Transplant Center Attitudes Toward Early Liver Transplant for Alcohol-associated Liver Disease

Background. Many centers have removed 6-mo pretransplant alcohol abstinence requirements to provide early liver transplant (ELT) for individuals with severe alcohol-associated liver disease (ALD), but the practice remains controversial. Using data collected from a nationally distributed survey, this study examines the practices and attitudes of transplant centers in the United States regarding ELT. Methods. A 20-item survey designed to assess center practices and provider attitudes was distributed to 225 medical and surgical directors from 143 liver transplant centers via email. Results. Surveys were completed by 28.9% (n = 65) of directors and 39% (n = 56) of transplant centers. All responding centers reported evaluating patients for ELT. Circumstances for considering ELT included <6 mo of survival without a transplant (96.4%) and inability to participate in alcohol addiction therapy pretransplant (75%). Most (66%) directors indicated their center had established criteria for listing candidates with severe ALD for ELT. Regarding important factors for ELT candidate listing, 57.1% indicated patient survival, 37.5% indicated graft survival, and 55.4% indicated having a low risk of relapse. Only 12.7% of directors affirmed the statement, “Six months of pretransplant abstinence decreases the risk of relapse.” Conclusions. More centers are providing ELT for severe ALD. Inability to participate in alcohol addiction therapy and <6 mo of survival are commonly reported circumstances for considering ELT. Continued investigation of posttransplant outcomes in patients receiving ELT is essential to establishing a national consensus for distributing this valuable resource.

1) Your participation in this study is voluntary and will involve completing an online survey.The risks to you as a participant are minimal.These include feeling uncomfortable to provide answers according to your clinical practice.However, you may choose to skip any questions that make you uncomfortable.
2) The results of this study may be published in scientific research journals or presented at professional conferences.However, your name and identity will not be revealed, and your record will remain anonymous.
3) Participation in this study is not compensated and will not benefit you directly, but your participation may benefit others by informing transplant practices.4) You can choose not to participate in this survey.If you decide not to participate, there will not be a penalty to you or loss of any benefits to which you are otherwise entitled.You may withdraw from this study at any time.5) Your decision to participate in the research will not affect (favorably or unfavorably) performance evaluations, career advancement, or other employment-related decisions made by peers or supervisors.▢ Do not receive referrals for patients with less than 6 months abstinence (1) ▢ Risk of decreased donation rates due to public opinion (2) ▢ Organizational opinion that it is unfair to allocate a limited resource to these patients (3) ▢ Risk of high alcohol relapse rates (4) ▢ Risk of poor post-transplant patient or graft survival (5) ▢ Lack of infrastructure to treat alcohol use disorder after transplantation (6) ▢ Other (enter below) ( 7

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Patient is unlikely to survive 6-months without liver transplant (1) ▢ Patient us unable to participate in alcohol use disorder therapy due to severity of illness (2) ▢ Patient has a living donor (3) ▢ Other (enter below) (4) __________________________________________________ Display This Question: If Does your center evaluate transplant candidates for early liver transplantation for alcohol assoc... = Yes Q6 Is there a minimum length of abstinence time required?o Yes (1) o No (2) Display This Question: If Is there a minimum length of abstinence time required?= Yes Q7 How many months of abstinence are required at your center?________________________________________________________________ Display This Question: If Does your center evaluate transplant candidates for early liver transplantation for alcohol assoc... = Yes Q8 Approximately how many patients are evaluated for early liver transplantation per year?center evaluate transplant candidates for early liver transplantation for alcohol assoc... = Yes Q9 Approximately how many patients undergo early liver transplantation per year?o 1-5 (1) o 6-10 (2) o >10 (3) Display This Question: If Does your center evaluate transplant candidates for early liver transplantation for alcohol assoc... = Yes Q10 What criteria does your center use to select candidates for early liver transplantation?Select all that apply: ▢ Strength of social support (1) ▢ Knowledge of previous alcohol-associated liver disease (2) ▢ Previous failed enrollments in alcohol rehabilitation programs (3) ▢ Written abstinence contract (4) ▢ Lack of severe comorbid psychiatric disease (5) ▢ Formal evaluation by substance use disorder provider (6) ▢ Formal evaluation by transplant social worker (7) ▢ Candidate level of insight into harmful drinking history (8) ▢ Age younger than xx (enter below) (9) __________________________________________________ ▢ Previous alcohol-associated legal consequences (10) ▢ Other (enter below) (11) __________________________________________________ Display This Question: If Does your center evaluate transplant candidates for early liver transplantation for alcohol assoc... = No Q11 What are the main reasons your center does not consider early liver transplantation for alcohol-associated liver disease?Select all that apply: you have questions about your rights as a research participant, you can call the Johns Hopkins University Institutional Review Board at 410-502-2092 and reference [00282599].Thank you.We value and appreciate your time!
Q14 Does your center require pre-transplantation weight loss or behavioral contract requirements for candidates listed for transplantation due to non-alcoholic fatty liver disease?Q16 Use the scale below to indicate the centers agreement or disagreement with the following statement: In evaluating a patient with Alcohol-associated liver disease for transplant... Q20 Use the scale below to indicate the centers agreement or disagreement with the following statements: It is appropriate to list a patient with alcohol-associated liver disease for LT if they have... Q18 Does your center offer post-LT alcohol use disorder treatment services as part of the standard post-LT follow up for alcohol associated liver disease patients?