Selective use of liver transplantation for severe alcohol-associated hepatitis

ABSTRACT

Introduction: Severe alcohol-associated hepatitis (sAH) portends high morbidity and mortality and there are no effective therapies for those ineligible or unresponsive to corticosteroids. Early liver transplantation (LT) defined as transplantation without a mandated period of sobriety, for sAH, is being increasingly considered as a rescue therapy.

Areas covered: PubMed and manual searches were combined and last performed on 28 October 2019. Key search terms were ‘alcoholic hepatitis’, ‘abstinence’, ‘alcohol relapse’, and ‘liver transplantation’. Terms were combined within each database. General reviews and references from published trials were also used.

Expert opinion: Early LT is indicated in highly selected patients with sAH. While long-term data are sparse, 1 and 3-year survival post-transplantation are excellent and comparable to other liver diseases. Alcohol relapse is uncommon but approaches 10-25% at 3 years and if use is heavy and/or sustained leads to reduced survival. Thus, for continued application of transplantation for this indication, there is a need to further refine selection criteria and to optimize management of alcohol use disorder (AUD) in the transplant setting. Integral to advancing these objectives is the elimination of societal stigmatization and an acknowledgment that AUD is a medical condition that requires long-term management.

KEYWORDS:

• Alcohol-associated liver disease
• alcoholic cirrhosis
• alcoholic Hepatitis
• alcohol Relapse
• alcohol Use Disorder
• six-month rule

Article highlights

• Severe alcohol-associated hepatitis (sAH) is an acute presentation of alcohol-related liver disease and if ineligible or refractory to corticosteroids is associated with high morbidity and mortality without liver transplantation.

• Early transplantation for sAH using stringent selection criteria achieves survival rates as high as 94% at 1 year.

• The majority of patients transplanted for sAH are abstinent post-transplantation but approximately one-third of patients relapse to alcohol use and 11% have harmful patterns of alcohol use.

• Selection of patients at low risk for harmful alcohol use after transplantation is key. The SALT score can identify those at low risk of harmful alcohol use after transplantation but has poor positive predictive value, and thus should not be used to exclude patients from consideration of transplantation.

• Young age and multiple failed rehabilitation attempts are most consistently associated with alcohol relapse post-transplantation. Lack of insight, while difficult to measure, also appears important.

• Alcohol use disorder is a medical condition that requires a combination of psychotherapy and pharmacotherapy in a multidisciplinary setting, both pre- and post-liver transplantation.

Declaration of interest

N Terrault has received institutional grant support from Gilead Sciences and consulting fees from EXIGO Management Consultants.

The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.