Liver transplantation for alcoholic liver disease

Abstract

Alcoholic liver disease (ALD) is the second commonest indication for liver transplantation after viral hepatitis in the United States and Europe. Controversies surround the indications and allocation of scarce and expensive resource for this so called self inflicted disease. Controversies stem from the apprehension that alcoholic recipients are likely to relapse and cause damage to the graft. There is a need to select those candidates with lower risk for relapse with the available predictive factors and scores. Substance abuse specialist and psychiatrists are mandatory in the pre-transplant evaluation and in the post-transplant follow-up. There is conflicting evidence to support a fixed period of pretransplant abstinence, although most units do follow this. Alcoholic hepatitis (AH) continues to be a contraindication for transplantation, however there is a need for further research in this field as a subset of patients with AH who do not respond to medical treatment, have high early mortality and could benefit from transplantation. One year, 3-year, and 5-year survival post-transplant is similar for both ALD and non-ALD recipients. The incidence of post-transplant rejection and retransplantation is also similar to other recipients. ALD with viral hepatitis especially hepatitis C virus leads to a more aggressive liver disease with early presentation for transplantation. ALD patients are more prone to develop de-novo malignancy; this is attributed to the long term effect of alcohol, tobacco combined with immunosuppression. Post-transplant surveillance is important to detect early relapse to alcoholism, presence of de-novo malignancy and treat the same adequately.

Figure 1

Indications for orthotopic liver transplantation according to the European Liver Transplant Registry (2008). Alcoholic liver disease (ALD) was an indication in 33%, 4% had combined aetiology of ALD and hepatitis C/B.

Figure 2

Indications for orthotopic liver transplantation according to the United Network for Organ Sharing (2009) data. ALD was an indication in 17% of recipients, 5% had combined indication of ALD and viral cirrhosis. HCV: Hepatitis C virus; PSC: Primary sclerosing cholangitis; PBC: Primary biliary cirrhosis.

Figure 3

Evolution in the indication for orthotopic liver transplantation in European Liver Transplant Registry (2008), alcoholic liver disease is the second common indication after viral cirrhosis.

Figure 4

Evolution in the indications for orthotopic liver transplantation in the United Network for Organ Sharing (2009) data, viral cirrhosis and alcoholic liver disease are the main indications.

Figure 5

European Liver Transplant Registry (2008) data. One year, 3-year, 5-year, and 10-year survival following orthotopic liver transplantation for three common indications. PBC: Primary biliary cirrhosis.