Quality of life, employment, and alcohol consumption after liver transplantation:

Liver Transplantation for Alcohol-Related Liver Disease

Alcoholic liver disease (ALD) is a common indication for liver transplantation. It is a much debated indication for deceased donor liver transplantation due to organ shortage and potential of alcohol relapse after liver transplantation. A six-month abstinence before liver transplantation is required at most centers to decrease chances of alcohol relapse after liver transplantation. However, this rule is not relevant for patients with severe alcoholic hepatitis or severely decompensated patients who are unlikely to survive till 6 months. Long-term care of these patients after liver transplantation includes assessment of relapse, smoking, and surveillance of de novo malignancies. Current review discusses role of abstinence, factors affecting alcohol relapse, liver transplantation for alcoholic hepatitis, role of living donor liver transplantation, and long-term care of ALD patients who undergo liver transplantation.

Risk factors for alcohol relapse after liver transplantation for alcoholic cirrhosis in Japan

Alcoholic liver cirrhosis (ALC) is an established indication for liver transplantation (LT). Most LT procedures in Japan are living donor liver transplantation (LDLT) because of an extreme shortage of deceased donors. Social circumstances enabling LDLT could be favorable for preventing relapse. The aims of this retrospective study were to analyze the outcomes of LDLT for ALC and to evaluate risk factors for relapse in this cohort. One hundred ninety-five subjects underwent LT [LDLT (n = 187), deceased donor LT (n = 5), or domino LT (n = 3)] for ALC in Japan from November 1997 to December 2011. Risk factors for alcohol relapse and the impact of relapse on outcomes were analyzed for 140 patients after the exclusion of 26 patients who died in the hospital and 29 patients without information about alcohol relapse. The incidence of alcohol consumption after LT was 22.9%. The risk factors for patient survival were a donor age ≥ 50 years (P < 0.01) and a Model for End-Stage Liver Disease score ≥ 19 (P = 0.03). The 10-year patient survival rates were 21.9% and 73.8% for patients who had relapsed and patients who had not relapsed 18 months after LT, respectively (P = 0.01). The relapse rates were 50.0%, 34.5%, 13.3%, 19.7%, and 14.3% for patients who had received livers from parents, siblings, spouses, sons/daughters, and deceased or domino donors, respectively. A history of treatment for psychological diseases other than alcoholism before LT was a significant indicator for the risk of recidivism (P = 0.02), and noncompliance with clinic visits after LT and smoking after transplantation were promising indicators for the risk of recidivism (P = 0.06, and P = 0.05, respectively). Preoperative alcohol consumption was not a risk factor. In conclusion, rather than selecting patients on the basis of preoperative alcohol use, we should provide sociomedical support to improve adherence after LT for ALC in Japan.

Liver transplantation for patients with alcoholic liver disease: an open question

End-stage alcoholic liver disease is a recognised indication for liver transplantation but some questions on the matter remain open. It is difficult to quantify alcohol consumption, and a single definition of post-transplant relapse is lacking. Moreover, there are no internationally accepted criteria for the selection of candidates for liver transplantation and the eligibility parameters for these patients are controversial. Additional clinical and psychological evaluations are necessary in this setting, especially to establish the risk of alcohol relapse. Nevertheless, patient and graft survival rates after liver transplantation in alcoholic liver disease are comparable to those after transplant for other aetiologies, alcohol consumption relapse being one of the most important problems in the post-transplant phase. In conclusion, alcohol-related liver disease is a good indication for liver transplantation. The main future goals are to formulate a well-defined pre-transplant approach and a single definition of alcohol relapse and to improve prevention strategies.

Quality of life and employment after liver transplantation

1. In general, the health-related quality of life (QOL) of transplant recipients is impaired before and improves after liver transplantation. 2. Transplant recipients report largest gains in those aspects of QOL most affected by physical health and smaller improvements in areas affected by psychological functioning. 3. No utility-based measures have been used with liver transplant recipients; therefore, the necessary QOL weights for use in cost-effectiveness evaluations of liver transplantation are lacking. 4. Pretransplantation, the percentage of candidates with alcoholic liver disease (ALD) who work is less than that of candidates without ALD. However, there is no difference in rates of employment posttransplantation. 5. No study has described types of wages and benefits associated with jobs before or after transplantation or the extent to which health insurance benefits associated with employment motivate changes in work status. 6. Many studies in this field used non-validated heterogeneous instruments to measure QOL and employment, thus limiting the opportunity to combine results across studies and compare outcomes for liver transplant recipients with other patient populations.