We read with great interest DiMartini and Dew's discussion of the therapeutic and practical issues involved in the monitoring of alcohol use in patients listed for liver transplantation (LT). The liver unit at St. James's University Hospital in Leeds is 1 of 7 LT units in the United Kingdom and performs adult LT 80 to 100 times each year. Patients with a diagnosis of alcohol-related liver disease (ALD) who are listed for LT in Leeds are required to sign a contract committing them to lifelong abstinence from alcohol. They also have to attend scheduled appointments for blood alcohol level (BAL) testing and consent to community-based random BAL testing without prior notice.
The timely identification of patients with ALD who are still drinking whilst they are on the transplant waiting list (WL) is crucial.
We conducted a retrospective review of 206 patients with ALD who were abstinent from alcohol for at least 6 months and had been listed for transplantation between 2006 and 2011 inclusive (Fig. 1). Fifteen patients (7%) were removed from the WL because of ongoing alcohol ingestion, and the majority of these patients (9 or 60%) were identified through random BAL testing. Eight of these 9 patients previously had negative BAL results at scheduled appointments. Four patients had positive BAL results at planned appointments.
The mean duration of abstinence at the time of listing was 18 months (range = 6-60 months). Interestingly, the majority of relapses (73%) occurred within the first 6 months after listing, and these patients had a shorter average duration of abstinence of 13 months. Carbonneau et al. identified the duration of prelisting abstinence as an independent predictor of alcohol use on the WL, and our results support this; in addition, our observations favor the use of random BAL testing instead of scheduled testing to identify patients with ALD who return to drinking. The frequency of screening should perhaps be intensified in the first 6 months after listing because we have identified this period as the one in which most patients suffer a relapse into drinking.
Only 2 patients who had previously claimed abstinence admitted to alcohol use on the WL at follow-up visits. We would exercise great caution in using patient disclosure as a means of identifying ongoing alcohol consumption because the rate of concealment of active drinking is likely to be significant, as noted by Hempel et al.
Hassan Bholah, M.D.
John Bate, M.D.
Kathryn Rothwell, B.A.
Mark Aldersley, M.D., Ph.D.
Department of HepatologySt. James's University HospitalLeeds, United Kingdom