By Mark Gold, MD
Times have changed for those suffering from alcohol-associated liver disease (ALD), an umbrella term for liver conditions like fatty liver and alcohol-related cirrhosis that are caused by heavy or excessive drinking. Liver disease is one of the major consequences of alcohol use disorder, often resulting, ultimately, in liver failure. In the past, people whose liver health had deteriorated due to ALD would not have been considered for a transplant. One reason for this was the stigma surrounding alcohol use disorders and addiction. Another was a lack of understanding among physicians on how to improve outcomes for patients with ALD and in need of a transplant. Today, attitudes amongst doctors have changed along with the outlook for people with ALD. Of the 33,000 liver transplant recipients since 2002, 36.7% of them received a transplant due to ALD, up from 24.2% in 2002. Drs. Mitchell and Maddrey examined in a recent multicenter, prospective, national cohort study what has changed in the approach to evaluating transplant candidates in recent years.
Shortly after the first National Institutes of Health Consensus Development Conference on Liver Transplantation brought senior hepatologists together in 1983, the question of whether, and how, to allocate transplant organs to patients with ALD was discussed. What was eventually agreed upon was a 6-month period of abstinence before a transplant for patients presenting with ALD, with the hope that this requirement for abstinence would encourage patients to engage in treatment for alcohol use disorder. This period of time was arbitrary, not an evidence-based requirement. Certainly, abstinence would be helpful to recovery and continued consumption might harm a new liver as it had harmed the original liver. However, research data has shown that abstinence had much less of an effect on outcomes than was previously believed. Long-term outcomes for patients with ALD were not related to a period of pre-transplant abstinence and relapse post-transplant is associated with factors other than a period of abstinence. Five years after transplantation, patients who were abstinent for six months prior to receiving a transplant and those who weren’t had about the same survival rates.1
With this knowledge, and the publication of a report in France and Belgium in 2011 that showed excellent short-term survival in patients with alcoholic hepatitis who received transplants, there has been a departure from the 6-month rule and a subsequent increase in the number of patients with ALD receiving transplants. Both the bias among providers against patients with ALD, and the belief that 6 months of abstinence from drinking is necessary seems to be on the decline.
ALD now edges out hepatitis C as the most common reason for liver transplants in the United States. One reason for the shift, researchers said, is that hepatitis C, which used to be the leading cause of liver transplants, has become easier to treat with medications. Hepatitis C is treatable, even curable, today - fewer patients with Hepatitis C reach a point where they need a transplant at all.
Looking to the Future
In addition to the shifting trends in liver transplantation, there is promising research that can help further decrease the mortality of people suffering from ALD, and possibly prevent them from reaching the point where liver transplantation is necessary at all. Clinical trials underway at the National Institute of Alcoholism and Alcohol Abuse (NIAAA) aim to help create better behavioral and medical treatments for those suffering from ALD to help improve short-term mortality. Such advancements could give patients more time to be stabilized, negating the need for some to have transplants at all, and allowing for a more thorough assessment of those who do need transplants. Until we are able to create and administer these treatments, future study should be focused on improving disparities in access to liver transplant for ALD and optimizing short- and long-term survival among transplant recipients with ALD.
Lee BP, Vittinghoff E, Dodge JL, Cullaro G, Terrault NA (2019). National trends and long-term outcomes of liver transplant for alcohol-associated liver disease in the United States. JAMA Internal Medicine
Dr. Mark S. Gold is a teacher of the year, translational researcher, author, mentor and inventor best known for his work on the brain systems underlying the effects of opiate drugs, cocaine and food. Read more by Dr. Gold here.