title: A shorter duration of pre-transplant abstinence predicts problem drinking after liver transplantation.
abstract: OBJECTIVE
  Liver transplantation for alcoholic liver disease (ALD) can be complicated by abusive or "problem" drinking (PD) after transplant. There are limited data for evaluating the effect of pre-transplant abstinence on post-transplant PD. Few existing studies have included a substantial number of patients with co-existing causes of hepatic dysfunction, and the effect of PD on survival in recent European studies has been controversial. We hypothesized that a longer duration of pre-transplant abstinence would lead to less PD after transplantation. Accordingly, the objectives of this study are to analyze a North American cohort of patients with ALD with or without a secondary diagnosis of liver disease to estimate (i) the incidence of PD and its predictors, as well as (ii) the effect of PD on patient survival.
  
  
  METHODS
  We conducted a retrospective review of all patients transplanted for ALD surviving for more than 3 months after transplant. PD was defined as either any drinking (AD) to the point of intoxication or drinking above the toxic threshold (>20 g/day in women and >40 g/day in men) on at least two separate occasions. We used Cox's proportional hazards regression to estimate risk ratios and Kaplan-Meier curves with log-rank analysis to compare survival.
  
  
  RESULTS
  Of 213 eligible transplant patients, 42 were excluded. Of the 171 remaining patients, 78% were male; mean age was 52 years. Overall 53% of patients had co-existing causes of liver dysfunction. The mean follow-up was 64.8 months. The median pre-transplant abstinence was 19 months. In all patients, the risk of AD was 24% and PD 13%. Pre-transplant abstinence duration was the only independent predictor of PD after transplant. For every 1-month increment in pre-transplant abstinence, there was a 5% decrease in the adjusted relapse rate. There was no survival difference noted between problem drinkers and non-drinkers.
  
  
  CONCLUSIONS
  The risk of PD decreased with increasing pre-transplant abstinence. Our data support pre-transplant abstinence as an important predictor of post-transplant recidivism; however, the optimal period of abstinence remains unclear. Patients with <18 months of abstinence may benefit from more intensive follow-up and rehabilitation after transplant.
authors.affiliation: Department of Medicine, University of Alberta, Edmonton, Canada. ptandon@ualberta.ca
authors.forename: Puneeta
authors.initials: P
authors.lastname: Tandon
authors.forename: Karen J
authors.initials: KJ
authors.lastname: Goodman
authors.forename: Mang M
authors.initials: MM
authors.lastname: Ma
authors.forename: Winnie W
authors.initials: WW
authors.lastname: Wong
authors.forename: Andrew L
authors.initials: AL
authors.lastname: Mason
authors.forename: Glenda
authors.initials: G
authors.lastname: Meeberg
authors.forename: Donna
authors.initials: D
authors.lastname: Bergsten
authors.forename: Michelle
authors.initials: M
authors.lastname: Carbonneau
authors.forename: Vincent G
authors.initials: VG
authors.lastname: Bain
mesh_terms: D000428:Alcohol Drinking / Q000009:adverse effects*; D002423:Cause of Death; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D006084:Graft Rejection / Q000401:mortality*; D006801:Humans; D053208:Kaplan-Meier Estimate; D008108:Liver Diseases, Alcoholic / Q000175:diagnosis / Q000401:mortality* / Q000601:surgery*; D008111:Liver Function Tests; D016031:Liver Transplantation / Q000379:methods / Q000401:mortality*; D008297:Male; D008875:Middle Aged; D011182:Postoperative Care; D011237:Predictive Value of Tests; D011300:Preoperative Care / Q000379:methods; D011336:Probability; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012307:Risk Factors; D012309:Risk-Taking; D012720:Severity of Illness Index; D018709:Statistics, Nonparametric; D016019:Survival Analysis; D013997:Time Factors