Trend watch: More liver transplants offered without requiring alcohol abstinence

Specialists at transplant institutions are performing liver transplants in select patients with severe alcoholic hepatitis more often, bucking the commonly mandated 6-month abstinence period from alcohol, according to results presented at Digestive Disease Week 2018 in Washington, DC.

"Liver transplant for severe alcoholic hepatitis is being increasingly accepted, with positive outcomes, and the hope is that more and more patients will be evaluated for transplants," said Saroja Bangaru, MD, University of Texas Southwestern Medical Center, Dallas, and co-author of the study. "The hope is that survival rates are encouraging enough for centers, so that even more of them will reverse past practices."

Specialists offer patients with severe alcoholic hepatitis steroids such as prednisolone as first-line treatment. A substantial number of these patients, however, are refractory to steroid treatment; unfortunately, many die within 3 months.

The intent behind requiring 6 months of abstinence from drinking involves concerns about relapse, as well as a perceived lack of patient adherence, which could play a role in transplant failure. Nevertheless, emerging research findings indicate an expanded number of variables that moderate relapse, including social support, psychiatric illness, and patient insight into their alcohol dependence.

Dr. Bangaru and colleagues formulated a brief questionnaire reflecting attitudes and practices toward liver transplantation in patients with alcoholic hepatitis. The investigators analyzed data from 45 of 109 responding transplant centers. In total, 23 centers (51.1%) reported that they performed liver transplants in patients with severe alcoholic hepatitis. Of these 23 centers, 17 (73.9%) reported 1-year survival rates >90%, akin to rates observed in alcoholic cirrhosis.

The team discovered that many transplant centers are willing to transplant in carefully chosen patients with alcoholic hepatitis, considering factors such as first presentation with alcoholic hepatitis, completion of psychosocial evaluation, and a strong social support system.

“There was no significant difference between centers that had transplanted for severe AH [alcoholic hepatitis] and those that had not with respect to age of program, transplant volume, post-transplant survival, and MELD at transplant,” the researchers wrote.

The top three reasons for transplant centers not offering transplants to patients with alcoholic hepatitis included the following: 1) increased risk of relapse, 2) insufficient duration of alcohol abstinence, and 3) potential for liver function recovery following abstinence.

Notably, only 65.2% of centers that performed transplants in patients with alcoholic hepatitis offered post-transplant psychiatric services. Moreover, only 35% of such centers offered support group therapy.

“LT [liver transplant] is increasingly being offered to selected patients presenting with severe [alcoholic hepatitis] in the USA with exceptional outcomes,” the researchers concluded. “Post-transplant psychiatric support which is important in these patients is still inadequate at most transplant institutions. Nevertheless, LT should be considered in well-selected patients with severe AH.”