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

BARCELONA . SPAIN
142 POSTGRADUATE COURSE SYLLABUS ALCOHOLIC LIVER DISEASE 143
APRIL 18 - 19/2012 THE INTERNATIONAL LIVER CONGRESS TM 2012
In a recent study based on ELTR (European Liver Transplant Registry) database, it has been demonstrated
that patient survival at 1, 3, 5 and 10 years from first transplantation was 84%, 78%, 73%, 58%, significantly
higher in alcoholic liver disease patients compared to HCV and HBV-relate liver disease recipients (82%,
74%, 70%, 60%) and cryptogenic cirrhosis patients (78%, 73%, 69%, 61%) (log rank p = 0.04 and p = 0.05,
respectively). When alcoholic liver disease patients were analysed according to HCV or HBV infection,
patient survival at 1, 3, 5 and 10 years from first transplantation was 84%, 75%, 65%, 52%, respectively,
in alcoholic liver disease with concomitant HCV infection group, significantly lower than 89%, 85%, 81%,
64%, respectively, observed in alcoholic liver disease with concomitant HBV infection patients (log rank p =
0.0002). The incidence of deaths due to all social causes was double in patients with an alcoholic etiology
of liver disease with or without viral infection, compared to other etiologies (1.3% alcoholic liver disease and
alcoholic liver disease with concomitant HCV or HBV infection vs. 0.7% HCV or HBV and 0.4% cryptogenic
cirrhosis, respectively; p = 0.03). In detail, transplanted patients or previous alcoholic liver disease had
double the incidence of deaths for suicide compared to viral etiology, p = 0.02 [24].
Alcohol relapse after liver transplantation
With the term “relapse” is generally defined any alcohol intake occurring after liver transplantation. Studies
which have evaluated alcohol relapse after liver transplantation for alcoholic cirrhosis have reported a wide
range of frequencies ranging from 10% to 50% in up to 5 years follow up [21, 25]. However most of the
studies evaluating alcohol relapse after liver transplantation are based on retrospective analysis of routine
screening tests, questionnaires or interviews with patients and/or family during routine follow-up, with a
consequent potential underestimate of patients’ real drinking habits.
In a study based on 51 patients with alcoholic liver disease who underwent strictly medical and psychological
evaluation before and after liver transplantation, alcohol abuse was recorder in 60% and alcohol dependence
in 40% of them before transplantation. Alcohol relapse was observed in 33% of transplanted patients, 64%
of who were occasional and 36% were heavy drinkers. The admission of alcoholism by the patient and his/
her family prior to transplantation significantly predicted abstinence after transplantation [26].
Combining results from many studies is evident that from a third to half of the alcoholic transplant recipients
start drinking again after transplantation often within the first year after surgery; amongst these nearly 10%
resume drinking in an abusive or dependent fashion [27].
Acute and chronic rejection
Patients transplanted for alcoholic cirrhosis experience fewer episodes of acute cellular rejection after
liver transplantation compared to patients transplanted for other reasons [28, 29]. Histologically-proven
acute cellular rejection was reported in 14% of patients 23-180 days after liver transplantation for alcoholic
cirrhosis [23].
Chronic ductopenic rejection is also very uncommon in alcoholics receiving liver transplants. In Padua Liver
Transplant Centre, since November 1990, 415 patients have undergone 480 liver transplantations. Eighty
of whom were transplanted for alcoholic liver disease either alone or in combination with viral hepatitis or
hepatocellular cancer. Among 312 long-term survivors, chronic rejection was seen in 6 (5%).
Medical complications following liver transplantation
Infections are common after liver transplantation for alcoholic liver disease. Bacterial infections seem to be
more frequent than in patients transplanted for other causes. The incidence of cytomegalovirus infection
was reportedly 14.3% in patients transplanted for alcoholic cirrhosis, which is no different from the 25%
incidence observed in patients transplanted for other causes. The incidence of new-onset insulin-dependent
diabetes is reportedly less than 10%, while for hypertension it is around 33%, again much the same as in
patients transplanted for non-alcoholic liver disease [30].
Patients transplanted for alcoholic liver disease may have an higher incidence of cardiovascular events
compared to patients transplanted for other causes of liver disease. It was recently demonstrated that
cardiovascular events were the cause of death in 8% of patients transplanted for alcoholic liver disease with
and without associated viral infection and in 5.3% of patients transplanted for HCV or HBV cirrhosis, and
the difference was statistically significant [24].
The prevalence of diabetes mellitus (10%), and hypertension (33%) are comparable with patients
transplanted for other aetiologies [30].
Te cerebral blood flow may also be impaired after liver transplantation since many functional alterations
in brain physiology are seen in alcoholic cirrhotic patients. Usually these abnormalities are reversed after
liver transplantation, but a reduction in the frontal cerebral blood flow may persist for up to 12 months after
surgery [31].
De novo neoplasms
An increased risk of de novo malignancies after liver transplantation has been reported to rise from 6%
to 55% at 15 years after liver transplantation and to account for a significant risk of late death [32]. An
overall incidence of oropharyngeal squamous cell carcinoma of 17% in alcohol-induced cirrhosis transplant
patients was reported [33]. In another series of patients who underwent liver transplantation for alcoholic
liver disease, an incidence of 4.2% of oropharyngeal and esophageal malignancies were seen between
8-40 months after surgery [34].
The incidence of the de novo tumors as cause of death was significantly higher in alcoholic compared with
non-alcoholic etiology of the primary liver disease. Among solid organ tumors, 2% of patients with viral
cirrhosis developed oral or upper GI tract tumors compared to 5.4% of patients with alcoholic liver disease
and the difference was statistically significant [24].
Quality of life and adherence to medical prescriptions
Whatever the reason for liver transplantation, quality of life improves after surgery in most domains [35].
Overall quality of life and employment levels appear similar between patients transplanted for alcoholic and
non-alcoholic liver disease [36].
Adherence of patients suffering from alcoholic cirrhosis is still under discussion. After liver transplantation
no difference between patients with or without alcohol relapse concerning compliance with medication,
incidence of rejection or adherence to check-ups were reported [37]. They appear to return to society to
lead active and productive lives, despite they seem less likely to be involved in structured social activities
than patients transplanted for non-alcoholic liver disease [38].
CONCLUSION
In conclusion, alcoholic cirrhosis is a widely accepted indication for liver transplantation, whereas the
experience of transplantation in patients with acute alcoholic hepatitis is limited to a restricted number of
patients with specific slection criteria.
Literature data showed that, despite alcohol relapse is ranging between 10% and 50% at 5 years after liver
transplantation, graft and patient survival is comparable with patients transplanted for different aetiology.
A psycho-social assessment to establish the likelihood of long-term abstinence after liver transplantation
and a psychiatric evaluation should be performed in all patients with alcoholic liver disease. The role of the
length of pretransplantation abstinence, the so called “6-month rule”, as predictor of posttransplantation
abstinence is still controversial.