*Purpose: More patients are presenting for liver transplant (LT) evaluation for alcohol-related liver disease (ALD). Detection of ETOH use has significant implications for patients undergoing LT evaluation. Urine ethyl glucuronide (EtG) and serum phosphatidylethanol (PEth) are the two most common biomarkers validated in patients with cirrhosis. We compared rates of screening for ETOH use using EtG and PEth in pre-LT patients over a 12-month period.

*Methods: As part of a QI initiative starting on 6/1/2016, all patients undergoing LT evaluation had one-time testing for ETOH use, while patients undergoing LT evaluation for ALD underwent mandatory quarterly screening for ETOH use with EtG. All patients got EtG testing if ETOH misuse was suspected. From 10/1/2019 to 9/30/2020, we incorporated quarterly PEth testing into our protocol. Adherence to screening was defined as completion of quarterly testing for ETOH use until LT or waitlist removal. EtG(+) was defined as EtG>500ng/ml whereas PEth(+) was defined as PEth>20ng/ml, both levels indicative of significant ETOH use. In the event of a positive test, the LT evaluation was placed on hold and a protocol was initiated. Upon satisfactory completion of the protocol, LT evaluation was resumed or the patient re-activated on the LT waiting list.

*Results: 226 patients started LT evaluation for any cause of liver disease over the study period while 31 patients with ALD were ultimately listed for LT. Median patient age at LT evaluation was 57, 132 (58%) patients were male and 186 (83%) patients were white. In patients listed for ALD, median age was 46, 19 (61%) patients were male and 27 (87%) patients were white. 146 (65%) patients undergoing LT evaluation had one-time ETG testing whereas 191 (85%) patients had PEth testing, p<0.0001. 24 (77%) patients listed for ALD were adherent to ETOH screening using EtG compared to 31 (100%) patients for PEth, p<0.0001. There were 7 patients who were EtG(+) over the study period compared to 16 who were PEth(+) for all patients undergoing LT evaluation, p= 0.057. 3 patients were both EtG & PEth(+). In the ALD patients, 0 were EtG(+) compared to 4 PEth(+) in 3 patients (2 patients with ETOH hepatitis). 6/23 (26%) patients with positive ETOH tests started chemical dependency treatment while 1/23 (4.3%) patient later underwent LT. An additional 10 patients who started LT evaluation before the study period were PEth(+).

*Conclusions: Ease of testing makes PEth superior to EtG for both initial and routine screening for ETOH use in patients undergoing evaluation or listed for ALD. PEth is also superior for detection of ETOH misuse in these patients. For these reasons, our center has retired EtG for PEth to screen for ETOH use in patients undergoing LT evaluation.

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