Orthotopic liver transplantation for alcoholic liver disease

Outcome of liver transplantation in critically ill patients with alcoholic cirrhosis: survival according to medical variables and sobriety

BACKGROUND

At our center from August 1989 to December 1992, 834 adults underwent orthotopic liver transplantation (OLT) using tacrolimus as the primary immunosuppressive agent. A total of 183 adults (22%) had alcohol-related liver disease. Patients with alcoholic cirrhosis had a better though not statistically significant 5-year survival rate compared with all other patients. We were interested in specific predictors of survival, particularly for alcoholic cirrhotics who were gravely ill at the point of transplantation.

METHODS

For the 78 patients with alcohol-related liver disease who were United Network for Organ Sharing status IIA (critically ill) at the point of transplantation, variables of length of sobriety, alcohol rehabilitation, and medical variables (ventilator support, dialysis, vasopressor support, degree of encephalopathy, and infection) were assessed for contribution to survival.

RESULTS

Although there was a trend toward poorer survival in patients with the shortest length of sobriety (< or =1 month), pre-OLT length of sobriety or alcohol rehabilitation did not predict survival. However, these patients tended to be in multiorgan failure and encephalopathic. Nevertheless, pre-OLT dialysis requirement was the only variable that predicted poorer survival (P < 0.002). This study was not designed to evaluate recidivism. However, we know that 24% of these patients have used alcohol at some point after OLT.

CONCLUSIONS

Short pre-OLT length of sobriety may not predict which patients are likely to resume alcohol consumption after OLT, but it may identify patients in whom there will exist a variety of poor outcome variables. In our study, in these patients, post-OLT survival was associated with medical rather than alcohol history variables.

Patterns of alcohol consumption after liver transplantation

BACKGROUND

Uncertainty exists about the extent and consequences of a return to alcohol consumption after liver transplantation for alcoholic liver disease (ALD).

AIMS

To determine the prevalence and consequences of alcohol consumption in patients transplanted for ALD.

METHODS

A retrospective case controlled study of all patients transplanted for ALD at the Queen Elizabeth Hospital, Birmingham, between 1987 and 1996.

RESULTS

Seventy patients with ALD were transplanted, of which 59 survived more than three months; 56 were interviewed. Twenty eight had consumed some alcohol after transplantation; for the nine "heavy drinkers" (HD), the median time to resumption of alcohol intake was six months and for the 19 "moderate drinkers" (MD) it was eight months. There was no significant difference in episodes of acute rejection or compliance with medication between those who were abstinent, MD, or HD. Histological evidence of liver injury was common in ALD patients who had returned to drink. Mild fatty change was found in 1/11 biopsy specimens from abstinent patients but moderate to severe fatty change and ballooned hepatocytes were seen in 3/5 MD and 2/5 HD specimens. Two HD patients had early fibrosis. One HD patient had died of alcohol related complications.

CONCLUSIONS

Moderate to heavy alcohol consumption occurs in patients transplanted for ALD. Patient recall of abstinence advice is unreliable, and patients return to alcohol mainly within the first year after liver transplantation. Return to alcohol consumption after liver transplantation is associated with rapid development of histological liver injury including fibrosis.

Alcoholic recidivism after liver transplantation for alcoholic cirrhosis

Liver transplantation (LT) for alcoholic cirrhosis remains controversial. This controversy surrounding LT in alcoholics focuses on the risk of alcohol recidivism and on potential noncompliance with the immunosuppressive regimen, both of which result in graft failure. Our study examined alcohol recidivism after LT by measuring alcohol in urine and its repercussion on the allograft. Forty-four consecutive alcoholic patients and a comparison group of 17 patients receiving LT were included in this study and followed up for a mean of 39.5 +/- 19.6 months. Seven percent (3 of 44) of patients with alcoholic liver disease and 0% of patients in the comparison group admitted to having used alcohol after LT. Alcohol in urine, however, was detected in 18% (8 of 44) of the alcoholic group; therefore the true recidivism rate was higher than the rate admitted. All patients in both groups were compliant with the medications, because the cyclosporine levels were within the therapeutic range in all. On histologic examination the only alcohol-induced lesion found in three of the eight recidivistic patients was steatosis. Therefore, although alcoholic recidivism occurs, it does not seem to affect compliance to treatment profoundly or to compromise graft function. Therefore, LT seems justified for end-stage alcoholic cirrhosis.

Current management of infectious complications in the injecting drug user

The diagnosis and management of infectious complications associated with injection drug use (IDU) are among some of the more challenging aspects of working with substance abusing populations. As the population of injection drug users age, we expect the number and severity of these complications to increase. Commonly seen infections, such as bacterial endocarditis and bacterial infections of bones, joints, and soft tissue, are now frequently complicated by concurrent immunodeficiency. Parenterally and sexually transmitted viral hepatitis is responsible for significant IDU morbidity and mortality. The human leukemia/lymphoma virus types I and II are increasing in prevalence in the IDU with uncertain long-term clinical effects. Immune dysfunction has been described in the IDU for decades, but the impact of host immune compromise on the transmission and the course of HIV-1 has yet to be fully appreciated. The integration of the treatment of substance abuse and its concurrent psychiatric disorders with the management of infectious complications, including immunodeficiency, promises to improve patient compliance with possible savings of overall medical costs.

Metabolism of ethanol and some associated adverse effects on the liver and the stomach

Current knowledge of alcohol oxidation and its effects on hepatic metabolism and its toxicity are summarized. This includes an evaluation of the relationship of the level of consumption to its interaction with nutrients (especially retinoids, carotenoids, and folate) and the development of various stages of liver disease. Ethanol metabolism in the stomach and its link to pathology and Helicobacter pylori is reviewed. Promising therapeutic approaches evolving from newly gained insight in the pathogenesis of medical complications of alcoholism are outlined. At present, the established approach for the prevention and treatment of alcoholism are outlined. At present, the established approach for the prevention and treatment of alcoholic liver injury is to control alcohol abuse, with the judicial application of selective antioxidant therapy, instituted at early stages, prior to the social or medical disintegration of the patient, and associated with antiinflammatory agents at the acute phase of alcoholic hepatitis. In addition, effective antifibrotic therapy may soon become available.

Common bile duct stenosis caused by chronic pancreatitis after liver transplantation for alcoholic cirrhosis

BACKGROUND

The prevalence of chronic pancreatitis in patients with alcoholic cirrhosis ranges from 7% to 11% and is not considered a contraindication for liver transplantation.

METHODS

Among 59 liver transplant recipients grafted for alcoholic cirrhosis, we report two observations of common bile duct stenosis due to chronic pancreatitis.

RESULTS

In both cases, pretransplant work-up disclosed no clinical or radiological evidence of chronic pancreatitis. The diagnosis of common bile duct stricture was made 6 and 60 months after liver transplantation. One patient was reoperated upon, and his choledochocholedochostomy was converted into a Rouxen-Y choledochojejunostomy. The second patient experienced metastatic laryngeal carcinoma and died before reoperation.

CONCLUSIONS

These observations suggest that common bile duct stricture caused by chronic pancreatitis may occur after liver transplantation for alcoholic cirrhosis, even after a long-standing history of abstinence.

Liver transplantation for alcoholic liver disease: selection and outcome

There is clear consensus that patients with alcoholic cirrhosis should be considerated for liver transplantation, barring complicating medical or psychosocial problems. Short-term and long-term survival rates are comparable to patients receiving transplants for other conditions, and the relapse rate to alcohol use averages 15%, with troublesome drinking seen uncommonly. To date, no nationally accepted selection criteria have been established and proved effective in predicting long-term sobriety and compliance. To maximize the outcome of liver transplantation in patients with alcoholic liver disease, an approach to the selection of candidates is outlined herewith. 1. Minimum pretransplant sobriety period of 6 months. 2. Assessment of overall psychosocial support and stress. 3. Assessment of comorbid psychiatric conditions that may impair ability to comply with the transplant protocol during and after transplantation. 4. Assessment of past and present compliance with medical treatment. 5. Acceptance of problem with alcohol and willingness to sign an alcohol contract. 6. Willingness to participate in alcohol rehabilitation treatment program. 7. Willingness to participate in liver support groups to improve understanding of the condition and obtain social support. 8. Willingness to undergo random toxicology screening to assess compliance with sobriety.

Exploring alcohol's effects on liver function

A large proportion of heavy drinkers develop serious alcoholic liver disease. Susceptibility to alcoholic hepatitis and cirrhosis appears to be influenced by heredity, gender, diet, and co-occurring liver illness. Most alcoholic liver damage is attributed to alcohol metabolism. Liver injury may be caused by direct toxicity of metabolic by-products of alcohol as well as by inflammation induced by these by-products. Exposure of liver cells to bacterial toxins may contribute to liver disease. Escalating liver injury can lead to fibrosis and, ultimately, to cirrhosis. Increased understanding of the mechanisms of liver injury has led to innovative treatments for alcoholic liver disease, including the use of corticosteroids, antioxidants, antibiotics, and certain polyunsaturated fats.

Long-term changes of markers of alcoholism after orthotopic liver transplantation (OLT)

Both physical rehabilitation and the course of the alcoholism improve after orthotopic liver transplantation (OLT) in patients with end-stage alcoholic liver cirrhosis. In the present study including 17 alcoholics and 14 nonalcoholics, after OLT, three of the alcoholic patients resumed their pre-OLT alcohol drinking habits, 4 consumed alcohol occasionally, 10 remained abstinent over the observation period of 13 to 36 months. The laboratory parameters before OLT did not discriminate alcoholics from nonalcoholic patients. Furthermore, the blood levels of two so-called alcogens (harman and norharman) were determined to investigate whether they discriminate between the two groups. Alcogens are natural compounds that are presumed to induce alcohol abuse in predisposed individuals. Both alcogens measured were elevated in plasma from nonalcoholics and alcoholics before OLT, suggesting a disturbance in inactivation in end-stage liver disease. Following OLT, the alcogens normalized but in the alcoholics this process was slower with respect to harman. The present exploratory study suggests that the normalized metabolic capacity of the liver after OLT causes a normalization of the levels of alcogens, for which harman and norharman are representative. These changes could contribute to the observed benefit to the outcome in alcoholics with respect to the alcohol dependence.

Psychosocial assessment of organ transplant candidates and the Americans with Disabilities Act

The use of psychosocial criteria to assess candidates for organ transplantation may violate the Americans with Disabilities Act (ADA). The ADA prohibits discrimination on the basis of disability or on the basis of eligibility criteria that disproportionately affect persons with disabilities. When organ programs deny access to a person because of schizophrenia, they are denying an organ on the basis of disability. When organ programs deny access to a noncompliant person, they are denying an organ on the basis of an eligibility criterion that is more common in persons with coexisting disabilities like mental illness. Accordingly, both of these denials may violate the ADA. However, the ADA recognizes that it often is appropriate to take a person's disability into account when allocating organs for transplantation. There is a legitimate social interest in allocating organs in a way that maximizes medical benefit, and a person's disability may compromise the benefit that the person will receive from a transplant. It is likely that courts will interpret the ADA to permit denials of organs or lower waiting list priorities for persons with disabilities as long as predictions of diminished benefit are based on scientifically valid criteria, the assessment of candidates is individualized and not based entirely on generalized predictors, and the transplant program undertakes reasonable steps like psychological counseling to compensate for an organ candidate's coexisting disability.

Assessment and follow-up of alcohol-dependent liver transplantation patients. A clinical cohort

We describe pretransplantation characteristics of 103 consecutive alcoholic cirrhotics who underwent orthotopic liver transplantation over a 28-month period, and follow-up characteristics for 58 of 82 survivors. We examined whether certain pretransplantation psychiatric and demographic variables predicted posttransplantation outcomes. Patients who were sober < or = 6 months and those who died after transplantation had longer transplant hospital stays, suggesting that physiological compromise may predict posttransplant course. Using survival analyses because of variable follow-up intervals, only age over 50 years and index hospital stays greater than 1 month showed statistical trends toward predicting shorter posttransplant survival duration. Neither pretransplant sobriety, gender, nor duration of pretransplant heavy drinking predicted posttransplant survival duration. No variable, including preoperative sobriety < or = 6 months or attendance at alcohol rehabilitation peritransplant, predicted relapse except for female gender and pretransplant unemployment, in which cases the relapse rate was doubled. Our relapse rate of 21% is comparable to recidivism rates reported from other centers and for the general alcoholic population. These findings, several of which are contrary to general beliefs, continue to challenge our presumed predictive variables in selecting the best candidates for liver transplantation.

Alcohol use following liver transplantation for alcoholic cirrhosis

Due to the significant increase in the number of patients with alcoholic liver cirrhosis being referred for liver transplantation, studies to determine recidivism rates and influential factors affecting those rates have become increasingly crucial. Between 12/85 and 12/91, 67 patients diagnosed with alcohol related end-stage liver disease underwent orthotopic liver transplantation at Baylor University Medical Center. A 3-8 year follow-up study was conducted wherein surviving patients were contacted by phone to evaluate subsequent alcohol consumption following transplantation (with the exception of two patients whose primary physicians were contacted). Of the 67 patients transplanted, 18 had expired, 7 were alive but unavailable, and 1 had been lost to follow-up. Of the remaining 41 patients interviewed, 21 had remained abstinent, while the other 20 had returned to some form of drinking. Of patients with less than 6 months of pretransplant abstinence, only 30% remained abstinent, while the other 70% had resumed drinking. Regarding patients with at least 6 months of pretransplant abstinence, 58% had remained abstinent, while the other 42% had resumed drinking. In both groups, nearly 1/3 of those who had admitted to posttransplant drinking reported themselves as again abstinent and recommitted to sobriety when interviewed. In conclusion, 49% of patients interviewed had resumed some type of drinking following transplantation-- however, this appears not to have affected compliance or survival potential. Only 2 (4.8%) of the 41 patients interviewed had returned to excessive drinking. Thus, our findings support the use of orthotopic liver transplantation for patients with alcohol related end-stage liver disease.

A survey estimate of academic liver transplant teams' selection practices for alcohol-dependent applicants

Alcoholism itself is not a contraindication to liver transplantation. However, certain individual alcoholic applicants may pose an unacceptably high psychosocial risk of poor outcome. Transplant psychiatrists or psychologists at 14 academic liver transplant centers were asked to estimate their centers' selection practices with regard to specific problems in the more difficult alcohol-dependent applicant and with regard to hypothetical problem cases. There was impressive variability in estimated selection practice between the centers. However, the centers consistently appeared to prefer to require rehabilitation or observation in difficult situations rather than to reject applicants outright. The results provide an initial estimate of current thinking and practice with regard to the more difficult alcoholic applicant and suggest directions for further study.

Long-term management of the liver transplant recipient

Despite the potential medical problems described here, the vast majority of liver transplant recipients report a remarkable improvement in the quality of their lives. Many, in fact, have normal lifestyles, in marked contrast to their disability before liver transplantation. Maintenance of this status, however, requires compliance with regular medical follow-up to implement preventive measures and early detection of complications. A basic knowledge of these issues should enable the internist, general practitioner, and gastroenterologist to diagnose and manage many of the problems unique to liver transplant recipients. The liver transplant center should encourage communication and be readily accessible to the primary care physician. This team approach is responsible for measuring the survival of liver transplant recipients in decades, rather than years.

The case for liver transplantation in end-stage alcoholic liver disease

Liver transplantation is now a routine procedure and is seen as a valid treatment option for end-stage liver disease. Alcoholism has been regarded as a relative or absolute contraindication to liver transplantation in many transplant units. Recent data document a success rate for transplantation in alcoholic patients that equals that in other patient groups. Issues relating to the ethical and scientific arguments surrounding this complex area of treatment are discussed. It is concluded that individual patients should be assessed in their own right for this treatment option. It is argued that patient groups should not be denied access to specific life-saving treatments.

Drinking patterns in liver transplant recipients

The study's objective was to evaluate in-depth and follow comprehensively a group of patients receiving liver transplantation. The group consisted of patients with Laennec's cirrhosis and alcohol abuse or dependency. The subjects included 68 of 556 transplant patients, studied over a 7-year period. The results revealed that 13% of the study sample (9 patients) had some relapse into drinking. Only one of these was a severe relapse with an adverse outcome. Four of the most significant relapses occurred in dual diagnosis patients. The patients as a group did as well medically as a comparison group of other transplant recipients.

Liver Transplantation for Alcoholics with Terminal Liver Disease

Most candidates for liver transplantation have irreversible cirrhosis caused by years of heavy alcohol consumption. Arguments against liver transplantation for alcoholics include the presumption of relapse to heavy drinking, which might damage the new liver or lead to its rejection. Corresponding ethical arguments focus on the presumption that alcoholics brought their condition upon themselves and should not compete with nonalcoholics for scarce donor livers. However, experimental data demonstrate that carefully selected alcoholics can survive liver transplantation and return to the workplace as productive citizens. Moreover, it has never been considered ethical for clinicians to refuse treatment to patients for diseases that are partly or wholly preventable.

Effect of alcohol use on allograft rejection rates after liver transplantation for alcoholic liver disease

Alcoholic liver disease is a major cause of liver disease and has become an ever-increasing indication for liver transplantation (LTx). Follow-up studies have reported a higher rate of alcohol recidivism in patients transplanted for alcoholic hepatitis, compared with those transplanted for endstage alcohol-associated cirrhosis. It is assumed widely that recurrent alcohol use is associated with reduced compliance with immune suppression and, as a result, an increased risk of graft rejection and loss. To assess this question, 209 alcoholic patients transplanted for either alcoholic hepatitis with cirrhosis or cirrhosis alone between January 1, 1986 and December 31, 1991 were followed, with a mean follow-up of 4.4 +/- 0.6 years. There were 175 episodes of acute cellular rejection (ACR) that occurred in 137 patients, for an overall rejection rate of 83.7% or at a rate of 1.25 episodes/patient with rejection. The rate of ACR was three times as great in those who remained alcohol-abstinent (2.24 episodes/patient), compared with those who admitted to continued alcohol use (0.75 episodes/patient) (p < 0.01). A total of 33 episodes of chronic rejection occurred in 26 patients, for an overall rate of 12.4%. As was the case for ACR, the chronic rejection rate was greater among those who were continuously alcohol-abstinent, compared with those who intermittently used alcohol after successful LTx. There were no differences in the mean FK 506 or cyclosporin A levels in the groups with and without a rejection episode at the time the rejection episode was documented by liver biopsy.(ABSTRACT TRUNCATED AT 250 WORDS)

The psychiatric assessment of liver transplant patients with alcoholic liver disease: a review

Patients with severe alcoholic liver disease are receiving liver transplants in increasing numbers. Alcoholic liver transplant patients appear to have a good prognosis, yet alcoholic candidates may be rejected on psychiatric grounds alone. The role of the psychiatrist in the multidisciplinary assessment is discussed and the use of a number of predictors of outcome for alcoholic candidates considered. Studies examining these variables have many methodological limitations and it is therefore very difficult to draw any firm conclusions on their validity or reliability. Long-term prospective studies using appropriate measures of outcome should enable the liaison psychiatrist to provide more useful advice on the psychosocial outcome and treatment requirements of this growing group of patients.

Changing indications in liver transplantation

During the last decade orthotopic liver transplantation has become virtually a routine procedure and most centres are reporting, in elective cases, survival rates at 1 year in excess of 90%. As experience with liver transplantation has grown, attention has focused more on refining the indications for transplantation and determining the optimal time for the procedure. In patients with fulminant hepatic failure, it may still be difficult to select those patients who require liver replacement early enough in their illness so that a suitable organ can be found and the procedure carried out before the onset of irreversible complications. Alternatives to orthotopic liver transplantation, including liver support, heterotopic transplantation, partial orthotopic liver transplantation and xenografting, are being assessed. Progress too has been made in improving indications in patients undergoing transplantation for viral hepatitis and alcoholic liver disease. Nonetheless, liver replacement remains a poor substitute for prevention of end-stage liver disease. Even with advances made in immunosuppression, there are long-term sequelae as a consequence of liver transplantation, and now more recently attention is being paid to reducing the toll of immunosuppressive drugs.

Evaluation of efficacy of liver transplantation in alcoholic cirrhosis by a case-control study and simulated controls

To assess the efficacy of liver transplantation in patients with alcoholic cirrhosis, we compared 2-year survival of 169 liver transplantation patients in 12 French centres with survival of two control groups treated conservatively. The matched group was 169 patients of similar age, cirrhosis severity, and bleeding history; the simulated group was 169 patients whose theoretical survival was determined in a cohort of 797 patients with alcoholic cirrhosis. The probability of survival to 2 years in transplanted patients was 73 (95% confidence interval 67-79%) versus 67% (59-75) in the matched and 67% (63-71) in simulated controls. When prognostic factors were taken into account, transplantation was associated with survival (r = 0.527; p = 0.069). Patients with severe liver disease (high-risk group) benefited most for 2-year survival: 64% (42-86) vs 41% (23-59) in the matched and 23% (19-27) in the simulated control groups (p < 0.01). There was no difference for patients at low and at medium risk. Liver transplantation increases the 2-year survival of patients with severe alcoholic cirrhosis. In patients with less severe disease, further studies should be done by non-randomised controlled studies with longer follow-up or by randomised trials.

Predicting recidivism after orthotopic liver transplantation for alcoholic liver disease

With appropriate selection criteria, patients with end-stage alcoholic liver disease who undergo orthotopic liver transplantation have similar graft and patient survivals as patients undergoing transplantation for other causes. However, because of the possibility of recidivism after orthotopic liver transplantation there is still reluctance to transplant alcoholic patients. This study examined the association between pretransplant psychosocial variables and the risk of recidivism after orthotopic liver transplantation. At our institution, 43 patients received orthotopic liver transplantation for the referral diagnosis of alcoholic liver disease from February 1, 1988 to May 1, 1991. This represented 17% of all first transplants (43 of 257) performed during this period. Patients were interviewed before orthotopic liver transplantation by a single psychiatrist and responses to a defined set of questions were entered into a clinical database. All 43 patients diagnosed with alcoholic liver disease and a comparison group of patients transplanted for diagnoses other than alcoholic liver disease received a postoperative questionnaire regarding past and present alcohol use. Patients enrolled in the study all had at least 7 mo of follow-up, with the median follow-up being 21 mo. Eighty-six percent of alcoholic liver disease patients (37 of 43) and 86% of patients in the comparison group (37 of 43) of ALD patients agreed to participate in the study. Nineteen percent of alcoholic liver disease patients (7 of 37) and 24% of patients in the comparison group (9 of 37) admitted to having used alcohol after orthotopic liver transplantation, wtih 8% (3 of 37) and 11% (4 of 37) currently using alcohol, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Alcohol and the liver: 1994 update

This article reviews current concepts on the pathogenesis and treatment of alcoholic liver disease. It has been known that the hepatotoxicity of ethanol results from alcohol dehydrogenase-mediated excessive generation of hepatic nicotinamide adenine dinucleotide, reduced form, and acetaldehyde. It is now recognized that acetaldehyde is also produced by an accessory (but inducible) microsomal pathway that additionally generates oxygen radicals and activates many xenobiotics to toxic metabolites, thereby explaining the increased vulnerability of heavy drinkers to industrial solvents, anesthetics, commonly used drugs, over-the-counter medications, and carcinogens. The contribution of gastric alcohol dehydrogenase to the first-pass metabolism of ethanol and alcohol-drug interactions is discussed. Roles for hepatitis C, cytokines, sex, genetics, and age are now emerging. Alcohol also alters the degradation of key nutrients, thereby promoting deficiencies as well as toxic interactions with vitamin A and beta carotene. Conversely, nutritional deficits may affect the toxicity of ethanol and acetaldehyde, as illustrated by the depletion in glutathione, ameliorated by S-adenosyl-L-methionine. Other "supernutrients" include polyunsaturated lecithin, shown to correct the alcohol-induced hepatic phosphatidylcholine depletion and to prevent alcoholic cirrhosis in nonhuman primates. Thus, a better understanding of the pathology induced by ethanol is now generating improved prospects for therapy.

Controversies in patient selection for liver transplantation

A variety of specific conditions often stimulate controversy regarding candidacy for liver transplantation. We review the published experience with liver transplantation for alcoholic liver disease, fulminant and chronic hepatitis B, and hepatocellular carcinoma and transplantation in older subjects. Liver transplantation for alcoholic liver disease and in subjects older than 60 years is becoming less controversial because recent data demonstrate that these patients have excellent survival and good quality of life after transplantation. Only 10% to 15% of persons with alcoholism return to drinking after transplantation, and most do so only transiently. Liver transplantation for patients with hepatitis B virus infection or primary liver cancer is more problematic because recurrent disease is common in both conditions. After transplantation for chronic hepatitis B, 80% to 90% of patients have reinfection of the allograft and long-term survival is 45% to 50%. Patients receiving transplants for hepatocellular carcinoma have only 20% to 30% long-term survival, but these survivors are cured of malignancy. Data are presented to support continued liver transplantation for chronic hepatitis B and hepatocellular carcinoma; however, patients must be selected based on factors that predict a favorable outcome, and experimental therapies should be employed to explore ways to improve the existing survival rates.

Liver transplantation for alcoholic liver disease: survival of patients transplanted with alcoholic hepatitis plus cirrhosis as compared with those with cirrhosis alone

From January 1986 through December 1991, a total of 221 patients with alcoholic liver disease received liver transplantation. In 147 of these cases, complete pretransplant histopathologic, demographic, and laboratory data (minimum of CBC, AST, ALT, total bilirubin, albumin, and prothrombin time) were available for review. Forty-five (30%) of the 147 recipients had alcoholic hepatitis plus cirrhosis (AH), whereas 70% had cirrhosis (CIRR) alone. Age and sex were similar in the subgroups, but the patients with CIRR had a greater AST/ALT ratio, longer protime, and lower platelet count (all p < 0.01). Coexistent hepatitis B (4.7%) or hepatitis C (4.1%) was similar in both groups. Current survival is 80% for patients with AH and 84% for those with CIRR (NS). Overall, survivors were younger (43.4 +/- 1.7 years) than nonsurvivors (53.6 +/- 3.2) (p < 0.01), an age influence that was significant in the CIRR group (p < 0.01) but not in the AH group. Inexplicably, the AST/ALT ratio was greater in AH survivors (1.5 +/- 0.2) than it was in nonsurvivors (0.4 +/- 0.1) (p < 0.01). In patients with CIRR, the platelet count was greater in survivors (252 +/- 29 vs. 86 +/- 11 x 10(9) cells/liter). The data support the clinical impression that patients with chronic decompensated cirrhosis referred for liver transplantation had more severe complications of their liver disease than did those with AH. Survival in both subgroups was similar, but overall the survivors are nearly a decade younger than the nonsurvivors.(ABSTRACT TRUNCATED AT 250 WORDS)

Liver transplantation for alcoholic liver disease

The role of liver transplantation as a treatment for end-stage liver disease occurring in alcoholic patients is controversial. Earlier predictions that survival of alcoholic patients after liver transplantation was worse than that of non-alcoholic liver graft recipients, or that few alcoholic patients with serious liver disease could meet stringent selection criteria, have proved false. As a result, in many liver transplant programmes, alcoholic liver disease constitutes one of the most common diagnoses among patients proceeding to transplantation. Survival of alcoholic patients after transplantation is similar to that in non-alcoholic patients, i.e. up to 80% or more alive at 1 year. A multidisciplinary selection process has been introduced which includes careful psychiatric assessment to try to identify those patients most likely to maintain long-term abstinence after transplantation. Using this method, approximately 45% of alcoholic patients referred for transplantation have been selected for surgery. Furthermore, the survival rate of alcoholic patients not selected for transplantation because they were considered a poor prognostic risk for sobriety was significantly less than that of alcoholic patients undergoing liver transplantation. The ethical foundations for this multidisciplinary approach are explained in this chapter. Good data on recidivism after transplantation are few. In many programmes, including ours, instances of recidivism, defined as a relapse to a pathologic pattern of alcohol use, are uncommon and occur in 10% or less of alcoholic patients selected for liver transplantation, at least in the first 3 postoperative years. This figure underestimates the incidence of consumption of small amounts of alcohol. The data are limited also by the relatively short period of follow-up in most studies published to date. Whether recidivism will become more common as more patients are followed beyond 3 years remains to be seen.

Is portal-systemic shunt worthwhile in Child's class C cirrhosis? Long-term results of emergency shunt in 94 patients with bleeding varices

A prospective evaluation was conducted of 94 unselected patients ("all comers") with biopsy-proven Child's class C cirrhosis (93% alcoholic) and endoscopically proven acutely bleeding esophageal varices who underwent emergency portacaval shunt (EPCS) (85% side-to-side, 15% end-to-side) within 8 hours of initial contact (mean, 6.1 hours) during the past 12 years. Follow-up has been 100% and includes all patients for at least 1 year, and 61 patients (65%) for 5 to 12 years. Incidence of serious risk factors on initial contact was: ascites, 97%; jaundice, 86%; portal-systemic encephalopathy including past history, 71%; severe muscle wasting, 96%; alcohol ingestion within 7 days, 66%; delirium tremens, 16%; serum albumin, less than or equal to 2.5 g/dL 76%; indocyanine green dye retention greater than or equal to 50% in 45 minutes, 66%; serum glutamic-oxaloacetic transaminase greater than or equal to 100 units/L, 60%; hyperdynamic cardiac output greater than or equal to 6 L/minute, 98%. Mean Child's point score was 13.7 out of a maximum of 15. EPCS reduced mean corrected free portal pressure from 286 to 23 mm saline, and permanently controlled variceal bleeding in every patient. Of the 94 patients, 74 (80%) left the hospital alive and 68 (72%) survived 1 year. Five-year actuarial survival rate is 64%. Hepatic failure was the main cause of death during initial hospitalization as well as during follow-up, when it was related to continued alcoholism. Portal-systemic encephalopathy, which was present on initial contact in 55% of patients, occurred at some time during follow-up in 18.7%, but was recurrent and required dietary protein restriction in only 9%, all of whom had resumed alcoholism. The low incidence of portal-systemic encephalopathy was attributable to the lifelong program of follow-up with regular dietary counseling and continued emphasis on both protein restriction to 60 g/day and abstinence from alcohol. Abstinence was sustained in 69%, liver function improved in 82%, general health was judged excellent or good in 73%, and Child's risk class converted to class B in 73% and class A in 21%. Excluding retirees because of age, 42% were gainfully employed or engaged in full-time housekeeping. Long-term shunt patency was documented in 100% of survivors by yearly angiography or Doppler ultrasonography. It is concluded that EPCS within 8 hours of initial contact permanently controls variceal hemorrhage and results in prolonged survival and a life of acceptable quality in many alcoholic cirrhotic patients in Child's class C.(ABSTRACT TRUNCATED AT 400 WORDS)

Selection for and outcome of liver transplantation in alcoholic liver disease

It has been proposed that evaluation of alcoholic patients for liver transplantation should comprise a multidisciplinary program including medical, surgical, and psychiatric assessment. This article presents the outcome in 99 alcoholic persons evaluated from 1985 through 1989. Alcoholism was defined as alcohol dependence or abuse according to the DSM-III-R. Forty-five patients (43%) were considered suitable candidates and underwent transplantation. Actuarial survival in this group was 78% and 73% at 12 and 24 months, respectively, and did not differ from that observed in nonalcoholic recipients. Return to alcohol use after transplantation has been documented in 5 persons, 2 of whom have had episodes of uncontrolled drinking. Of 54 patients not selected for transplantation, 17 were considered too well and suitable for alternative therapy. Actuarial survival was 93% at 12 and 18 months but declined to 59% at 24 months. Nineteen patients were medically unsuitable and had very poor survival; survival was 35% at 3 months and 0% at 12 months. Seventeen patients were not selected on psychiatric grounds. Actuarial survival in this group (65% at 12 months, 43% at 18 months) was significantly less than that in alcoholics with transplants (P less than 0.05). There were no differences in age, sex ratio, degree of hepatic dysfunction, or duration of abstinence between alcoholics with transplants and those considered psychiatrically unsuitable. It was concluded that liver transplantation is successful in selected patients with alcoholic cirrhosis, that patients who are not selected because they are "too well" need continuing surveillance as a significant decline in survival can occur 18-24 months after initial evaluation and, finally, that patients not selected on psychiatric grounds have a significantly worse survival rate than those with transplants.

The effects of alcohol use on rebleeding and mortality in patients with alcoholic cirrhosis following variceal haemorrhage

The effect of continued alcohol intake on prognosis in alcoholic cirrhotics who have already bled from varices is controversial. To investigate the effect of alcohol intake on prognosis we studied 189 consecutive alcoholic cirrhotics admitted, for the first time, to the Royal Free Hospital with variceal bleeding. Sixty-six died within 30 days of admission and 23 were excluded from the study for other reasons. Of the 100 remaining 15 remained 'probably abstinent' over long-term follow-up, 29 drank occasionally and 56 continued to misuse/abuse alcohol. The percentage survival probability at 2 years was 66% in the probable abstainers, 68% in the occasional drinkers and 63% in the alcohol abuse/misuse group. There were no significant differences in either mortality or rebleeding rates between the three groups. A rebleeding index (designed to take account of the number of rebleeds per patient and the total length of follow-up) also failed to show any significant difference between the three groups. The Cox proportional hazard model was used to study the effect of the following factors on rebleeding and mortality; age, sex, alcohol use, Pugh's score, acute treatment received for initial variceal bleed and long-term treatment received for prevention of recurrent variceal haemorrhage. Pugh's score was significantly related to risk of death during follow-up (p = 0.0122), but none of the other factors was significantly related to risk of rebleeding or mortality. Using conventional methods to determine alcohol use we were unable to demonstrate significant effects of alcohol intake on rebleeding or mortality in alcoholic cirrhotics who had bled from oesophageal varices.

Modern approach to alcoholic liver disease

The pathogenesis of alcoholic liver disease is unclear. The recent literature on pathogenic factors, including direct effects of ethanol and its proximate metabolite acetaldehyde, associated nutritional factors, the formation of acetaldehyde-protein adducts, associated immune alterations, and the potential for liver injury due to coexisting hepatitis virus infection, is highlighted. The therapy of patients with advanced alcoholic liver injury, especially alcoholic hepatitis, is also controversial. It seems reasonable that all patients should receive adequate nutrition even if parenteral or enteral supplementation is required. Corticosteroid administration may benefit those patients with alcoholic hepatitis who have coexisting spontaneous hepatic encephalopathy and no gastrointestinal bleeding. For patients with complications from end-stage alcoholic cirrhosis, liver transplantation should be considered, as the patient with alcoholic cirrhosis does as well after liver transplantation as those patients with other forms of end-stage liver disease.

Long term management of oesophageal varices

Effective control of variceal rebleeding (secondary prophylaxis) or prevention of the initial bleeding (primary prophylaxis) are the main objectives of the treatment of portal hypertension. Endoscopic sclerotherapy is the treatment of choice for secondary prophylaxis, since it significantly decreases rebleeding and, to some extent, mortality. A combination of propranolol and sclerotherapy may be of benefit by decreasing postsclerotherapy rebleeding. Endoscopic variceal band ligation and transjugular intrahepatic shunt are emerging as useful alternative techniques. Devascularisation and preferably selective shunts should be reserved for use as salvage of sclerotherapy failures. Liver transplantation, if feasible, could become the ultimate therapy by controlling variceal bleeding and improving hepatic function. Pharmacotherapy, while not very successful for secondary prophylaxis, has shown promise for primary prophylaxis of variceal bleeding. Nonselective beta-blockers significantly decrease the rebleeding rates but are associated with only marginal survival benefits. beta-Blockers alone cannot decrease the hepatic venous pressure gradient adequately (to less than 12mm Hg). Combination with nitrates and other drugs may prove beneficial and requires clinical evaluation. Endoscopic sclerotherapy and surgery have little role in primary prevention of variceal bleeding in patients with cirrhosis but need evaluation in noncirrhotic patients.

Improvement in cognitive functioning of alcoholics following orthotopic liver transplantation

Cognitive functioning in alcoholic cirrhotics before and 1 year following orthotopic liver transplantation was compared with age- and sex-matched normal subjects. The alcoholic group improved significantly following transplantation on tests measuring psychomotor, visuopractic and abstracting abilities whereas the performance of normal controls remained virtually unchanged. In contrast, memory capacity in alcoholics with cirrhosis did not statistically improve following successful transplantation. Further investigation, using more sophisticated measures of memory function, are required to determine whether memory deficits are either associated with alcohol neurotoxicity or an irreversible component of hepatic encephalopathy. These findings suggest that a reversible hepatic encephalopathy underlies many of the neuropsychologic deficits observed in cirrhotic alcoholics and can be ameliorated following successful liver transplantation.

Liver transplantation. Experience with 100 cases

Between March 1988 and November 1989, 100 liver transplants were performed on 90 patients at Pacific Presbyterian (now California Pacific) Medical Center in San Francisco. The immunosuppressive regimen was a combination of prophylactic Minnesota antilymphocyte globulin, cyclosporine, and low-dose corticosteroids. Rejections were treated with OKT3, a monoclonal antibody, or corticosteroids. Of the 100 transplants, 32 were done on 30 children, 18 of whom weighed less than 10 kg and 9 of whom received livers that had been surgically reduced in size to fit the recipient. The overall patient survival at 2 years was 85%. Of 100 liver transplants, treatment was given for 80 (80%) for at least 1 episode of rejection. At least 1 episode of serious infection occurred in 34 of the 60 adult patients and 25 of the 30 children. Of the entire group, 2% had hepatic artery thrombosis, and 12% had biliary complications that necessitated reoperation. The quality of life has been good, with a follow-up from 1 to almost 3 years (mean = 22 months). Comparing these data with those of other published series shows a decreased incidence of surgical complications and a lower rate of fungal and viral infections. We attribute this to the reduction of steroid dosage during convalescence without jeopardizing patient or graft survival.

Liver transplantation for alcoholic liver disease, viral hepatitis, and hepatic neoplasms

In closing, it is important to note that the indications for liver transplantation are not static but rather are remarkably dynamic and capable of change over time. Thus yesterday's major indications can become relative contraindications, while yesterday's absolute contraindications have become today's nuisances. The goal for physicians who care for individuals with problems such as alcoholic liver disease, viral hepatitis, and hepatic cancer should be to develop new strategies of care that will ultimately eliminate these diseases as problems, rather than eliminating individuals with such health problems from currently available health options. In other words, physicians who accept the responsibility for a patient's life should be searching for the best form of therapy available for their patient rather than examining the reasons that exist for limiting one's choice in health care.

Liver transplantation in patients with alcoholic cirrhosis: selection criteria and rates of survival and relapse

OBJECTIVE

To evaluate the outcome of liver transplantation in patients with alcoholic cirrhosis with respect to selection criteria, survival, and evidence suggesting a return to harmful drinking.

DESIGN

Nine year retrospective study.

SETTING

Cambridge and King's College Hospital liver transplant programme.

SUBJECTS

24 Patients (three women, 21 men) with alcoholic cirrhosis.

MAIN OUTCOME MEASURES

Survival, rehabilitation, and clinical and laboratory evidence of a return to harmful drinking after transplantation.

RESULTS

15 Patients were selected for transplantation because of repeated admission to hospital for the complications of advanced portal hypertension despite abstinence, and six because they had a hepatocellular carcinoma superimposed on alcoholic cirrhosis. Three patients who were not abstinent received transplants. The one year survival rate was 66%, and of the 18 patients surviving at least three months, 17 had been rehabilitated. In three patients laboratory variables and histological examination of the liver suggested a return to drinking, though they did not admit to taking alcohol. These patients represented the only cases in the series that were not abstinent before transplantation.

CONCLUSIONS

The survival and rehabilitation of patients who received transplants for alcoholic cirrhosis compared favourably with those of patients who received transplants for cirrhosis of other aetiology. The criteria for selection for liver transplantation in patients with alcoholic cirrhosis should include recurrent complications related to severe portal hypertension despite maximum medical treatment in addition to a minimum period of six months of abstinence before transplantation.