DDN May2021 May 2021 | Page 14


Due to overwhelming


The heaviest drinkers buy most of the alcohol sold in the UK , with 4 per cent of the population consuming 30 per cent . Despite a decline in average consumption there has been a paradoxical increase in certain alcohol-related harms , including a 400 per cent increase in deaths due to liver disease . This peaked in 2015-18 , with 60 per cent of these deaths attributed to alcohol .

In 2018 , more than 4,500 people died due to alcohol-related liver disease , but the work of liver transplant centres has suppressed this number by performing around 1,000 liver transplants per year . The demand for liver transplantation for alcohol-related liver disease is such that liver transplant centres have employed substance misuse specialists to assist in the assessment , monitoring and treatment of people with alcohol use and substance misuse disorders . These individuals have worked together to uphold national standards and formed a group called the Substance Misuse Specialists in Liver Transplant ( SMSLT ).
We are a group of substance misuse specialist nurses working across five of the seven transplant centres in the UK . We see patients with alcohol-related liver disease ( ArLD ) and other substance misuse
With rates of alcoholrelated illness continuing to rise , Charlie Parker and Ian Webzell describe the vital work of the Substance Misuse Specialists in Liver Transplant ( SMSLT )
disorders who are being considered for liver transplantation . We work closely with alcohol liaison nurses from referring hospitals and community drug and alcohol services . We actively encourage engagement with peer support and mutual aid services such as AA and SMART , and involve families in the transplant assessment and workup period . We use motivational interviewing and relapse prevention interventions to enhance the patient ’ s recovery capital and reduce the risk of relapse .
Patients must have been abstinent for at least three months – but the longer the better – in order to be considered for liver transplant , and are required to commit to lifelong abstinence from alcohol . For people struggling with symptoms of liver disease , liver transplantation offers the opportunity for improved quality of life and longevity .
ArLD is an umbrella term describing a range of alcoholrelated liver injury including fatty liver , fibrosis and cirrhosis . Cirrhosis can be compensated or decompensated – compensated means the liver can continue to work and function , whereas decompensated disease results in symptoms such as ascites ( fluid in the abdomen ), jaundice , hepatic encephalopathy ( confusion and memory problems caused by a build-up of toxins ) and sarcopenia ( muscle wasting ). A liver transplant may be required when someone has decompensated cirrhosis or hepatocellular carcinoma ( HCC ).
Anyone diagnosed with liver disease should avoid alcohol , but this is particularly important for people with ArLD as ongoing alcohol use will continue to cause damage to the liver . Drinking after a transplant can cause serious issues , including recurrence of cirrhosis and liver failure which can be fatal . Across Europe , around 50 per cent of liver transplants are wholly or partially related to alcohol use .
During a liver transplant assessment , the substance misuse specialist will undertake a comprehensive assessment of candidates including a detailed drug and alcohol history . This allows them to formulate a risk assessment and provide an opinion to the team regarding the risk of relapse . If a patient is considered to be at a relatively high risk of relapse then we would offer interventions to engage the patient in their recovery journey . As the transplant centres are regional services we often see people from
Liver transplant journey
a wide geographical area , which is why we rely upon support from local alcohol recovery services , even when people are abstinent . As a result of the COVID pandemic telephone or video appointments are increasingly offered .
Nationally agreed guidelines recommend that patients are abstinent from alcohol , stop smoking and do not use any illicit drugs including cannabis . Prescribed opioid substitution therapy is not a contraindication to transplantation . Patients will be screened throughout their assessment and time on the waiting list . Any positive screens will be taken seriously by the liver transplant team and may result in removal from the waiting list . Being on the waiting list can be a period of uncertainty for candidates – these are periods of poor health , during which recovery is beyond the control of the individual . They may feel anxious or low in mood , and it is our job to continue to review people , provide support and work through any difficulties .
The recovery period following a transplant is focused upon people ’ s physical health during the first six months and over time
• Patient is seen by gastroenterology or hepatology at their local hospital and diagnosed with liver disease
• Patient with decompensated cirrhosis and three or more months abstinence is referred to transplant unit
• Patient is seen in outpatient clinic or as inpatient depending on severity of disease
• Patient has multi-disciplinary transplant assessment ( inpatient or outpatient )
• Patient is discussed at liver transplant MDT meeting
• Patient is either listed , not listed or listed pending further investigations or interventions
• Patient engages with substance misuse nurse specialist , alcohol liaison / community alcohol services , peer support and mutual aid ( this may have happened before assessment )
• If MDT in agreement patient can be placed on liver transplant waiting list
• Alcohol levels are monitored before , during and after transplant
• Patient remains under lifelong follow with transplant centre / local hospital
• If patient lapses / relapses aim to re-engage with alcohol services to support abstinence