Transplantation for acute alcoholic hepatitis

New Indications for Liver Transplantation

Liver transplantation (LT) is an important therapeutic option for the treatment of several liver diseases. Modern LT is characterized by remarkable improvements in post-transplant patient survival, graft survival, and quality of life. Thanks to these great improvements, indications for LT are expanding. Nowadays, clinical conditions historically considered exclusion criteria for LT, have been considered new indications for LT, showing survival advantages for patients. In this review, we provide an updated overview of the principal newer indications for LT, with particular attention to alcoholic hepatitis, acute-on-chronic liver failure (ACLF), cholangiocarcinoma and colorectal cancer metastases.

Limitations of current liver donor allocation systems and the impact of newer indications for liver transplantation

Liver transplantation represents a life-saving treatment for patients with decompensated cirrhosis, a severe condition associated with a high risk of waiting list mortality. When decompensation occurs rapidly in the presence of extrahepatic organ failures, the condition is called acute-on-chronic liver failure, which is associated with an even higher risk of death, though liver transplantation can also markedly improve survival in affected patients. However, there are still gaps in our understanding of how to optimise prioritisation and organ allocation, as well as survival among patients with acute-on-chronic liver failure (both before and after transplant). Moreover, it is urgent to address inequalities in access to liver transplantation in patients with severe alcoholic hepatitis and non-alcoholic steatohepatitis. Several controversies still exist regarding gender and regional disparities, as well as the use of suboptimal donor grafts. In this review, we aim to provide a critical perspective on the role of liver transplantation in patients with decompensated cirrhosis and address areas of ongoing uncertainty.

Severe acute alcoholic hepatitis: can we offer early liver transplantation?

Alcohol-related liver disease is one of the most prevalent liver diseases worldwide and is the second most common indication for liver transplantation. Most transplant programs require 6 months of abstinence prior to transplantation; commonly referred to as the "six-month rule." According to this rule, the patients admitted for severe acute alcoholic hepatitis are not eligible for liver transplantation in most transplant centers. However, there is increasing evidence that if liver transplantation is performed in selected patients after the first episode of severe decompensation with no response to steroid therapy, it represents an effective treatment. In such selected patients, the post-transplant outcomes are good with survival rates that are significantly higher when compared with patients not responding to medical therapy and not transplanted. A multidisciplinary assessment, involving several stakeholders such as a transplant hepatologist, transplant surgeon, psychologist and psychiatrist is becoming mandatory to properly evaluate the candidate to liver transplantation for alcoholic liver diseases and severe acute alcoholic hepatitis. In the clinical setting of severe acute alcoholic hepatitis, further studies are needed for the identification of accepted selection clinical and psychosocial criteria that can provide the best long-term results. The early liver transplantation option should therefore be explored within strict criteria for this setting.