Patients' Perspectives on Early Liver Transplantation in Alcohol‐Related Liver Disease

Abstract

Liver transplant programs in Canada require a period of 6 months of abstinence from alcohol before considering a patient with liver disease secondary to alcohol for transplantation. Although some studies have demonstrated good outcomes following a transplant in carefully selected patients before the 6‐month abstinence period has been met, there have been arguments against this, including the claim that the public has a general negative perception of those with alcohol dependence. We performed a multicenter cross‐sectional survey to determine the perception of people in British Columbia, Canada, toward liver transplantation in patients with liver disease due to alcohol who have not demonstrated the capacity to remain abstinent from alcohol for 6 months. A total of 304 patient questionnaires were completed, and 83.1% agreed with a period of abstinence of 6 months. In those patients who were unlikely to survive 6 months without a transplant, 34.1% of respondents agreed with, 44.1% did not agree with, and 21.4% were neutral about, early transplantation; 42.8% would have less trust in the process of transplantation if a period of abstinence was not maintained, but relaxing the requirement for an abstinence period would not have an impact on the majority's decision to donate organs. Only 30.5% would support abandoning the abstinence criteria. Conclusion: Among patients followed at general gastroenterology, medicine, or transplant clinics, there is a willingness to relax the criteria in selected patients unlikely to survive without a transplant, although a general consensus remains in support of the existing 6‐month alcohol abstinence rule. A larger scale survey of all provinces in Canada would be required to assess support for such a change in policy.

Assessment of Canadian policies regarding liver transplant candidacy of people who use alcohol, tobacco, cannabis, and opiates

“…The concept of a specific period of abstinence continues to be debated (17,18) and remains controversial, with potential legal implications (19). A survey of patients in British Columbia showed that 43% would be less trusting of the transplantation process if a period of abstinence was not maintained, and only 30.5% would support eliminating a specific period of abstinence altogether (20).…”

Liver Transplantation in Alcohol-related Liver Disease and Alcohol-related Hepatitis

“…In Canada, all transplant centers require 6-months of abstinence before listing patients with ARLD and early LT is still contraindicated in patients with severe AH (101). However, there is a desire to relax the criteria in selected patients who are unlikely to survive without transplantation, such as those with severe AH who do not respond to steroids (101,102). The Ontario ARLD Pilot Program, which was launched in 2018 to challenge the "6-month abstinence rule" (33) observed no significant differences in survival between patients transplanted through the program or after more than 6 months of abstinence and 6.8% of patients returned to alcohol use an average of 260 days after transplantation.…”

Debate on Selection Criteria for Liver Transplantation for Alcoholic Hepatitis: Tighten or Loosen?

“…( 1 ) Although the use of donated livers for those with ALD is still not strongly supported by the public, a review of the United Kingdom Organ Donor Register shows no clear evidence that this lack of support translates into loss of donors. ( 2,3 ) Return to a damaging pattern of alcohol use is associated with a worse outcome, but graft loss from disease recurrence (that is, a return to alcohol) is low and less than that seen in many other indications for LT. ( 4,5 ) Thus, the debate is not about the ethics of access to LT of those with a self‐inflicted condition, but whether expanding the indication is in line with the best available evidence.…”