The clinical monitoring protocol designed and employed by Bholah et al. at St. James's University Hospital in Leeds is a model for other transplant programs with wait-listed patients with alcoholic liver disease. Although we advocate for clinical interviewing, as they and Hempel et al. have demonstrated, the use of clinical interviewing alone may not always be sufficient to reveal all cases of alcohol use. Even scheduled alcohol levels do not capture all occurrences. In fact, Bholah et al. found that random alcohol testing provided the largest number of positive blood alcohol values. However, a review of their monitoring methods showed that every method of monitoring was able to identify some additional cases (ie, alcohol-using individuals) not identified by the other methods. Thus we agree that their multi-method clinical monitoring procedure is the best strategy, and we have recommended such an approach for monitoring alcohol use following transplantation as well, an approach based on all available data.[2, 3] Obtaining random alcohol levels requires additional planning, time, and effort by transplant and other staff. However, these extra assessments are worth the effort, especially when we consider the identification of a patient who is not yet ready for transplantation. Additionally, Bholah et al. reported that the majority of these discoveries were made in the first 6 months of wait listing for transplantation, mostly because of the shorter abstinence of these individuals. Because of the current controversy over the listing of individuals with acute alcoholic hepatitis due to their short length of sobriety, it is only fair that consistent monitoring of wait-listed candidates with alcoholic cirrhosis be conducted, especially for patients with similarly short periods of sobriety, to prevent them from maintaining their listing while they are actively drinking.
Andrea DiMartini, M.D.1,2,6
Mary Amanda Dew, Ph.D.1,3-5
Departments of 1Psychiatry, 2Surgery, 3Psychology, 4Epidemiology, and 5Biostatistics
School of Medicine
University of Pittsburgh
6Starzl Transplant Institute
University of Pittsburgh Medical Center