Rapidly Progressive Liver Injury and Fatal Alcoholic Hepatitis Occurring After Liver Transplantation in Alcoholic Patients

Abstract

Alcohol-related liver disease (ALD) is a common indication for orthotopic liver transplantation (OLT) in adults. Although return to 'heavy drinking' post-OLT is believed to be uncommon, the prevalence and severity of alcohol-related liver injury in such patients is not well characterized. We retrospectively reviewed the records of 68 adult patients who underwent OLT for ALD to determine the incidence of return to heavy drinking and to assess their clinical outcome. Follow-up ranged from 8-99 months (mean 42) post-OLT; 54 patients were followed for > or = 12 months. Ten patients (15%) had evidence of coexisting viral hepatitis (hepatitis C in 9 and hepatitis B in 1) before OLT. Six of 68 patients (8%) returned to heavy drinking post-OLT, and three of those died of alcoholic hepatitis at nine months, 2.5 and 3.5 years after OLT. In two of these three patients, premortem liver biopsy showed histologic features of alcoholic hepatitis in addition to bridging fibrosis or cirrhosis. None of the three patients who died of ALD had coexisting viral hepatitis. Of the 57 patients surviving for > or = 3 months post-OLT, 4 of 8 patients (50%) with steatosis and Mallory bodies in their native livers returned to heavy drinking compared to only 2/49 (4%) without these histologic findings (P<0.05). In conclusion, the incidence of heavy drinking post-OLT was uncommon, however, it was associated with fatal alcoholic hepatitis in 50% of patients. Rapidly progressive alcohol-related liver injury was seen even in the absence of coexisting viral hepatitis. The presence of steatosis and Mallory bodies in the native liver, which suggests recent or ongoing alcohol-related liver injury, predicted a return to heavy drinking post-OLT.

Liver Transplantation for Alcoholic Cirrhosis: Long Term Follow-Up and Impact of Disease Recurrence1

“…Here, recurrent alcohol liver disease was limited to steatosis (42) and was not responsible for progressive fibrosis. These results compare favorably with others: allograft alcoholic hepatitis and cirrhosis after relapse are well described (5,16,43,44), but are uncommon and rarely cited as a significant cause of graft failure (6,27,30). Steatosis affected fewer than 10% of patients after 7 years follow-up, compared with much higher recurrence rates for autoimmune liver diseases or viral hepatitis (15-25% and >50%, respectively), with a proportion of the latter developing cirrhosis by that time.…”

“…In our cohort, daily ethanol consumption better predicted relapse, perhaps because it better indicates the severity of addiction (37). No explant histological feature in this or another (38) study predicted relapse, unlike with Conjeevaram et a1., who correlated Mallory bodies with relapse (16). The finding of many Mallory bodies in 16% of explants in the Conjeevaram study (16), compared with small foci in 33% explants here, suggest different pretransplant drinking behaviors.…”

“…In such cases, which are often without earlier biopsy, the final histology might be indeterminate for cause. Second, at least 31% of the patients in this and other studies had coexistent conditions that alone could have been the indication for liver transplantation (7,(13)(14)(15)(16)(17)(18). Indeed, native livers from hepatitis C-infected patients here and in other studies often showed morphology of chronic hepatitis rather than alcohol injury ( Table 1), suggesting that alcohol had exacerbated viral damage rather than the other way around (19,20).…”

Perceptions of post-transplant recidivism in liver transplantation for alcoholic liver disease

“…Alcohol recidivism has been reported to impair long-term outcome [24,26,27,[29][30][31] , presumably due to its negative influence on the recipients, including alcohol toxicity, poor compliance, development of post-transplantation malignancies and occurrence of cardiovascular diseases. Rates of graft loss due to alcoholic recidivism range between 0% and 50% [21,27,30,40,41] , and significant association of ALD patients with increased development of post-transplantation malignancy and occurrence of cardiovascular diseases were suggested [1,42] .…”

Recurrence of non-viral liver disease after orthotopic liver transplantation

“…A recent retrospective analysis of 300 patients who underwent OLT for alcoholic liver disease between 1989 and 2002 demonstrated that survival was significantly reduced in subjects who resumed abusive drinking compared with abstinent subjects or subjects with occasional 'slips' (96). Other studies have also shown that recurrent alcoholic liver disease accounts for the majority of deaths among recipients who resumed abusive drinking after transplantation (97,98). Therefore, it is imperative to implement programmes that prevent OLT recipients from further alcohol abuse.…”