Alcohol Consumption the Day of Liver Transplantation for Alcohol‐Associated Liver Disease Does Not Affect Long‐Term Survival: A Case‐Control Study

Abstract

Alcohol abstinence before liver transplantation (LT) for alcohol-associated liver disease (ALD) is required for every candidate. Some listed patients might relapse, resulting in LT for patients nonabstinent during the pretransplant period. Long-term survival outcomes of these patients have never been studied. We sought to determine whether alcohol consumption on the day of the LT influenced long-term survival after LT. We conducted a retrospective case-control study among French LT centers. Cases were defined as recipients between January 1995 and December 2007 having positive blood and/or urine alcohol levels the day of LT. Each case was paired with 2 controls corresponding to patients transplanted for ALD during the same trimester. Patients were classified into 3 categories per alcohol consumption: abstainers, occasional or transitory excessive consumers, or patients with a sustained excessive consumption (daily consumption >20-30 g/day). During the study period, 3052 LTs for ALD were conducted in France. We identified 42 cases paired with 84 controls. Median blood alcohol level was 0.4 g/L (range 0.1-4.1 g/L) and median urine alcohol level was 0.2 g/L (range 0.1-2.0 g/L). Median follow-up period until death or censoring was 12.9 years (CI 95% = [12.3; 13.6]). Long-term survival was not different between the groups. Relapse to any alcohol consumption rate was higher in the case group (59.5%) than in the control group (38.1%, odds ratio 2.44; CI 95% = [1.13; 5.27]), but sustained excessive consumption was not significantly different between the groups (33.3% versus 29.8% in case and control groups respectively, χ 2 = 0.68). Rates of recurrent cirrhosis and cirrhosis-related deaths were more frequent in the case group. Liver transplantation for nonabstinent patients during the immediate pretransplant period does not result in impaired long-term survival despite higher relapse and recurrent cirrhosis rates.

Results of Early Transplantation for Alcohol-Related Cirrhosis: Integrated Addiction Treatment With Low Rate of Relapse

“…Compared to previous studies that only included patients with SAH, our results confirm a similar survival benefit for early transplantation for patients with less than 6 months of abstinence, 13 even in the setting of decompensated cirrhosis, as well as lower relapse rates to alcohol 20 compared to ALD patients with longer periods of abstinence. 9 Although it is notable that some of the patients would have been more than 6 months abstinent at the time of transplantation, it is also true that many patients were urgently unwell with a very short duration of abstinence and likely would not have survived if they had not been able to be evaluated before the 6-month mark. One of the many benefits of our protocol was the ability to begin a patient's transplantation evaluation early, rather than having to wait until they reached 6 months of abstinence before assessment, as this was our previous practice before the pilot in Ontario and in Canada.…”

“…7 Furthermore, overall outcomes of LT for ALD are similar or sometimes better than other well-accepted indications for transplantation, such as hepatitis C-related liver cirrhosis or hepatocellular carcinoma. 8,9 It has become increasingly clear that the traditional 6month rule is inadequate for predicting survival and relapse rates and requires re-evaluation to ensure equitable access to transplantation for patients with ALD. In response to such perceptual shifts, various procedural changes have been proposed by a number of centers and professional associations throughout the world.…”

Canadian Society of Transplantation White Paper: Ethical and Legal Considerations for Alcohol and Cannabis Use in Solid Organ Listing and Allocation

“…In the case of ALD, relapse of alcohol use disorder after the transplant is associated with recurrent alcohol related cirrhosis and cirrhosis associated death. 57 Historically, this has served as a justification for the alcohol abstinence rule: it was assumed that those actively using alcohol would both be nonadherent with treatment and continue to consume alcohol posttransplant, which could potentially lead to cirrhosis recurrence in the transplanted liver. However, as addressed earlier, recent evidence shows the importance of the 6-mo abstinence rule may be overemphasized, as patients with ALD who have not met the 6-mo abstinence rule may still have good patient and graft survival when they are carefully selected, have appropriate social support, have insight into the cause of their liver disease, and are connected to addiction specialists.…”

Establishing a blueprint for successful liver transplantation for alcohol-related cirrhosis: the importance of a multidisciplinary team

“…The "6-month rule" is insufficient to predict the risk of relapse and is progressively being abandoned by learned societies recommendations (7,8). Moreover, situations in which a recent alcohol consumption is obvious, such as alcoholic hepatitis or positive blood and/or urine test before the procedure, are associated with good outcomes (9)(10)(11).…”