Debate on Selection Criteria for Liver Transplantation for Alcoholic Hepatitis: Tighten or Loosen?

Abstract

Although liver transplantation (LT) for alcohol‐associated liver disease (ALD) is a well‐accepted practice, LT for severe alcoholic hepatitis (AH) remains controversial due to concerns about the limited organ supply and the risk of return to harmful drinking. Recognizing an increasing body of favorable evidence, a convergence of practice guideline recommendations from leading hepatology and gastroenterology societies have suggested that the length of abstinence should not be a sole criterion for LT selection and, thus, that LT may be considered in carefully selected severe AH patients with favorable psychosocial profiles not responding to medical therapy. We sought to examine this new consensus in greater detail, debating whether candidate selection criteria for LT in AH should be tightened or loosened.

Excessive intragastric alcohol administration exacerbates hepatic encephalopathy and provokes neuronal cell death in male rats with chronic liver disease

“…However, the assessment period pre‐LT for those with end‐stage alcoholic liver disease raises difficult questions. Usually, a period of abstinence lasting 6 months or longer is required for someone to be eligible for LT, although these criteria remain a topic of debate (Im & Neuberger, 2020; Syed et al., 2020). Multiple studies have indicated that alcohol liver disease patients experience poor outcomes post‐LT if they continue consuming alcohol (Cuadrado et al., 2005; DiMartini et al., 2006; Pfitzmann et al., 2007).…”

Acute on chronic liver failure: A South Australian experience

“…This arbitrary threshold of abstinence is controversial and is not a strong predicator of relapse reduction 32,33 . Early LT performed for carefully selected severe alcoholic hepatitis (SAH) patients with favorable psychosocial and clinical profile without 6 months of abstinence was shown to have lower rates of harmful alcohol relapse post LT without any reduction in post‐LT survival 34–37 . In fact, a recent meta‐analysis of patients who underwent LT for SAH has revealed an alcohol relapse rate of 14%, similar to those undergoing elective LT for alcohol‐related cirrhosis 38 .…”

Alcohol-Associated Liver Disease: Evolving Concepts and Treatments

“…This also highlights that LT does not cure AUD, which requires ongoing monitoring and treatment. LT for severe alcohol-associated hepatitis (and even AAC) is an evolving field, and whether to tighten or loosen transplant selection criteria remains a topic of debate [ 117 ].…”