Liver Transplantation for Alcohol-Related Liver Disease

Abstract

Alcoholic liver disease (ALD) is a common indication for liver transplantation. It is a much debated indication for deceased donor liver transplantation due to organ shortage and potential of alcohol relapse after liver transplantation. A six-month abstinence before liver transplantation is required at most centers to decrease chances of alcohol relapse after liver transplantation. However, this rule is not relevant for patients with severe alcoholic hepatitis or severely decompensated patients who are unlikely to survive till 6 months. Long-term care of these patients after liver transplantation includes assessment of relapse, smoking, and surveillance of de novo malignancies. Current review discusses role of abstinence, factors affecting alcohol relapse, liver transplantation for alcoholic hepatitis, role of living donor liver transplantation, and long-term care of ALD patients who undergo liver transplantation. ( J CLIN EXP HEPATOL 2016;6:47-53) A lcoholic liver disease (ALD) is common indication for liver transplantation worldwide, 1,2 and is a common cause of decompensated cirrhosis and acute-on-chronic liver failure in India as well. 3,4 ALD has good outcome after liver transplantation that is comparable or better than other etiologies of liver transplantation. Recent European liver transplant registry data showed 73% 5-year and a 59% 10-year survival rate for ALD. 2 However, survival is lower in recipients who relapse to harmful pattern of drinking as noted in a systemic review of 13 studies by Rustad et al. 5 Liver transplantation for ALD leads to improvement in quality of life and employment rates. 6,7 During selection of these patients for liver transplantation, it is important to identify other alcohol-related problems like cardiomyopathy, chronic pancreatitis, skeletal muscle wasting, and neurotoxicities that may preclude or impair outcome of liver transplantation. 8 Patients who have lack of social support, are active smokers, and have psychiatric disorders or alcohol dependence should be listed only with reservations. 9 Smoking worsens the outcome of alcohol-related liver disease 10 and active smoking at the time of liver transplantation has been shown to be associated with post-transplant recidivism also. 11 PREDICTORS OF RELAPSEWhile liver transplantation improves functions of liver and cures complications of portal hypertension, it does not affect alcoholism and recipients may relapse again, sometimes to harmful levels of drinking, and pretransplant sobriety does not confirm sobriety after liver transplant. [12][13][14] Relapse may be in the form of occasional slips or harmful drinking pattern for a prolonged period; the later affects graft and patient survival. 5,11 Initially, 6-month abstinence was considered as a requirement before allocating organ to patients with ALD; however, it was based on poor quality small data. 15 The 6-month rule serves 2 purposes; it provides patient time to demonstrate a certain period of abstinence and patient may recover on medical management, and thus preempt...

ACG Clinical Guideline: Alcoholic Liver Disease

“…As patients with AH are neither listed for urgent LT nor receive exception points, live donor LT is being performed in many Asian countries. Limited data on outcomes of living donor LT in AH patients are similar compared with LT using deceased donors (191). In light of these emerging data, early LT as a definitive therapy is gaining momentum and acceptance within the transplant community, as well as the general public ( 190,192 ).…”

Long-term Management of the Adult Liver Transplantation Recipients

“…Alcohol relapse (any amount) has been shown in 16%-33.8% of LT recipients in various studies, and harmful drinking is shown to be in 10%-18% of LT recipients. 82 Harmful alcohol relapse is associated with poor survival. 83 The various predictors of relapse include absence of structured program, length of sobriety (range from <3 months to < 1 year), other substance abuse/psychiatric comorbidities, lack of social support, younger age, low motivation for alcohol treatment,…”

“…Patients with pretransplantation renal impairment remain at higher risk One of important causes of late morbidity and mortality Generally multifactorial (pretransplantation injury, effect of immunosuppression, diabetes, hypertension) Early modification of immunosuppression is better than late modification active smoking, poor stress management skills, criminal history, and history of complications in post-LT course, as well as continued engagement in social activities with alcohol present. [82][83][84][85][86] Active involvement of psychiatry team may decrease risk of relapse. Bj€ ornsson et al 87 demonstrated relapse rate of 48% (19/40) compared to 22% in structured management program group.…”

Psychosocial characteristics of alcoholic and non-alcoholic liver disease recipient candidates in liver transplantation: A prospective observational study

“…Liver transplantation for alcoholic liver disease involves many issues, such as the validity of the 6-month abstinence rule [1][2][3], indications regarding liver transplantation for acute alcoholic hepatitis [4][5][6] and alcohol relapse [7,8]. In particular, the importance of psychosocial evaluation before and after liver transplantation has been emphasized to prevent alcohol relapse [9,10].…”