Liver transplantation in alcoholic hepatitis: We need new consensus among transplantation specialists

This is half of a two-part debate — read the opposing argument. 

Even though this dialogue is constructed as a point–counterpoint, the reader will find that Dr. Shah and I have more in common than in conflict. First, we agree that severe alcoholic hepatitis is a terrible disease for which the currently available treatments are inadequate. The early mortality rate in the most ill of patients with alcoholic hepatitis — those who are not responding to maximal medical care — can be as high as 75 percent in 28 days, a poor rate rivaling the worst cancers. Furthermore, these patients are often young adults with families. We have shared the pain of these families as their loved one slips into multisystem organ failure and dies. This is why the report by Mathurin et al on rescue liver transplantation was, as Dr. Shah points out, game changing.1 Here we have a treatment that is lifesaving for patients who may be in an otherwise hopeless situation.

Indeed, many challenges must be resolved before we can convert the message of this inspirational report into everyday practice. The first problem arises with the protean behavior of severe alcoholic hepatitis. All types of therapy for alcoholic hepatitis start with abstention from alcohol. When abstinence is combined with medical management of infection, renal failure and the complications of portal hypertension, up to 25 percent of patients with alcoholic hepatitis in the highest risk group may survive. Indeed, the justification, which was offered 30 years ago, for the six-month abstinence rule was that it mandated a sufficient interval to allow recovery from severe alcoholic hepatitis. I agree with Dr. Shah that we want to avoid transplanting patients who would have recovered with medical treatment alone. We need better prognostic indicators to identify patients most likely to die without a transplant, and we need to be able to do so while there is still time to affect liver transplantation.


We need new consensus among transplantation specialists and primary care professionals; representatives of patients and third-party payors on better selection criteria; and better processes and policies in place for patients with AUD when undergoing evaluation for a liver transplant.


Another controversy involves the selection of patients with alcohol use disorder (AUD) as candidates for liver transplantation. The French– Belgian study used a very strict selection process and Dr. Shah wonders whether the same limitations are likely to apply outside the confines of a clinical study.1

His concerns are well founded. In the U.S., centers specializing in liver transplantation retain considerable autonomy when determining their policies in regard to patient selection for a liver transplant. No consensus exists within the North American transplantation community regarding the appropriate inclusionary and exclusionary criteria for patients with AUD. Third-party payors also exert considerable influence in setting boundaries on selection criteria for liver transplant. Consequently, a patient with alcohol-associated liver disease (AALD) and recent alcohol use might be considered a suitable candidate in one program but excluded without assessment in another several miles away.

Although postoperative abstinence is the goal for all patients with AUD and AALD after liver transplantation, we should not let perfection be the enemy of the good. AUD is a disorder of remission and relapse. Relapse after liver transplantation takes many forms, and even patients who relapse can be helped back to sobriety, which, over time, becomes secure. Our goal during transplant evaluation is to avoid selection for liver transplant when we are able to confidently predict a significantly shortened life expectancy due to alcohol relapse after liver transplantation. Alternatively, we should not discriminate against patients who would die without a liver transplant but who would achieve a long life after receiving a liver transplant, even though the post–liver transplant survival rate might include episodes of relapse and remission of AUD.

It is my hope that the reader can see that the differences we have in opinion are only small. We agree that we need studies to improve pre–liver transplantation prognostic instruments. We need new consensus among transplantation specialists and primary care professionals; representatives of patients and third-party payors on better selection criteria; and better processes and policies in place for patients with AUD when undergoing evaluation for a liver transplant. We need more nuanced understanding of and treatment for AUD after liver transplantation. With better studies and more transparency, we can honor the gift of these deceased donors and their families, support the endeavors of all the professionals involved in transplantation, and celebrate the health of patients whose lives have been transformed by liver transplants.

Dr. Lucey has received research support from Abbvie and Gilead.


Dr. Shah describes why liver transplantation should not be viewed as standard of care.


Reference
1. Mathurin, P., Moreno, C., Samuel, D. et al, Early liver transplantation for severe alcoholic hepatitis. N Engl J Med. 2011;365:1790-1800.

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