Natural History of Recurrent Alcohol‐Related Cirrhosis After Liver Transplantation: Fast and Furious

Abstract

Alcohol‐related liver disease (ALD) is one of the main indications for liver transplantation (LT). Severe alcohol relapse can rapidly lead to recurrent alcohol‐related cirrhosis (RAC) for the graft. The aim of this study was to describe the natural history of RAC and the overall survival after LT and after an RAC diagnosis. From 1992 to 2012, 812 patients underwent primary LT for ALD in 5 French transplant centers. All patients with severe alcohol relapse and an RAC diagnosis on the graft were included. The diagnosis of cirrhosis was based on the analysis of liver biopsy or on the association of clinical, biological, radiological, and/or endoscopic features of cirrhosis. RAC was diagnosed in 57/162 patients (35.2%) with severe alcohol relapse, and 31 (54.4%) of those patients had at least 1 episode of liver decompensation. The main types of decompensation were ascites (70.9%), jaundice (58.0%), and hepatic encephalopathy (9.6%). The cumulative probability of decompensation was 23.8% at 5 years, 50.1% at 10 years, and 69.9% at 15 years after LT. During the follow‐up, 36 (63.2%) patients died, the main cause of death being liver failure (61.1%). After diagnosis of cirrhosis, the survival rate was 66.3% at 1 year, 37.8% at 5 years, and 20.6% at 10 years. In conclusion, RAC is associated with a high risk of liver decompensation and a poor prognosis. Prevention of severe alcohol relapse after LT is a major goal to improve patient survival.

The Practice of Retransplantation for Recurrent Alcohol-associated Liver Disease in the United States Is Uncommon With Acceptable Outcomes

“…Another point to consider is that our non-ALD re-LT control group may not be wholly representative of the current patient population that undergoes liver re-LT retransplantation given the high proportion of patients whose primary listing indication was HCV infection. HCV as a listing indication for re-LT has drastically reduced since the approval In conclusion, our study suggests a nationwide reluctance by LT centers for re-LT for recurrent ALD despite a significant increase in AUD, ALD, and initial LT for ALD and AH 21,22 ; however, our results show acceptable outcomes in recurrent ALD re-LT and support the practice (from a survival perspective) should a recurrent ALD LT candidate be deemed appropriate. Future studies will be needed with particular attention to the optimal preretransplant patient selection and postretransplant care given the anticipated increase in recurrent ALD re-LT practice.…”

Assessment of Canadian policies regarding liver transplant candidacy of people who use alcohol, tobacco, cannabis, and opiates

“…Identification of patients in the pre-transplant setting at higher risk of returning to alcohol use, especially problematic use, is important given the potential association with increased rates of mortality and graft injury (22). If alcohol-related cirrhosis develops in a graft, survival is very poor (23,24). Potential strategies to improve outcomes can include increased use of an addiction specialist and a multidisciplinary team to identify highrisk patients and provide appropriate care for their alcohol use disorder (25,26) because it is not cured post-transplant.…”

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

“…However, in this study, as in subsequent ones, follow‐up was relatively short (2 years), and a significant proportion of those patients transplanted for ALD will return to a damaging pattern of alcohol consumption after this time. ( 34 ) Thus, longer follow‐up is needed before there is a degree of validation that the criteria developed by Mathurin and his team are valid in different countries. ( 9 )…”