*Purpose: Liver transplantation (LT) for alcohol-related liver disease (ALD) is increasing. The primary issue in these patients is often recidivism, therefore screening for ETOH use is important. Urine ethyl glucuronide (EtG) and serum phosphatidylethanol (PEth) are two highly sensitive and the most common biomarkers used in the diagnosis of ETOH relapse. We compared rates of screening for post-LT ETOH use using PEth and EtG over a 12-month period.

*Methods: As part of a prospective quality improvement initiative at our center, patients who receive a LT for ALD have undergone mandatory quarterly screening for ETOH use with urine EtG for the first 12 months after LT since 2016 while any LT recipient undergoes testing if ETOH misuse is suspected. From 1^st October 2019 to 30^th September, we incorporated quarterly PEth testing into our protocol. Adherence to screening was defined as completion of 4 ETOH tests over the first 12 months after LT. A positive EtG test was defined as EtG>500ng/ml whereas a positive PEth test was defined as PEth>20ng/ml, both levels indicative of significant ETOH use. Positive tests resulted in the activation of a protocol involving the patient’s RN coordinator, hepatologist, social worker and chemical dependency resources.

*Results: 70 adult patients underwent LT over the study period. 38 patients were transplanted for ALD: 36 patients with ETOH cirrhosis and 2 patients with acute ETOH hepatitis. Median age at LT was 53, 25 (66%) patients were male, 30 (83%) patients were white and median MELD at LT was 29. 31 (81.6%) patients had mental illness prior to LT. Adherence to ETOH screening was 52% for EtG and 87% for PEth, p= 0.0008. There were 2 positive EtG tests compared to 13 positive PEth tests, p= 0.025, over the study period. 7 (19.4%) patients had a positive ETOH test with 4/7 (57.1%) patients adhering to the positive test protocol, although no patients started chemical dependency treatment. Of note, there were 30 positive tests (6 positive EtG and 24 positive PEth) over the study period in 22 patients transplanted prior to October 1^st 2019, up to 13 years after LT.

*Conclusions: ETOH relapse remains an important issue in a large proportion of patients who undergo LT for ALD, even several years after LT. Screening for ETOH use is significantly higher when using PEth compared to EtG while PEth is significantly better at detecting ETOH relapse. Although identification of ETOH misuse is an essential step, initiation of patients into chemical dependency treatment is a separate, significant challenge.

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