Liver transplantation in alcoholic liver disease: is a period of sobriety necessary?

One discussion this week included early liver transplantation in patients with alcoholic liver disease (ALD).

Reference: Godfrey EL, Stribling R, Rana A. Liver transplantation for alchoholic liver disease: an update. Clinics in Liver Disease. 2019 Feb;23(1):127-139. doi: 10.1016/j.cld.2018.09.007.

Summary (quoted from the article): ALD, a major cause of global morbidity and mortality, is expected to continue to increase in the global health burden. Although several new therapies have become available for other causes of liver disease, very few effective therapies exist for ALD other than liver transplantation. To ensure good outcomes and appropriate allocation of scarce donated organs, stringent selection criteria must be used to determine who is eligible to receive a graft, and effective, integrated alcohol use treatment must be used to prevent relapse.

In addition to assiduous monitoring for alcohol use relapse before and after transplantation, these patients must also be managed for their unique health concerns, including pre-transplantation malnutrition and post-transplantation elevated risk of malignancy, obesity, and cardiac disease.

If long sobriety periods were required for transplantation, then these patients would have no options left open to them. French consensus recommendations were the earliest to abandon a specific length of sobriety; an early multicenter prospective trial of OLT for sAH was reported in 2011. Unsurprisingly, 6-month survival was vastly higher in subjects who received early OLT (77% vs 23%), and that benefit persisted over 2 years of follow-up. Only 3 of the 26 relapsed.

Older transplantation practices limited transplants to those patients who were able to demonstrate 6 months of sobriety; however, more flexible guidelines are emerging to address those with more acute conditions such as sAH. Outcomes have been good, supporting continued flexibility in selection and treatment protocols.

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