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Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jul 14, 2018; 24(26): 2785-2805
Published online Jul 14, 2018. doi: 10.3748/wjg.v24.i26.2785
Liver transplantation and alcoholic liver disease: History, controversies, and considerations
Claudio Augusto Marroni, Alfeu de Medeiros Fleck Jr, Sabrina Alves Fernandes, Lucas Homercher Galant, Marcos Mucenic, Mario Henrique de Mattos Meine, Guilherme Mariante-Neto, Ajacio Bandeira de Mello Brandão
Claudio Augusto Marroni, Sabrina Alves Fernandes, Lucas Homercher Galant, Guilherme Mariante-Neto, Ajacio Bandeira de Mello Brandão, Graduate Program in Medicine: Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre 90430-080, RS, Brazil
Claudio Augusto Marroni, Alfeu de Medeiros Fleck Jr, Sabrina Alves Fernandes, Lucas Homercher Galant, Marcos Mucenic, Mario Henrique de Mattos Meine, Guilherme Mariante-Neto, Ajacio Bandeira de Mello Brandão, Liver Transplant Adult Group, Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre 90035-072, RS, Brazil
Sabrina Alves Fernandes, Nutrition at the Centro Universitário Metodista (IPA), Porto Alegre 90420-060, RS, Brazil
Author contributions: All authors reviewed and analyzed the literature and contributed to the writing of the manuscript; Marroni CA also provided the overarching intellectual input into the study design and edited the final version of the manuscript.
Conflict-of-interest statement: No potential conflicts of interest. No financial support.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Claudio Augusto Marroni, MD, PhD, Professor, Graduate Program in Medicine: Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Rua José Kanan Aranha, 102, Jardim Isabel, Porto Alegre 91760-470, RS, Brazil. nmarroni@terra.com.br
Telephone: +55-51-999638306 Fax: +55-51-32483202
Received: April 3, 2018
Peer-review started: April 4, 2018
First decision: April 27, 2018
Revised: May 23, 2018
Accepted: June 16, 2018
Article in press: June 16, 2018
Published online: July 14, 2018
Abstract

Alcohol consumption accounts for 3.8% of annual global mortality worldwide, and the majority of these deaths are due to alcoholic liver disease (ALD), mainly alcoholic cirrhosis. ALD is one of the most common indications for liver transplantation (LT). However, it remains a complicated topic on both medical and ethical grounds, as it is seen by many as a “self-inflicted disease”. One of the strongest ethical arguments against LT for ALD is the probability of relapse. However, ALD remains a common indication for LT worldwide. For a patient to be placed on an LT waiting list, 6 mo of abstinence must have been achieved for most LT centers. However, this “6-mo rule” is an arbitrary threshold and has never been shown to affect survival, sobriety, or other outcomes. Recent studies have shown similar survival rates among individuals who undergo LT for ALD and those who undergo LT for other chronic causes of end-stage liver disease. There are specific factors that should be addressed when evaluating LT patients with ALD because these patients commonly have a high prevalence of multisystem alcohol-related changes. Risk factors for relapse include the presence of anxiety or depressive disorders, short pre-LT duration of sobriety, and lack of social support. Identification of risk factors and strengthening of the social support system may decrease relapse among these patients. Family counseling for LT candidates is highly encouraged to prevent alcohol consumption relapse. Relapse has been associated with unique histopathological changes, graft damage, graft loss, and even decreased survival in some studies. Research has demonstrated the importance of a multidisciplinary evaluation of LT candidates. Complete abstinence should be attempted to overcome addiction issues and to allow spontaneous liver recovery. Abstinence is the cornerstone of ALD therapy. Psychotherapies, including 12-step facilitation therapy, cognitive-behavioral therapy, and motivational enhancement therapy, help support abstinence. Nutritional therapy helps to reverse muscle wasting, weight loss, vitamin deficiencies, and trace element deficiencies associated with ALD. For muscular recovery, supervised physical activity has been shown to lead to a gain in muscle mass and improvement of functional activity. Early LT for acute alcoholic hepatitis has been the subject of recent clinical studies, with encouraging results in highly selected patients. The survival rates after LT for ALD are comparable to those of patients who underwent LT for other indications. Patients that undergo LT for ALD and survive over 5 years have a higher risk of cardiorespiratory disease, cerebrovascular events, and de novo malignancy.

Keywords: Alcoholic liver disease, Alcoholic hepatitis, Alcoholic cirrhosis, Alcoholism, Liver transplantation, Alcoholic recurrence, Controversies, Alcoholic abstinence, Relapse, Selection criteria

Core tip: Alcohol consumption accounts for 3.8% of annual global mortality worldwide. Cirrhosis is a common complication of alcoholic liver disease (ALD) and when end-stage liver disease is reached, the only chance of survival is liver transplantation (LT). There are controversies and ethical dilemmas associated with LT for ALD. This study reviews the history and controversies and considers the development of, indications for, and outcomes of LT in ALD, including severe acute alcoholic hepatitis. Relapse, therapeutic options, and outcomes are emphasized.