barcelona . spain - European Association for the Study of the Liver

BARCELONA . SPAIN
118 POSTGRADUATE COURSE SYLLABUS ALCOHOLIC LIVER DISEASE 119
APRIL 18 - 19/2012 THE INTERNATIONAL LIVER CONGRESS TM 2012
NOTES
year (Dawwas et al) and over 70% at 5 years, whether done for cirrhosis (alcohol-associated and other
etiologies) or acute liver failure.
Survival of the control group is not that poor: Mathurin’s study showed that those who meet the criteria for
transplantation but are not transplanted will have more than 25% probability of being alive at 12 months.
Thus the overall benefit of transplantation in those with AH is less than for accepted indications (including
alcohol-associated cirrhosis). If transplantation is accepted for AH, where the absolute and relative benefit
is less than for other indications, then surely similar considerations must apply to those with primary liver
cell cancers outwith the UCSF criteria or those with changiocarcinoma who are excluded from access to
transplantation, not because they would not benefit but because they would not benefit enough.
PUBLIC ATTITUDES
Although allocation should be done on legally and ethically valid grounds, it must be recognised that where
ever public opinion has been sought, the public would give very low priority to those who provide not only
the funds for transplantation but also the grafts (ref). For the public to lose confidence in the process of
patient selection and organ allocation will jeopardise an already fragile availability. This may be exacerbated
when, in those jurisdictions where donated livers are allocated according to MELD score, those with AH
would have priority.
WHO DOES NOT GET A TRANSPLANT
Finally, the organ donor pool is already inadequate for the need; if the recipient pool is to be expanded
by inclusion of new indications, then others must be denied access. Those who advocate transplanting
carefully selected patients with AH must agree who to exclude, unless the donor pool is expanded. The
study from Mathurin suggests that less than 3% of the donor pool would be taken by those with AH: it
is a concern that if transplantation were used for those selected patients with AH, the strict criteria used
by Mathurin and colleagues would be gradually eroded and more patients would be offered and receive
access to this scarce resource.
CLINICAL CASE: LONG-TERM MANAGEMENT OF ALD
A. De Gottardi
Bern, Switzerland
N. Goossens
Geneva, Switzerland
E-mail: Nicolas.Goossens@hcuge.ch
A 48 year old man with chronic HCV infection, genotype 1b and cirrhosis (Child-Pugh B 7, MELD 14) comes
for a routine visit to your outpatient clinic.
He was treated for alcoholic hepatitis 5 years ago and after this episode he continued to drink excessively.
After an inpatient treatment for alcoholism, he stopped his alcohol intake 6 months ago. Currently he
drinks 3 alcohol-free beers a day. He injected intravenous drugs when he was a teenager and he currently
consumes intranasal cocaine once a month. He smokes 20 cigarettes per day.
His medication includes losartan, sertralin, propranolol, spironolactone and torasemide.
He works as a barkeeper and has a stable family situation.
An ultrasound examination with intravenous contrast shows a 3 cm lesion in the right liver with arterial
enhancement and washout suggesting hepatocellular carcinoma. There is, in addition, a partial thrombosis
of the splenomesenteric confluence. There is no ascites and the spleen is 15 cm in diameter.
Laboratory analyses show albumin 31 g/L, bilirubin 32 umol/L (1.87 mg/dL), creatinine 101 umol/L (1.14
mg/dL), INR 1.5, alpha-fetoprotein 20 ug/L.
REFERENCES
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Nat Rev Gastroenterol Hepatol 2011;8:491-501.
Brown RS, Transplantation for alcoholic hepatitis – time to re-think the 6-month rule.
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Dawwas MF, Gimson AE, Lewsey JD, Copley LP, van der Meulen JHP on behalf of the UK
and Ireland Liver Transplant Audit, Survival after liver transplantation in the United Kingdom
and Ireland compared with the United States. Gut 2007;56:1606-13.
Gao B, Bataller R. Alcoholic liver disease: pathogenesis and new therapeutic targets,
Gastroenterology 2011;141:1572-85.
**Mathurin P, Moreno C, Samuel D et al. Early liver transplantation for severe alcoholic hepatitis.
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