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Alcohol-associated liver disease predicts increased post-liver transplant opioid use.

Abstract:

BACKGROUND: Alcohol-associated liver disease (ALD) is a rising indication for liver transplantation (LT). Prolonged opioid use after LT leads to increased graft loss and mortality. The aim is to determine if patients transplanted with a primary diagnosis of ALD had higher risk of post-LT opioid use (p-LTOU) compared to non-ALD patients.

METHODS: This is a retrospective study of patients who underwent LT between 2015 and 2018 at Medstar Georgetown Transplant Institute. Patients with prolonged hospitalization post-LT (>90 days), death within 90 days post-LT, and re-transplants were excluded.

RESULTS: Two hundred and ninety-seven patients were transplanted, among 29% for indications of ALD. ALD patients were younger (52 vs. 56 years), more likely to be male (76% vs. 61%), Caucasian (71% vs. 44%), have higher MELD (28.8+/-8.8 vs. 25+/-8.8), and psychiatric disease than non-ALD patients (P < .05). There was no difference in pre-LT use of opioids, tobacco, marijuana, or illicit drugs between ALD and non-ALD patients. Pre-LT opioid use (OR = 11.7, P < .001), ALD (OR = 2.5, P = .01), and MELD score (OR = .95, P = .02) independently predicted 90-day p-LTOU.

CONCLUSIONS: ALD, pre-LT opioid use, and MELD score independently predict p-LTOU. Special attention should be paid to identify post-LT prolonged opioid use in ALD patients.

Comments made by Cale Kassel M.D., FASA

 

Summary:

In this retrospective study, the Johnson-Laghi et al reviewed patients undergoing liver transplantation focusing on patients with known alcoholic liver disease and previous opioid use prior to transplantation. As has been described, the use of pre-operative opioids is associated with worse outcomes in other surgical procedures. The authors sought to identify if post-LT opioid use (p-LTOU) was greater in patients with alcoholic liver disease (ALD) compared to those without alcoholic liver disease.

Patient demographic data included diagnosis of psychiatric disease, use of psychiatric medications, use of illicit drugs, use of benzodiazepines, use of marijuana, prior alcoholic rehabilitation, and legal encounters related to alcohol (DUI). Use of pre-operative opioids included use both scheduled and as needed within the three months prior to transplantation. The total dose was converted to morphine equivalents for comparison.

Overall, opioid use post-LT was more common with patients with ALD compared to those without at 30, 60, and 90 days. At 90 days, 44% of ALD patients were taking opioids compared to 27% of non-ALD patients (p = 0.004). Multi-variate logistic regression demonstrated pre-LT opioid use, primary diagnosis of ALD, and lower MELD predicted 90-day post-LT opioid use.

Further analysis showed specific risk factors for p-LTOU at 60 days to include living alone. As the authors noted, this shows the importance of good social support for patients evaluated for LT. This was not a significant variable at 90 days however.

As the authors noted, more research is needed on this topic to further identify risk factors for opioid use following LT. Additionally, this is an area for anesthesiologist involved in the listing process to add value. Opioid tapering prior to LT may provide benefit for patients. Identifying patients with any patient who take opioids, can allow for early intervention including opioid tapering.

Utilization and outcomes of deceased donor SARS-CoV-2–positive organs for solid organ transplantation in the United States.

Abstract:

Coronavirus disease-19 has had a marked impact on the transplant population and processes of care for transplant centers and organ allocation. Several single-center studies have reported successful utilization of deceased donors with positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) tests. Our aims were to characterize testing, organ utilization, and transplant outcomes with donor SARS-CoV-2 status in the United States. We used Scientific Registry of Transplant Recipients data from March 12, 2020 to August 31, 2021 including a custom file with SARS-CoV-2 testing data. There were 35 347 donor specimen SARS-CoV-2 tests, 77.5% upper respiratory samples, 94.6% polymerase chain reaction tests, and 1.2% SARS-CoV-2-positive tests. Donor age, gender, history of hypertension, and diabetes were similar by SARS-CoV-2 status, while positive SARS-CoV-2 donors were more likely African-American, Hispanic, and donors after cardiac death (p-values <.01). Recipient demographic characteristics were similar by donor SARS CoV-2 status. Adjusted donor kidney discard (odds ratio = 2.08, 95% confidence interval [CI] 1.66-2.61) was higher for SARS-CoV-2-positive donors while donor liver (odds ratio = 0.44, 95% CI 0.33-0.60) and heart recovery (odds ratio = 0.44, 95% CI 0.31-0.63) were significantly reduced. Overall post-transplant graft survival for kidney, liver, and heart recipients was comparable by donor SARS-CoV-2 status. Cumulatively, there has been significantly lower utilization of SARS-CoV-2 donors with no evidence of reduced recipient graft survival with variations in practice over time.

 

Comments made by Cale Kassel M.D., FASA  

Summary:

When the COVID-19 pandemic began, there were obvious concerns among the transplant community. First and foremost, how could we protect patients following transplant and while waiting from transplant. As our understanding of COVID-19 evolved, so to did our ability to manage the disease in organ transplantation. The question of utilizing COVID-positive organs for transplantation emerged. Schold, et al reviewed SRTR data to look at utilization of COVID-positive organs (kidney, liver, and heart) from early in the pandemic to present. Several key findings emerged as they evaluated the data. 

First, they found utilizing COVID-positive grafts did not demonstrate worse outcomes for patients. Graft survival was similar between COVID-positive and COVID-negative grafts for kidney (95.5% vs. 95.3%), liver (93.9% vs. 97.0%), and heart (92.8% vs. 96.7%). 

Second, utilization of COVID-positive donors remained low. Recovery of COVID-positive organs was lower for kidneys, livers, and hearts. Additionally, discard of recovered grafts were lower in COVID-positive grafts. However, kidney graft discard rate of COVID-positive grafts was lower in the later study period (Dec 2020-April 2021) compared to the early study period (March 2020-November 2020). The overall rate of discard for COVID-positive kidneys was still lower than COVID-negative. Heart and liver discard rates were lower in COVID-positive donors as well. 

As we continue to learn more about the effect of transplantation of COVID-positive organs, we can continue to optimize patients and grafts to improve outcomes. Early data from this study and others suggests COVID-positive grafts can provide a safe option for patients awaiting transplantation.

References:

Schold JD, Koval CE, Wee A, Eltemamy M, Poggio ED. Utilization and outcomes of deceased donor SARS-CoV-2–positive organs for solid organ transplantation in the United States. American Journal of Transplantation 2022;22(9):2217-2227. DOI: https://doi.org/10.1111/ajt.17126.