the six month rule - aisf · georges-philippe pageaux chu saint eloi, pôle digestif...
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Georges-Philippe PageauxCHU Saint Eloi, Pôle [email protected]
The Six month RuleWhen we still need it and when we don’t
Alcoholic Liver Disease: the new challengeRome, October 6 th, 2017
GP Pageaux, MD, PhDCHU Saint Eloi, Montpellier, France
I have financial relationships to disclose within the past 12 months relevant to my presentation
Advisory Board, Speaking, Grants: Astellas, Novartis
AND
My presentation does not include/includes discussion of off-label or investigational use
LT for ALD: increasing indication
Liver Transplantation and ALD in France
Rapport ABM 2015
Patients transplanted during the year
2005 2010 2015
Total 1024 1092 1355
Primary ALD 296(29%) 261(24%) 363(27%)
Secondary ALD 8 174 233HCC, HCV, HBV
29.6% 40% 44%
In 2015, 1756 new inscriptions / 47% alcohol
Outline
The 6-month rule as a determinant of transplant can didacy
The 6-month rule as a predictor of alcohol use afte r LT
Post-LT alcohol use as a predictor of graft/patient survival
From the 6-month rule to a thorough psychosocialand substance abuse assessment
an accepted principle or instruction that states the way things are or should be done, and tells you what you are allowed or are not allowed to do
rule
Julapalli VR, Liver Transpl 2005
The 6-month rule may affect referral patterns for L T evaluation
Prioritize the “deserving” patients
J Hepatol 2012 J Hepatol 2016
Veldt BJ, J Hepatol 2002
The medical management of ALD starts with abstinenc efrom alcohol: first step of liver function recovery
The 6-month ruleto avoid unnecessary transplantation
74 pts CP CImprovement = CP B or A66% at 3 and 6 months
In the MELD era, what is the cut-off?
Male, 56 yrs One month later, abstinentAlcoholic cirrhosis, Ascites controlled ascitesAbsence of HE
INR 1.8 1.2Bilirubin 145 µmol/L 87Creatinine 95 µmol/L 78
MELD 21 15
Male, 59 yrs One month later, abstinentAlcoholic cirrhosis, Ascites non controlled ascitesStage 1HE fluctuant
INR 2.5 1.9Bilirubin 216 µmol/L 195Creatinine 95 µmol/L 89
MELD 27 24
Outline
The 6-month rule as a determinant of transplant can didacy
The 6-month rule as a predictor of alcohol use afte r LT
Post-LT alcohol use as a predictor of graft/patient survival
From the 6-month rule to a thorough psychosocialand substance abuse assessment
an accepted principle or instruction that states the way things are or should be done, and tells you what you are allowed or are not allowed to do
rule
The 6-month ruleas a predictor of relapse
DiMartini A, Liver Transpl 2006
Prediction of relapseusing months soberprior to LT
« Longer pre-LT sobriety predictsless risk of alcohol use after LT »
Perney P, Transplant Int 2005
Tandon P, Am J Gastroenterol 2009
PD: problem drinking / > 20g/d F, > 40g/d M
Outline
The 6-month rule as a determinant of transplant can didacy
The 6-month rule as a predictor of alcohol use afte r LT
Post-LT alcohol use as a predictor of graft/patient survival
From the 6-month rule to a thorough psychosocialand substance abuse assessment
an accepted principle or instruction that states the way things are or should be done, and tells you what you are allowed or are not allowed to do
rule
Is it important to predict alcohol use after LT?Alcohol use after LT
DiMartini A, Am J Transplant 2010
Alcohol relapse after LT
208 patients
80% abstinent or minimal6% early onset moderate use6% early onset heavy use8% late onset moderate to heavy
Faure S, J Hepatol 2012
441 patientsmean FU 82 monthsExcessive alcohol use 13%
Is it important to predict alcohol use after LT?
Dumortier J, Am J Gastroenterol 2015
Is it important to predict alcohol use after LT?
Outline
The 6-month rule as a determinant of transplant can didacy
The 6-month rule as a predictor of alcohol use afte r LT
Post-LT alcohol use as a predictor of graft/patient survival
From the 6-month rule to a thorough psychosocialand substance abuse assessment
an accepted principle or instruction that states the way things are or should be done, and tells you what you are allowed or are not allowed to do
rule
High Risk Alcohol Relapse
High Risk Alcohol Relapse
From a single criterion to a more sophisticated eva luation
Who are the relapsers ?Favorable factors We don’t need
The ackowledgment by the patient of his/her alcoholis mThe presence of strong social supportSubstitute activitiesA source of self-esteem or hopeA rehabilitation relationshipAn awareness of the negative consequences of alcohol re lapse
Negative factors We « need »
Preexisting psychotic disordersUnstable character disordersUnremitting multidrug abuseRepeated unsuccessful attempts of rehabilitationSocial isolationYears of heavy drinkingAlcohol dependency
Vaillant GE, Addiction 2003Perney P, Transpl Int 2005DiMartini A, Liver Transpl 2006Pfitzmann R, Liver Transpl 2007Lucey MR, Liver Transpl 2011
Estimating the prognosis for abstinence after LT
No single measure is a reliable prognostic factor for relaps einto harmful drinking after transplantation
The psychosocial assessment by a trained addiction special istdetermines lower and higher risks of relapsing into harmfuldrinking, but does not determine the absolute risk
The severely ill patient who has been drinking recently but h asother favorable prognostic factors with respect to addicti onposes a difficult question for a transplant program
Lucey MR, Liver Transpl 2011
Who does the job?Transplant team or independent addiction specialist
Addolorato G, Alcohol Clin Exp Res 2013
AAU = alcohol addiction unit
Transplantation 2016