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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
Liver Transpl. Author manuscript; available in PMC 2010 June 11.
Published in final edited form as:
PMCID: PMC2883859

Meta-Analysis of Risk for Relapse to Substance Use After Transplantation of the Liver or Other Solid Organs

Mary Amanda Dew, Ph.D.,1,2,3 Andrea F. DiMartini, M.D.,1,4,7 Jennifer Steel, Ph.D.,4,7 Annette De Vito Dabbs, Ph.D., R.N.,5 Larissa Myaskovsky, Ph.D.,6,8,1 Mark Unruh, M.D., M.Sc.,6 and Joel Greenhouse, Ph.D.9,1


For patients receiving liver or other organ transplants for diseases associated with substance use, risk for relapse post-transplant is a prominent clinical concern. However, there is little consensus regarding either the prevalence or risk factors for relapse to alcohol or illicit drug use in these patients. Moreover, the evidence is inconsistent as to whether patients with pre-transplant substance use histories show poorer post-transplant medical adherence. We conducted a meta-analysis of studies published between 1983–2005 in order to estimate relapse rates, rates of nonadherence to the medical regimen, and potential risk factors' associations with these rates. The analysis included 54 studies (50 liver, 3 kidney, and 1 heart). Average alcohol relapse rates (examined only in liver studies) were 5.6 cases per 100 patients per year (PPY) for relapse to any alcohol use and 2.5 cases per 100 PPY for relapse with heavy alcohol use. Illicit drug relapse averaged 3.7 cases per 100 PPY, with a significantly lower rate in liver vs. other recipients (1.9 vs. 6.1 cases). Average rates in other areas (tobacco use, immunosuppressant and clinic appointment nonadherence) were 2–10 cases per 100 PPY. Risk factors could be examined only for relapse to any alcohol use. Demographics and most pre-transplant characteristics showed little correlation with relapse. Poorer social support, family alcohol history and pre-transplant abstinence of ≤ 6 months showed small but significant associations with relapse (r's=.17–.21). Future research should focus on improving the prediction of risk for substance use relapse, and on testing interventions to promote continued abstinence post-transplant.

Keywords: liver transplantation, alcohol relapse, illicit drug relapse, tobacco use, nonadherence

Organ transplantation has become an increasingly accepted strategy for the treatment of end-stage diseases associated with substance abuse or dependence. For example, despite early reservations as to whether patients with alcoholic liver disease (ALD) were appropriate transplant candidates(14), ALD is now among the most common indications for liver transplantation in both the United States and Europe(58), and short-term (1–5 year) survival rates for these patients are similar to or exceed those of patients transplanted for other types of liver disease(5,9). A small literature suggests that favorable outcomes are also possible for liver and other solid organ transplant recipients with histories of other types of substance abuse (e.g., heroin use)(1013).

Nevertheless, concerns remain regarding patients' risk of return to alcohol or other substance use post-transplant, especially in light of a growing body of data showing that substance use relapse—especially return to heavy or “harmful” use(14)—bodes poorly for long-term graft function, extra-hepatic health, and patient survival(1521). But how commonly do patients return to substance use after transplantation, and what are the strongest predictors of this outcome? Reviews and commentaries indicate that we cannot yet answer either part of this question. For example, crude rates (unadjusted for follow-up duration) of alcohol relapse after liver transplantation have been reported to range from 0% to 95%(5,19,2231).

Reviews summarizing alcohol relapse rates post-transplant note that differences across studies are difficult to interpret or reconcile due to variations in study methodology, definition and assessment of relapse, and follow-up duration(5,25,31,32). Addressing differences in follow-up duration has proved particularly vexing, with the most common approaches to date consisting of commenting on such differences qualitatively (without any corresponding empirical adjustment of rate estimates)(5,25,26,28,29) or considering small groups of studies piecemeal (e.g., examining the small group that report 6-month relapse rates, those reporting 12-month relapse rates, etc.)(22,23,32). Neither approach allows for full integration across studies. Moreover, despite the wide-spread promotion of strategies believed to reduce post-transplant relapse risk (e.g., requiring that patients have >6 months of abstinence pre-transplant or that patients participate in formal substance use rehabilitation pro-grams),31,33 reviews note that the empirical evidence linking such factors to post-transplant relapse remains sparse and contradictory(7,25,31,34,35). Finally, a longstanding debate has concerned whether patients with histories of substance use/abuse are at risk not only for relapse post-transplant but for nonadherence to the medical regimen (either alone or in concert with substance use relapse)(3,37). Yet evidence to support or refute assertions of heightened nonadherence risk remains scattered across this literature(11,17,3640) and has not received systematic review.

Without precise information about level of risk and predictors of risk for relapse to substance use after liver and other forms of organ transplantation, it becomes difficult either to (a) appropriately target clinical resources to minimize the risk, or (b) design intervention research to empirically evaluate promising clinical strategies for risk reduction. Therefore, we performed a meta-analysis in order to achieve two goals. First, we sought to provide precise estimates of the rates of alcohol and illicit drug relapse in individuals receiving liver or other solid organ transplants. As part of this goal, we also examined post-transplant rates of nonadherence to critical components of the medical regimen (e.g., taking immunosuppressant medications) in transplant recipients with pre-transplant histories of substance use. Where there was substantial variation in substance relapse or other nonadherence outcome rates across studies, we examined whether this variation could be explained by differences in study characteristics (e.g., study design). Second, we sought to determine whether substance use relapse was associated with features of pre-transplant substance use history and other psychosocial characteristics hypothesized to influence post-transplant relapse risk.


The methodology for conducting and reporting the meta-analysis followed established guidelines(41,42).

Search strategy and study selection

Eligible studies reported on transplant recipients with pre-transplant histories of substance abuse/dependence or diseases indicative of such use (e.g., ALD). Studies included in the present report were drawn from a larger literature search on nonadherence to the medical regimen (including substance use) after organ transplantation. We divided this literature into studies that focused on general transplant samples and studies that focused on samples of patients transplanted due to substance use. The former samples were examined in an earlier meta-analysis(43). In contrast, the present report examines all papers describing samples of patients transplanted due to substance use.

Figure 1 summarizes our study retrieval and selection strategy. From 691 articles initially retrieved, 603 articles were excluded from the analyses herein. As shown in the figure, articles were excluded if they provided no data on post-transplant substance use relapse or any other nonadherence outcome in transplant recipients with substance abuse/dependence histories. Studies were also excluded if they provided neither (a) the number of persons who relapsed (or had any other outcome we examined) and the duration of observation time for sample, nor (b) the association of relapse (or any other outcome) with at least one of the psychosocial risk factors we considered (as described below). Finally, studies were excluded if they reported on relapse or nonadherence exclusively in samples of patients with poor health outcomes (e.g., graft loss, death). The rationale for this exclusion was that studies limited to patients with poor outcomes, some of which can be produced by substance use, would not provide rate information generalizable to the larger group of transplant recipients who remained alive.

Figure 1
Identification of independent studies for current meta-analysis.

Data extraction

Substance use and other nonadherence outcomes

Pairs of authors (one of whom was M.A.D.) reviewed all studies. The three primary outcomes for the present analyses pertained to substance use relapse: relapse to any alcohol use post-transplant, relapse to heavy alcohol use, and relapse to any illicit drug use. Three secondary outcomes pertained to behaviors in other areas of the post-transplant medical regimen: tobacco use, immunosuppressant medication nonadherence, and failure to attend clinic appointments. No other areas of nonadherence (e.g., failure to complete blood work and tests, failure to monitor vital signs) were examined in any report focused on transplant recipients with histories of substance use.

Three of our six outcomes—alcohol relapse, illicit drug relapse, and tobacco use—were consistently defined across the original study reports as any use (vs. none). For remaining outcomes (alcohol relapse with heavy use, nonadherence to immunosuppressants, and nonadherence to clinic appointments), we followed the standards of the Cochrane Collaboration(44,45) and other meta-analyses of nonadherence in non-transplant populations(46): we extracted information from each study on the occurrence of each outcome based on the study authors' definition (i.e., their definition of what constituted heavy drinking, or their definition of nonadherence to immunosuppressants or required clinic appointments). (These definitions necessarily varied somewhat depending on studies' method of outcome assessment; we evaluated the impact of method differences on outcome as described below.) Authors' definitions of medication and clinic appointment nonadherence reflected their transplant programs' requirements in these areas.

Assessment-related and other study characteristics

We aimed to categorize the method used to assess each substance use and nonadherence outcome into five broad groups(46): (a) self-report (e.g., patient interview, paper-and-pencil survey, diary); (b) collateral report by family member or health care professional (e.g., through interview or survey); (c) biologic or other “indirect”(47) measure (e.g., blood level, electronic medication monitoring); (d) historical data retrieved from medical records, and (e) combinations of two or more of these methods (e.g., self report + medical record data). However, no studies were found that fell into categories (b) or (c). We also recorded descriptive information about each investigation (e.g., type of transplant studied, geographic region where the study was conducted, study design).

Finally, following current meta-analysis standards(41), pairs of us rated each study on five components of methodologic quality, using a validated scoring system for each(48). We employed a consensus approach where any disagreements were resolved before assigning a final score. The five components (each rated as 1=yes, 0=no) were whether: (a) the sample was clearly described (e.g., including demographic information, dates of transplant), (b) the patients approached for enrollment were representative of the population of patients with histories of substance use who were transplanted at the study's site, (c) the sample enrolled was representative of those approached, (d) the source of outcome data (e.g., on relapse or other areas of nonadherence) and the time period covered by the outcome measure were clearly described, and (e) analyses of outcome rates were appropriate (i.e., if patients varied in follow-up duration, rates were calculated via techniques such as survival analysis). A composite quality score was created for each study which was the count of the number of these five areas that were rated as “yes” (total score range, 0–5).

Potential correlates of substance use and nonadherence outcomes

From each study, we extracted information on the size of the associations of our outcomes with a series of psychosocial characteristics. We aimed to examine as many as possible of the characteristics hypothesized in the substance use and adherence literatures to be important(15,23,25,26,31,32,34,43,46,4952). However, there were only sufficient numbers of studies (i.e., ≥ 5 for any given psychosocial characteristic) for us to examine: (a) a single outcome, alcohol relapse (any use), in relation to (b) the variables of patient gender, age, education, marital status, employment status, social support, pre-transplant psychiatric history (Axis I disorders), pre-transplant illicit drug use, family history of alcohol abuse/dependence, duration of abstinence from substance use before transplant, and participation in a substance use rehabilitation program before transplant. (It is noteworthy that there were also too few studies to examine even the single outcome of alcohol relapse in relation to other outcomes such as immunosuppressant or clinic appointment nonadherence.) Among the potential psychosocial correlates of alcohol relapse, one variable, duration of pre-transplant abstinence, has been used in some studies as a dichotomous variable (≤ 6 months of abstinence vs. longer abstinence), and in other studies as a continuous variable. Thus, we considered it both ways in the present analyses so that relevant information on abstinence duration from as many studies as possible could be evaluated. In addition, because it has been suggested that there is a strong negative association between time since transplant and risk for alcohol relapse(5) (yet too few studies report any empirical estimate of this association), we examined the timing of relapse descriptively.

Statistical analysis

Examination of rates of relapse and nonadherence

Patients in most studies had unequal follow-up time, typically because they entered a given study at different time points (e.g., different transplant dates) or were lost to follow-up at varying time points (e.g., due to death). Thus, given our goal to compare rates in the face of differences in duration of observation(53,54), we examined event rates—e.g., cases of relapse—per 100 persons per year (i.e., per 100 person-years of observation). If total person-years of observation was not reported directly, we calculated it from either reported cumulative probabilities or descriptive information about the distribution of follow-up duration in the sample(53). The person-years metric is routinely used in examining health-related outcome rates in many patient populations(5558).

We calculated the pooled, or average, estimate of the rate in each study outcome (rate = cases per 100 persons per year [PPY]) across all contributing studies, as well as within each organ transplant type (when studies varied in the type of transplant recipients considered). The pooled estimate is a weighted average that takes within-study variance into account. It was calculated under a random effects model, in order to allow generalizability beyond the retrieved studies(59). For each statistically significant pooled estimate, we evaluated the impact of publication bias (i.e., that studies finding outcome rates exceeding zero may have been more likely to be published) by calculating the “fail-safe N.” This is the number of missing studies obtaining null findings that would need to be added to the analysis so that the pooled estimate would no longer be significant(60,61).

For outcomes with substantial variability in rates among contributing studies (as determined with the Q test for heterogeneity), we used random effects meta-regression to determine whether the variability could be independently explained by any of four study characteristics: geographic location, year of publication, study design, study quality, and method of assessment of the study outcome.

Examination of psychosocial risk factors in relation to study outcomes

The association of alcohol relapse (any use) with each psychosocial variable was examined by extracting r, the Pearson correlation coefficient, as the measure of effect size (ES). (When the size of the association was not reported directly, we calculated it from the relevant test statistic reported for it, e.g., a t-test or a chi squared value.) The ES indicates the strength and direction of association between pairs of variables; we chose it for its flexibility and applicability across measurement scenarios (i.e., with continuous, dichotomous, or ranked variables(62,63)). For each statistically significant average ES, we calculated the fail-safe N. We determined whether there was significant variability in ES across studies with the Q test, and we examined whether study characteristics defined above accounted for the variability. Although we could not extract ES data on the association between time since transplant and risk for alcohol relapse, we provide descriptive data relevant to this association.


Retrieved studies

A total of 54 studies met our inclusion criteria; all but four pertained to liver recipients. Table 1 provides descriptive information for the complete set of studies. (Appendix A lists each study and the substance use or other nonadherence outcomes examined; a bibliography is available from M.A.D.) Similar numbers of studies were conducted in North America (all in the United States) and Europe (including France, Germany, the United Kingdom, Spain, Austria, and Italy). Over 3,600 patients were included across all studies, contributing over 13,800 person-years of observation time. The average duration of observation was over 4 years, ranging up to almost 13 years. Most studies examined substance use or other nonadherence outcomes retrospectively, rather than by prospectively charting the incidence of the outcomes over time. The majority of the studies received total methodologic quality scores in the low to moderate range.

Table 1
Descriptive information for 54 independent studies of substance use and other outcomes in patients with pre-transplant histories of alcohol or illicit drug use.

The number of reports contributing data on each of our primary and secondary outcomes are also shown in Table 1. Studies of post-transplant alcohol relapse (any use) were most common and included only liver recipients. Although there are far fewer studies of illicit drug relapse, it has been considered across multiple types of organ recipients. The secondary outcomes have rarely been reported in individuals with pre-transplant histories of alcohol or illicit substance use.

Rates of study outcomes and rate differences by type of transplant

Figure 2 shows the average rate and 95% confidence interval (CI) for the primary and secondary outcomes. For example, the average rate for alcohol relapse (any use) was 5.6, or approximately 6 cases per 100 persons per year of observation. The average rates for all outcomes except nonadherence to clinic appointments differ significantly from zero (i.e., CIs do not include zero). The rate for tobacco use is higher than rates for any other outcomes, although its CI is also wider than that of any other outcome.

Figure 2
Pooled estimates of post-transplant rates of substance use and other nonadherence outcomes.

The relatively large fail-safe N's for the rates in Figure 2, especially for alcohol relapse (any use) alcohol relapse with heavy use, indicate that these average rates are very robust to the discovery of many additional studies reporting null findings (i.e., the observed rates are not artifacts of publication bias favoring reports finding large, significant rates). The Q tests in Figure 2 indicate that, except for clinic appointment attendance, there is significant variability in the rates across studies. Is this variability explained by type of transplant (i.e., liver vs. kidney or heart)? Only two outcome areas have been examined across multiple types of transplant recipients: as shown in Table 2, the rate of illicit drug relapse was significantly lower in liver recipient studies than in studies of other types of recipients. The rate of immunosuppressant nonadherence appeared to be lower in liver recipients than in heart recipients. However, we could not formally test this difference because the heart recipient rate was based on a single study.

Table 2
Rates of study outcomes by type of organ transplant (cases per 100 persons per year).a

Study-related characteristics accounting for variability in outcome rates

We focused on the outcomes where there was significant variability and, because meaningful analysis is difficult with small numbers of studies, we considered only those outcomes with more than 5 contributing studies. Results for the four outcomes meeting these criteria are shown in Table 3. For each outcome, the estimated rate is shown according to study characteristic. For example, for relapse to any alcohol use, the second column of Table 3 shows that European studies had a higher average rate (6.7; ~ 7 cases per 100 persons per year) than North American studies (rate of 4.4). This difference in rates was statistically significant (Z=3.53, p<.01). European studies also yielded significantly higher rates of relapse to heavy alcohol use. However, European studies showed lower rates of immunosuppressant nonadherence.

Table 3
Study characteristics potentially accounting for variability in outcome rates (per 100 persons per year) across independent studies of patients with pre-transplant histories of alcohol or illicit drug use.a

Table 3 shows that two other study characteristics were associated with significantly greater risk for relapse to any alcohol use: study publication in 1995 or earlier, and use of either self-report or multiple method approaches to assessment. No study characteristic other than geographic location was associated with any other outcome.

Associations of outcomes with psychosocial variables

We were able to examine alcohol relapse (any use) in relation to 12 potential psychosocial risk factors. (As noted earlier, no other outcome was examined in sufficient numbers of studies in relation to any risk factors.) Figure 3 shows the direction and strength of the alcohol relapse-psychosocial variable correlations, as well as the number of studies examining each correlation. For example, across the 14 reports contributing data on the alcohol-gender correlation, the average ES was r = −.01 (CI, −.10, .07). Only three of the 12 psychosocial variables were significantly correlated with alcohol relapse: poorer social support, a family history of alcohol abuse/dependence, and duration of pre-transplant abstinence of ≤ 6 months (ESs of .17, .17, and .21, respectively; CIs not overlapping with zero). The fail-safe Ns of 9 or less for social support and family history are small, but the fail-safe N of 179 for abstinence ≤ 6 months suggest that this latter association with alcohol relapse is robust to the discovery of many additional reports with null effects.

Figure 3
Associations between post-transplant alcohol relapse (any use) and psychosocial variables.a

Q was significant for several ESs in Figure 3. However, no study characteristics (e.g., design, quality) significantly accounted for the observed variability in ESs across studies.

Finally, although we could not quantitatively examine an association between time since transplant and alcohol relapse risk (because too few studies reported a relevant ES), Figure 4 shows descriptive data on relapse timing. Eleven studies reported the earliest and latest time post-transplant at which relapse occurred (and sometimes reported the midpoint), based on survival analysis. Figure 4 shows that risk for alcohol relapse (any use) begins early post-transplant and may continue for many years. Of the 9 studies following patients beyond 7 years, 6 observed new cases of relapse to continue to occur as late as 4 to 9.5 years post-transplant. Some of the 11 studies show a long time lag between the final occurrence of relapse and continued follow-up in the remainder of the sample who remained abstinent (as denoted by the dashed lines that continue to the end of follow-up). Others show that new cases of relapse continued to occur through much or all of the follow-up period.

Figure 4
Time to alcohol relapse (any use) after liver transplant


The literature on post-transplant relapse to substance use consists almost exclusively of studies of liver recipients. With few exceptions, then, the interpretation of our findings is limited to these patients. With this caveat, the rates of the outcomes we examined, summarized in Figure 2, provide essential information to guide clinicians' assessments of the overall risk of these outcomes in their patients. Such rate estimates can also be valuable for developing clinical strategies to reduce or limit risk(43,53). From a research standpoint, Figure 2 reveals the areas for which there remains limited post-transplant risk information in patients with substance use histories. Alcohol relapse has clearly received the greatest attention to date, despite equally salient concerns about relapse risk in the growing numbers of transplant recipients with other types of substance use histories(23,64,65). In particular, many patients with hepatitis C virus—now the most common indication for liver transplant, alone or in combination with ALD(5,6)—are likely to have acquired the virus via illicit drug use(23). Thus, relapse to drug use demands increased scrutiny in future studies.

The average rates of all outcomes we examined suggest that during any given year of observation, most transplant recipients with substance use histories will neither use substances nor become nonadherent to components of the medical regimen. For example, the post-transplant healthcare provider can expect to see only approximately 6 patients relapse to alcohol use and 4 relapse to illicit drug use for every 100 former substance users during a given year of follow-up. Tobacco use post-transplant was the most prevalent outcome, at approximately 10 cases per 100 persons per year. Although this estimate was based on only three studies, our finding of a relatively high prevalence of tobacco use is consistent with the increased attention that this outcome is receiving in the clinical literature(6669), including mounting evidence that it is associated with significant morbidities (e.g., lung and oropharyngeal cancers(70); vascular complications(69)) after liver transplantation. The tobacco use rate found in the present analysis was greater than the rate of 3.4 cases per 100 persons per year that we observed in our earlier meta-analysis of general transplant samples(43). Overall, our findings support the need for smoking cessation programs to be more widely available to transplant patients(68), particularly those with substance use histories because these individuals are more likely than other patients to also be smokers(66).

In contrast, we observed a lower rate of immunosuppressant medication nonadherence than we found in our earlier analysis of general liver transplant samples (3.2 cases vs. 6.7 cases per 100 persons per year, respectively). These results, then, belie assertions that persons with pre-transplant substance use histories are at greater risk for medication nonadherence than other patients. We could not examine, however, whether relapse to substance use post-transplant elevates the risk for medication nonadherence because too few studies have considered this issue.

With respect to our primary outcomes, relapse to any alcohol use after liver transplantation was over twice as common as relapse with heavy alcohol use (almost 6 vs. less than 3 cases per 100 persons per year). This suggests that only a minority of recipients who return to alcohol use may become heavy or “harmful” drinkers. (It can be argued that relapse to “any” alcohol use does not specify quantity of use and that perhaps most if not all individuals in the 49 studies reporting on “any use” actually relapsed to heavy use. However, 20 of the 49 studies reported both outcomes for their cohorts [see Appendix A]. The findings from these 20 studies are virtually identical to those reported across all available studies: approximately 6 cases per 100 persons per year return to any use, while less than 3 per 100 per year return to heavy use.)

The alcohol use outcome rates are annualized rates. Since our descriptive analysis of time to onset of drinking (Figure 4) suggested that new cases are observed from early post-transplant to many years later, it is the cumulative rates of relapse to any use or heavy use that become particularly worrisome. For example, at a rate of almost 6 cases of relapse to any alcohol use per 100 patients per year, the cumulative incidence rate would be approximately 11 cases by 2 years post-transplant, 28 cases by 5 years, and so on. In Figure 5, we plot the expected cumulative incidence rate for both of the alcohol outcomes, based on the meta-analysis findings. Figure 5 also shows the rates extracted from the individual studies. It is possible that the cumulative incidence rates would eventually level off, but our analyses do not allow us to determine when that might occur. However, the fact that some studies report new cases of relapse even many years post-transplant suggests that cumulative rates may continue to grow even in the late-term years. As shown in the figure, very few studies have followed cohorts beyond 7 to 8 years post-transplant, and thus it is difficult to extrapolate beyond that point.

Figure 5
Rate of alcohol relapse as a function of time since transplant

Our results suggest that illicit drug relapse was slightly less common than relapse to any alcohol use. It is the only outcome that was considered in multiple studies beyond liver transplantation. Indeed, the rate of illicit drug relapse was significantly higher in recipients of other organs than in liver recipients. We suspect that this partly reflects the fact that most studies of other types of recipients were conducted earlier than the liver recipient studies. These kidney and heart recipient reports either note that pre-transplant abstinence was not as closely monitored as is current practice(11), do not comment on whether there was any monitoring(10,71), or emphasize issues other than abstinence (e.g., adherence to dialysis for kidney patients) were more important both pre- and post-transplant for these patients(10,72).

Geographic and other study methodologic characteristics were related to variations in the substance use and nonadherence outcome rates. Of particular note, European studies showed higher rates of relapse to any alcohol use and relapse with heavy alcohol use, compared to North American (United States) studies. We know of no evidence to suggest that the higher European rates reflect any differential degree of emphasis across transplant programs on the importance of abstinence either before or after transplant. Instead, the effects may arise from the fact that ALD patients in Europe are exposed to cultures with higher average levels of alcohol consumption than in North America(73). These environmental conditions may make it more difficult for liver recipients with histories of alcohol use to continue to abstain from alcohol post-transplant.

Independent of geographic location, studies published after 1995 have found lower rates of relapse to any alcohol use. This may reflect transplant programs' increasingly stringent protocols for the selection of liver transplant candidates with histories of alcohol use(15,16,26,33). Finally, assessment method affected observed alcohol relapse rates. Self-report alone and multiple-method assessments (typically self-report + biological measures such as blood tests, or self-report + collateral report) yielded the highest rates of alcohol relapse. Our findings indicate that medical record reviews alone seriously underestimate alcohol relapse rates.

An important objective of our analysis was to determine the degree to which study outcomes were associated with patient psychosocial characteristics. The literature permitted us to examine only one outcome, relapse to any alcohol use, in relation to only some hypothesized psychosocial predictors. We found that patient demographic characteristics, pre-transplant psychiatric and illicit drug history, and pre-transplant participation in rehabilitation bore little to no association with relapse. Three significant associations were found, although they were modest in size: poorer social support, a family history of alcohol abuse/dependence, and a pre-transplant duration of abstinence of 6 months or less each mildly increased the risk for post-transplant relapse (correlations of .17 to .21). Overall, the fact that these modest associations were statistically reliable indicates that these variables have some predictive utility. However, they are not strong enough to predict risk with a high degree of accuracy. In the case of pre-transplant abstinence, its limited impact may be due to the fact that transplant programs strive to apply the “6-month rule” as a key criterion for candidate selection. If the highest risk patients (those with shorter or no abstinence) are largely eliminated from the candidate pool, then it would be expected that this variable should show only a limited correlation with relapse.

There are limitations to the present meta-analysis. We included only studies in which the full text was in English. However, the number of potentially relevant non-English reports was minute relative to the number of reports reviewed for possible inclusion. We have already noted other limitations that reflect the areas of focus and omission within the body of research that we synthesized: (a) little consideration of samples beyond liver transplantation, (b) beyond substance use outcomes, consideration of nonadherence in only a narrow range of the components of the medical regimen, (c) examination of psychosocial variables only in relation to relapse to any alcohol use, despite calls for the literature to focus on heavy or harmful use(7,8,14), (d) inability to examine associations between post-transplant substance use relapse and medical regimen adherence because too few studies examined such effects, and (e) inability to examine many variables proposed to be important predictors of substance use relapse (e.g., whether past substance use met criteria for dependence vs. abuse, presence of personality disorder) because too few studies have included them. Indeed, these areas of focus and omission in the literature provide a roadmap for work in the future.

Several additional challenges must also be addressed in new research, given our findings. First, in terms of prediction of relapse risk, it may be most important to determine how many risk factors a person possesses, even if each of those risk factors alone bears only a weak association with relapse. The idea that a constellation of risk factors may be critical is not new(36,74,75). But research to date typically evaluates the independent effect of each factor rather than searching for additive predictive power and attempting to identify a critical threshold of risk burden. The modest findings from the present analyses—that no single factor seems to be of major importance as a predictor—suggests that a new approach is needed. Alternatively, our findings may indicate that careful candidate selection has eliminated the highest risk patients—but the fact that cumulative risk for relapse appears ultimately rather large suggests that there is still room for improving prediction.

Second, research to develop and test post-transplant abstinence-promoting interventions is essential. Such work need not await the identification of risk factors if a model of “universal prevention”(76) is adopted, in which preventive interventions are offered to all recipients with pre-transplant histories of substance use. Post-transplant intervention research in this area is undoubtedly difficult, given patients' medical burden, complex treatment regimen, and frequent denial of need for intervention(77). Yet, given our findings regarding enduring risk for substance use relapse after transplantation, intervention efforts would be well-justified.


This article was supported in part by a grant from the International Transplant Nurses Society, a grant from Astellas Pharma US Inc., and grant MH072718 from the National Institute of Mental Health, Rockville, MD, USA. None of the funding agencies reviewed the contents of the article nor provided comments on it.

Appendix A Independent studies included in meta-analysis.a

Study first author, year (and first author, year of additional related publications)CountryOutcome areas examinedExamined psychosocial correlates included the meta-analysis
Alcohol relapse, any useAlcohol relapse, heavy useIllicit drug relapse, any useTobacco useNonadherence to immunosup-present medsNonadherence to clinic appointment follow-up
Liver transplant studies
Starzl, 1988USAX
Kumar, 1989 (Arria, 1991)USAXXX
Bird, 1990UKX
Beresford, 1992 (Lucey, 1992; Beresford, 1994; Lucey, 1994; Campbell, 1997; Lucey, 1997; Campbell, 1998)USAXXXX
Doffoel, 1992FranceX
Knechtle, 1992USAXX
Bonet, 1993 (Van Thiel, 1995; Tringali, 1996)USAXXX
Gish, 1993USAXX
Goldstein, 1993 (Tripp, 1996; Gerhardt, 1996)USAXXX
Osorio, 1993 (Osorio, 1994)USAXX
Pageaux, 1993 (Pageaux, 1999; 2003)FranceXXXX
Berlakovich, 1994a (Berlakovich, 1994b; Berlakovich, 1999)AustriaXXX
Howard, 1994 (Pereira, 1997; 2000)UKXXXXX
Krom, 1994 (Jauhar, 2004)USAXX
Poynard, 1994 (Poynard, 1999)FranceX
Raakow, 1995 (Rommelspacher, 1996)GermanyXX
Reeck, 1995GermanyX
Durand, 1996FranceXX
Zibari, 1996USAX
Anand, 1997 (Tang, 1998)UKXXX
Chapman, 1997USAX
Coffman, 1997USAXXX
Everson, 1997 (Talamantes, 1998)USAXXX
Foster, 1997USAXXX
Pera, 1997SpainX
Stephanini, 1997ItalyXX
Wiesner, 1997USAX
Fábrega, 1998 (Cuadrado, 2005)SpainXXXX
Heineman, 1998GermanyX
Berlakovich, 1999a (Berlakovich, 1999b; 2000)AustriaXXX
Conjeevaram, 1999USAX
Gledhill, 1999UKXX
Newton, 1999USAXX
Romano, 1999 (Rodriguez Romano, 2002)SpainX
Talaulicar, 1999GermanyX
Burra, 2000 (Burra, 2001)ItalyXXX
DiMartini, 2000USAX
Jain, 2000 (Bellamy, 2001)USAXX
Platz, 2000GermanyXX
DiMartini, 2001 (DiMartini, 2005)USAXXX
Gish, 2001USAXX
Karman, 2001USAXX
Mackie, 2001UKXXX
Ayata, 2002 (Goldar-Najafi, 2002)USAX
Tome, 2002 (Varo, 2002)SpainXX
Walter, 2002GermanyXX
Liu, 2003USAX
Miguet, 2004FranceXXX
Bjornsson, 2005SwedenXXX
Perney, 2005FranceXXX
Kidney transplant studies
Stevens, 1983USAX
Gordon, 1986USAX
Butkus, 2001USAX
Heart transplant studies
Hanrahan, 1991 (Hanrahan, 2001)USAXX
aEach row in this table describes an independent study of a given type of transplant recipient.


1. Atterbury CE. The alcoholic in the lifeboat: Should drinkers be candidates for liver transplantation? J Clin Gastroenterol. 1986;8:1–4. [PubMed]
2. Cohen C, Benjamin M. Alcoholics and liver transplantation. The Ethics and Social Impact Committee of the Transplant and Health Policy Center. JAMA. 1991;265:1299–1301. [PubMed]
3. Moss AH, Siegler M. Should alcoholics compete equally for liver transplantation? JAMA. 1991;265:1295–1298. [PubMed]
4. Sherman D, Williams R. Commentary: Liver transplantation and the alcoholic patient. Alcohol Alcoholism. 1995;30:141–143. [PubMed]
5. Anantharaju A, Van Thiel DH. Liver transplantation for alcoholic liver disease. Alcohol Research Health. 2003;27:257–268. [PubMed]
6. Reid AE, Resnick M, Chang YC, Buerstatte N, Weissman JS. Disparity in use of orthotopic liver transplantation among blacks and whites. Liver transplantation. 2004;10:834–841. [PubMed]
7. Neuberger J, Schulz KH, Day C, Fleig W, Berlakovich GA, Berenguer M, et al. Transplantation for alcoholic liver disease. J Hepatol. 2002;36:130–137. [PubMed]
8. Webb K, Shepherd L, Day E, Masteron G, Neuberger J. Transplantation for alcoholic liver disease: Report of a consensus meeting. Liver Transplantation. 2006;12:301–305. [PubMed]
9. Belle SH, Beringer K, Detre KM. Liver transplantation for alcoholic liver disease in the United States 1988–1995. Liver Transplant Surg. 1997;3:212–219. [PubMed]
10. Gordon MJV, White R, Matas AJ, Tellis VA, Glicklich D, Quinn T, et al. Renal transplantation in patients with a history of heroin abuse. Transplantation. 1986;42:556–557. [PubMed]
11. Hanrahan JS, Eberly C, Mohanty PK. Substance abuse in heart transplant recipients: A 10-year follow-up study. Prog Transplant. 2001;11:285–290. [PubMed]
12. Liu LU, Schiano TD, Lau N, O'Rourke M, Min AD, Sigal SH, et al. Survival and risk of recidivism in methadone-dependent patients undergoing liver transplantation. Am J Transplant. 2003;3:1273–1277. [PubMed]
13. Weinrieb RM, Barnett R, Lynch KG, DePiano M, Atanda A, Olthoff KM. A matched comparison study of medical and psychiatric complications and anesthesia and analgesia requirements in methadone-maintained liver transplant recipients. Liver Transplantation. 2004;10:97–106. [PubMed]
14. Lucey MR. Liver transplantation for alcoholic liver disease: Past, present, and future. Liver Transplant. 2007;13:190–192. [PubMed]
15. Kran LE, DiMartini A. Psychiatric and psychosocial aspects of liver transplantation. Liver Transplant. 2005;11(10):1157–1168. [PubMed]
16. Campbell DA, Jr, Magee JC, Punch JD, Merion RM, Turcotte JG, Bromberg JS. One center's experience with liver transplantation: Alcohol use relapse over the long term. Liver Transplant Surg. 1998;4:S58–S64. [PubMed]
17. Conjeevaram HS, Hart J, Lissoos TW, Schiano TD, Dasgupta K, Befeler AS, et al. Rapidly progressive liver injury and fatal alcoholic hepatitis occurring after liver transplantation in alcoholic patients. Transplantation. 1999;67:1562–1568. [PubMed]
18. Cuadrado A, Fábrega E, Casfont F, Pons-Romero F. Alcohol recidivism impairs long-term patient survival after orthotopic liver transplantation for alcoholic liver disease. Liver Transplant. 2005;11:420–426. [PubMed]
19. Lucey MR, Carr K, Beresford TP, Fisher LR, Shieck V, Brown KA, et al. Alcohol use after liver transplantation in alcoholics: A clinical cohort follow-up study. Hepatol. 1997;25:1223–1227. [PubMed]
20. Pageaux G-P, Bismuth M, Perney P, Costes V, Jaber S, Possoz P, et al. Alcohol relapse after liver transplantation for alcoholic liver disease: Does it matter? J Hepatol. 2003;38:629–634. [PubMed]
21. Pfitzmann R, Schwenzer J, Rayes N, Seehofer D, Neuhaus, Nüssler NC. Long-term survival and predictors of relapse after orthotopic liver transplantation for alcoholic liver disease. Liver Transplant. 2007;13:197–205. [PubMed]
22. Burra P, Lucey MR. Liver transplantation in alcoholic patients. Transplant Int. 2005;18:491–498. [PubMed]
23. DiMartini A, Weinrieb R, Fireman M. Liver transplantation in patients with alcohol and other substance use disorders. Psychiatr Clin North America. 2002;25:195–209. [PubMed]
24. Foster PF, Febrega F, Karademir S, Sankary HN, Mital D, Williams JW. Prediction of abstinence from ethanol in alcoholic recipients following liver transplantation. Hepatol. 1997;25:1469–1477. [PubMed]
25. Lim JK, Keeffe EB. Liver transplantation for alcoholic liver disease: Current concepts and length of sobriety. Liver Transplant. 2004;10(10, Suppl 2):S31–S38. [PubMed]
26. Maldonato JR, Keeffe EB. Liver transplantation for alcoholic liver disease: Selection and outcome. Clin Liver Disease. 1997;1(2):305–321. [PubMed]
27. McMaster P. Transplantation for alcoholic liver disease in an era of organ shortage. Lancet. 2000;355:424–425. [PubMed]
28. Neuberger J, Tang H. Relapse after transplantation: European studies. Liver Transplant Surg. 1997;3(3):275–279. [PubMed]
29. Pageaux GP, Michel J, Coste V, Perney P, Possoz P, Perrigault PF, Navarro F, et al. Alcoholic cirrhosis is a good indication for liver transplantation, even for cases of recidivism. Gut. 1999;45:421–426. [PMC free article] [PubMed]
30. Watt KDS, McCashland TM. Transplantation in the alcoholic patient. Semin Liver Disease. 2004;24(3):249–255. [PubMed]
31. Weinreib RM, Van Horn DHA, McLellan AT, Lucey MR. Interpreting the significance of drinking by alcohol-dependent liver transplant patients: Fostering candor is the key to recovery. Liver Transplantation. 2000;6(6):769–776. [PubMed]
32. Bravata DM, Olkin I, Barnato AE, Keeffe EB, Owens DK. Employment and alcohol use after liver transplantation for alcoholic and nonalcoholic liver disease: A systematic review. Liver Transplant. 2001;7:191–203. [PubMed]
33. Beresford TP, Everson GT. Liver transplantation for alcoholic liver disease: Bias, beliefs, 6-month rule, and relapse—But where are the data? Liver Transplant. 2000;6(6):777–778. [PubMed]
34. Beresford TP. Predictive factors for alcoholic relapse in the selection of alcohol-dependent persons for hepatic transplant. Liver Transplant Surg. 1997;3(3):280–291. [PubMed]
35. Berlakovich GA. Wasting your ogan (sic) with your lifestyle and receiving a new one? Annals Transplant. 2005;10:38–43. [PubMed]
36. Berlakovich GA, Langer F, Freundorfer E, Windhager T, Rochenschaub S, Sporn E, et al. General compliance after liver transplantation for alcoholic cirrhosis. Transplant Int. 2000;13:129–135. [PubMed]
37. Beresford TP, Schwartz J, Wilson D, Merion R, Lucey MR. The short-term psychological health of alcoholic and non-alcoholic liver transplant recipients. Alcohol Clin Experimental Res. 1992;16:996–1000. [PubMed]
38. Everson G, Bharadhwaj G, House R, Talamantes M, Bilir B, Shrestha R, et al. Long-term follow-up of patients with alcoholic liver disease who underwent hepatic transplantation. Liver Transplant Surg. 1997;3(3):263–274. [PubMed]
39. Howard L, Fahy T, Wong P, Sherman D, Gane E, Williams R. Psychiatric outcome in alcoholic liver transplant patients. Quart J Medicine. 1994;87:731–736. [PubMed]
40. Tringali RA, Trzepacz PT, DiMartini A, Dew MA. Assessment and follow-up of alcohol-dependent liver transplantation patients: A clinical cohort. Gen Hosp Psychiatry. 1996;18:70S–77S. [PubMed]
41. Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, et al. Meta-analysis of observational studies in epidemiology (MOOSE): A proposal for reporting. JAMA. 2000;283:2008–2012. [PubMed]
42. Moher D, Cook DJ, Eastwood S, Olkin I, Rennie D, Stroup DJ. Improving the quality of reports of meta-analyses of randomised controlled trials: The QUOROM statement. Lancet. 1999;354:1896–1900. [PubMed]
43. Dew MA, DiMartini AF, De Vito Dabbs A, Myaskovsky L, Steel J, Unruh M, et al. Rates and risk factors for nonadherence to the medical regimen after adult solid organ transplantation. Transplantation. in press. [PubMed]
44. Haynes RB, Yao X, Degani A, Kripalani S, Garg A, McDonald HP. Interventions for enhancing medication adherence. Cochrane Consumers and Communication Group, Cochrane Database of Systematic Reviews. 2006;4 Article No. CD000011. [PubMed]
45. McDonald HP, Garg AX, Haynes RB. Interventions to enhance patient adherence to medication prescriptions: Scientific review. JAMA. 2002;288(22):2868–2879. [PubMed]
46. DiMatteo MR. Variations in patients' adherence to medical recommendations: A quantitative review of 50 years of research. Med Care. 2004;42:200–209. [PubMed]
47. Farmer KC. Methods for measuring and monitoring medication regimen adherence in clinical trials and clinical practice. Clin Therapeutics. 1999;21(6):1074–1090. [PubMed]
48. Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health. 1998;52:377–384. [PMC free article] [PubMed]
49. Bunzel B, Laederach-Hofmann K. Solid organ transplantation: Are there predictors for posttransplant noncompliance? A literature overview. Transplantation. 2000;70(5):711–716. [PubMed]
50. Dew MA, Dunbar-Jacob J, Switzer GE, DiMartini AF, Stilley C, Kormos RL. Adherence to the medical regimen in transplantation. In: Rodrigue JR, editor. Biopsychosocial Perspectives on Transplantation. Kluwer Academic/Plenum Publishers; NY: 2001. pp. 93–124.
51. Loghman-Adham M. Medication noncompliance in patients with chronic disease: Issues in dialysis and renal transplantation. Am J Managed Care. 2003;9(2):155–171. [PubMed]
52. World Health Organization . Adherence to long-term therapies: Evidence for action. WHO; Geneva: 2003. [Last accessed March 29, 2007]. (www.
53. Lilienfeld DE, Stolley PD. Foundations of epidemiology. 3rd ed. Oxford University Press; NY: 1994.
54. Kalbfleisch JD, Prentice RL. The statistical analysis of failure time data. 2nd ed. Wiley; Hoboken, NJ: 2002.
55. U.S. Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients . Annual Report, Transplant Data 1996–2005. Dept. of Health and Human Services, Health Resources and Services Administration, Healthcare Systems Bureau, Division of Transplantation; United Network for Organ Sharing; University Renal Research and Education Association; Rockville, MD: Richmond, VA: Ann Arbor, MI: 2006. 2006. [Last accessed March 29, 2007]. (
56. Palella FJ, Jr, Delaney KM, Moorman AC, Loveless MO, Fuhrer J, Satten GA, et al. Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. HIV Outpatient Study Investigators. NEJM. 1998;338(13):853–860. [PubMed]
57. Eaden JA, Abrams KR, Mayberry JF. The risk of colorectal cancer in ulcerative colitis: A meta-analysis. Gut. 2001;48:526–535. [PMC free article] [PubMed]
58. Law MR, Wald NJ, Rudnicka AR. Quantifying effect of statins on low density lipoprotein cholesterol, ischaemic heart disease, and stroke: Systematic review and meta-analysis. BMJ. 2003;326(7404):1423–1429. [PMC free article] [PubMed]
59. Fleiss JL. The statistical basis of meta-analysis. Stat Methods Med Res. 1993;2:121–145. [PubMed]
60. Begg CB. Publication bias. In: Cooper H, Hedges LV, editors. Handbook of Research Synthesis. Russell Sage; NY: 1994. pp. 399–409.
61. Rosenthal R. The “file-drawer problem” and tolerance for null results. Psychol Bull. 1979;86:638–641.
62. Rosenthal R. Parametric measures of effect size. In: Cooper H, Hedges LV, editors. Handbook of Research Synthesis. Russell Sage; NY: 1994. pp. 231–244.
63. Rosenthal R, DiMatteo MR. Meta-analysis: Recent developments in quantitative methods for literature reviews. Ann Rev Psychology. 2001;52:59–82. [PubMed]
64. Koch M, Banys P. Liver transplantation and opioid dependence. JAMA. 2001;28:1056–1058. [PubMed]
65. DiMartini A, Weinrieb R. Liver transplantation for methadone-maintained opiate dependents: Making the case for cautious optimism. Am J Transplant. 2003;3:1183–1184. [PubMed]
66. DiMartini A, Javed L, Russell S, Dew MA, Fitzgerald MG, Jain A, Fung J. Tobacco use following liver transplantation for alcoholic liver disease: An underestimated problem. Liver Transplant. 2005;11:679–683. [PubMed]
67. Ehlers SL, Rodrigue JR, Widows MR, Reed AI, Nelson DR. Tobacco use before and after liver transplantation: A single center survey and implications for clinical practice and research. Liver Transplant. 2004;10:412–417. [PubMed]
68. Muñoz SJ. Tobacco use by liver transplant recipients: Grappling with a smoking gun. Liver Transplant. 2005;11(6):606–609. [PubMed]
69. Pungpapong S, Manzarbeitia C, Ortiz J, Reich DJ, Araya V, Rothstein KD, Muñoz SJ. Cigarette smoking is associated with an increased incidence of vascular complications after liver transplantation. Liver Transplant. 2002;8:582–587. [PubMed]
70. Jain A, DiMartini A, Kashyap R, Youk A, Ronal S, Fung J. Long-term follow-up after liver transplantation for alcoholic liver disease under tacrolimus. Transplantation. 2000;70:1335–1342. [PubMed]
71. Stevens J, Callender CO, Simon J, Dillard P, Yeager CL. Renal transplantation in heroin addicts. Surg Gyn Obstetrics. 1083;156:651–655. [PubMed]
72. Butkus DE, Dottes AL, Meydrech EF, Barber WH. Effect of poverty and other socioeconomic variables on renal allograft survival. Transplantation. 2001;72:261–266. [PubMed]
73. European Commission, Directorate General Communication, European Union . Special Eurobarometer No. 272b: Attitudes towards alcohol. European Commission; Belgium: 2007. [Last accessed March 29, 2007]. (
74. Valliant GE. The natural history of alcoholism revisited. Harvard University Press; Cambridge, MA: 1997.
75. Valliant GE. The natural history of alcoholism and its relationship to liver transplantation. Liver Transplant Surg. 1997;3(3):304–310. [PubMed]
76. Committee on Prevention of Mental Disorders, Division of Biobehavioral Sciences and Mental Disorders, Institute of Medicine . In: Reducing risks for mental disorders: Frontiers for preventive intervention research. Mrazek PJ, Haggerty RJ, editors. National Academy Press; Washington DC: 1994. [PubMed]
77. Weinrieb RM, Van Horn DHA, McLellan AT, Alterman AI, Calarco JS, O'Brien CP, Lucey MR. Alcoholism treatment after liver transplantation: Lessons learned from a clinical trial that failed. Psychosomatics. 2001;42:110–116. [PubMed]