This is half of a two-part debate — read the opposing argument.
Innovation requires rigorous vetting for successful and sustained implementation. Such is the case for liver transplantation for alcoholic hepatitis. The seminal paper by Mathurin et al in 2011 stimulated debate regarding liver transplantation for patients with acute alcoholic hepatitis.1 This study showed that carefully selected patients with alcoholic hepatitis could have outstanding outcomes with a liver transplant. However, this approach is not ready for broad application across the transplant community at this time. I will highlight some points below, suggesting that we need additional, carefully implemented studies before liver transplant can be considered as standard care in patients with alcoholic hepatitis.
Some patients with alcoholic hepatitis will survive without a liver transplant
Approximately 20 to 25 percent of patients with severe alcoholic hepatitis whose disease is unresponsive to corticosteroids will survive without a liver transplant.2 This means that one in four patients who received a transplant for this indication did not need it. We can anticipate that this number will increase given that many centers do not use corticosteroids as first-line therapy and therefore may funnel ill patients directly to transplantation rather than sending only patients with disease unresponsive to corticosteroids to transplantation. Thus, a large number of organs could potentially be allocated to patients with alcoholic hepatitis who did not need a liver transplant.
The number of patients with alcoholic hepatitis who qualify for transplantation based on rigorous psychosocial criteria is very small but will grow indiscriminately if criteria are not objective and codified
Subjective expansion of the criteria based on Mathurin et al is likely to occur in real-world practice.1 In that study, the criteria were very strict for selecting patients with alcoholism for liver transplantation; in fact, only 2.9 percent of candidates underwent liver transplantation and, in turn, accounted for a very small percentage of the total transplantations performed in France.1 However, many of the criteria in that study are susceptible to subjective expansion. In the subsequent study from Lee et al, 7.4 percent of patients referred underwent transplantation, suggesting that, even in this rigorous analysis, the criteria were expanded from the original French study.3 The trend to expand psychosocial criteria to achieve more transplants would likely continue. Maybe an external board should adjudicate appropriate cases?
We owe it to the deceased donors who have provided this precious resource to continue to pursue rigorously tested medical policy and care.
Post-transplant abstinence is difficult to predict
Most studies suggest a 20 to 30 percent risk of recidivism in patients with alcoholic cirrhosis who undergo transplantation.4 These are patients monitored for longer periods of time and undergo treatment for addiction therapy. Patients with alcoholic hepatitis, especially those presenting with their first episode of alcoholic hepatitis, have had little interface with the multidisciplinary transplantation team. Although studies suggest that the relapse rate after transplantation may be similar among patients with alcoholic hepatitis and those with cirrhosis, when relapse occurs, it may occur in a more spectacular fashion in alcoholic hepatitis with very heavy alcohol use after transplantation.3 If we decide that a record of abstinence is unnecessary in patients with alcoholic hepatitis, then we may make a similar case for our patients with alcoholic cirrhosis as well. Although legitimate pushback has occurred on the six-month rule, some duration of abstinence helps predict the likelihood a patient might relapse and allows the clinician to assess any spontaneous improvement of the patient’s condition.
We owe it to the deceased donors who have provided this precious resource to continue to pursue rigorously tested medical policy and care. The ethics of transplantation in this setting merit consideration. Are society’s needs being met? Members of our society will support transplantation for patients with alcoholic hepatitis if objective criteria are further tested and validated and a cogent education strategy is pursued. At the present time, this is not the case. In fact, some proponents of transplantation for alcoholic hepatitis are codifying this treatment as standard care. The momentum of the pendulum is certainly swinging hard and fast toward liver transplantation for alcoholic hepatitis, but, if we go too fast, then the pendulum will quickly swing the other way to the detriment of our patients with alcoholic hepatitis. Part of the research and transition process should include transparency and community acceptance so we do not see decreases in overall donation rates, which would exacerbate the problem of organ shortage. As the adage goes: “Sometimes you have to go slow to go fast.”
- Liver transplantation for alcoholic hepatitis is promising, but it should not be viewed as standard care but rather as an area warranting rigorous investigation at select centers.
Dr. Shah is on the advisory board for Novartis, Merck, Durect and Afimmune. He is also an abstract reviewer for AASLD’s SIG, and an associate editor for EASL’s Journal of Hepatology.
1. Mathurin, P., Moreno, C., Samuel, D. et al, Early liver transplantation for severe alcoholic hepatitis. N Engl J Med. 2011;365:1790-1800.
2. Singal, A.K., Bataller, R., Ahn, J., Kamath, P.S., Shah, V.H. ACG clinical guideline: alcoholic liver disease. Am J Gastroenterol. 2018;113:175-194.
3. Lee, B.P., Chen, P.H., Haugen, C. et al, Three-year results of a pilot program in early liver transplantation for severe alcoholic hepatitis. Ann Surg. 2017;265:20-29.
4. Kubiliun, M., Patel, S.J., Hur, C., Dienstag, J.L., Luther, J. Early liver transplantation for alcoholic hepatitis: Ready for primetime? J Hepatol. 2018;68:380-382.