Spotlight on early transplants for alcoholic liver disease

Two studies showed that providing liver transplants to patients who hadn't abstained from alcohol for six months didn't reduce survival rates, while another found that relatively few patients with severe alcoholic hepatitis experience spontaneous remission.

Several recent studies looked at early liver transplants for alcoholic liver disease (ALD), that is, those occurring after less than six months of abstinence by the transplant recipient.

Patients with ALD who underwent transplant after less than 180 days of abstinence had similar outcomes as those who waited the standard six months, according to a study published by JAMA Surgery on Aug. 11. It included 163 patients with ALD, 88 undergoing early transplant and 75 who got standard transplants. The recipients of early transplant were younger (median age, 49.7 vs. 54.6 years) and had a higher median Model for End-stage Liver Disease (MELD) score at listing (35.0 vs. 20.0), but the groups had similar rates of one-year survival (94.1% vs. 95.9%), allograft survival (92.7% vs. 90.5%), relapse-free survival (80.4% vs. 83.5%), and hazardous relapse-free survival (85.8% vs. 89.6%). The results suggest that patients with ALD should not be excluded from transplant solely on the basis of six months of abstinence, the authors said. “As a field, transplantation needs to shift its focus from adherence to this arbitrary time frame to identification of factors associated with poor posttransplant outcomes, posttransplant interventions that minimize relapse, and strategies that treat relapse when it occurs,” they wrote. Such factors may include psychiatric comorbidities, social support, and age, among others, the authors noted.

An accompanying editorial raised some concerns about early transplantation, including “lack of time to educate the patient/family and evaluate their compliance and a lack of addiction specialists in many centers,” as well as the risk that this practice may increase disparities. “The urgency in wait-listing and its subjective nature can further exacerbate inequity in organ transplant,” the commentary authors wrote, noting that 90% of the patients who underwent transplant in this study were White.

A prospective pilot program designed “to challenge the paradigm” of six months of abstinence found similar success with early transplantation, according to results published by Gastroenterology on Aug. 6. The pilot included initial in-depth examination of patients' alcohol use, social support, and psychiatric comorbidity, as well as pre- and post-transplant addiction treatment. Of 703 referrals to the program, 101 patients were listed for transplant and 44 got transplants. Their survival rates were similar to those of a control group of 111 patients receiving transplants after more than six months of abstinence (P=0.07). Three pilot program patients returned to alcohol use during the average follow-up period of 339 days. In a multivariate analysis, younger age and lower MELD score were associated with an increased likelihood of alcohol use after transplant. The study authors expressed concern that patients who were married or had higher incomes were more likely to be approved for early transplant and that 84% of the patients they assessed were White. “The question remains as to what structural inequities might be barring racialized and marginalized populations from accessing a referral for transplant evaluation in the first place, regardless of their indications for transplant,” they wrote.

Finally, a study published by Hepatology on Aug. 13 looked at patients with severe alcohol-related hepatitis who were denied early transplant. It included 144 patients, 49 who underwent liver transplant and 95 who did not. It found that 23.6% of the patients who didn't get a transplant experienced spontaneous remission; predictive factors included younger age, lower index international normalized ratio, and lower peak MELD. Rates of one- and three-year survival were higher in patients who received transplants than in those who didn't: 89.7% and 85.2% versus 37.1% and 24.9%, respectively. Patients who spontaneously recovered had worse survival than those who received a transplant. There was no difference in alcohol use during follow-up between transplanted and nontransplanted patients, and transplant was the only factor associated with survival. Most of the patients who recovered without transplant did so quickly, before they could be placed on the transplant list, the authors noted. The results alleviate concerns that liver transplants might be provided to patients who would recover on their own, “the stated justification for the 6-month interval of abstinence, required in earlier iterations of criteria for transplantation,” they wrote.