Early liver transplant research challenges 6-month ‘rule’ for alcoholics
MedWire News: Early liver transplantation increases survival in patients with severe alcoholic hepatitis, who are usually refused the procedure until completion of 6 months' abstinence from alcohol, according to research published in the New England Journal of Medicine.
"Liver transplantation for alcoholic liver disease has been controversial since the advent of the procedure," writes Robert Brown from Columbia University College of Physicians and Surgeons, in an accompanying editorial. "The perception that alcohol-related liver disease is self-inflicted, combined with concerns about recidivism to alcohol use and poor adherence to post-transplantation care, has led the public and physicians to not support transplantation in patients with alcoholism."
This latest research by Philippe Mathurin (Université Lille Nord de France, Lille, France) and colleagues showed the outcomes of 26 patients with severe alcoholic hepatitis who were granted liver transplantation within 13 days of nonresponse to medical therapy.
The patients were selected on the basis that they had support from family members, no prior episodes of alcoholic liver disease, no evidence of psychologic disease, and agreement to life-long total abstinence from alcohol.
The 6-month survival rate was significantly higher among these transplantation patients compared with 69 controls, matched for age, gender, severity of alcoholic hepatitis, and nonresponse to medical therapy, who did not undergo transplant (77 vs 23%). Eighteen of the 20 deaths among the control group occurred within 2 months of being recognized as nonresponsive to medical therapy, thereby suggesting substantial advantages are conferred by early transplantation.
Of the six transplantation patients that died, five deaths were due to infection within 2 weeks of surgery. Among the patients who survived 6 months, their liver tests and creatine levels returned to normal levels within the first month after transplantation.
Most programs require patients to prove abstinence from alcohol for 6 months before they can be considered for transplantation, explain the researchers.
"Our findings challenge both the notion of a prescribed abstinence period as the only alcoholism-related criterion for transplant eligibility, and the opinion of experts that alcoholic hepatitis is a contradiction for transplantation," they say.
Commenting on possible alternative criteria for deciding on alcoholism-related liver transplantation recipients, Brown describes the need to "balance issue of utility and justice."
"I would recommend the development and use of predictive tools and reproducible methods to objectively select patients at low risk for recidivism," he says. "Because of the scarcity of organs, we cannot afford to choose candidates in an arbitrary way that cannot be defended in the public eye."
However, the researchers acknowledge several limitations to their study, and emphasize the need to demonstrate that their selection process is reproducible.
By Chloe McIvor