Liver Transplantation in Alcohol-related Liver Disease and Alcohol-related Hepatitis

Abstract

Alcohol-related liver disease (ARLD) remains one of the leading causes of chronic liver disease and the prevalence of alcohol-related cirrhosis is still increasing worldwide. Thus, ARLD is one of the leading indications for liver transplantation (LT) worldwide especially after the arrival of direct-acting antivirals for chronic hepatitis C infection. Despite the risk of alcohol relapse, the outcomes of LT for ARLD are as good as for other indications such as hepatocellular carcinoma (HCC), with 1-, 5-, and 10- year survival rates of 85%, 74%, and 59%, respectively. Despite these good results, certain questions concerning LT for ARLD remain unanswered, in particular because of persistent organ shortages. As a result, too many transplantation centers continue to require 6 months of abstinence from alcohol for patients with ARLD before LT to reduce the risk of alcohol relapse even though compelling data show the poor prognostic value of this criterion. A recent pilot study even observed a lower alcohol relapse rate in patients receiving LT after less than 6 months of abstinence as long as addictological follow-up is reinforced. Thus, the question should not be whether LT should be offered to patients with ARLD but how to select patients who will benefit from this treatment.

Keywords: AH, alcohol-related hepatitis; ARLD, Alcohol-related liver disease; AUDIT, Alcohol Use Disorders Identification Test; CLD, chronic liver disease; ELTR, European Liver Transplant Registry; HCC, hepatocellular carcinoma; HCV, hepatitis C virus; LT, liver transplantation; NASH, non-alcoholic steatohepatitis; NIAAA, National Institute on Alcohol Abuse and Alcoholism; UNOS, United Network for Organ Sharing; alcohol; alcohol-related hepatitis; alcohol-related liver disease; liver transplantation; survival.

Figure 1

Liver transplantation for alcohol related cirrhosis.

Figure 2

Algorithm for management of patients with severe alcoholic hepatitis. †There is no consensus in patients with 0.45 < Lille < 0.56 to continue or stop prednisolone. In patients with no sign of infection, we propose to consider a further challenge by steroids for 7 additional days, but this is not evidence-based and this is only an expert opinion. ‡Liver biopsy can also have a prognostic value (Altamirano et al. Gastroenterology 2014). ∗Team evaluation: surgeon, anesthesist, nurse, resident, senior hepatologist, specialist in addiction.