When a liver transplant recipient goes back to alcohol abuse: Should we be more selective?

Abstract

Alcoholic liver disease (ALD) is one of the most common indications for liver transplantation (LT). However, it has always remained as a complicated topic from both medical and ethical grounds, as it is seen for many a "self-inflicted disease". Over the years, the survival rate of transplanted patients has significantly improved. The allocation system and the inclusion criteria for LT has also undergone some modifications. Early LT for acute alcoholic hepatitis has been subject to recent clinical studies with encouraging results in highly selected patients. We have learned from studies the importance of a multidisciplinary evaluation of candidates for LT. Complete abstinence should be attempted to overcome addiction issues and to allow spontaneous liver recovery. Risk factors for relapse include the presence of anxiety or depressive disorder, short duration of sobriety pre-LT and lack of social support. The identification of risk factors and the strengthen of social support system may decrease relapse among these patients. Family counseling of candidates is highly encouraged to prevent relapse to alcohol. Relapse has been associated with different histopathological changes, graft damage, graft loss and even decrease in survival among some studies. Therefore, each patient should be carefully selected and priority is to continue to lean on patients with high probability of success. The ethical issue remains as to the patient returning to drinking after the LT, hindering the way for other patients who could have received the same organ.

Rede social significativa no processo de adoecimento de pessoas com cirrose hepática alcoólica: uma revisão integrativa.

“…Os estudos remetem à família (imediata/nuclear e extensa) como principal referência encontrada e a reforçam como modelo ideal para o apoio e suporte social, (Altamirano et al, 2012;Heyes et al, 2016;Leon, Varon & Surani, 2016;McCallum & Masterton, 2006;Rivera, Jowsey, Alsina & Torres, 2012;Salinas & Tovar, 2007;Satapathy et al, 2015;Telles-Correia &Mega, 2015;Telles-Correia, 2011). Dentre os familiares, a existência de um cônjuge/parceiro foi destacada e qualificada como salutar, sendo esta pessoa nomeada como "pessoa de apoio" (Bramstedt & Jabbour, 2006;Heyes et al, 2016;Kotlyar, Burke, Campbell & Weinrieb, 2008;McCallum & Masterton, 2006;Pfitzmann et al, 2007).…”

“…Um dos estudos elencou a equipe de transplante como parte da rede, particularmente em termos de experiência, orientação e assistência no manejo da ansiedade pré-cirurgia (Heyes, Schofield, Gribble, Day & Haber, 2016). Dois estudos (Leon, Varon & Surani, 2016; Telles-Correia, 2011) mencionaram as instituições Rede social significativa no pRocesso de adoecimento de pessoas com ciRRose hepática alcoólica: uma Revisão integRativa para tratamento da dependência e grupos terapêuticos e de assistência domiciliar, caracterizando-os como possibilidade de recomendação e encaminhamento.…”

Wahrnehmung des Verteilungssystems in der Lebertransplantation aus dem Blickwinkel unterschiedlicher Interessengruppen

“…Die Lebertransplantation aufgrund alkoholbedingter Leberzirrhose ist in der Gesellschaft durch das vermeintlich selbstverschuldete Verhalten der Patienten negativ belegt, obwohl die Alkoholabhängigkeit als Krankheit anerkannt ist [14][15][16]. Diese gesellschaftliche Ablehnung senkt womöglich sogar die Spendebereitschaft [15,17].…”

“…Ein Rückfall kann zwar nicht ausgeschlossen werden, es wurde jedoch gezeigt, dass das Risiko wiederholten Alkoholkonsums höher ist, wenn eine geringere als die 6-monatige Abstinenzphase eingehalten wurde [25]. Des Weiteren wurde gezeigt, dass ein erneuter schädlicher Gebrauch von Alkohol das (längerfristige) Überleben der Patienten nach Transplantation reduziert [25][26][27][28] und alkoholinduzierte Transplantatschäden, ein reduziertes Transplantatüberleben und letztendlich Transplantatverlust dokumentiert [14,29]. Weitere Studien sind notwendig, um die Auswirkungen genauer zu untersuchen.…”

Alcoholic Hepatitis and Liver Transplantation

“…We think that LT indication without the 6-month rule should also be extended to patients with progressive end-stage liver disease (ESLD) who come to the transplant team for the first time and who do not improve after a 3-month abstinence period. In 2014, an Italian position statement (6) suggested proposals to ensure the right balance between ethics and clinical success (9)(10)(11)(12). The proposals in relation to the complex population of ALD patients are as follows: at an alcohol rehabilitation center for some time must ensure 6 months of abstention.…”