Early liver transplantation for severe alcoholic hepatitis

Nahas, Jonathan; Im, Gene Y.

doi:10.1002/cld.693

Cited by 2 publications

(4 citation statements)

References 23 publications

(35 reference statements)

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“…Multiple studies have documented the survival benefit of LT compared to standard medical therapy. [10][11][12]14,15 However, the implementation of this strategy continues to raise ethical dilemmas and practical considerations, fueling ongoing debates regarding the appropriate criteria for LT in this group of patients.…”

Section: Discussionmentioning

confidence: 99%

“…A groundbreaking study 4 examined outcomes of carefully selected patients who did not respond to corticosteroid treatment and were offered “early LT.” The findings demonstrated a substantial improvement in two‐year survival rates compared to the matched control group (71% vs. 23%), and many medical centers now adopt a similar approach to consider LT for highly selected individuals with SAH. Multiple studies have documented the survival benefit of LT compared to standard medical therapy 10–12,14,15 . However, the implementation of this strategy continues to raise ethical dilemmas and practical considerations, fueling ongoing debates regarding the appropriate criteria for LT in this group of patients.…”

Section: Discussionmentioning

confidence: 99%

“…Studies have shown a statistically significant increased risk of infection leading to an increased 90‐day mortality (independent of MELD score). Up to one‐third of patients with SAH develop infection on corticosteroid treatment and can contribute to increased mortality 7,15,18–22 . It raises questions as to why guidelines still recommend corticosteroids as the first‐line therapy despite limited data supporting their long‐term benefits and studies suggesting an increased risk of harm.…”

Section: Discussionmentioning

confidence: 99%

“…Up to one-third of patients with SAH develop infection on corticosteroid treatment and can contribute to increased mortality. 7,15,[18][19][20][21][22] It raises questions as to why guidelines still recommend corticosteroids as the first-line therapy despite limited data supporting their long-term benefits and studies suggesting an increased risk of harm. The controversy surrounding early LT for SAH continues, but its superiority over corticosteroid therapy is undeniable.…”

Section: While Corticosteroids Have Been the Primary Treatment Optionmentioning

confidence: 99%

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Expedited liver transplantation as first‐line therapy for severe alcohol hepatitis: ELFSAH; deferring corticosteroids in the sickest subset of patients

Mohy‐ud‐din,

Lin,

Rachakonda

et al. 2024

Clinical Transplantation

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Background & aimsSevere alcohol‐associated hepatitis (SAH) represents a lethal subset of alcohol‐associated liver disease. Although corticosteroids are recommended by guidelines, their efficacy and safety remain questionable and so liver transplantation (LT) has been increasingly utilized. The timing and indication of corticosteroid use, specifically in patients being considered for LT requires further clarification.MethodsA retrospective analysis was conducted on 256 patients with SAH between 2018 and 2022 at a single US center.ResultsTwenty of these patients underwent LT. Of the 256 patients, 38% had what we termed “catastrophic” SAH, defined as a MELD‐Na ≥35 and/or discriminant function (DF) ≥100, which carried a mortality of 90% without LT. Compared with 100 matched controls, patients undergoing LT exhibited a one‐year survival rate of 100% versus 35% (p < .0005). LT provided an absolute risk reduction of 65%, with a number needed to treat of 1.5. Steroid utilization in the entire cohort was 19% with 60% developing severe complications. Patients administered steroids were younger with lower MELD and DF scores. Only 10% of those prescribed steroids derived a favorable response. Sustained alcohol use post‐LT was 20%.ConclusionsWe propose ELFSAH: Expedited LT as First Line Therapy for SAH; challenging the current paradigm with recommendations to defer steroids in patients with “catastrophic” SAH (defined as: MELD‐Na ≥35 and/or DF ≥100). Patients should be seen urgently by hepatology, transplant surgery, psychiatry and social work. Patients without an absolute contraindication should be referred for LT as first‐line therapy during their index admission.

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