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Abstract
PURPOSE The aim of this paper is to summarize the allocation challenges facing the field of liver transplantation while providing examples of the expansion of indications for the procedure. METHODS UNOS allocation policy was reviewed as well as the recent literature describing expanded criteria for recipient candidate selection. RESULTS Liver allocation policy changes for deceased-donor organs remain gridlocked in legal and bureaucratic red tape. Meanwhile, the indications for liver transplantation are being expanded to include acute alcoholic hepatitis, intrahepatic cholangiocarcinoma, and colorectal metastasis, previously viewed as absolute contraindications, but under strict selection criteria. CONCLUSIONS Attempting to meet the demand for livers, transplant centers are increasingly turning to living donor liver transplantation, protocols such as HCV-positive to HCV-negative transplants, and machine perfusion of marginal organs.
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Shroff H, Lemmer A, Maddur H. PRO: Patients With Alcoholic Hepatitis Should Be Considered for Liver Transplantation. Clin Liver Dis (Hoboken) 2020; 16:178-181. [PMID: 33318783 PMCID: PMC7727854 DOI: 10.1002/cld.942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 01/25/2020] [Indexed: 02/04/2023] Open
Affiliation(s)
- Hersh Shroff
- Division of Gastroenterology and HepatologyDepartment of MedicineNorthwestern UniversityChicagoIL
| | - Alexander Lemmer
- Division of Gastroenterology and HepatologyDepartment of MedicineNorthwestern UniversityChicagoIL
| | - Haripriya Maddur
- Division of Gastroenterology and HepatologyDepartment of MedicineNorthwestern UniversityChicagoIL
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53
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Patel P, Wang J, Pillai A. CON: Liver Transplant Should Not Be Performed in Patients With Acute Alcoholic Hepatitis. Clin Liver Dis (Hoboken) 2020; 16:182-185. [PMID: 33318784 PMCID: PMC7727858 DOI: 10.1002/cld.937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 01/25/2020] [Indexed: 02/04/2023] Open
Affiliation(s)
- Parita Patel
- Section of Gastroenterology, Hepatology, and NutritionUniversity of Chicago Medical CenterChicagoIL
| | - Jennifer Wang
- Section of Gastroenterology, Hepatology, and NutritionUniversity of Chicago Medical CenterChicagoIL
| | - Anjana Pillai
- Section of Gastroenterology, Hepatology, and NutritionUniversity of Chicago Medical CenterChicagoIL
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Syed A, Sadler MD, Borman MA, Burak KW, Congly SE. Assessment of Canadian policies regarding liver transplant candidacy of people who use alcohol, tobacco, cannabis, and opiates. CANADIAN LIVER JOURNAL 2020; 3:372-380. [PMID: 35990508 PMCID: PMC9202737 DOI: 10.3138/canlivj.2020-0005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 03/18/2020] [Indexed: 07/29/2023]
Abstract
BACKGROUND When last assessed in 2013, all Canadian liver transplant programs required 6 months of abstinence from alcohol. New studies have questioned the validity of this policy. Moreover, with recreational cannabis now legal in Canada, more transplant candidates may use cannabis. Given these changes, our objective was to obtain an understanding of current Canadian practices regarding liver transplantation and candidates with addiction or alcohol, tobacco, cannabis, or opiate use. METHODS Electronic surveys were distributed to the medical directors of all seven adult liver transplant programs in Canada. Questions were based on either a Likert-scale ranking or free response. The complete data set was aggregated to provide a national perspective on this topic and ensure each individual program remained anonymous. RESULTS All seven programs responded to the survey. Of these programs, 43% always require 6-month abstinence from alcohol, 29% usually require it, and 14% sometimes require it. Formal alcohol rehabilitation is mandatory in two programs. The majority (57%) of programs never or rarely consider transplant for patients with acute alcoholic hepatitis; 29% require smoking cessation before consideration for transplant; and 71% felt that cannabis use is rarely or never a contraindication to liver transplantation. CONCLUSIONS Significantly more Canadian programs now perform liver transplant for patients who have less than 6 months abstinence from alcohol, and alcoholic hepatitis is no longer an absolute contraindication in Canada. Policies on smoking and opiates are quite variable. Further study and discussion are critical for development of national policies to obtain equitable access to liver transplant for all.
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Affiliation(s)
- Ahsan Syed
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matthew D Sadler
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Meredith A Borman
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kelly W Burak
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Stephen E Congly
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute of Public Health, University of Calgary, Calgary, Alberta, Canada
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Abstract
INTRODUCTION Liver transplantation is a life-changing event for patients and survival following transplantation has improved significantly since the first transplantation in 1967. Following liver transplantation, patients face a unique set of healthcare management decisions including transplantation-specific complications, recurrence of primary liver disease, as well as metabolic and malignancy concerns related to immunosuppression. As more patients with liver disease receive transplantation and live longer, understanding and managing these patients will require not only transplant specialist but also local subspecialist and primary care physicians. AREAS COVERED This review covers common issues related to the management of patients following liver transplantation including immunosuppression, liver allograft dysfunction, metabolic complications, as well as routine health maintenance such as immunizations and cancer screening. EXPERT OPINION Optimizing medical care for patients following liver transplant will benefit from ensuring all providers, not just transplant specialist, have a basic understanding of the common issues encountered in the post-transplant patient. This review provides an overview of common healthcare concerns and management options for patients following liver transplantation.
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Affiliation(s)
- Nicholas Hoppmann
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham , Birmingham, Alabama, USA
| | - Omar Massoud
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham , Birmingham, Alabama, USA
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56
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Winder GS, Shenoy A, Dew MA, DiMartini AF. Alcohol and other substance use after liver transplant. Best Pract Res Clin Gastroenterol 2020; 46-47:101685. [PMID: 33158473 DOI: 10.1016/j.bpg.2020.101685] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 08/31/2020] [Indexed: 01/31/2023]
Abstract
In this article we tackle the controversial subject of alcohol and other substance use following liver transplantation (LT). Most of the literature on and importance of this topic pertains not to recreational use of alcohol or substances but to patients who have alcohol or substance use disorders (AUDs/SUDs). To understand these behaviors after such a lifesaving and resource-intensive procedure as LT necessitates an understanding of these disorders as chronic medical diseases. It also requires an awareness that management of these disorders begins before transplant, so we will briefly touch on considerations to prepare patients for the transplantation. Additionally, we review not only the rates of alcohol and substance use post-LT but strategies clinicians could adopt to identify and manage these events post-LT. Thus, we will summarize approaches for monitoring use and a range of therapeutic treatment options, including pharmacotherapy, to employ once use is discovered. While clinical gastroenterologists may be the primary clinicians responsible for the care of LT recipients, we emphasize a multidisciplinary team approach which, especially for the behavioral health components of the treatment, is likely to be the most successful. This article concludes with a summary of recommendations for clinicians working with these patients and possible future directions for both clinical care and research. While the bulk of the literature is on LT in the context of AUD, we review the smaller body of literature available on non-alcohol substance use.
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Affiliation(s)
- Gerald Scott Winder
- Departments of Psychiatry and Surgery, University of Michigan, Ann Arbor, MI, 48109, USA.
| | - Akhil Shenoy
- Department of Psychiatry, Columbia University Medical Center, 622 West 168th Street, PH14-105, New York, NY, 10032, USA.
| | - Mary Amanda Dew
- Departments of Psychiatry, Psychology, Epidemiology, Nursing, Biostatistics and Clinical and Translational Science, University of Pittsburgh, Pittsburgh, PA, 15213, USA.
| | - Andrea F DiMartini
- Departments of Psychiatry, Surgery and Clinical and Translational Science, University of Pittsburgh, Pittsburgh, PA, 15213, USA.
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57
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Satapathy SK, Thornburgh C, Heda R, Jiang Y, Kedia SK, Nair SP, Eason JD, Maluf D. Predicting harmful alcohol relapse after liver transplant: The HALT score. Clin Transplant 2020; 34:e14003. [PMID: 32506677 DOI: 10.1111/ctr.14003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 05/18/2020] [Accepted: 05/29/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Alcohol-associated liver disease (AALD) is a rapidly growing indication for liver transplantation (LT). We aimed to examine various clinical, demographic, and behavioral factors to predict post-LT alcohol relapse and graft survival. METHODS Retrospective analysis was performed on 241 LT recipients with AALD as either a primary or secondary indication for LT (2006-2015). RESULTS Patients with <6 months of alcohol abstinence had significantly increased cumulative incidence for alcohol relapse compared to those with >6 months of abstinence (P = .0041, Log-Rank). We identified four variables to predict harmful alcohol relapse post-LT: age at LT, non-alcohol-related criminal history, pre-LT abstinence period (Ref >6 months of alcohol abstinence), and drinks per day (Ref <10 drinks/day). Area under the curve (AUC) for the final model was 0.79 (95% CI: 0.68-0.91). Our multivariable model was evaluated with internal cross-validation; random sampling of the study subjects 100 times yielded a median C statistic of 75 (±SD 0.097) and accuracy of 91 (±SD 0.026). The four-variable model served to form the harmful alcohol use post-LT (HALT) score. Graft survival remained significantly lower in patients with <6 months of pre-LT alcohol abstinence and those with blue-collar jobs. CONCLUSION The HALT score identifies LT candidates with AALD at significant risk for alcohol relapse, potentially guiding transplant centers for pre- and post-LT interventions for improved patient outcomes.
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Affiliation(s)
- Sanjaya K Satapathy
- Division of Hepatology and Sandra Atlas Bass Center for Liver Diseases & Transplantation, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Manhasset, United States, USA
| | - Cody Thornburgh
- College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Rajiv Heda
- College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Yu Jiang
- School of Public Health, University of Memphis, Memphis, TN, USA
| | - Satish K Kedia
- School of Public Health, University of Memphis, Memphis, TN, USA
| | - Satheesh P Nair
- James D Eason Transplant Institute, Methodist University Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - James D Eason
- James D Eason Transplant Institute, Methodist University Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Daniel Maluf
- James D Eason Transplant Institute, Methodist University Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
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58
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Marot A, Moreno C, Deltenre P. Liver transplant for alcoholic hepatitis: a current clinical overview. Expert Rev Gastroenterol Hepatol 2020; 14:591-600. [PMID: 32511039 DOI: 10.1080/17474124.2020.1775579] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Current management of severe alcoholic hepatitis is based on corticosteroid therapy and abstinence from alcohol. As liver transplantation is lifesaving in alcoholic hepatitis patients at high risk of early death, refractory alcoholic hepatitis has become a new indication for liver transplantation in highly selected non-responders to corticosteroids. AREAS COVERED This review summarizes the conditions under which liver transplantation may be considered, the available data on liver transplantation for refractory alcoholic hepatitis and explores the ethical considerations surrounding the use of liver transplantation in these patients. EXPERT OPINION Selection of candidates should be made according to available scientific results on post-liver transplantation outcomes and the risk of alcohol relapse. Currently, a strict selection process based on a good psychosocial profile, including social stability, no previous treatments for alcohol dependence, no current drug use, and no co-existing severe mental disorder, seems to be the best way to manage these issues. Well-defined selection criteria for candidate selection and accurate tools to predict alcohol relapse after liver transplantation are still needed.
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Affiliation(s)
- Astrid Marot
- Department of Gastroenterology and Hepatology CHU UCL Namur, Université Catholique De Louvain , Yvoir, Belgium
| | - Christophe Moreno
- Department of Gastroenterology Hepatopancreatology, and Digestive Oncology, C.U.B. Hôpital Erasme, Université Libre De Bruxelles , Brussels, Belgium
| | - Pierre Deltenre
- Department of Gastroenterology Hepatopancreatology, and Digestive Oncology, C.U.B. Hôpital Erasme, Université Libre De Bruxelles , Brussels, Belgium.,Department of Gastroenterology and Hepatology, Clinique St Luc , Bouge, Belgium
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59
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Eswaran S, Chan E. Meeting Report: The Dallas Consensus Conference on Liver Transplantation for Alcohol Associated Hepatitis. Liver Transpl 2020; 26:950-951. [PMID: 32232940 DOI: 10.1002/lt.25767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 03/10/2020] [Indexed: 01/13/2023]
Affiliation(s)
- Sheila Eswaran
- Section of Hepatology, Departments of Medicine, Rush University Medical Center, Chicago, IL
| | - Edie Chan
- General Surgery, Rush University Medical Center, Chicago, IL
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60
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Lee BP, Vittinghoff E, Pletcher MJ, Dodge JL, Terrault NA. Medicaid Policy and Liver Transplant for Alcohol-Associated Liver Disease. Hepatology 2020; 72:130-139. [PMID: 31705545 PMCID: PMC7318101 DOI: 10.1002/hep.31027] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 10/22/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIMS In some states, liver transplantation (LT) for alcohol-associated liver disease (ALD) is covered by Medicaid only with documentation of abstinence and/or alcohol rehabilitation. Different Medicaid policies may affect the distribution of LT for ALD, particularly post-2011, as centers have adopted early (i.e., specific abstinence period not required) LT practices. APPROACH AND RESULTS We surveyed Medicaid policies in all states actively performing LT and linked state policies to prospectively collected national registry data on LT recipients from 2002 to 2017 with ALD as the primary listing diagnosis. We categorized Medicaid policies for states as "restrictive" (requiring documentation of a specific abstinence period and/or rehabilitation) versus "unrestrictive" (deferring to center eligibility policies). Difference-of-differences analysis, comparing 2002-2011 versus 2012-2017, evaluated whether restrictive policies were associated with decreased proportion of LTs paid by Medicaid among patients with ALD post-2011. We performed sensitivity analyses to account for any differences by diagnosis of hepatocellular carcinoma, hepatitis C virus, nonalcoholic steatohepatitis, or Medicare insurance. We also performed a sensitivity analysis to account for any difference by prevalence of ALD among restrictive versus unrestrictive states. Of 10,836 LT recipients in 2002-2017, 7,091 were from 24 states in the restrictive group and 3,745 from 14 states in the unrestrictive group. The adjusted proportion (95% confidence interval) of LTs paid by Medicaid among restrictive versus unrestrictive states between 2002 and 2011 was 17.6% (15.4%-19.8%) versus 18.9% (15.4%-22.3%) (P = 0.54) and between 2012 and 2017, 17.2% (14.7%-19.7%) versus 23.2% (19.8%-26.6%) (P = 0.005). In difference-of-differences analysis, restrictive (versus unrestrictive) policies were associated with a 4.7% (0.8%-8.6%) (P = 0.02) absolute lower adjusted proportion of LTs for ALD paid by Medicaid post-2011. CONCLUSIONS Restrictive Medicaid policies are present in most states with active LT centers and are associated with lower proportions of LTs for ALD paid by Medicaid post-2011 compared to states with unrestrictive Medicaid policies. Reevaluation of Medicaid alcohol use policies may be warranted, to align more closely with contemporary center-level practices.
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Affiliation(s)
- Brian P. Lee
- Department of Gastroenterology, University of California, San Francisco, San Francisco, CA
| | - Eric Vittinghoff
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Mark J. Pletcher
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Jennifer L. Dodge
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Norah A. Terrault
- Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles, CA
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61
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Abstract
BACKGROUND Liver transplant candidacy determination can be contentious. When transplantation is declined for reasons perceived as violating fundamental rights or discriminating against a protected class-for example, age, race, religion, nationality-the case may involve a constitutional claim. Judicial review of such cases may result in decisions with sweeping implications for transplant policy. METHODS We reviewed all published court opinions involving liver transplantation in 2 legal databases (Lexis Nexus and WestLaw). We included all cases that involved a denial of liver transplant candidacy in violation of constitutional rights. RESULTS The search returned 1562 cases: 290 involved the denial of insurance coverage for a transplant due to a patient's failure to abstain from drinking, 273 cases involved incarcerated inmates who were denied a liver transplant, 2 involved a constitutional claim for patient requesting a bloodless transplant for religious reasons, and 2 cases arose from age discrimination in transplant criteria. These cases highlight legal pitfalls related to the First Amendment (religious freedom), Eighth Amendment (cruel and unusual punishment), and the Fourteenth Amendment (equal protection and due process). CONCLUSIONS The risk of a constitutional claim highlights concrete steps needed to ensure the equity of transplant policy. These include efforts to standardize transplant candidacy criteria across payers for candidates with alcohol-related liver disease and advanced age. Efforts to constrain emerging liabilities related to the citizenship of transplant candidates and the definition of donor service areas are also discussed.
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Abstract
Although alcohol-associated liver disease has long been a major component of the liver disease landscape, it was overshadowed by chronic hepatitis C until recently. Nevertheless, with the declining incidence of hepatitis C in the wake of highly effective antiviral therapy, attention has shifted to the increasing burden of alcohol-associated liver disease. The incidence of advanced alcohol-associated liver disease, including acute alcoholic hepatitis and alcohol-associated cirrhosis, is rising in parallel with increasing rates of alcohol use disorders. As a result, alcohol-associated liver disease is now one of the most common indications for liver transplantation. Rates of liver transplantation for acute alcoholic hepatitis are rising as well in spite of the sparse guidance regarding candidate selection, counseling, postoperative care, long-term follow-up, and other best practices. To this day, liver transplant for acute alcoholic hepatitis remains a hotly debated clinical controversy.
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63
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Alcohol-related liver disease: Clinical practice guidelines by the Latin American Association for the Study of the Liver (ALEH). Ann Hepatol 2020; 18:518-535. [PMID: 31053546 DOI: 10.1016/j.aohep.2019.04.005] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 03/06/2019] [Indexed: 02/04/2023]
Abstract
Alcohol-related liver disease (ALD) is a major cause of advanced chronic liver disease in Latin-America, although data on prevalence is limited. Public health policies aimed at reducing the alarming prevalence of alcohol use disorder in Latin-America should be implemented. ALD comprises a clinical-pathological spectrum that ranges from steatosis, steatohepatitis to advanced forms such as alcoholic hepatitis (AH), cirrhosis and hepatocellular carcinoma. Besides genetic factors, the amount of alcohol consumption is the most important risk factor for the development of ALD. Continuous consumption of more than 3 standard drinks per day in men and more than 2 drinks per day in women increases the risk of developing liver disease. The pathogenesis of ALD is only partially understood and recent translational studies have identified novel therapeutic targets. Early forms of ALD are often missed and most clinical attention is focused on AH, which is defined as an abrupt onset of jaundice and liver-related complications. In patients with potential confounding factors, a transjugular biopsy is recommended. The standard therapy for AH (i.e. prednisolone) has not evolved in the last decades yet promising new therapies (i.e. G-CSF, N-acetylcysteine) have been recently proposed. In both patients with early and severe ALD, prolonged abstinence is the most efficient therapeutic measure to decrease long-term morbidity and mortality. A multidisciplinary team including alcohol addiction specialists is recommended to manage patients with ALD. Liver transplantation should be considered in the management of patients with end-stage ALD that do not recover despite abstinence. In selected cases, increasing number of centers are proposing early transplantation for patients with severe AH not responding to medical therapy.
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64
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Liver transplantation for alcoholic hepatitis: update. Curr Opin Gastroenterol 2020; 36:157-163. [PMID: 32101986 DOI: 10.1097/mog.0000000000000623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
PURPOSE OF REVIEW Alcoholic liver disease continues to be a major public health concern in the United States and around the world. Alcoholic liver disease remains the third most common indication for liver transplantation in the United States. Mortality has been reported in up to 30-50% of patients with severe alcoholic hepatitis. Liver transplantation can be lifesaving for patients with alcoholic hepatitis. Liver transplantation for alcoholic liver disease was traditionally only considered in patients who have achieved 6 months of abstinence. The majority of patients with severe alcoholic hepatitis who fail medical therapy will not live long enough to meet this requirement. The purpose of this review is to provide an update from the most recent peer reviewed articles regarding early liver transplantation of alcoholic hepatitis. RECENT FINDINGS This review shows that liver transplantation offers the best survival benefit to patients with alcoholic hepatitis. Selection criteria is a key component for a successful transplant. No change in 1-year graft survival between patients who have 6 months sobriety vs. those transplanted prior to 6 months abstinence. Liver transplantation is limited by very narrow selection criteria and limited long-term data. SUMMARY Liver transplantation offers the best survival benefit to patients with alcoholic hepatitis. Selection criteria of patients has evolved and have become more permissive and the period of sobriety has become less important in the evaluation of process. However, long-term outcomes continue to lack in the literature. On the basis of previous studies, patients with longer pretransplant abstinence, disease process insight, older age at the time of transplant, the presence of social support that lives with the patient in the same dwelling place were noted to have lower rates of return to alcohol use after liver transplantation.
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65
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Liver transplantation in patients with alcohol-related liver disease: current status and future directions. Lancet Gastroenterol Hepatol 2020; 5:507-514. [DOI: 10.1016/s2468-1253(19)30451-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 12/15/2019] [Accepted: 12/19/2019] [Indexed: 12/19/2022]
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66
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Shipley LC, Singal AK. Liver transplantation for alcoholic hepatitis. Transl Gastroenterol Hepatol 2020; 5:26. [PMID: 32258530 DOI: 10.21037/tgh.2019.11.17] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 11/05/2019] [Indexed: 12/12/2022] Open
Abstract
Alcoholic hepatitis (AH) is associated with a high short-term mortality. Currently, most transplant centers require minimum six months of abstinence from alcohol use before considering liver transplant for patients with end stage liver disease. Some recent data are emerging on the benefits and safety of early liver transplantation for patients with severe AH, a population who cannot meet the minimum six months sobriety. This article reviews the current status, benefits, challenges, barriers, and future prospects on early liver transplantation in patients with severe, acute AH.
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Affiliation(s)
- Lindsey C Shipley
- Division of Internal Medicine, University of Alabama, Birmingham, AL, USA
| | - Ashwani K Singal
- Division of Gastroenterology and Hepatology, University of South Dakota, Avera McKennan University Health Center and Transplant Institute, Sioux Falls, SD, USA
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67
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Mitra S, De A, Chowdhury A. Epidemiology of non-alcoholic and alcoholic fatty liver diseases. Transl Gastroenterol Hepatol 2020; 5:16. [PMID: 32258520 DOI: 10.21037/tgh.2019.09.08] [Citation(s) in RCA: 260] [Impact Index Per Article: 65.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 09/05/2019] [Indexed: 12/12/2022] Open
Abstract
Liver diseases are fast emerging as global health priorities. Fatty liver is described in the setting of non-alcoholic fatty liver disease (NAFLD) as well as alcoholic liver disease (ALD), the pathogenesis of excess fat being different in the two conditions while both are important components of the changing face of burden of liver diseases worldwide. They are intimately associated with a globalized economy and an increasingly homogenous socio- cultural order with a westernized lifestyle. The accompanying adoption of a progressively sedentary life, consumption of diet dense in calories facilitate development of NAFLD while a spiraling upward trend in alcohol use along with earlier age of drinking as well as increased amount of per capita alcohol consumption increases the prevalence of ALD globally. Adverse health outcomes in NAFLD as well as ALD are caused not only by progressive liver fibrosis that is the most significant factor for liver related and all-cause mortality in both but also by non-liver (cardiovascular, cancer, accidents, neurological) clinical outcomes that calls for a multidisciplinary and social approach to these conditions. We present here an outline of facets of epidemiology of both NAFLD as well as ALD along with its' public health implications. A broad-based integrated approach that incorporates social, behavioral as well as biological targets need to be undertaken at a health system level in a planned manner for these evolving liver health priorities that disproportionately challenges the low- and middle-income countries of Asia, South America and Africa.
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Affiliation(s)
- Souveek Mitra
- Indian Institute of Liver and Digestive Sciences Sitala (east), Jagadishpur, Sonarpur, Kolkata, India
| | - Arka De
- Department of Hepatology, Post Graduate Institute of Medical Education and Research Chandigarh, Chandigarh, India
| | - Abhijit Chowdhury
- Indian Institute of Liver and Digestive Sciences Sitala (east), Jagadishpur, Sonarpur, Kolkata, India.,Department of Hepatology School of Digestive and Liver Diseases Institute of Post Graduate Medical Education & Research Kolkata, India
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68
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Addolorato G, Abenavoli L, Dallio M, Federico A, Germani G, Gitto S, Leandro G, Loguercio C, Marra F, Stasi E. Alcohol associated liver disease 2020: A clinical practice guideline by the Italian Association for the Study of the Liver (AISF). Dig Liver Dis 2020; 52:374-391. [PMID: 32001151 DOI: 10.1016/j.dld.2019.12.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 11/06/2019] [Accepted: 12/17/2019] [Indexed: 12/11/2022]
Abstract
Alcohol use disorder which includes alcohol abuse and dependence represents one of the leading risk factors for premature mortality in Europe and it is responsible of over 200 conditions, including neuropsychiatric disorders, chronic diseases, cancers and accidents leading to permanent disability. Alcohol use disorder represents the most common cause of liver damage in the Western world, with a wide spectrum of diseases ranging from steatosis, steatohepatitis, fibrosis, cirrhosis and cancer. The present clinical practice guidelines by the Italian Association for the Study of the Liver (AISF) are focused on the current knowledge about epidemiology, pathophysiology, clinical features, diagnosis and treatment of alcohol associated liver disease, aiming to provide practical recommendations on the management of this complex pathological condition.
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Affiliation(s)
- Giovanni Addolorato
- Alcohol Use Disorder Unit, Division of Internal Medicine, Gastroenterology and Hepatology Unit, Catholic University of Rome, A. Gemelli Hospital, Rome, Italy; "Agostino Gemelli" Hospital Foundation - IRCCS, Rome, Italy.
| | - Ludovico Abenavoli
- Department of Health Sciences, University Magna Graecia, Catanzaro, Italy
| | - Marcello Dallio
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Alessandro Federico
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Giacomo Germani
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy
| | - Stefano Gitto
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| | - Gioacchino Leandro
- National Institute of Gastroenterology "S. De Bellis" Research Hospital, Castellana Grotte, Italy
| | - Carmelina Loguercio
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Fabio Marra
- Department of Experimental and Clinical Medicine, University of Florence, Italy; Research Center Denothe, University of Florence, Italy
| | - Elisa Stasi
- National Institute of Gastroenterology "S. De Bellis" Research Hospital, Castellana Grotte, Italy
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69
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Ayyala-Somayajula D, Han H, Terrault NA. Selective use of liver transplantation for severe alcohol-associated hepatitis. Expert Rev Gastroenterol Hepatol 2020; 14:175-184. [PMID: 32077333 DOI: 10.1080/17474124.2020.1733414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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.
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Affiliation(s)
| | - Hyosun Han
- Department of Medicine, USC Keck School of Medicine, Los Angeles, CA, USA.,Division of Gastrointestinal and Liver Diseases, USC Keck School of Medicine, Los Angeles, CA, USA
| | - Norah A Terrault
- Department of Medicine, USC Keck School of Medicine, Los Angeles, CA, USA.,Division of Gastrointestinal and Liver Diseases, USC Keck School of Medicine, Los Angeles, CA, USA
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70
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Kitajima T, Moonka D, Yeddula S, Rizzari M, Collins K, Yoshida A, Abouljoud MS, Nagai S. Liver transplant waitlist outcomes in alcoholic hepatitis compared with other liver diseases: An analysis of UNOS registry. Clin Transplant 2020; 34:e13837. [PMID: 32073688 DOI: 10.1111/ctr.13837] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 01/30/2020] [Accepted: 02/16/2020] [Indexed: 12/19/2022]
Abstract
There is growing interest in performing liver transplantation (LT) in patients with alcoholic hepatitis (AH) without a mandated abstinence period. The aim of this study is to investigate waitlist outcomes in AH patients compared to those with other liver diseases. Using data from the UNOS registry, adult patients listed for LT between 2009 and 2018 were evaluated. Waitlist outcomes were compared among liver diseases. A total of 64 646 patients were eligible, including 286 with AH, 16 871 with alcoholic cirrhosis (AC), 13 730 with hepatitis C (HCV), 10 315 with non-alcoholic steatohepatitis (NASH), and 5841 with cholestatic liver disease (CLD). In comparison with AH patients, patients with HCV, NASH, and CLD had a significantly higher risk of waitlist mortality and a lower likelihood of recovery on the waitlist. These trends were more prominent in the waiting-time period of 91-365 days than in shorter periods. In intention-to-treat analysis, positive prognostic effect of LT was significant in AH patients with MELD score ≥35 (HR 0.04, P < .001). AH patients showed lower mortality risk and a higher chance of recovery while on waitlist than other liver diseases, especially when waiting time exceeded 90 days. These results indicate the importance of continuous evaluation of disease progression in AH patients awaiting LT.
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Affiliation(s)
- Toshihiro Kitajima
- Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Dilip Moonka
- Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, MI, USA
| | - Siri Yeddula
- Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Michael Rizzari
- Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Kelly Collins
- Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Atsushi Yoshida
- Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Marwan S Abouljoud
- Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Shunji Nagai
- Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI, USA
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Abstract
Alcoholic hepatitis is the severest clinical presentation of alcoholic liver disease. Lacking an effective pharmacologic treatment, alcoholic hepatitis is associated with a poor prognosis and its recovery relies mostly on abstinence. With alcohol use disorder being universally on the rise, the impact of alcoholic hepatitis on society and health-care costs is expected to increase significantly. Prognostic factors and liver biopsy can help with timely diagnosis, to determine eligibility and response to corticosteroids, and for prognostication and transplant referral. Although recent discoveries in the pathophysiology of alcoholic hepatitis are encouraging and could pave the way for novel treatment modalities, a multidisciplinary approach considering timely identification and treatment of liver-related complications, infectious and metabolic disease, malnutrition, and addiction counseling should be emphasized. Apart from proper selection of candidates, transplant programs should provide adequate post-transplant addiction support in order to make of early liver transplantation for alcoholic hepatitis the ultimate sobering experience in the next decade.
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Affiliation(s)
- Vikrant Rachakonda
- Division of Gastroenterology and Hepatology, Starzl Transplantation Institute, and Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Ramon Bataller
- Division of Gastroenterology and Hepatology, Starzl Transplantation Institute, and Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Andres Duarte-Rojo
- Division of Gastroenterology and Hepatology, Starzl Transplantation Institute, and Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, PA, 15213, USA
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72
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Crabb DW, Im GY, Szabo G, Mellinger JL, Lucey MR. Diagnosis and Treatment of Alcohol-Associated Liver Diseases: 2019 Practice Guidance From the American Association for the Study of Liver Diseases. Hepatology 2020; 71:306-333. [PMID: 31314133 DOI: 10.1002/hep.30866] [Citation(s) in RCA: 415] [Impact Index Per Article: 103.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 05/31/2019] [Indexed: 12/12/2022]
Affiliation(s)
- David W Crabb
- Indiana University School of Medicine, Indianapolis, IN
| | - Gene Y Im
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - Gyongyi Szabo
- University of Massachusetts Medical School, Worcester, MA
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73
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Asrani SK, Trotter J, Lake J, Ahmad A, Bonagura A, Cameron A, DiMartini A, Gonzalez S, Im G, Martin P, Mathurin P, Mellinger J, Rice JP, Shah V, Terrault N, Wall A, Winder S, Klintmalm G. Meeting Report: The Dallas Consensus Conference on Liver Transplantation for Alcohol Associated Hepatitis. Liver Transpl 2020; 26:127-140. [PMID: 31743578 PMCID: PMC8151800 DOI: 10.1002/lt.25681] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 10/29/2019] [Indexed: 12/13/2022]
Abstract
Liver transplantation (LT) for alcohol associated hepatitis (AH) remains controversial. We convened a consensus conference to examine various aspects of LT for AH. The goal was not to unequivocally endorse LT for AH; instead, it was to propose recommendations for programs that perform or plan to perform LT for AH. Criteria were established to determine candidacy for LT in the setting of AH and included the following: (1) AH patients presenting for the first time with decompensated liver disease that are nonresponders to medical therapy without severe medical or psychiatric comorbidities; (2) a fixed period of abstinence prior to transplantation is not required; and (3) assessment with a multidisciplinary psychosocial team, including a social worker and an addiction specialist/mental health professional with addiction and transplantation expertise. Supporting factors included lack of repeated unsuccessful attempts at addiction rehabilitation, lack of other substance use/dependency, acceptance of diagnosis/insight with a commitment of the patient/family to sobriety, and formalized agreement to adhere to total alcohol abstinence and counseling. LT should be avoided in AH patients who are likely to spontaneously recover. Short-term and longterm survival comparable to other indications for LT must be achieved. There should not be further disparity in LT either by indication, geography, or other sociodemographic factors. Treatment of alcohol-use disorders should be incorporated into pre- and post-LT care. The restrictive and focused evaluation process described in the initial LT experience for AH worldwide may not endure as this indication gains wider acceptance at more LT programs. Transparency in the selection process is crucial and requires the collection of objective data to assess outcomes and minimize center variation in listing. Oversight of program adherence is important to harmonize listing practices and outcomes.
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Affiliation(s)
- Sumeet K Asrani
- Baylor University Medical Center, Dallas, Texas,Corresponding author: Sumeet K Asrani MD MSc, Associate Professor of Medicine, Baylor University Medical Center, Dallas Texas, , Tele: 214 820 8500, Fax: 214 820 0993
| | | | - Jack Lake
- University of Minnesota, Minneapolis, Minnesota
| | | | | | | | | | | | | | - Paul Martin
- University of Miami health system, Miami, Florida
| | - Philippe Mathurin
- Service d’Hépato-gastroentérologie, Hôpital Claude Huriez, Lille, France
| | | | | | | | - Norah Terrault
- University of Southern California, Los Angeles, California
| | - Anji Wall
- Baylor University Medical Center, Dallas, Texas
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74
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Testino G, Vignoli T, Patussi V, Scafato E, Caputo F. Management of end-stage alcohol-related liver disease and severe acute alcohol-related hepatitis: position paper of the Italian Society on Alcohol (SIA). Dig Liver Dis 2020; 52:21-32. [PMID: 31757596 DOI: 10.1016/j.dld.2019.09.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 08/28/2019] [Accepted: 09/23/2019] [Indexed: 02/07/2023]
Abstract
Worldwide, the prevalence of alcohol use disorder (AUD) is 20-30% in men and 10-15% in women, and cirrhosis due to alcohol-related liver disease (ALD) is responsible for 0.9% of global deaths and 47.9% of cirrhosis-related deaths. End-stage ALD (ESALD) is the final condition of alcohol-related cirrhosis, and severe acute alcohol-related hepatitis (SAAH) is a distinct clinical syndrome associated with the consumption of large amounts of alcohol. In some cases, ESALD, and SAAH may need liver transplantation (LT). Thus, the management of ESALD and SAAH in patients affected by AUD may be an essential part of the clinical skills for hepatologists. For these reasons, the national board of the Italian Society on Alcohol have reviewed the most recent data on the management of ESALD, SAAH and LT for ALD in patients with AUD, formulating a position paper with related recommendations regarding four issues of specific clinical interest in this field: (a) the management of hepatic encephalopathy in patients with AUD, and LT in patients with ESALD; (b) the management of SAAH; (c) the management of AUD in patients with ESALD and SAAH; (d) special populations: polydrug addicts.
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Affiliation(s)
- Gianni Testino
- Unit of Addiction and Hepatology ASL3 Liguria, San Martino Hospital, Genova, Italy
| | - Teo Vignoli
- Unit of Addiction Treatment, Lugo, Ravenna, Italy
| | | | - Emanuele Scafato
- National Observatory on Alcohol, National Institute of Health, Roma, Italy
| | - Fabio Caputo
- Department of Internal Medicine, SS Annunziata Hospital, Cento, Ferrara, Italy; "G. Fontana" Centre for the Study and Multidisciplinary Treatment of Alcohol Addiction, Department of Medical and Surgical Sciences, University of Bologna, Italy.
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75
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Schlagintweit HE, Lynch MJ, Hendershot CS. A review of behavioral alcohol interventions for transplant candidates and recipients with alcohol-related liver disease. Am J Transplant 2019; 19:2678-2685. [PMID: 31419015 DOI: 10.1111/ajt.15569] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 07/16/2019] [Accepted: 08/06/2019] [Indexed: 01/25/2023]
Abstract
Alcohol-related liver disease (ALD) is a common indication for liver transplantation. Reflecting growing consensus that early transplant (ie, prior to sustained abstinence) can be a viable option for acute alcoholic hepatitis, access to liver transplantation for ALD patients has increased. Prevention of alcohol relapse is critical to pretransplant stabilization and posttransplant survival. Behavioral interventions are a fundamental component of alcohol use disorder treatment, but have rarely been studied in the transplant context. This scoping review summarizes published reports of behavioral and psychosocial alcohol interventions conducted with ALD patients who were liver transplant candidates and/or recipients. A structured review identified 11 eligible reports (3 original research studies, 8 descriptive papers). Intervention characteristics and clinical outcomes were summarized. Interventions varied significantly in orientation, content, delivery format, and timing/duration. Observational findings illustrate the importance of situating alcohol interventions within a multidisciplinary treatment context, and suggest the potential efficacy of cognitive-behavioral and motivational enhancement interventions. However, given extremely limited research evaluating behavioral alcohol interventions among ALD patients, the efficacy of behavioral interventions for pre- and posttransplant alcohol relapse remains to be established.
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Affiliation(s)
- Hera E Schlagintweit
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Marie-Josée Lynch
- Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Christian S Hendershot
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.,Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Psychology, University of Toronto, Toronto, Ontario, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
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76
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Giard JM, Dodge JL, Terrault N. Superior Wait-List Outcomes in Patients with Alcohol-Associated Liver Disease Compared With Other Indications for Liver Transplantation. Liver Transpl 2019; 25:1310-1320. [PMID: 31063642 PMCID: PMC8544021 DOI: 10.1002/lt.25485] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 04/17/2019] [Indexed: 01/18/2023]
Abstract
Alcohol-associated liver disease (ALD) is the most common indication for liver transplantation (LT) in the United States and Europe. A 6-month alcohol abstinence period has been required by many transplant programs prior to listing, which may influence wait-list (WL) outcomes. Therefore, we examined WL events in patients with ALD versus non-ALD with a special interest in whether these outcomes differed by sex. All US adults listed for LT from January 2002 to December 2016 were eligible except status 1 patients, Model for End-Stage Liver Disease exceptions, retransplants and those with acute alcoholic hepatitis. The outcomes of interest were cumulative WL death or being too sick and WL removal for improvement within 2 years of listing. Competing risk regression models were used to evaluate recipient factors associated with the outcomes. Among the 83,348 eligible WL patients, 23% had ALD. Unadjusted cumulative WL removal within 2 years was 19.0% for ALD versus 21.1% for non-ALD (P < 0.001). In fully adjusted models, ALD was associated with a significantly lower risk of WL removal for death or being too sick (subhazard ratio [SHR], 0.84; 95% confidence interval [CI], 0.81-0.87; P < 0.001) and a higher risk of removal for improvement (SHR, 2.91; 95% CI, 2.35-3.61; P < 0.001) versus non-ALD patients. After adjusting for potential confounders, women with ALD had a higher risk of removal for death or being too sick (SHR, 1.09; 95% CI, 1.00-1.08; P < 0.001) and a higher chance for improvement (SHR, 2.91; 95% CI, 2.35-3.61; P < 0.001) than men with ALD. In conclusion, WL candidates with ALD have more favorable WL outcomes than non-ALD patients with a 16% lower risk of removal for deterioration and 191% higher risk of removal for improvement. This result likely reflects the benefits of alcohol abstinence, but it suggests that listing criteria for ALD may be too restrictive, with patients who might derive benefit from LT not being listed.
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Affiliation(s)
- Jeanne-Marie Giard
- University of California San Francisco, San Francisco, CA, United States.,Université de Montréal, Montréal, Québec, Canada
| | - Jennifer L. Dodge
- University of California San Francisco, San Francisco, CA, United States
| | - Norah Terrault
- University of California San Francisco, San Francisco, CA, United States
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77
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Chuncharunee L, Yamashiki N, Thakkinstian A, Sobhonslidsuk A. Alcohol relapse and its predictors after liver transplantation for alcoholic liver disease: a systematic review and meta-analysis. BMC Gastroenterol 2019; 19:150. [PMID: 31438857 PMCID: PMC6704694 DOI: 10.1186/s12876-019-1050-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 07/17/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Alcoholic liver disease (ALD) is the leading cause of liver transplantation (LT). The magnitude and risk factors of post-LT alcohol relapse are not well described. We conducted a meta-analysis to evaluate alcohol relapse rate and its predictors after LT. METHODS Searches of MEDLINE and SCOPUS identified eligible published studies of alcohol relapse after LT published up to 31 March 2018. Alcohol relapse was defined as any alcohol consumption post-LT, and heavy alcohol relapse was defined as a relapse of alcohol consumption that was associated with a significant harm. Data for the proportion of alcohol relapse was pooled using a meta-analysis for pooling proportion. An odds ratio (OR) of the predictor of alcohol relapse was extracted and pooled using meta-analysis for the pooling risk factor. Data were analyzed using a random effect model if heterogeneity was presented; otherwise, a fixed effect model was applied. The study was registered at PROSPERO (CRD42017052659). RESULTS Ninety-two studies with over 8000 cases were recruited for pooling proportion of alcohol relapse. The alcohol relapse rate and heavy alcohol relapse rate after LT during the mean follow-up time of 48.4 ± 24.7 months were 22% (95% confidence interval (CI): 19-25%) and 14% (95%CI: 12-16%). Psychiatric comorbidities (odds ratio (OR) 3.46, 95%CI: 1.87-6.39), pre-transplant abstinence of less than 6 months (OR 2.76, 95%CI: 2.10-3.61), unmarried status (OR 1.84, 95%CI: 1.39-2.43), and smoking (OR 1.72, 95%CI: 1.21-2.46) were associated with alcohol relapse after LT. However, we noticed publication bias of unpublished negative studies and high heterogeneity of results. CONCLUSIONS Post-transplant alcohol relapse occurred in about one-fifth of patients who underwent alcohol-related LT. Psychiatric comorbidities represented the strongest predictor of alcohol relapse. Psychiatric comorbidities monitoring and pre-LT alcohol abstinence for at least 6 months may decrease alcohol relapse after LT.
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Affiliation(s)
- Lancharat Chuncharunee
- Division of Gastroenterology and Hepatology, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama 6 Road, Bangkok, 10400, Thailand
| | | | - Ammarin Thakkinstian
- Section for Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Abhasnee Sobhonslidsuk
- Division of Gastroenterology and Hepatology, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama 6 Road, Bangkok, 10400, Thailand.
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78
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Philips CA, Augustine P, Yerol PK, Rajesh S, Mahadevan P. Severe alcoholic hepatitis: current perspectives. Hepat Med 2019; 11:97-108. [PMID: 31496843 PMCID: PMC6691395 DOI: 10.2147/hmer.s197933] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 07/18/2019] [Indexed: 12/12/2022] Open
Abstract
Severe acute alcoholic hepatitis (AH) is a catastrophic disease in the natural history of alcoholic liver disease with a very high 180-day mortality. It can present as acute on chronic liver failure with worse prognosis in the presence of infections and higher grades of liver disease severity. The clinical scenario involves a patient with a recent history of heavy alcohol consumption within three months of presentation with jaundice and characteristic liver enzyme elevation pattern with coagulopathy, hepatic encephalopathy, variceal bleeding and sepsis that results in extrahepatic organ failures. Several liver disease severities and therapy response indicators are in clinical use. Even though not approved, the only recommended treatment option for patients with severe AH is corticosteroids, which is without long term survival benefit. Novel efficacious treatment options awaiting high-quality multi-center studies include liver transplantation (involves strict selection criteria), growth factor therapy and fecal microbiota transplantation. In this exhaustive review, we discuss the definitions, disease severity, histopathology, and treatment options – past, present, and future, in patients with severe alcoholic hepatitis.
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Affiliation(s)
- Cyriac Abby Philips
- The Liver Unit, Cochin Gastroenterology Group, Ernakulam Medical Centre, Cochin, Kerala, India
| | - Philip Augustine
- Gastroenterology, Cochin Gastroenterology Group, Ernakulam Medical Centre, Cochin, Kerala, India
| | - Praveen Kumar Yerol
- Department of Gastroenterology, Government Medical College and Hospital, Thrissur, Kerala, India
| | - Sasidharan Rajesh
- Interventional Radiology, Hepatobiliary Division, Cochin Gastroenterology Group, Ernakulam Medical Centre, Cochin, Kerala, India
| | - Pushpa Mahadevan
- Clinical Pathology, VPS Lakeshore Hospital, Nettoor, Kerala, India
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79
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Lee BP, Samur S, Dalgic OO, Bethea ED, Lucey MR, Weinberg E, Hsu C, Rinella ME, Im GY, Fix OK, Therapondos G, Han H, Victor DW, Voigt MD, Eswaran S, Terrault NA, Chhatwal J. Model to Calculate Harms and Benefits of Early vs Delayed Liver Transplantation for Patients With Alcohol-Associated Hepatitis. Gastroenterology 2019; 157:472-480.e5. [PMID: 30998988 PMCID: PMC6650344 DOI: 10.1053/j.gastro.2019.04.012] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 04/03/2019] [Accepted: 04/08/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND & AIMS Early liver transplantation (without requiring a minimum period of sobriety) for severe alcohol-associated hepatitis (AH) is controversial: many centers delay eligibility until a specific period of sobriety (such as 6 months) has been achieved. To inform ongoing debate and policy, we modeled long-term outcomes of early vs delayed liver transplantation for patients with AH. METHODS We developed a mathematical model to simulate early vs delayed liver transplantation for patients with severe AH and different amounts of alcohol use after transplantation: abstinence, slip (alcohol use followed by sobriety), or sustained use. Mortality of patients before transplantation was determined by joint-effect model (based on Model for End-Stage Liver Disease [MELD] and Lille scores). We estimated life expectancies of patients receiving early vs delayed transplantation (6-month wait before placement on the waitlist) and life years lost attributable to alcohol use after receiving the liver transplant. RESULTS Patients offered early liver transplantation were estimated to have an average life expectancy of 6.55 life years, compared with an average life expectancy of 1.46 life years for patients offered delayed liver transplantation (4.49-fold increase). The net increase in life expectancy from offering early transplantation was highest for patients with Lille scores of 0.50-0.82 and MELD scores of 32 or more. Patients who were offered early transplantation and had no alcohol use afterward were predicted to survive 10.85 years compared with 3.62 years for patients with sustained alcohol use after transplantation (7.23 life years lost). Compared with delayed transplantation, early liver transplantation increased survival times in all simulated scenarios and combinations of Lille and MELD scores. CONCLUSIONS In a modeling study of assumed carefully selected patients with AH, early vs delayed liver transplantation (6 months of abstinence from alcohol before transplantation) increased survival times of patients, regardless of estimated risk of sustained alcohol use after transplantation. These findings support early liver transplantation for patients with severe AH. The net increase in life expectancy was maintained in all simulated extreme scenarios but should be confirmed in prospective studies. Sustained alcohol use after transplantation significantly reduced but did not eliminate the benefits of early transplantation. Strategies are needed to prevent and treat posttransplantation use of alcohol.
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Affiliation(s)
| | | | - Ozden O. Dalgic
- Massachusetts General Hospital Institute for Technology Assessment, Boston, MA, USA
| | - Emily D. Bethea
- Massachusetts General Hospital Institute for Technology Assessment, Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael R. Lucey
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Ethan Weinberg
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Christine Hsu
- Department of Gastroenterology, Georgetown University School of Medicine, Washington, DC, USA
| | - Mary E. Rinella
- Department of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Gene Y. Im
- Department of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Oren K. Fix
- Department of Gastroenterology, Swedish Medical Center, Seattle, WA, USA
| | - George Therapondos
- Department of Gastroenterology, Ochsner Medical Center, Jefferson, LA, USA
| | - Hyosun Han
- Department of Gastroenterology, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - David W. Victor
- Department of Gastroenterology, Houston Methodist Hospital, Houston, TX, USA
| | - Michael D. Voigt
- Department of Gastroenterology, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Sheila Eswaran
- Department of Gastroenterology, Rush Medical College, Chicago, IL, USA
| | | | - Jagpreet Chhatwal
- Massachusetts General Hospital Institute for Technology Assessment, Boston, Massachusetts.
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80
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Suzuki Y, Kakisaka K, Suzuki A, Takahara T, Sasaki T, Sato T, Yonezawa T, Nitta H, Takikawa Y. A Lille model for predicting the response of severe alcoholic hepatitis to corticosteroid treatment in Japanese patients. Hepatol Res 2019; 49:758-764. [PMID: 30901152 DOI: 10.1111/hepr.13334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 02/22/2019] [Accepted: 03/16/2019] [Indexed: 12/19/2022]
Abstract
AIM Corticosteroids are the most widely used agents for the treatment of severe alcoholic hepatitis (SAH). The therapeutic effectiveness of corticosteroids is assessed by the Lille model, which has been validated well in patient cohorts in North America and Europe; however, its usefulness has not yet been confirmed independently in Japanese patients. The present study aimed to determine whether the Lille model could predict the prognosis of SAH in Japanese patients. METHODS This was a retrospective cohort study including 32 SAH patients who were admitted to our institute from April 2011 to February 2018. According to the previously validated Lille model cut-off value, patients who received corticosteroids were classified as corticosteroid responders or non-responders (with responders obtaining a Lille score ≥ 0.45), followed by assessment for the 6-month prognosis. RESULTS Out of 32 patients, 26 were treated with corticosteroids. The 28-day and 6-month mortality rates in the corticosteroid-treated group were 23.1% and 46.2%, respectively. The median Lille score was significantly higher in patients who died or underwent liver transplantation (0.647) than in those who survived without undergoing transplantation (0.226; P < 0.0182). The 6-month transplant-free survival rate of non-responders (Lille score ≥ 0.45) was significantly lower (27.3%; 95% confidence interval, 9.0-58.6%) than that of responders (Lille score < 0.45, 73.3%; 95% confidence interval, 46.7-90.0%; P = 0.0149, log-rank test). CONCLUSIONS The Lille score could be useful for predicting the 6-month prognosis of Japanese SAH patients after corticosteroid therapy.
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Affiliation(s)
- Yuji Suzuki
- Division of Hepatology, Department of Internal Medicine, Iwate Medical University School of Medicine, Morioka, Japan
| | - Keisuke Kakisaka
- Division of Hepatology, Department of Internal Medicine, Iwate Medical University School of Medicine, Morioka, Japan
| | - Akiko Suzuki
- Division of Hepatology, Department of Internal Medicine, Iwate Medical University School of Medicine, Morioka, Japan
| | - Takeshi Takahara
- Department of Surgery, Iwate Medical University School of Medicine, Morioka, Iwate, Japan
| | - Tokio Sasaki
- Division of Hepatology, Department of Internal Medicine, Iwate Medical University School of Medicine, Morioka, Japan
| | - Takuro Sato
- Division of Hepatology, Department of Internal Medicine, Iwate Medical University School of Medicine, Morioka, Japan
| | - Takehiro Yonezawa
- Division of Hepatology, Department of Internal Medicine, Iwate Medical University School of Medicine, Morioka, Japan
| | - Hiroyuki Nitta
- Department of Surgery, Iwate Medical University School of Medicine, Morioka, Iwate, Japan
| | - Yasuhiro Takikawa
- Division of Hepatology, Department of Internal Medicine, Iwate Medical University School of Medicine, Morioka, Japan
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Choudhary NS, Saigal S, Gautam D, Saraf N, Rastogi A, Goja S, Bhangui P, Thiagrajan S, Yadav SK, Mehrotra S, Rastogi V, Soin AS. Good outcome of living donor liver transplantation for severe alcoholic hepatitis not responding to medical management: A single center experience of 39 patients. Alcohol 2019; 77:27-30. [PMID: 30772702 DOI: 10.1016/j.alcohol.2018.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 07/17/2018] [Accepted: 07/19/2018] [Indexed: 12/15/2022]
Abstract
INTRODUCTION There are limited data on outcomes of living donor liver transplantation (LDLT) for patients with severe alcoholic hepatitis. METHODS The study included LDLT recipients for severe alcoholic hepatitis (n = 39) who did not improve with medical treatment and compared their outcomes with patients who underwent LDLT for alcoholic liver disease (n = 461). The diagnosis of severe alcoholic hepatitis was based on both clinical and explants data. No patients had psychiatric contraindications for liver transplant and all had good family support. The data are shown as number, mean (SD), or median (25-75 interquartile range). RESULTS All transplant recipients were males, aged 42 ± 8 years. The patients with alcoholic hepatitis were abstinent for a duration of 4 ± 1.8 months at the time of LDLT. All patients underwent LDLT with a graft to recipient weight ratio of 0.95 ± 0.17. The post-transplant ICU and hospital stay were 5.4 ± 1.3 and 17.6 ± 8.4 days, respectively. When patients with alcoholic hepatitis (n = 39) were compared to patients who underwent LDLT for alcoholic liver disease without alcoholic hepatitis (n = 461), patients with alcoholic hepatitis were significantly younger (43.2 ± 8.5 vs. 48.2 ± 9.1 years, p = 0.001) and had higher Child's (10.9 ± 1.5 vs. 9.8 ± 1.8) and MELD scores (22.1 ± 4.5 vs. 18.4 ± 5.9, p = 0.000). Post-operative infections were also significantly more common in the alcoholic hepatitis group (71.7% vs. 51.6%, p = 0.018). Fungal infections developed in 23% of alcoholic hepatitis patients as compared to 14% in the rest of the alcoholic patients (p = 0.247). Six recipients (15.7%) died at a median follow-up of 28 (6-37) months due to infections, and five (12.8%) patients had relapse of alcohol drinking. Survival was not different between the two groups. CONCLUSION Living donor liver transplantation can be successfully performed with good survival for patients with severe alcoholic hepatitis.
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Affiliation(s)
- Narendra S Choudhary
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Sanjiv Saigal
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India.
| | - Dheeraj Gautam
- Department of Histopathology, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Neeraj Saraf
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Amit Rastogi
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Sanjay Goja
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Srinivasan Thiagrajan
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Sanjay K Yadav
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Saurabh Mehrotra
- Department of Mental Health and Quality of Life, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Vipul Rastogi
- Department of Mental Health and Quality of Life, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Arvinder S Soin
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
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82
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Im GY. Outcomes of Liver Transplantation for Severe Alcohol-Related Hepatitis. Clin Liver Dis (Hoboken) 2019; 13:123-127. [PMID: 31236258 PMCID: PMC6544417 DOI: 10.1002/cld.795] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 12/15/2018] [Indexed: 02/04/2023] Open
Affiliation(s)
- Gene Y. Im
- Icahn School of Medicine at Mount Sinai, Division of Liver DiseasesRecanati‐Miller Transplantation InstituteNew YorkNY
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83
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Early liver transplantation for severe alcoholic hepatitis: moving from controversy to consensus. Curr Opin Organ Transplant 2019; 23:229-236. [PMID: 29389821 DOI: 10.1097/mot.0000000000000507] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Alcohol-related liver disease is now the most common indication for liver transplant in the United States. Acute alcoholic hepatitis represents a subpopulation with short-term mortality approaching 70% in severe cases - these patients are not typically eligible for liver transplant, as most centers require a period of alcohol abstinence (typically 6 months) prior to transplant. Early liver transplant (prior to a requisite period of abstinence) is being increasingly offered in a minority of U.S. centers. The present review examines clinical and ethical considerations surrounding liver transplant for severe alcoholic hepatitis, key published studies and knowledge gaps, and future directions for clinical research to achieve optimal patient outcomes. RECENT FINDINGS Since a European pilot study published in 2011, published U.S. original studies in early liver transplantation for severe alcoholic hepatitis are limited to 1 UNOS review, and 2 retrospective single-center studies. A preliminary report from the ACCELERATE-AH consortium show short-term outcomes are acceptable and that use of alcohol posttransplant occurs in 25% of patients. These studies confirm the survival benefit of early liver transplant for alcoholic hepatitis and report rates of alcohol use posttransplant similar to historic cohorts in alcohol-related cirrhosis. SUMMARY Early liver transplantation for severe alcoholic hepatitis is lifesaving, with acceptable short to intermediate-term patient survival and rates of alcohol use posttransplant. Further study is needed to determine long-term outcomes, and how best to select and manage patients for this new indication for liver transplant.
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84
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Szabo G, Kamath PS, Shah VH, Thursz M, Mathurin P, Bataller R, Burra P, Castera L, Cortez Pinto H, Diehl AM, Gao B, Gilmore SI, Hampe J, Jürgen R, Karin M, Krag A, Leon D, Leptak C, Louvet A, Lucey M, McClain C, Nagy L, Pageaux G, Sanyal A, Schnabl B, Tiniakos D, Trautwein C, Tsukamoto H. Alcohol-Related Liver Disease: Areas of Consensus, Unmet Needs and Opportunities for Further Study. Hepatology 2019; 69:2271-2283. [PMID: 30645002 DOI: 10.1002/hep.30369] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 10/31/2018] [Indexed: 12/16/2022]
Abstract
A joint meeting of the European Association for the Study of the Liver (EASL) and the American Association for the Study of Liver Diseases (AASLD) was held in London on September 30 and October 1, 2017. The goals of the meeting were to identify areas of broad agreement and disagreement, develop consensus, and determine future directions to ultimately reduce the burden, morbidity, and mortality of alcohol-related liver disease (previously termed alcoholic liver disease). The specific aims of the meeting were to identify unmet needs and areas for future investigation, in order to reduce alcohol consumption, develop markers for diagnosis and prognosis of disease, and create a framework to test novel pharmacological agents with pre-specified treatment endpoints. A table summary of these goals and aims is provided in the context of epidemiology, current management strategies, next steps for future trials and translational science.
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Affiliation(s)
- Gyongyi Szabo
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, US
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN, US
| | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN, US
| | - Mark Thursz
- Digestive Diseases Division, Department of Surgery & Cancer, Imperial College, London, UK
| | - Philippe Mathurin
- Service des Maladies de l'Appareil Digestif, Hôpital Claude Huriez, Lille, France
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85
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Ma M, Falloon K, Chen PH, Saberi B, Pustavoitau A, Ozdogan E, Li Z, Philosophe B, Cameron AM, Gurakar A. The Role of Liver Transplantation in Alcoholic Hepatitis. J Intensive Care Med 2019; 34:277-291. [PMID: 29879862 DOI: 10.1177/0885066618780339] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Acute alcoholic hepatitis is a syndrome of jaundice and hepatic decompensation that occurs with excessive alcohol consumption. The diagnosis can be made with a combination of clinical characteristics and laboratory studies, though biopsy may be required in unclear cases. Acute alcoholic hepatitis can range from mild to severe disease, as determined by a Maddrey discriminant function ≥32. Mild forms can be managed with supportive care and abstinence from alcohol. While mild form has an overall good prognosis, severe alcoholic hepatitis is associated with an extremely high short-term mortality of up to 50%. Additional complications of severe alcoholic hepatitis can include hepatic encephalopathy, gastrointestinal bleeding, renal failure, and infection; these patients frequently require intensive care unit admission. Corticosteroids may have short-term benefit in this group of patients if there are no contraindications; however, a subset of patients do not respond to steroids. New emerging therapies, which target hepatic regeneration, bile acid metabolism, and extracorporeal liver support, are being investigated. Liver transplantation for alcoholic liver disease was traditionally only considered in patients who have achieved 6 months of abstinence, in part due to social and ethical concerns regarding the use of a limited resource. However, the majority of patients with severe alcoholic hepatitis who fail medical therapy will not live long enough to meet this requirement. Recent studies have demonstrated that early liver transplantation in carefully selected patients with severe alcoholic hepatitis who fail medical therapy can provide a significant survival benefit and yields survival outcomes comparable to liver transplantation for other indications, with 6-month survival rates ranging from 77% to 100%. Alcohol relapse posttransplantation remains an important challenge, and heavy consumption can contribute to graft loss and mortality. Future investigation should address the substantial post-liver transplantation recidivism rate, from improving selection criteria to increasing posttransplantation substance abuse treatment resources.
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Affiliation(s)
- Michelle Ma
- 1 Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Katie Falloon
- 2 Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Po-Hung Chen
- 1 Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Behnam Saberi
- 1 Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aliaksei Pustavoitau
- 3 Department of Anesthesiology and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elif Ozdogan
- 1 Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Zhiping Li
- 1 Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Benjamin Philosophe
- 4 Division of Transplant Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Andrew M Cameron
- 4 Division of Transplant Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ahmet Gurakar
- 1 Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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86
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Lee BP, Vittinghoff E, Hsu C, Han H, Therapondos G, Fix OK, Victor DW, Dronamraju D, Im GY, Voigt MD, Rice JP, Lucey MR, Eswaran S, Chen PH, Li Z, Maddur H, Terrault NA. Predicting Low Risk for Sustained Alcohol Use After Early Liver Transplant for Acute Alcoholic Hepatitis: The Sustained Alcohol Use Post-Liver Transplant Score. Hepatology 2019; 69:1477-1487. [PMID: 30561766 PMCID: PMC6453818 DOI: 10.1002/hep.30478] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 09/23/2018] [Indexed: 12/20/2022]
Abstract
Early liver transplant (LT) for alcohol-associated disease (i.e., without a specific sobriety period) is controversial but increasingly used. Using the multicenter American Consortium of Early Liver Transplantation for Alcoholic Hepatitis (ACCELERATE-AH) cohort, we aimed to develop a predictive tool to identify patients pretransplant with low risk for sustained alcohol use posttransplant to inform selection of candidates for early LT. We included consecutive ACCELERATE-AH LT recipients between 2012 and 2017. All had clinically diagnosed severe alcoholic hepatitis (AH), no prior diagnosis of liver disease or AH, and underwent LT without a specific sobriety period. Logistic and Cox regression, classification and regression trees (CARTs), and least absolute shrinkage and selection operator (LASSO) regression were used to identify variables associated with sustained alcohol use post-LT. Among 134 LT recipients for AH with median period of alcohol abstinence pre-LT of 54 days, 74% were abstinent, 16% had slips only, and 10% had sustained alcohol use after a median 1.6 (interquartile range [IQR]: 0.7-2.8) years follow-up post-LT. Four variables were associated with sustained use of alcohol post-LT, forming the Sustained Alcohol Use Post-LT (SALT) score (range: 0-11): >10 drinks per day at initial hospitalization (+4 points), multiple prior rehabilitation attempts (+4 points), prior alcohol-related legal issues (+2 points), and prior illicit substance abuse (+1 point). The C statistic was 0.76 (95% confidence interval [CI]: 0.68-0.83). A SALT score ≥5 had a 25% positive predictive value (95% CI: 10%-47%) and a SALT score of <5 had a 95% negative predictive value (95% CI: 89%-98%) for sustained alcohol use post-LT. In internal cross-validation, the average C statistic was 0.74. Conclusion: A prognostic score, the SALT score, using four objective pretransplant variables identifies candidates with AH for early LT who are at low risk for sustained alcohol use posttransplant. This tool may assist in the selection of patients with AH for early LT or in guiding risk-based interventions post-LT.
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Affiliation(s)
- Brian P Lee
- Department of Gastroenterology, University of California, San Francisco, San Francisco, CA
| | - Eric Vittinghoff
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Christine Hsu
- Department of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Hyosun Han
- Department of Gastroenterology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | | | - Oren K Fix
- Department of Gastroenterology, Swedish Medical Center, Seattle, WA
| | - David W Victor
- Department of Gastroenterology, Houston Methodist Hospital, Houston, TX
| | - Deepti Dronamraju
- Department of Gastroenterology, School of Medicine, University of Maryland, Baltimore, MD
| | - Gene Y Im
- Department of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michael D Voigt
- Department of Gastroenterology, Carver College of Medicine, University of Iowa, Iowa City, IA
| | - John P Rice
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI
| | - Michael R Lucey
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI
| | - Sheila Eswaran
- Department of Gastroenterology, Rush Medical College, Chicago, IL
| | - Po-Hung Chen
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Zhiping Li
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Haripriya Maddur
- Department of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Norah A Terrault
- Department of Gastroenterology, University of California, San Francisco, San Francisco, CA
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87
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Mazumder N, Boike J, Maddur H. Con: The Abstinence Period Should Be Determined on a Case-by-Case Basis. Clin Liver Dis (Hoboken) 2019; 13:87-89. [PMID: 30988944 PMCID: PMC6446453 DOI: 10.1002/cld.730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 05/11/2018] [Indexed: 02/04/2023] Open
Affiliation(s)
- Nikhilesh Mazumder
- Department of Medicine, Division of Gastroenterology and HepatologyNorthwestern UniversityChicagoIL
| | - Justin Boike
- Department of Medicine, Division of Gastroenterology and HepatologyNorthwestern UniversityChicagoIL
| | - Haripriya Maddur
- Department of Medicine, Division of Gastroenterology and HepatologyNorthwestern UniversityChicagoIL
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88
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Davis JP, Reutemann BA, Argo CK. Pro: The Abstinence Period Should Be the Same for All Patients Undergoing Evaluation for Transplant. Clin Liver Dis (Hoboken) 2019; 13:82-86. [PMID: 30988943 PMCID: PMC6446445 DOI: 10.1002/cld.747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 07/20/2018] [Indexed: 02/04/2023] Open
Affiliation(s)
- Jessica P. Davis
- Division of Gastroenterology and HepatologyUniversity of Virginia Health SystemCharlottesvilleVA
| | - Bethany A. Reutemann
- Division of Gastroenterology and HepatologyUniversity of Virginia Health SystemCharlottesvilleVA
| | - Curtis K. Argo
- Division of Gastroenterology and HepatologyUniversity of Virginia Health SystemCharlottesvilleVA
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89
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Lee BP, Terrault NA. Liver-related mortality in the United States: hepatitis C declines, non-alcoholic fatty liver and alcohol rise. Transl Gastroenterol Hepatol 2019; 4:19. [PMID: 30976722 DOI: 10.21037/tgh.2019.03.04] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 12/28/2018] [Indexed: 12/21/2022] Open
Affiliation(s)
- Brian P Lee
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Norah A Terrault
- Department of Medicine, University of Southern California, Los Angeles, CA, USA
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90
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Mitchell MC, Maddrey WC. Changing Times in Liver Transplantation for Alcohol-Associated Liver Disease. JAMA Intern Med 2019; 179:348-350. [PMID: 30667460 DOI: 10.1001/jamainternmed.2018.6532] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Mack C Mitchell
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Willis C Maddrey
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
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91
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Lee BP, Vittinghoff E, Dodge JL, Cullaro G, Terrault NA. National Trends and Long-term Outcomes of Liver Transplant for Alcohol-Associated Liver Disease in the United States. JAMA Intern Med 2019; 179:340-348. [PMID: 30667468 PMCID: PMC6439700 DOI: 10.1001/jamainternmed.2018.6536] [Citation(s) in RCA: 137] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE Alcohol-associated liver disease (ALD) has emerged as the most common indication for liver transplant in the United States, but data on the reasons for this increase and long-term post-liver transplant outcomes among liver transplant recipients are sparse. OBJECTIVE To characterize trends and long-term outcomes of liver transplant for ALD in the United States between 2002 and 2016. DESIGN, SETTING, AND PARTICIPANTS This multicenter, prospective, national cohort study used data from the United Network for Organ Sharing database to evaluate all liver transplants performed in the United States between January 1, 2002, and December 31, 2016. MAIN OUTCOMES AND MEASURES National and regional trends in liver transplant for ALD, with a sensitivity analysis with hepatitis C virus (HCV) infection and hepatocellular carcinoma (HCC) included, and early (≤90 days after liver transplant) and late (>90 days after liver transplant) patient and graft survival. RESULTS The cohort consisted of 32 913 patients, including 9438 with ALD and 23 475 without ALD (patients who had HCV infection and HCC indications were excluded). Median age of patients with ALD was 54 years (interquartile range, 47-60 years) and of patients without ALD was 54 years (interquartile range, 44-61 years). Patients with ALD (vs non-ALD) were more frequently male (7197 of 9438 [76.2%] vs 11 767 of 23 475 [50.1%]; P < .001) and white (7544 [80.0%] vs 17 251 [73.5%]; P < .001). The proportion of liver transplants for ALD increased from 24.2% (433 of 1791) in 2002 to 27.2% (556 of 2044) in 2010 and 36.7% (1253 of 3419) in 2016. With HCV infection included, the proportions of liver transplant for ALD were 15.3% in 2002, 18.6% in 2010, and 30.6% in 2016, representing a 100% increase in liver transplant for ALD, of which 48% was associated with a decrease in HCV infection as an indication for liver transplant. The magnitude of increase in ALD was regionally heterogeneous and associated with changes in patient characteristics suggestive of alcoholic hepatitis: decreasing age (χ2 = 36.5; P = .005) and increasing model for end-stage liver disease score (χ2 = 69.1; P < .001). Cumulative unadjusted 5-year posttransplant survival was 79% (95% CI, 78%-80%) for ALD vs 80% (95% CI, 79%-80%) for non-ALD; cumulative unadjusted 10-year posttransplant survival was 63% (95% CI, 61%-64%) for ALD vs 68% (95% CI, 67%-69%) for non-ALD (P = .006). In multivariable analysis, ALD was associated with increased risk of late death after liver transplant (adjusted hazard ratio, 1.11; 95% CI, 1.03-1.20; P = .006). CONCLUSIONS AND RELEVANCE The findings suggest that early liver transplant for alcoholic hepatitis may be leading to broader acceptance of ALD for liver transplant. Late survival among liver transplant recipients with ALD was inferior to that among recipients with non-ALD indications, suggesting a need for future studies to identify patient profiles associated with best outcomes. Regional differences suggest heterogeneity in policies toward liver transplant for ALD.
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Affiliation(s)
- Brian P Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco
| | - Eric Vittinghoff
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | | | - Giuseppe Cullaro
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco
| | - Norah A Terrault
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco
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92
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Alcohol-related liver disease: Areas of consensus, unmet needs and opportunities for further study. J Hepatol 2019; 70:521-530. [PMID: 30658117 DOI: 10.1016/j.jhep.2018.10.041] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 10/26/2018] [Accepted: 10/31/2018] [Indexed: 12/19/2022]
Abstract
A joint meeting of the European Association for the Study of the Liver (EASL) and the American Association for the Study of Liver Diseases (AASLD) was held in London on September 30 and October 1, 2017. The goals of the meeting were to identify areas of broad agreement and disagreement, develop consensus, and determine future directions to ultimately reduce the burden, morbidity, and mortality of alcohol-related liver disease (previously termed alcoholic liver disease). The specific aims of the meeting were to identify unmet needs and areas for future investigation, in order to reduce alcohol consumption, develop markers for diagnosis and prognosis of disease, and create a framework to test novel pharmacological agents with pre-specified treatment endpoints.
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93
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Liver transplantation for alcoholic hepatitis. J Hepatol 2019; 70:328-334. [PMID: 30658734 DOI: 10.1016/j.jhep.2018.11.007] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 11/05/2018] [Accepted: 11/08/2018] [Indexed: 12/19/2022]
Abstract
While liver transplantation (LT) has become a standard therapy for life-threatening alcohol related cirrhosis, LT as a treatment for severe alcoholic hepatitis (AH) has remained a taboo owing to concerns about the limited organ supply and the risk that the AH liver recipient will return to harmful drinking. The adoption of a 6-month abstinence requirement (the so-called '6-month rule') by many centres made AH a contraindication to LT. Given the high short-term mortality of severe AH, the lack of effective medical therapies and an increasing recognition that the 6-month rule unfairly excluded otherwise favourable candidates, a seminal European pilot study of LT for AH was performed. The success of the European study, which has been corroborated in retrospective analyses from the United States, represented a paradigm shift in therapy for highly selected patients with severe AH who are not responding to medical therapy. However, prospective studies are urgently needed to resolve the controversies that still surround the criteria for selection of patients with AH for LT and the long-term outcomes of the associated alcohol use disorder.
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94
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Wang W, Xu Y, Jiang C, Gao Y. Advances in the treatment of severe alcoholic hepatitis. Curr Med Res Opin 2019; 35:261-273. [PMID: 29781336 DOI: 10.1080/03007995.2018.1479247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Severe alcoholic hepatitis (SAH) is a costly and worldwide public health issue with high morbidity and mortality. Specific effective treatments for SAH have yet to be established. The aim of the present article is to review the current knowledge of the pathogenesis, assessment and treatment options in patients with SAH. To date, alcohol abstinence and enteral nutrition are the recommended first-line treatments. Although corticosteroids remain the preferred therapy for certain patients with a modified Maddrey discriminant function level greater than 54, they only improve short-term survival rates. New research focuses on liver inflammation, liver regeneration, the gut-liver axis, human induced pluripotent stem cells and extracorporeal albumin dialysis. Liver transplantation is considered the last medical option for patients with SAH who are nonresponsive to other medical treatments.
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Affiliation(s)
- Wenjun Wang
- a Department of Hepatology , First Hospital of Jilin University, Jilin University , Jilin , China
| | - Ying Xu
- a Department of Hepatology , First Hospital of Jilin University, Jilin University , Jilin , China
| | - Chang Jiang
- a Department of Hepatology , First Hospital of Jilin University, Jilin University , Jilin , China
| | - Yanhang Gao
- a Department of Hepatology , First Hospital of Jilin University, Jilin University , Jilin , China
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95
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Magistri P, Marzi L, Guerzoni S, Vandelli M, Mereu F, Ascari F, Guidetti C, Tarantino G, Serra V, Guerrini G, Ballarin R, Moscara M, De Maria N, Villa E, Di Benedetto F. Impact of a Multidisciplinary Team on Alcohol Recidivism and Survival After Liver Transplant for Alcoholic Disease. Transplant Proc 2019; 51:187-189. [DOI: 10.1016/j.transproceed.2018.02.212] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Accepted: 02/06/2018] [Indexed: 11/26/2022]
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96
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Artzner T, Michard B, Besch C, Levesque E, Faitot F. Liver transplantation for critically ill cirrhotic patients: Overview and pragmatic proposals. World J Gastroenterol 2018; 24:5203-5214. [PMID: 30581269 PMCID: PMC6295835 DOI: 10.3748/wjg.v24.i46.5203] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 11/12/2018] [Accepted: 11/13/2018] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation for critically ill cirrhotic patients with acute deterioration of liver function associated with extrahepatic organ failures is controversial. While transplantation has been shown to be beneficial on an individual basis, the potentially poorer post-transplant outcome of these patients taken as a group can be held as an argument against allocating livers to them. Although this issue concerns only a minority of liver transplants, it calls into question the very heart of the allocation paradigms in place. Indeed, most allocation algorithms have been centered on prioritizing the sickest patients by using the model for end-stage liver disease score. This has led to allocating increasing numbers of livers to increasingly critically ill patients without setting objective or consensual limits on how sick patients can be when they receive an organ. Today, finding robust criteria to deem certain cirrhotic patients too sick to be transplanted seems urgent in order to ensure the fairness of our organ allocation protocols. This review starts by fleshing out the argument that finding such criteria is essential. It examines five types of difficulties that have hindered the progress of recent literature on this issue and identifies various strategies that could be followed to move forward on this topic, taking into account the recent discussion on acute on chronic liver failure. We move on to review the literature along four axes that could guide clinicians in their decision-making process regarding transplantation of critically ill cirrhotic patients.
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Affiliation(s)
- Thierry Artzner
- Service de Réanimation Médicale, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg 67000, France
| | - Baptiste Michard
- Service de Réanimation Médicale, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg 67000, France
- Service de Chirurgie Hépatobiliaire et Transplantation, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg 67000, France
| | - Camille Besch
- Service de Chirurgie Hépatobiliaire et Transplantation, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg 67000, France
| | - Eric Levesque
- Service d’Anesthésie et Réanimation Chirurgicale, Hôpital Henri Mondor, Créteil 94000, France
| | - François Faitot
- Service de Chirurgie Hépatobiliaire et Transplantation, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg 67000, France
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97
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Nguyen-Khac E, Dejour V, Sarba R, Yzet T, Turpin J, Chatelain D, Marcq I, Chivot C, Maizel J, Papillon C, Attencourt C, Houchi H. Hépatite alcoolique aiguë sévère. MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Tout patient consommateur chronique et excessif d’alcool avec un ictère récent doit être évalué par le score de Maddrey à la recherche d’une hépatite alcoolique aiguë sévère. Les corticostéroïdes représentent le traitement de première ligne, associés à un soutien nutritionnel adapté et à une abstinence alcoolique. La combinaison corticostéroïdes plus N-acétylcystéine (perfusée pendant les cinq premiers jours) améliore la survie à court terme par rapport aux corticostéroïdes seuls, constituant une option thérapeutique de première ligne. La réponse au traitement est évaluée au septième jour par le modèle de Lille inférieur ou égal à 0,45. Le pronostic des patients non répondeurs aux corticostéroïdes avec un modèle de Lille supérieur à 0,45 est sombre avec une survie de 23 % à six mois. Pour des patients non répondeurs aux corticostéroïdes et sélectionnés, la transplantation hépatique précoce améliore significativement la survie à six mois et à long terme.
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98
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Obed A, Bashir A, Stern S, Jarrad A. Severe acute alcoholic hepatitis and liver transplant: A never-ending mournful story. Clin Mol Hepatol 2018; 24:358-366. [PMID: 30360030 PMCID: PMC6313024 DOI: 10.3350/cmh.2018.0044] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Accepted: 08/16/2018] [Indexed: 02/06/2023] Open
Abstract
Severe acute alcoholic liver disease (SAAH) unresponsive to medical therapy shows one-year-mortality rates of up to 90%. Most transplant centers request six months of alcohol abstinence prior to transplantation, the so-called "6-month rule." This regulation is not based on strong evidence, repeatedly making it a topic of controversial debates. The majority of patients with SAAH will die before fulfilling the 6-month rule. Therefore, liver transplantation (LT) protocols are becoming more flexible towards the rigid abstinence regulation, especially concerning SAAH patients. We conducted a literature review regarding LT in SAAH and its outcomes, including post-transplant mortality and recidivism. We studied available data on PubMed from 2011 and onwards whilst including articles dealing with genetic components, medical therapy and historic snapshots of alcoholism. Emerging studies recommend LT in SAAH not responding to medical therapies even without realizing the required abstinence period, since the majority of these patients would die within 6 months. SAAH without response to medical therapy has one-year-mortality rates of up to 90%. The 6-month rule is not based on strong evidence and is repeatedly a topic of controversial debates. There is genetic linkage to alcoholism and medical therapy is not as effective as estimated, yet. The 6-months-regulation has not shown to evidently decrease the risk of recidivism post-LT, which is a lifesaving treatment in SAAH patients. Insisting on rigid sobriety rules results in excluding patients with a low risk of recidivism from being transplanted. Moreover, the genetic linkage of alcoholism must be recognized.
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Affiliation(s)
- Aiman Obed
- Division of General, Hepatobiliary and Transplant Surgery, Jordan Hospital, Amman, Jordan
| | - Abdalla Bashir
- Division of General, Hepatobiliary and Transplant Surgery, Jordan Hospital, Amman, Jordan
| | - Steffen Stern
- Faculty of Law, Bielefeld University, Bielefeld, Germany
| | - Anwar Jarrad
- Division of Gastroenterology, Jordan Hospital, Amman, Jordan
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99
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Al-Saeedi M, Barout MH, Probst P, Khajeh E, Weiss KH, Diener MK, Mehrabi A. Meta-analysis of patient survival and rate of alcohol relapse in liver-transplanted patients for acute alcoholic hepatitis. Langenbecks Arch Surg 2018; 403:825-836. [PMID: 30349998 DOI: 10.1007/s00423-018-1720-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 10/11/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE This review investigated survival and alcoholic relapse following liver transplantation (LT) in patients with severe acute alcoholic hepatitis (AH) without 6 months of alcohol abstinence. METHODS All studies comparing acute AH patients undergoing LT with a control group were included. CENTRAL, MEDLINE, and Web of Science databases were searched. Survival benefits or odds ratios (OR) and 95% confidence intervals (CI) were assessed by meta-analyses using a random effects model. The study was registered in PROSPERO (CRD42017057971). According to the search results, two separate meta-analyses were performed: meta-analysis A compared early LT with medical therapy alone in patients with severe AH that were not responding to medical therapy and meta-analysis B compared LT outcome in patients with AH and chronic alcoholic cirrhosis (AC). RESULTS The search yielded 2232 articles. Eight studies were included in the two meta-analyses-two studies in meta-analysis A and six studies in meta-analysis B. The two studies (n = 70) included in meta-analysis A revealed that 1-year patient survival was significantly higher in the LT group compared with the medical therapy-alone group (survival benefit, 15.88; 95% CI, 3.98-63.35; p < 0.0001). The six studies in meta-analysis B (including 1091 patients) showed that 1-year (survival benefit, 1.65; 95% CI, 0.95-2.89; p = 0.08), 3-year (survival benefit, 1.31; 95% CI, 0.79-2.18; p = 0.30), and 5-year survival (survival benefit, 1.54; 95% CI, 0.92-2.56; p = 0.10) were not significantly different between AH and AC groups. There was no significant difference in the rate of alcohol relapse between the groups (OR, 1.26; 95% CI, 0.53-2.96; p = 0.60). CONCLUSIONS Early LT is a life-saving treatment for AH patients that do not respond to medical therapy. The chance of alcohol relapse after LT is not increased in selected patients.
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Affiliation(s)
- Mohammed Al-Saeedi
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Muhammed H Barout
- The Study Center of the German Surgical Society (SDGC), University of Heidelberg, Im Neuenheimer Feld 130/3, 69120, Heidelberg, Germany
| | - Pascal Probst
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
- The Study Center of the German Surgical Society (SDGC), University of Heidelberg, Im Neuenheimer Feld 130/3, 69120, Heidelberg, Germany
| | - Elias Khajeh
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Karl Heinz Weiss
- Department of Internal Medicine IV, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Markus K Diener
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
- The Study Center of the German Surgical Society (SDGC), University of Heidelberg, Im Neuenheimer Feld 130/3, 69120, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
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100
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Gelu-Simeon M, Mathurin P. Liver Transplantation for Severe Alcoholic Hepatitis: Where Are We Now? Liver Transpl 2018; 24:1327-1328. [PMID: 30218596 DOI: 10.1002/lt.25337] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 09/10/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Moana Gelu-Simeon
- Centre Hospitalier Universitaire Guadeloupe, Université des Antilles, Service d'Hépato-Gastroentérologie, Pointe-à-Pitre, Guadeloupe.,INSERM, Unités Mixtes de Recherche en Santé1085/IRSET, Rennes, France
| | - Philippe Mathurin
- Service des Maladies de l'Appareil Digestif, Hôpital Huriez, CHRU Lille, Université Lille 2, INSERM U795, Lille, France
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