Second, only smll portion of ptients initite the use of lcohol-free beer fter ALD dignosis (29%) so this observtion is bsed in smll group of ptients. Our study hs strengths nd limittions. One of the strengths is tht psycho-socil evlutions were evluted by mens of comprehensive structured interview pplied by experienced personnel in ddictions. On the other hnd, few studies hve evluted the risk fctors for filure to meet listing requirements in liver trnsplnt cndidtes with lcoholic cirrhosis. In our study we evluted fctors ssocited with stopping lcohol consumption nd 6-months of bstinence. Another originl point in this study ws the evlution of the use of lcohol-free beer mong ptients evluted for liver trnsplnttion. Then min limittion of the study is the retrospective nture nd lck of follow-fter LT, thus vribles regrding relpse in the post LT period could not be evluted.

8 220 Altmirno J, et l., 2012; 11 (2): In summry, the fctors tht influence both cesstion in lcohol consumption nd sustined lcohol bstinence (6 months or more) in ALD ptients evluted for LT re the wreness of lcohol toxicity nd fmily recognition of the problem. The use of lcohol-free beer ws ssocited with higher rte of 6-months of bstinence in the subgroup of ptients who did not stop lcohol intke t ALD dignosis. Future studies re required to vlidte this lst observtion. ACKNOWLEDGMENTS & GRANT SUPPORT This work ws supported by grnts from Fondo de Investigción Snitri (FIS PI nd FIS PS09/01164 to RB nd JC). JA hs grnt from Fundción Bnco Bilbo Vizcy Argentri (FBBVA) nd is enrolled in the Mster on Reserch in Liver Diseses of the Universitt de Brcelon. CIBERehd is funded by the Instituto de Slud Crlos III. ABBREVIATIONS ALD: Alcoholic liver disese. LT: Liver trnsplnttion. REFERENCES 1. Centers for Disese Control nd Prevention (CDC). Alcohol-ttributble deths nd yers of potentil life lost mong Americn Indins nd Alsk Ntives United Sttes, MMWR Morb Mortl Wkly Rep 2008; 57: Cortez-Pinto H, Gouvei M, dos Sntos Pinheiro L, et l. The burden of disese nd the cost of illness ttributble to lcohol drinking results of ntionl study. Alcohol Clin Exp Res 2010; 34: Blkrishnn R, Allender S, Scrborough P, et l. The burden of lcohol-relted ill helth in the United Kingdom. J Public Helth (Oxf) 2009; 31: Méndez-Sánchez N, Grcí-Villegs E, Merino-Zeferino B, et l. Liver diseses in Mexico nd their ssocited mortlity trends from 2000 to 2007: A retrospective study of the ntion nd the federl sttes. Ann Heptol 2010; 9: Pessione F, Rmond MJ, Peters L, et l. Five-yer survivl predictive fctors in ptients with excessive lcohol intke nd cirrhosis. Effect of lcoholic heptitis, smoking nd bstinence. Liver Int 2003; 23: Crrion AF, Ghnt R, Crrsquillo O, et l. Chronic Liver Disese in the Hispnic Popultion of the United Sttes. Clin Gstroenterol Heptol Doi: / j.cgh Burr P, Senzolo M, Adm R, et l. Liver trnsplnttion for lcoholic liver disese in Europe: study from the ELTR (Europen Liver Trnsplnt Registry). Am J Trnsplnt 2010; 10: Wki K, Tmur S, Sugwr Y, et l. An nlysis of the OPTN/UNOS Liver Trnsplnt Registry. Clin Trnspl 2009: Kotlyr DS, Burke A, Cmpbell MS, et l. A criticl review of cndidcy for orthotopic liver trnsplnttion in lcoholic liver disese. Am J Gstroenterol 2008; 103(3): ; Quiz 744. Epub 2007 Dec Burr P, Mioni D, Cillo U, et l. Long-term medicl nd psycho-socil evlution of ptients undergoing orthotopic liver trnsplnttion for lcoholic liver disese. Trnspl Int 2000; 13(Suppl. 1): S174-S Lucey MR. Liver trnsplnttion in ptients with lcoholic liver disese. Liver Trnspl 2011; 17: Gish RG, Lee AH, Keeffe EB, Rome H, Concepcion W, Esquivel CO. Liver trnsplnttion for ptients with lcoholism nd end-stge liver disese. Am J Gstroenterol 1993; 88: Lim JK, Keeffe EB. Liver trnsplnttion for lcoholic liver disese: current concepts nd length of sobriety. Liver Trnspl 2004; 10(Suppl. 2): S31-S Tndon P, Goodmn K, M MM, et l. The durtion of pretrnsplnt bstinence predicts problem drinking post liver trnsplnttion. Am J Gstroenterol 2009; 104: Osorio RW, Ascher NL, Avery M, et l. Predicting recidivism fter orthotopic liver trnsplnttion for lcoholic liver disese. Heptology 1994; 20: Kumr S, Stuber RE, Gvler JS, et l. Orthotopic liver trnsplnttion for lcoholic liver disese. Heptology 1990; 11: Gish RG, Lee A, Brooks L, et l. Long-term follow-up of ptients dignosed with lcohol dependence or lcohol buse who were evluted for liver trnsplnttion. Liver Trnsp 2001; 7: Foster PF, Fbreg F, Krdemir S, et l. Prediction of bstinence from ethnol in lcoholic recipients following liver trnsplnttion. Heptology 1997; 25: Juhr S, Tlwlkr JA, Schneekloth T, et l. Anlysis of fctors tht predict lcohol relpse following liver trnsplnttion. Liver Trnspl 2004; 10: Mckie J, Groves K, Hoyle A, et l. Orthotopic liver trnsplnttion for lcoholic liver disese: A retrospective nlysis of survivl, recidivism, nd risk fctors predisposing to recidivism. Liver Trnspl 2001; 7: Coffmn KL, Hoffmn A, Sher L, et l. Tretment of the postopertive lcoholic liver trnsplnt recipient with other ddictions. Liver Trnspl Surg 1997; 3: Hrper RG, Wger J, Chcko RC. Psychosocil fctors in noncomplince during liver trnsplnt selection. J Clin Psychol Med Settings 2010; 17: Cudrdo A, Fbreg E, Csfont F, et l. Alcohol recidivism impirs long-termptient survivl fter orthotopic liver trnsplnttion for lcoholic liver disese. Liver Trnspl 2005; 11: Dignostic nd Sttisticl Mnul of Mentl Disorders: DSM-IV, Americn Psychitric Assocition, Wshington, D.C Spnish version: DSM-IV-TR. Mnul Dignóstico y estdístico de los trstornos mentles. Brcelon: Msson; Gul A, Contel M, Segur L, et l. The ISCA (Systemtic Interview of Alcohol Consumption), new instrument to detect risky drinking. Med Clin 2001; 117:

9 Abstinence in ptients undergoing liver trnsplnttion., 2012; 11 (2): Grhm JR, Strenger VE. MMPI chrcteristics of lcoholics: review. J Consult Clin Psychol 1988; 56: Lligoñ A, Freix N, Btller R. Clinicl guideline for the evlution of liver trnsplnt cndidtes with ddictions. Gstroenterol Heptol 2009; 32: Lucey MR, Schubel DE, Guidinger MK, et l. Effect of lcoholic liver disese nd heptitis C infection on witing list nd posttrnsplnt mortlity nd trnsplnt survivl benefit. Heptology 2009; 50: Crbonneu M, Jensen LA, Bin VG, et l. Alcohol use while on the liver trnsplnt witing list: single-center experience. Liver Trnsp 2010; 16(1): Pfitzmnn R, Schwenzer J, Ryes N, et l. Long-term survivl nd predictors of relpse fter orthotopic liver trnsplnttion for lcoholic liver disese. Liver Trnspl 2007; 13: Krmn JF, Sileri P, Kmud D. Risk fctors for filure to meet listing requirements in liver trnsplnt cndidtes with lcoholic cirrhosis. Trnsplnttion 2001; 15(71): Monrs M, Freix N, Lligoñ A, Gul A. Defensividd psicológic y deterioro cognitivo en lcohólicos. Están relciondos y son útiles pr el pronóstico los 5 ños? Psiq Biol 1999; 6(4): Kelly M, Chick J, Gribble R, et l. Predictors of relpse to hrmful lcohol fter orthotopic liver trnsplnttion. Alcohol Alcohol 2006; 41: Prochsk JO, Di Clemente CC. Trnstheoreticl therpy: Towrd more integrtive model of chnge. Psychotherpy: Theory, Reserch, nd Prctice 1982;