Liver Transplantation for Alcoholic Liver Disease

ABSTRACT & COMMENTARY

Synopsis: This protocol was useful in selecting suitable patients with alcoholic liver disease for liver transplantation.

Source: Anand AC, et al. Hepatology 1997;25:1478-1484.

Anand and colleagues prospectively analyzed all patients with alcoholic liver disease who were referred for transplantation to a major transplant center in the United Kingdom between 1987 and 1994. The patients were selected for liver transplantation if they had end-stage liver disease and had remained abstinent from the time they were medically advised to stop alcohol intake. Of all 137 patients available for evaluation, 39 had been transplanted and four were awaiting transplantation at the time of analysis. One-year actuarial survival was 79% for the transplanted patients, 0% for those considered too sick, 45% for medically unsuitable patients, 65% for psychologically unsuitable patients, and 94% for those considered too well for transplantation. Only five of the transplanted patients (13%) reverted to drinking. They also observed that the actuarial survival in the transplanted patients was found to be better than their expected survival. The authors conclude that their protocol was useful in selecting suitable patients with alcohol liver disease for liver transplantation, which resulted in significant survival advantage with a low recidivism rate.

COMMENT BY EAMONN M.M. QUIGLEY, MD

At a time of increasing concern with regard to the cost of medical care and of a considerable shortage of donor organs, attention is being focused on the selection of patients for transplantation in general, and liver transplantation in particular. As waiting lists show, transplantation centers are being asked to carefully scrutinize the eligibility and suitability of patients being considered for transplantation. Needless to say, particular concern has surrounded selection of patients with alcohol-related liver disease. At one extreme, those who adopt a more moralistic tone wish to deny liver transplantation to individuals with any self-inflicted injury, such as alcohol-related liver disease. At the other extreme, a very small minority have advocated transplantation even for those with acute alcohol-related injury who are actively drinking. Most have attempted to find some middle ground. This and other studies from the United States have suggested that the adoption of a rigidly enforced selection policy will minimize the risk of recidivism following transplantation. In the United States, for example, most centers have adopted a policy of insisting on at least six months of documented abstinence under the supervision of an alcohol treatment specialist and with random drug and alcohol testing. As illustrated by this particular study, the adoption of this approach to patient selection will result in an excellent outcome for transplantation and a very low rate of resumption of alcohol ingestion. Most authorities in this area now feel that liver transplantation is indicated in patients with alcohol-related liver disease providing, first, that they have established end-stage liver disease, second, that they fulfill standard indications for transplantation, and third, have demonstrated a sustained period of abstinence.

Suggested Reading

1. Sorell MF, et al. Transplantation in alcoholics: A stalking horse for a larger problem. Gastroenterol 1992; 102:1806-1808.

2. Lucey MR, et al. Selection and outcome of liver transplantation in alcoholic liver disease. Gastroenterol 1992;102:1738-1741.