S19 * LIVER TRANSPLANTATION IN PATIENTS WITH ALCOHOLIC LIVER DISEASE

Autor: A. Louvet, P. Milkiewicz, F Braun, T. Becker, T. Doede, R. Günther
Rok vydání: 2013
Předmět:
Zdroj: Alcohol and Alcoholism. 48:i19-i20
ISSN: 1464-3502
0735-0414
Popis: S19.1 LIVER TRANSPLANTATION FOR PATIENTS WITH ALCOHOL-INDUCED CIRRHOSIS {#article-title-2} Patients with end-stage alcohol-induced cirrhosis might be candidates for liver transplantation (LTx). However, the shortage of postmortal donor livers requires selection of potential candidates by prognosis and urgency status according to the German transplantation law and guidelines. Furthermore, the German guideline allows listing for LTx in patients with alcoholic cirrhosis only if the patients were abstinent for a period of at least 6 months. Parameters to proof eligibility for LTx in waiting list patients are: (I) psychological judgment, (II) frequency and accuracy of outpatient visits and evaluation appointments, (III) laboratory test like blood alcohol concentration, ethylglucuronide (ETG) concentration in urine or hairs and carbohydrate-deficient transferrin (CDT) concentration in blood, and (IV) voluntary attendance in a self-help group. Internationally, it is well known that prognosis after LTx in this group of patients is good. However, there is still an ongoing discussion if patients with alcoholic cirrhosis should have the same legitimation for LTx like patients with primary sclerosing cirrhosis, primary biliary cirrhosis or autoimmune hepatitis in times of shortage of postmortal donor livers. Also, patients with alcoholic cirrhosis and acute-on-chronic decompensation are often difficult to evaluate if they require intensive-care treatment and mechanical ventilation. Under such circumstances, these patients are not sufficiently evaluable by a psychologist regarding abstinence if they had a history of drinking behaviour. Most recently, a selected group of patients with severe alcoholic hepatitis underwent successful LTx in France. In Germany, such an approach is forbidden by the guideline. Finally, patients with other indications than alcoholic cirrhosis might also have concomitant alcohol abuse and should be carefully screened during the evaluation process for LTx. # S19.2 PUBLIC ATTITUDES TOWARDS LIVER DONATION IN ALCOHOLICS {#article-title-3} Severe public attitudes exist towards liver donation for alcoholics; nevertheless, there is no scientific literature about this theme. The controversy peaked in the 1990s when celebrities with drinking problems – Larry Hagman, David Crosby and Mickey Mantle – got liver transplants. More recently, British soccer star George Best received a new liver in 2002, started drinking again and died three years later. Alcohol can cause lethal, liver-destroying diseases such as cirrhosis and hepatitis. Nearly one in five liver transplants in the U.S. go to current or former heavy drinkers. In Germany in 2012 in summary 1.658 patients have been liver transplanted, 489 because of an alcoholic liver disease. Transplant hospitals commonly require patients waiting for a new liver to give up drinking for six months as a way of assuring doctors they are serious staying sober after the operation. # S19.3 SPECIFIC PRE- AND POST-TRANSPLANT PROBLEMS IN ALCOHOLIC LIVER GRAFT RECIPIENTS {#article-title-4} Over last two decades alcoholic liver disease (ALD) has remained the second most common indication for liver transplantation (LTx) in Western countries (1). However only 5% of patients with this condition is eventually assessed for the procedure. An arbitrary 6-month period of abstinence is widely accepted but in many aspects remains controversial (2). An involvement of a psychiatrist or a person with a vast experience in dealing with substance dependence is crucial in transplant evaluation process. Major concern associated with LTx in ALD is related to the fact that the disease is widely perceived as self-inflicted (3). There are also obvious concerns associated to the risk of recidivism. Various studies assessed this risk as being between 11 and 49% at the period of 3-5 years after LTx. However the general experience is that only a small proportion of patients resumes heavy alcohol abuse and loose their graft due to alcohol induced liver failure (4). HRAR (High Risk Alcoholism Relapse) score has been found useful in assessing the risk of recidivism after grafting (5). Patients in Child score A and B have a comparable 1- and 5-year survival to their matched controls transplanted for other indications. The survival is even better in ALD patients transplanted with Child score C when compared to other indications (6). The role of liver transplantation in subjects with alcoholic hepatitis is highly controversial. Some experts strongly support this concept and recent multicentre study confirmed not only the superiority of LTx over medical treatment but also a low rate of recidivism in transplanted subjects (7). However, it is still generally accepted that shortage of donors precludes LTx in this circumstance. # S19.4 EXTENDING LIVER TRANSPLANTATION TO PATIENTS WITH SEVERE ALCOHOLIC HEPATITIS - CHANGE OF PARADIGM {#article-title-5} In severe alcoholic hepatitis (defined by a Maddrey's discriminant function greater than 32), several meta-analyses and randomized controlled trials have concluded that corticosteroids are efficient in improving short-term survival. Response to treatment can be assessed by the Lille model, which is calculated after seven days of treatment. This model is predictive of death at 6 months and a score above 0.45 predicts a risk of death at 6 months of about 70-75%. In these non-responders to medical therapy, no pharmaceutical intervention has been proven to be effective and most deaths occur within 2 months. Thus, strict application of a period of sobriety as a policy for transplant eligibility is unfair, as most of them will have died prior to the end of the 6-month sober period. Liver transplantation in those patients is attractive but controversial as it challenges the 6-month abstinence rule. A pilot study showed recently that early liver transplantation improved short-term outcome of non-responders to treatment. The selection of these patients was based on drastic criteria which were: patients undergoing their first episode of liver disease, absolute consensus of paramedical and medical staff, no co-morbidities, social integration, and supportive family members. Only three patients relapsed to alcohol during the follow-up. These results support future evaluation of transplantation in a carefully selected subgroup of patients. However, early liver transplantation is relevant only for a minority of patients and these encouraging results must be confirmed by other teams. Moreover, long-term data are strongly warranted, in particular with regard to alcohol relapse.
Databáze: OpenAIRE
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