ACG Clinical Guideline: Alcoholic Liver Disease

Abstract

Alcoholic liver disease (ALD) comprises a clinical-histologic spectrum including fatty liver, alcoholic hepatitis (AH), and cirrhosis with its complications. Most patients are diagnosed at advanced stages and data on the prevalence and profile of patients with early disease are limited. Diagnosis of ALD requires documentation of chronic heavy alcohol use and exclusion of other causes of liver disease. Prolonged abstinence is the most effective strategy to prevent disease progression. AH presents with rapid onset or worsening of jaundice, and in severe cases may transition to acute on chronic liver failure when the risk for mortality, depending on the number of extra-hepatic organ failures, may be as high as 20-50% at 1 month. Corticosteroids provide short-term survival benefit in about half of treated patients with severe AH and long-term mortality is related to severity of underlying liver disease and is dependent on abstinence from alcohol. General measures in patients hospitalized with ALD include inpatient management of liver disease complications, management of alcohol withdrawal syndrome, surveillance for infections and early effective antibiotic therapy, nutritional supplementation, and treatment of the underlying alcohol-use disorder. Liver transplantation, a definitive treatment option in patients with advanced alcoholic cirrhosis, may also be considered in selected patients with AH cases, who do not respond to medical therapy. There is a clinical unmet need to develop more effective and safer therapies for patients with ALD.

Transplantation for Alcoholic Hepatitis: Are We Achieving Justice and Utility?

“…Each organ used for a patient with severe AH is an organ not used for a suffering patient with CLD. Again, perhaps sensitive to this concern, proponents of this practice frequently cite that early LT for AH accounts for “only 1.5%‐3% of the organ pool.” However, these estimations are derived from the earliest pilot studies in which only a tiny portion of eligible patients with AH underwent transplantation. As the practice of early LT for AH expands and has now emerged in guidelines as a standard of care option for highly selected candidates, these earlier projections underestimate how the donor pool will be affected .…”

“…Again, perhaps sensitive to this concern, proponents of this practice frequently cite that early LT for AH accounts for “only 1.5%‐3% of the organ pool.” However, these estimations are derived from the earliest pilot studies in which only a tiny portion of eligible patients with AH underwent transplantation. As the practice of early LT for AH expands and has now emerged in guidelines as a standard of care option for highly selected candidates, these earlier projections underestimate how the donor pool will be affected . And it should be noted that early LT for AH eliminates the possibility that a patient might recover without a transplant and will correspondingly increase the number of organs extracted from the donor pool; if this percentage is indeed 20%‐40%, then out of every five transplants performed for early LT in AH, at least one to two organs are used unnecessarily.…”

“…Early liver transplantation (LT) is an emerging therapy for acute severe alcoholic hepatitis (AH); in fact, recent data show that alcoholic liver disease is the predominant driver of cirrhosis‐related mortality among U.S. adults aged 25 to 34 . Because multiple small studies have demonstrated that “highly selected” patients with AH have 1‐year and 3‐year survival comparable with those with chronic liver disease (CLD) in receipt of LT, there is increasing momentum to waive the usual expectation of demonstrated alcohol abstinence before transplantation …”

Corticosteroid therapy in drug‐induced liver injury: Pros and cons

“…So far, corticosteroids were considered a convincingly effective therapeutic intervention for patients with autoimmune hepatitis (AIH) . If there are no contraindications, corticosteroids should also be used in patients with severe alcoholic hepatitis (AH) . Since most studies indicated that the administration of corticosteroids was beneficial to only a few severe AH patients, early recognition of the non‐responders using the Lille score is important to limit unnecessary exposure …”

A Call to Standardize Definitions, Data Collection, and Outcome Assessment to Improve Care in Alcohol‐Related Liver Disease

“…Alcohol‐related liver disease (ALD) is a leading cause of liver failure, is increasing in prevalence, and is a leading cause of mortality . ALD occurs in the setting of underlying alcohol use disorder (AUD) and broadly encompasses a pathological and clinical spectrum ranging from asymptomatic steatosis to acute alcohol‐related hepatitis (AH) to decompensated cirrhosis with or without hepatocellular carcinoma . Current medical interventions are of limited efficacy and focus on the treatment of AH.…”