As survival rates after liver transplantation (LT) are very good, long-term care of recipients is important. Cardiovascular diseases and de novo malignancies are among the main causes of mortality in the long term after LT.1,2 Smoking, alcohol, and tobacco/betel nut chewing are some of the modifiable risk factors for de novo malignancy.3, 4, 5 We aim to describe the prevalence of these modifiable risk factors in a living donor liver transplantation setting.
The study prospectively included 181 (18 were female and 163 were male) consecutive adult liver transplant recipients who attended outpatient services from July 2022 to November 2023 and had a minimum follow-up of 1 year after LT. Only Indian LT recipients were included, and international patients were not included. Two groups are compared with Fisher's exact test. The mean age of the study group was 48.7 ± 9.2 years at the time of LT, and the median (interquartile range) follow-up was 48 (24–72 months) after LT. The etiologies of LT were hepatitis B (n = 22), hepatitis C (n = 11), alcohol-related liver disease (n = 75), metabolic-dysfunction-associated steatohepatitis or cryptogenic (n = 49), and others in 24 (including 13 patients with autoimmune etiology). None of the females had a history of smoking or betelnut/tobacco chewing or alcohol before or after LT. Post-LT smoking (n = 9, 4.9%) was significantly more common in those with alcohol as etiology and in the presence of a history of smoking or tobacco/betel nut chewers before LT. These patients started smoking from 2 months to 4 years after LT. A total of 13 (7.1%) patients had a history of betel nut/tobacco chewing after LT. It was significantly more common in recipients with alcohol as etiology and in patients with a history of betel nut/tobacco chewing before LT (Table 1). Three patients with a history of chewing betel nut or tobacco after LT were also smokers. Only one patient did not have a history of betel nut/tobacco chewing history before LT and started it after LT. A total of 12 (6.6% of the total cohort) patients had a history of taking alcohol after LT; six of these had more than 20 gm/day. The alcohol relapse was 11/75 (14.6%) in patients with alcohol as the etiology of LT, which is slightly higher than that reported in an earlier reported study from our center.6 Only one patient started alcohol in the absence of alcohol as an etiology before LT. LT recipients with a history of alcohol/smoking after LT were asked to meet a psychiatrist for deaddiction. Recipients with a history of tobacco/betel nut chewing were asked for an ear nose throat examination annually. We get a chest X-ray and ultrasound the whole abdomen every 6 months routinely in all recipients for de novo malignancy screening. Recipients were explained about the risk of development of de novo malignancies, cardiovascular risk (because of smoking), and the risk of graft loss because of alcohol.
Table 1.
Comparison of Risk Factors in Various Groups.
| Comparison of alcohol-related liver disease versus other etiologies | |||
|---|---|---|---|
| Parameter | Alcohol-related liver disease (n = 75) | Other etiologies (n = 106) | P value |
| Post-LT alcohol intake | 11 (14.6%) | 1 (0.9%) | 0.000 |
| Smoking before LT | 20 (26.6%) | 4 (3.7%) | 0.000 |
| Smoking after LT | 8 (10.6%) | 1 (0.9%) | 0.004 |
| Tobacco/betel nut chewing before LT | 15 (20%) | 7 (6.6%) | 0.010 |
| Tobacco/betel nut chewing after LT | 9 (12%) | 4 (3.7%) | 0.043 |
| Smoking after LT | |||
| Yes (n = 9) | No (n = 172) | P value | |
| History of smoking before LT | 9 (100%) | 15 (8.7%) | 0.000 |
| Tobacco/betel nut chewing before LT | 3 (33.3%) | 19 (11%) | 0.081 |
| Tobacco/betel nut chewing after LT | 3 (33.3%) | 10 (5.8%) | 0.019 |
| Tobacco/betel nut chewing after LT | |||
| Yes (n = 13) | No (n = 168) | ||
| Tobacco/betel nut chewing before LT | 12 (9.2%) | 10 (5.9%) | 0.000 |
| Smoking before LT | 3 (23%) | 21 (12.5%) | 0.039 |
Abbreviation: LT = liver transplantation.
None of these patients had cardiovascular morbidity or de novo malignancy till their inclusion in this study. We found some interesting findings in this prospective cohort. All smokers after LT had a history of smoking before LT, and all but one with betel nut/tobacco had the same history before LT. Both these habits were more in patients with alcohol as an etiology. Thus, these are the risk groups where we can make more efforts to prevent smoking or betel nut/tobacco chewing. As oral/oropharyngeal malignancies and those of the lung are the most common de novo malignancies after LT in India, and smoking and betel nut increase the risk (more risk if oral tobacco is also used) of these malignancies,5,7 patients with a pre-LT history of these habits should be counseled in detail and should be kept under vigilance.
There are several limitations of this study. It should be noted that the prevalence of these risk factors may be higher in patients not in routine follow-up. Noncompliance to clinical visits was shown to be a risk factor for alcohol relapse in the study by Egawa et al.8 Also, alcohol relapse was considered based on history and not based on biochemical tests. These factors may have led to some underreporting of alcohol relapse. This is a single-center study, and the sample size is small (partly because of the preference for telemedicine in the post-COVID period by patients and not including recipients with <1 year of follow-up). The prevalence of smoking, tobacco/betel nut chewing, and alcohol intake after LT are low in this living donor liver transplant study. Patients with pre-LT history of smoking, betel nut chewing/tobacco chewing, or alcohol as etiology are more likely to develop these high-risk behaviors after LT. Multiple such habits in the same patient are common, while de novo development of these habits is rare. These risk groups should be monitored after LT for relapse. Patients with alcohol-related liver disease require multidisciplinary management involving a psychiatrist, a deaddiction specialist, and a psychologist even post-LT. Given the low prevalence of risk factors in the study group, a larger sample size is required for a better understanding of these risk factors in LT recipients and to make strong conclusions.
Credit authorship contribution statement
Conceptualization: NSC, NS; Data curation and analysis: NSC, AP, SW; writing—original draft: NSC, KAS; writing—review and editing: NS, ASS.
Conflicts of interest
None for any author.
Acknowledgments
We would like to thank Ms Shivani Sharma (research coordinator).
Funding
None.
References
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