Project 2-Optimization of Post-Transplant care via Biomarkers and Behavioral Interventions

在美国，酒精性肝病(ALD)是肝脏的第二大常见适应症 移植(LT)。传统上，ALD患者被要求完成为期六个月的强制性 LT前戒酒。最近，重型酒精性肝炎的早期肝移植没有在 任何移植前的酒精治疗，因为与此相关的高医学敏锐度和死亡率 疾病。重要的是，到目前为止的有限研究表明，早期(ELT)与 标准(SLT)移植受者。对于所有ALD的LT接受者来说，重新饮酒是一个主要的担忧， 估计酒精复吸率在16%到49%之间。尽管大多数LT诊所已经强制实施了LT前检查 酒精治疗，尽管风险高且严重，但对肝移植后服务的关注要少得多 在此期间旧病复发的后果。有许多基于证据的酒精治疗方法可供选择 使用障碍(澳元)。近年来，我们团队和其他人开发了基于Web和文本的版本 这些经验支持的干预措施扩大了它们的覆盖范围，并可在正规酒精诊所之外推广 设置。在非传统环境中提供AUD干预是可行的，患者可以接受，并且 在减少酒精使用方面很有效。我们建议实施和评估酒精治疗的效果 融入常规的肝移植术后护理。所有患者都接受医生的指示，停止饮酒并从事 酒精服务(照常治疗：tau)。ELT(N=100)和SLT(N=100)患者将在 AUD综合治疗(IAT)或TAU的依据为2：1。IAT将包括在医院使用计算机提供的商业智能， 每次门诊LT随访时护士提供的酒精监测咨询，以及居家参与 在基于网络的7会话CBT4CBT中，辅以定制的文本消息。另外，因为有证据 ALD患者向LT提供者严重低估了他们的饮酒情况，我们将比较LT后的酒精 使用经过良好验证的近期饮酒生物标记物(PEH)的复发率，患者自我报告 酒精仪器，并向其LT供应商报告患者情况。最后，我们将确定LT后酒精含量的预测因素 ELT和SLT患者的使用和治疗参与度。主要措施包括：饮酒； 参与酒精治疗；保留移植后的后续护理；情绪和焦虑；以及质量 生活。鉴于ELT和SLT接受者酗酒的严重后果，至关重要的是 准确识别酒精使用情况，并在移植后早期实施酒精干预 优化患者的短期和长期结果，并最终为这一高危人群量身定做治疗。

In the United States, alcoholic liver disease (ALD) is the second most common indication for liver transplant (LT). Traditionally, ALD patients have been required to complete a six-month mandatory period of alcohol abstinence before LT. More recently early LT for severe alcoholic hepatitis is being performed without any pre-transplant alcohol treatment because of the high medical acuity and mortality associated with this disease. Importantly, the limited studies to-date demonstrate comparable survival among early (ELT) versus standard (SLT) transplant recipients. Return to alcohol use is a major concern for all LT recipients with ALD, with estimates of alcohol relapse ranging between 16 and 49%. Although most LT clinics have enforced pre-LT alcohol treatment, far less attention has been paid to post-LT services, despite the high risk and severe consequences of relapse during this period. Numerous evidence-based treatments are available for alcohol use disorder (AUD). In recent years, our group and others have developed web- and text-based versions of these empirically-supported interventions to expand their reach and replicability outside of formal alcohol clinic settings. Delivery of AUD interventions in non-traditional settings is feasible, acceptable to patients, and effective in reducing alcohol use. We propose to implement and evaluate the effects of alcohol treatment integrated into routine post-LT care. All patients receive physician instructions to stop drinking and engage in alcohol services (treatment as usual: TAU). ELT (N=100) and SLT (N=100) patients will be randomized on a 2:1 basis to integrated AUD treatment (IAT) or TAU. IAT will include computer-delivered BI in the hospital, nurse-delivered alcohol monitoring counseling at each outpatient LT follow-up visit, and at-home participation in web-based, 7-session CBT4CBT, supplemented by tailored text messages. Also, because of the evidence that ALD patients significantly underreport their drinking to LT providers, we will compare post-LT alcohol relapse rates using a well-validated biomarker of recent drinking (PEth), patient self-report on a validated alcohol instrument, and patient report to their LT provider. Finally, we will identify predictors of post-LT alcohol use and treatment engagement for ELT and SLT patients. Key measures will include: alcohol use; engagement in alcohol treatment; retention in post-transplant follow-up care; mood and anxiety; and quality of life. Given the severe consequences of alcohol relapse among both ELT and SLT recipients, it is critical to accurately identify alcohol use and implement alcohol interventions early in the post-transplant period to optimize short- and long-term patient outcomes and ultimately tailor treatments for this high-risk population.