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

BARCELONA . SPAIN
140 POSTGRADUATE COURSE SYLLABUS ALCOHOLIC LIVER DISEASE 141
APRIL 18 - 19/2012 THE INTERNATIONAL LIVER CONGRESS TM 2012
PATIENTS WITH ALCOHOLIC LIVER DISEASE AND LIVER
TRANSPLANTATION: SPECIFIC ISSUES
Patrizia Burra
Padova, Italy
E-mail: burra@unipd.it
KEY POINTS
• Outcomes of liver transplantation for alcohol-related cirrhosis are comparable with those of
liver transplantation for other aetiologies.
• Most transplant programs in the US and Europe consider acute alcoholic hepatitis a
contraindication to liver transplantation. However early liver transplantation in selected patients
with a first episode of severe alcoholic hepatitis not responding to medical therapy has been
shown to improve survival.
• The role of the length of pre-transplantation abstinence, the so called “6-month rule”, as
predictor of post-transplantation abstinence is still controversial.
• A psycho-social assessment to establish the likelihood of long-term abstinence after liver
transplantation should be performed in patients with alcoholic liver disease considered
potential candidates for liver transplantation.
• Alcohol relapse after liver transplantation for alcoholic cirrhosis ranges between 10% and 50%
in up to 5 years follow-up, according to the method used to assess alcohol relapse.
• Overall quality of life and employment levels appear similar between patients transplanted for
alcoholic and non-alcoholic liver disease. However the incidence of deaths due to all social
causes has been shown to be double in patients with an alcoholic etiology of liver disease,
compared to other etiologies.
INTRODUCTION
Alcoholic liver disease is one of the most common causes of cirrhosis and indications for liver transplantation
in Europe and North America [1-3]. Despite the results of liver transplantation for alcohol-related cirrhosis
are comparable with those of liver transplantation for other aetiologies, alcoholic liver disease has been
considered a controversial indication to liver transplantation. The reluctance to transplant alcoholics stems
in part from the view that alcoholics bear responsibility for their illness [3] and there is also the perception
that the alcoholic person is likely to relapse into alcohol use after transplantation and thereby damage the
allograft.
ALCOHOLIC LIVER DISEASE AND INDICATION FOR LIVER TRANSPLANTATION
Liver transplantation in patients with alcoholic cirrhosis was first acknowledged in 1983 [4]. Poynard et al.
[5] showed that there was a survival benefit when patients with advanced de-compensation (Child-Turcotte-
Pugh score ranging between 11 and 15) underwent transplantation, whereas there was no survival benefit
when alcoholic patients with better compensated liver function were transplanted.
Most of the patients with severe alcoholic hepatitis, whether occurring in the previously healthy liver or
in patients with established cirrhosis, fail to recover despite abstinence and maximal medical therapy.
Most transplant programs in the US and Europe consider acute alcoholic hepatitis a contraindication to
liver transplantation [6, 7]. However a recent multicenter study by Mathurin et al. [8] showed that early
liver transplantation can improve survival in patients with a first episode of severe alcoholic hepatitis not
responding to medical therapy. Twenty-six patients with no prior episode of alcoholic hepatitis and with no
response to medical therapy or rapid worsening of liver function despiite medical treatment were selected
after an adequate psychiatric and social evaluation. The cumulative 6-month survival rate was higher among
patients who received early transplantation than among those who did not (77±8% vs. 23±8%; p