Liver transplantation in alcoholic liver disease current status and controversies

Abstract

Alcoholic cirrhosis remains the second most common indication for liver transplantation. A comprehensive medical and psychosocial evaluation is needed when making a decision to place such patients on the transplant list. Most transplant centers worldwide need a minimum of 6 mo of alcohol abstinence for listing these patients. Patients with alcohol dependence are at high risk for relapse to alcohol use after transplantation (recidivism). These patients need to be identified and require alcohol rehabilitation treatment before transplantation. Recidivism to the level of harmful drinking is reported in about 15%-20% cases. Although, recurrent cirrhosis and graft loss from recidivism is rare, occurring in less than 5% of all alcoholic cirrhosis-related transplants, harmful drinking in the post-transplant period does impact the long-term outcome. The development of metabolic syndrome with cardiovascular events and de novo malignancy are important contributors to non liver-related mortality amongst transplants for alcoholic liver disease. Surveillance protocols for earlier detection of de novo malignancy are needed to improve the long-term outcome. The need for a minimum of 6 mo of abstinence before listing makes transplant a nonviable option for patients with severe alcoholic hepatitis who do not respond to corticosteroids. Emerging data from retrospective and prospective studies has challenged the 6 mo rule, and beneficial effects of liver transplantation have been reported in select patients with a first episode of severe alcoholic hepatitis who are unresponsive to steroids.

Keywords: Alcoholic liver disease, Liver transplantation, Transplant evaluation, Recidivism, Six months rule, Alcoholic hepatitis

Core tip: Alcoholic cirrhosis remains the second most common indication for liver transplantation. Due to effective immune suppression regimens, graft loss and recurrent alcoholic liver disease rarely leads to mortality. However, the development of non-hepatic disorders such as malignancy and metabolic syndrome contributes to long-term morbidity and mortality. Although recidivism does impact long-term survival, data on the accuracy of 6 mo rule in predicting recidivism are scanty and controversial. Emerging data on the beneficial role of liver transplant provides a ray of hope for select patients with alcoholic hepatitis.