Early Liver Transplantation for Severe Alcoholic Hepatitis in the United States—A Single-Center Experience

Abstract

Early liver transplantation (LT) in European centers reportedly improved survival in patients with severe alcoholic hepatitis (AH) not responding to medical therapy. Our aim was to determine if a strategy of early LT for severe AH could be applied successfully in the United States. We reviewed 111 patients with severe AH at our center from January 2012 to January 2015. The primary end point was mortality at 6 months or early LT, with a secondary end point of alcohol relapse after LT. Survival was compared between those receiving early LT and matched patients who did not. Using a process similar to the European trial, 94 patients with severe AH not responding to medical therapy were evaluated for early LT. Overall, 9 (9.6%) candidates with favorable psychosocial profiles underwent early LT, comprising 3% of all adult LT during the study period. The 6-month survival rate was higher among those receiving early LT compared with matched controls (89% vs. 11%, p<0.001). Eight recipients are alive at a median of 735 days with 1 alcohol relapse. Early LT for severe AH can achieve excellent clinical outcomes with low impact on the donor pool and low rates of alcohol relapse in highly selected patients in the United States.

Treatment of Alcohol Use Disorder in Patients with Alcoholic Liver Disease

“…One-year relapse rates range from 67 to 81%(69) in patients with alcoholic liver disease therefore, effective, ongoing rehabilitation for alcohol addiction is necessary to achieve sustained abstinence(70). Of note, liver transplantation without the 6-month abstinence requirement has been used to treat patients with severe, acute alcoholic hepatitis who fail to respond to steroid therapy(71, 72). Liver transplantation in this population results in long-term survival benefits with recidivism to drinking at rates comparable or below those liver transplant patients who were required to have 6 months abstinence.…”

Diagnosis and Treatment of Alcoholic Hepatitis: A Systematic Review

“…Compared to 85 severe AH patients not responding to corticosteroids and ineligible for early LT, patients receiving salvage LT had better six months survival (89 vs. 11%, P<0.001). (Im et al, 2016) Benefit of liver transplantation was also shown in a population-based study using the United Network of Organ Sharing database in the US. The study showed that the outcomes of AH patients are similar to transplant recipients for alcoholic cirrhosis.…”

“…(Hasanin et al, 2015) Recidivism after liver transplantation for AH in all these four studies was similar to recidivism after transplantation for alcoholic cirrhosis. (Mathurin et al, 2011a, Singal et al, 2012a, Hasanin et al, 2015, Im et al, 2016) Common barriers to liver transplantation in AH include socio-cultural factors, public opinion that alcohol is in itself a self- inflicted disease, and shortage of donor organs. (Hasanin et al, 2015) However, if used for select severe AH patients, this approach would not consume more than 1–3% of the liver donor pool.…”

“…(Hasanin et al, 2015) However, if used for select severe AH patients, this approach would not consume more than 1–3% of the liver donor pool. (Hasanin et al, 2015, Mathurin et al, 2011a, Im et al, 2016) Liver transplantation should be considered for select AH patients as salvage therapy as this condition affects young and middle-aged individuals (Figure 2). …”

Liver Transplantation for Alcoholic Liver Disease

“…These data have been confirmed in a similar, albeit single-center, prospective evaluation of rescue LT in severe AH carried out in New York. 44 In summary, these pilot studies, along with retrospective analysis of LT in patients found to have AH, 45,46 support future evaluation of LT in a carefully selected subgroup of patients with severe AH failing to respond to medical therapy, despite the fact that early LT in such patients contravenes the 6-month abstinence rule. Future studies should clarify the methods of selection for LT, maintenance of addiction health both before and after LT, in addition to patient and graft survivals.…”