Predicting Low Risk for Sustained Alcohol Use After Early Liver Transplant for Acute Alcoholic Hepatitis

The Sustained Alcohol Use Post–Liver Transplant Score

Brian P. Lee, Eric Vittinghoff, Christine Hsu, Hyosun Han, George Therapondos, Oren K. Fix, David W. Victor, Deepti Dronamraju, Gene Y. Im, Michael D. Voigt, John P. Rice, Michael R. Lucey, Sheila Eswaran, Po-Hung Chen, Zhiping Li, Haripriya Maddur, Norah A. Terrault

Research output: Contribution to journalArticle

Abstract

Early liver transplant (LT) for alcohol-associated disease (i.e., without a specific sobriety period) is controversial but increasingly used. Using the multicenter American Consortium of Early Liver Transplantation for Alcoholic Hepatitis (ACCELERATE-AH) cohort, we aimed to develop a predictive tool to identify patients pretransplant with low risk for sustained alcohol use posttransplant to inform selection of candidates for early LT. We included consecutive ACCELERATE-AH LT recipients between 2012 and 2017. All had clinically diagnosed severe alcoholic hepatitis (AH), no prior diagnosis of liver disease or AH, and underwent LT without a specific sobriety period. Logistic and Cox regression, classification and regression trees (CARTs), and least absolute shrinkage and selection operator (LASSO) regression were used to identify variables associated with sustained alcohol use post-LT. Among 134 LT recipients for AH with median period of alcohol abstinence pre-LT of 54 days, 74% were abstinent, 16% had slips only, and 10% had sustained alcohol use after a median 1.6 (interquartile range [IQR]: 0.7-2.8) years follow-up post-LT. Four variables were associated with sustained use of alcohol post-LT, forming the Sustained Alcohol Use Post-LT (SALT) score (range: 0-11): >10 drinks per day at initial hospitalization (+4 points), multiple prior rehabilitation attempts (+4 points), prior alcohol-related legal issues (+2 points), and prior illicit substance abuse (+1 point). The C statistic was 0.76 (95% confidence interval [CI]: 0.68-0.83). A SALT score ≥5 had a 25% positive predictive value (95% CI: 10%-47%) and a SALT score of <5 had a 95% negative predictive value (95% CI: 89%-98%) for sustained alcohol use post-LT. In internal cross-validation, the average C statistic was 0.74. Conclusion: A prognostic score, the SALT score, using four objective pretransplant variables identifies candidates with AH for early LT who are at low risk for sustained alcohol use posttransplant. This tool may assist in the selection of patients with AH for early LT or in guiding risk-based interventions post-LT.

Original languageEnglish (US)
Pages (from-to)1477-1487
Number of pages11
JournalHepatology
Volume69
Issue number4
DOIs
StatePublished - Apr 1 2019

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Alcoholic Hepatitis
Alcohols
Transplants
Liver
Confidence Intervals
Alcohol Abstinence

ASJC Scopus subject areas

  • Hepatology

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Predicting Low Risk for Sustained Alcohol Use After Early Liver Transplant for Acute Alcoholic Hepatitis : The Sustained Alcohol Use Post–Liver Transplant Score. / Lee, Brian P.; Vittinghoff, Eric; Hsu, Christine; Han, Hyosun; Therapondos, George; Fix, Oren K.; Victor, David W.; Dronamraju, Deepti; Im, Gene Y.; Voigt, Michael D.; Rice, John P.; Lucey, Michael R.; Eswaran, Sheila; Chen, Po-Hung; Li, Zhiping; Maddur, Haripriya; Terrault, Norah A.

In: Hepatology, Vol. 69, No. 4, 01.04.2019, p. 1477-1487.

Research output: Contribution to journalArticle

Lee, BP, Vittinghoff, E, Hsu, C, Han, H, Therapondos, G, Fix, OK, Victor, DW, Dronamraju, D, Im, GY, Voigt, MD, Rice, JP, Lucey, MR, Eswaran, S, Chen, P-H, Li, Z, Maddur, H & Terrault, NA 2019, 'Predicting Low Risk for Sustained Alcohol Use After Early Liver Transplant for Acute Alcoholic Hepatitis: The Sustained Alcohol Use Post–Liver Transplant Score', Hepatology, vol. 69, no. 4, pp. 1477-1487. https://doi.org/10.1002/hep.30478
Lee, Brian P. ; Vittinghoff, Eric ; Hsu, Christine ; Han, Hyosun ; Therapondos, George ; Fix, Oren K. ; Victor, David W. ; Dronamraju, Deepti ; Im, Gene Y. ; Voigt, Michael D. ; Rice, John P. ; Lucey, Michael R. ; Eswaran, Sheila ; Chen, Po-Hung ; Li, Zhiping ; Maddur, Haripriya ; Terrault, Norah A. / Predicting Low Risk for Sustained Alcohol Use After Early Liver Transplant for Acute Alcoholic Hepatitis : The Sustained Alcohol Use Post–Liver Transplant Score. In: Hepatology. 2019 ; Vol. 69, No. 4. pp. 1477-1487.
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abstract = "Early liver transplant (LT) for alcohol-associated disease (i.e., without a specific sobriety period) is controversial but increasingly used. Using the multicenter American Consortium of Early Liver Transplantation for Alcoholic Hepatitis (ACCELERATE-AH) cohort, we aimed to develop a predictive tool to identify patients pretransplant with low risk for sustained alcohol use posttransplant to inform selection of candidates for early LT. We included consecutive ACCELERATE-AH LT recipients between 2012 and 2017. All had clinically diagnosed severe alcoholic hepatitis (AH), no prior diagnosis of liver disease or AH, and underwent LT without a specific sobriety period. Logistic and Cox regression, classification and regression trees (CARTs), and least absolute shrinkage and selection operator (LASSO) regression were used to identify variables associated with sustained alcohol use post-LT. Among 134 LT recipients for AH with median period of alcohol abstinence pre-LT of 54 days, 74{\%} were abstinent, 16{\%} had slips only, and 10{\%} had sustained alcohol use after a median 1.6 (interquartile range [IQR]: 0.7-2.8) years follow-up post-LT. Four variables were associated with sustained use of alcohol post-LT, forming the Sustained Alcohol Use Post-LT (SALT) score (range: 0-11): >10 drinks per day at initial hospitalization (+4 points), multiple prior rehabilitation attempts (+4 points), prior alcohol-related legal issues (+2 points), and prior illicit substance abuse (+1 point). The C statistic was 0.76 (95{\%} confidence interval [CI]: 0.68-0.83). A SALT score ≥5 had a 25{\%} positive predictive value (95{\%} CI: 10{\%}-47{\%}) and a SALT score of <5 had a 95{\%} negative predictive value (95{\%} CI: 89{\%}-98{\%}) for sustained alcohol use post-LT. In internal cross-validation, the average C statistic was 0.74. Conclusion: A prognostic score, the SALT score, using four objective pretransplant variables identifies candidates with AH for early LT who are at low risk for sustained alcohol use posttransplant. This tool may assist in the selection of patients with AH for early LT or in guiding risk-based interventions post-LT.",
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T1 - Predicting Low Risk for Sustained Alcohol Use After Early Liver Transplant for Acute Alcoholic Hepatitis

T2 - The Sustained Alcohol Use Post–Liver Transplant Score

AU - Lee, Brian P.

AU - Vittinghoff, Eric

AU - Hsu, Christine

AU - Han, Hyosun

AU - Therapondos, George

AU - Fix, Oren K.

AU - Victor, David W.

AU - Dronamraju, Deepti

AU - Im, Gene Y.

AU - Voigt, Michael D.

AU - Rice, John P.

AU - Lucey, Michael R.

AU - Eswaran, Sheila

AU - Chen, Po-Hung

AU - Li, Zhiping

AU - Maddur, Haripriya

AU - Terrault, Norah A.

PY - 2019/4/1

Y1 - 2019/4/1

N2 - Early liver transplant (LT) for alcohol-associated disease (i.e., without a specific sobriety period) is controversial but increasingly used. Using the multicenter American Consortium of Early Liver Transplantation for Alcoholic Hepatitis (ACCELERATE-AH) cohort, we aimed to develop a predictive tool to identify patients pretransplant with low risk for sustained alcohol use posttransplant to inform selection of candidates for early LT. We included consecutive ACCELERATE-AH LT recipients between 2012 and 2017. All had clinically diagnosed severe alcoholic hepatitis (AH), no prior diagnosis of liver disease or AH, and underwent LT without a specific sobriety period. Logistic and Cox regression, classification and regression trees (CARTs), and least absolute shrinkage and selection operator (LASSO) regression were used to identify variables associated with sustained alcohol use post-LT. Among 134 LT recipients for AH with median period of alcohol abstinence pre-LT of 54 days, 74% were abstinent, 16% had slips only, and 10% had sustained alcohol use after a median 1.6 (interquartile range [IQR]: 0.7-2.8) years follow-up post-LT. Four variables were associated with sustained use of alcohol post-LT, forming the Sustained Alcohol Use Post-LT (SALT) score (range: 0-11): >10 drinks per day at initial hospitalization (+4 points), multiple prior rehabilitation attempts (+4 points), prior alcohol-related legal issues (+2 points), and prior illicit substance abuse (+1 point). The C statistic was 0.76 (95% confidence interval [CI]: 0.68-0.83). A SALT score ≥5 had a 25% positive predictive value (95% CI: 10%-47%) and a SALT score of <5 had a 95% negative predictive value (95% CI: 89%-98%) for sustained alcohol use post-LT. In internal cross-validation, the average C statistic was 0.74. Conclusion: A prognostic score, the SALT score, using four objective pretransplant variables identifies candidates with AH for early LT who are at low risk for sustained alcohol use posttransplant. This tool may assist in the selection of patients with AH for early LT or in guiding risk-based interventions post-LT.

AB - Early liver transplant (LT) for alcohol-associated disease (i.e., without a specific sobriety period) is controversial but increasingly used. Using the multicenter American Consortium of Early Liver Transplantation for Alcoholic Hepatitis (ACCELERATE-AH) cohort, we aimed to develop a predictive tool to identify patients pretransplant with low risk for sustained alcohol use posttransplant to inform selection of candidates for early LT. We included consecutive ACCELERATE-AH LT recipients between 2012 and 2017. All had clinically diagnosed severe alcoholic hepatitis (AH), no prior diagnosis of liver disease or AH, and underwent LT without a specific sobriety period. Logistic and Cox regression, classification and regression trees (CARTs), and least absolute shrinkage and selection operator (LASSO) regression were used to identify variables associated with sustained alcohol use post-LT. Among 134 LT recipients for AH with median period of alcohol abstinence pre-LT of 54 days, 74% were abstinent, 16% had slips only, and 10% had sustained alcohol use after a median 1.6 (interquartile range [IQR]: 0.7-2.8) years follow-up post-LT. Four variables were associated with sustained use of alcohol post-LT, forming the Sustained Alcohol Use Post-LT (SALT) score (range: 0-11): >10 drinks per day at initial hospitalization (+4 points), multiple prior rehabilitation attempts (+4 points), prior alcohol-related legal issues (+2 points), and prior illicit substance abuse (+1 point). The C statistic was 0.76 (95% confidence interval [CI]: 0.68-0.83). A SALT score ≥5 had a 25% positive predictive value (95% CI: 10%-47%) and a SALT score of <5 had a 95% negative predictive value (95% CI: 89%-98%) for sustained alcohol use post-LT. In internal cross-validation, the average C statistic was 0.74. Conclusion: A prognostic score, the SALT score, using four objective pretransplant variables identifies candidates with AH for early LT who are at low risk for sustained alcohol use posttransplant. This tool may assist in the selection of patients with AH for early LT or in guiding risk-based interventions post-LT.

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