Liver transplantation for alcohol-related hepatitis has been a controversial topic. University of Miami researchers are now helping to develop clear guidelines on appropriate indications for liver transplantation in this patient group.
According to Paul Martin, M.D., professor of medicine at the University of Miami Miller School of Medicine and chief of the Division of Digestive Health and Liver Diseases, “there has been continuing debate about offering transplantation to patients with liver failure due to alcoholic hepatitis as they typically have had recent alcohol. Many of these patients are young adults. The major issue has been a perception that these patients are more likely to return to alcohol use after liver transplant.”
Dr. Martin is co-author of a paper by Dr. Summeet Asrani on this topic entitled “Meeting Report: The Dallas Consensus Conference on liver transplantation for alcohol associated hepatitis” that was published in Liver Transplantation in January.
A few decades ago, this line of thinking was also common for patients with alcohol-related liver disease (ALD). Among other factors, the development of a “six-month abstinence” rule helped change management of ALD. With the implementation of this rule, liver transplantation became accepted therapy for life-threatening alcohol-related cirrhosis. By 2017, alcohol-related liver disease was the most common indication for liver transplantation in the U.S., with survival rates similar to other diagnoses.
Conversely, liver transplantation as a treatment for severe alcohol-related hepatitis (AH) has remained controversial because of concerns about limited organ supply and the risk that liver recipients with AH will return to excessive drinking. “Generally, patients with AH have not been accepted for liver transplantation,” Dr. Martin said. “Any patient with alcohol issues, not just AH, is required to address their alcohol issues as a condition for acceptance for transplant.” As a result, many patients with AH “receive supportive care but have a high mortality rate without liver transplant.”
When it comes to AH, the adoption of a six-month abstinence requirement isn’t feasible, reflecting the high short-term mortality of severe AH. Many patients with the disease who have not responded to medical care will die during a required interval of abstinence. The difficulty in assessing patients with AH is that the alcohol use is more recent, Dr. Martin said. In cirrhosis due to ALD, “patients have had many months of sobriety but still continue to experience liver failure.”
The goal of the Dallas Consensus Conference was not to unequivocally endorse liver transplantation for AH — or discourage it — but to provide clear guidelines for institutions. Over this two-day conference last April, many aspects of liver transplantation in AH were considered at length, including patient selection, contraindications, listing criteria, ethical considerations and post-op follow-up. The result was a comprehensive set of recommendations developed by the consensus panel.
According to Dr. Martin, one of the most important recommendations that he and his colleagues at the Consensus Conference addressed in the AH population was “the standard requirement for six months of sobriety prior to liver transplant.” New recommendations say that in those with AH, “an inflexible period of abstinence prior to transplantation is not desirable. Acceptance for liver transplantation listing should be based upon the severity of liver dysfunction and a comprehensive psychosocial evaluation.”
This is just one of more than 25 recommendations from the Consensus Conference. As these new recommendations are adopted and make their way into clinical practice, treatment options for patients with AH will ultimately evolve as they did for patients with cirrhosis due to ALD. Dr. Martin predicts this will lead to “earlier referral for liver transplant.”