Post Liver Transplant Management and Outcomes in Alcohol-Related Liver Disease.

S19 * LIVER TRANSPLANTATION IN PATIENTS WITH ALCOHOLIC LIVER DISEASE

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Alcoholic liver diesease (ALD) is still the most frequent and lethal complication in chronic alcoholism. Primary treatment modalities are abstinence, agents that suppress inflammation, anticytokine therapy and nutritional support, among others. For alcoholic liver cirrhosis, transplantation is an accepted option but requires careful consideration of alcohol history and future prognosis resp treatment options. Although there is a relationship between the lemgth of sobriety and future abstience, the present methods to predict future drinking are inexact. Approximately 20% of patients return to harmful drinking after transplantation (Lucey, 2011). Compared with other patient groups, relapse rates in patients with ALD are low. A number of other clinical variables apart from length of abstinence (Tandon et al. , 2008) may predict outcome as alcohol research shows. This may include alcohol-associated symptoms, previous treatments and psychopathological symptoms including cogntion and history of suicide attempts. In general, DSM-IV-Tr alcoholism criteria appear to have greater utility for predicting survival differences beyond pathophysiologically defined alcoholic liver failure (Rowley et al. , 2010). Implications for diagnosis and treatment are discussed. REFERENCES Lucey M (2011) Liver transplantaion in patients with alcoholic liver disease. Liver Transpl , doi. 10.1002/lt.22330. Rowley AA, Hong BA, Chapmna W et al. (2010) The psychiatric disgnosis of alcohol abuse and the medical diagnosis of alcoholic related liver disease: effect on liver transplant survival. J Clin Psychol Med Settings 17 :195–202. Tandon P, Goodman KJ, Ka MM et al. (2009) A shorter duration of pre-transplant abstinence predicts problem drinking after liver transplantation. Am J Gastroenterol 104 :1700–1706. # S16.4 EARLY LIVER TRANSPLANTATION AS A RESCUE OPTION FOR PATIENTS WITH SEVERE ALCOHOLIC HEPATITIS NON-RESPONSIVE TO THERAPY: A CHANGE OF PARADIGMS? {#article-title-2} Although liver transplantation (LT) for alcoholic liver disease has a favorable outcome, it remains controversial in the eyes of the public. To ration organs, most programs require a 6-month period of abstinence prior to evaluation of alcoholic patients, which is presumed to: (a) permit patients to recover from liver failure; (b) identify subsets of patients likely to maintain abstinence after LT. Acute alcoholic hepatitis (AAH) is the most severe form of alcoholic liver disease. In its severe form (defined by a discriminant function ≥32), the risk of dying within 2 months is 40–50%. A recent analysis of individual data from five randomized controlled studies evaluating corticosteroids in severe AAH patients demonstrated a better short-term survival in the group of patients treated by steroids. The so-called Lille model enables clinicians to identify early on those patients unlikely to respond to medical management. Using this approach, strict application of the 6-month rule may be unfair to such patients, since 70–80% of them die prior to the end of the sobriety period. Alternative therapies, such as pentoxifylline or MARS therapy, have been demonstrated to be inefficient in patients non-responsive to corticosteroids. The recent French and Belgian pilot experience in highly selected patients showed that early LT clearly improves 6-month survival of patients with severe AAH refractory to medical management. In this preliminary experience, the relapse rate was limited and occurred late after LT. This approach opens new perspectives for such patients, but will need a drastic selection of candidate patients by expert centers. These encouraging results must be confirmed by other groups. REFERENCES Lucey M, Mathurin P, Morgan TR (2009) Alcoholic hepatitis. N Engl J Med 360 :2758–2769. Mathurin P, O'Grady J, Carithers RL et al. (2011) Corticosteroids improve short-term survival in patients with severe alcoholic hepatitis: meta-analysis of individual patient data. Gut 60 :255–260. Louvet A, Naveau S, Abdelnour M et al. (2007) The Lille model: a new tool for therapeutic strategy in patients with severe alcoholic hepatitis treated with steroids. Hepatology 45 :1348–1354. Louvet A, Diaz E, Dharancy S et al. (2008) Early switch to pentoxifylline in patients with severe alcoholic hepatitis is inefficient in non-responders to corticosteroids. J Hepatol 48 :465–470. Moreno C, Duclos-Vallee JC, Castel H et al. (2010) Early transplantation improves survival of non-responders to corticosteroids in severe alcoholic hepatitis: a challenge to the 6 month rule of abstinence. Am J Transplant A398.

Alcohol-related liver disease (ALD) is the leading indication for liver transplantation (LT) in the USA. Alcohol relapse post-LT can negatively impact long-term outcomes, and prognostic scoring systems are available for further study. Our study aims were to: (1) evaluate the relationship between alcohol relapse and rejection and mortality, (2) investigate risk factors for relapse, and (3) assess predictive validity of the SIPAT (Stanford Integrated Psychosocial Assessment for Transplant) and SALT (Sustained Alcohol Use Post-Liver Transplant) scores on post-LT alcohol relapse. We conducted a retrospective chart review of 155 patients transplanted for chronic ALD at a single transplant center. Cox proportional hazard models assessed the relationship between alcohol relapse and allograft rejection and psychosocial risk factors for relapse. 20% of patients met criteria for alcohol relapse. Alcohol relapse was associated with allograft rejection (HR 2.33, 95% CI 1.11-4.91, p = .03). Three variables most strongly associated with alcohol relapse: prior relapse, failure to engage in recommended alcohol treatment, and continued drinking with liver disease, which were combined into a psychosocial model. SIPAT score≥ 21 and SALT score ≥ 7 were associated with alcohol relapse (HR 6.40, 95% CI 1.36-30.18, p = .019 and HR 2.30, 95% CI 1.12-4.75, p = .024). Receiver operator characteristic analysis compared predictive ability of our psychosocial model to SIPAT (C-statistic .83 compared to .71) and SALT (C-statistic = .77 compared to .62). We identified important psychosocial predictors of post-LT alcohol relapse and validated SIPAT and SALT scores as pre-transplant risk factors for alcohol relapse.

Alcoholic relapse damages liver allografts

Early liver transplantation (ELT) describes liver transplantation (LT) for alcohol-related liver disease (ALD) performed before 6 months of alcohol abstinence, commonly known as the "6-month rule." Although recent evidence demonstrates favorable outcomes after ELT, concern that the public may withdraw from organ donation if ELT grows as a practice is underexplored empirically. We sought to investigate desire to donate after exposure to information about ELT. We designed a public perception survey using expert feedback, cognitive interviewing, and pilot testing. We used quota-based sampling based on US national demographics and distributed the survey from November 15, 2023 to January 10, 2024 using Qualtrics research services. Of 2032 respondents who completed the survey, 57.4% of respondents reported being registered organ donors or specifying an intent to donate in a living will. After learning about ELT, 61.0% of respondents expressed agreement with ELT, a similar proportion to those who expressed agreement with LT for ALD without being given prior information (64.1%). In response to information that some centers do not require the 6-month alcohol-free period, 55.7% of respondents indicated they wanted to be an organ donor, 15.5% did not want to be a donor, and 28.8% were unsure. Of the respondents who stated they were organ donors, 82.9% reported a desire to be organ donors after exposure to information about ELT. Public perceptions of ELT do not appear substantially different from perceptions regarding LT for ALD. Our findings do not support concerns about widespread public withdrawal from organ donation due to ELT.

IntroductionIn the UK, alcohol related liver disease (ArLD) is the leading indication for liver transplant (LT) wait-listing. Outcomes post LT for ArLD compare very well with those for other aetiologies,...

Alcohol-related liver disease (ALD) has become the major cause of liver transplantation (LT) in Korea, and is currently the most common cause of LT in Europe and the United States. Although, ALD is one of the most common indications for LT, it is traditionally not considered as an option for patients with ALD due to organ shortages and concerns about relapse. To select patients with terminal liver disease due to ALD for transplants, most LT centers in the United States and European countries require a 6-month sober period before transplantation. However, Korea has a different social and cultural background than Western countries, and most organ transplants are made from living donors, who account for approximately twice as many procedures as deceased donors. Most LT centers in Korea do not require a specific period of sobriety before transplantation in patients with ALD. As per the literature, 8%–20% of patients resume alcohol consumption 1 year after LT, and this proportion increases to 30%–40% at 5 years post-LT, among which 10%–15% of patients resume heavy drinking. According to previous studies, the risk factors for alcohol relapse after LT are as follows: young age, poor familial and social support, family history of alcohol use disorder, previous history of alcohol-related treatment, shorter abstinence before LT, smoking, psychiatric disorders, irregular follow-up, and unemployment. Recognition of the risk factors, early detection of alcohol consumption after LT, and regular follow-up by a multidisciplinary team are important for improving the short- and long-term outcomes of LT patients with ALD.

Introduction: Although elderly liver transplant (LT) recipients have shown to have inferior outcomes to younger recipients, optimizing recipient selection may minimalize this discrepancy. LT trends and outcomes in the elderly within the three leading indications for LT, chronic hepatitis C (HCV), alcoholic liver disease (ALD) and non-alcoholic steatohepatitis (NASH) have yet to be defined. Methods: Using the United Network for Organ Sharing database, we analyzed LT trends and post-LT survival in an elderly age-specific (age > 65) cohort with a diagnosis of HCV, ALD or NASH from 2005-2014. Additionally, we compared demographic data (age, gender and ethnicity), Model End-Stage Liver Disease (MELD) score and hepatocellular carcinoma (HCC) within LT recipients < 65 years and > 65 years. Kaplan-Meir survival methods were performed to determine long-term (5-year LT) survival. Results: Overall from 2005-2014, there were 28,872 LT recipients secondary to HCV, ALD and NASH. Elderly LT recipients constituted 3,954 (13.0%) of LT. The proportion of elderly LT recipients was highest in NASH (n=1185, 26.7%), ALD (n=1076, 13.2%) and HCV (n=1693, 9.5%). Within this decade the number of elderly LT performed increased 8.6% annually. Compared to NASH LT recipients < 65, elderly NASH LT recipients had a significantly (p < 0.05) higher prevalence of non-Hispanic Whites (87.9% to 72.7%) and HCC (22.2% to 10.4%) and a lower mean MELD at LT excluding HCC cases (20.9 to 23.2) (Table). Although elderly LT recipients had a higher prevalence of HCC than their younger counterparts within all three etiologies, elderly LT recipients without HCC were transplanted at a lower acuity of illness or MELD score (Table). Compared to the younger cohorts, elderly LT had a significantly (p < 0.01) lower survival rate with the largest disparity seen in elderly NASH LT (< 65, 85.2%; > 65, 76.8%, p < 0.01) (Table). Within the elderly LT recipients, 5-year post LT survival rate was similar amongst NASH and ALD (NASH 76.8%, ALD 76.0%, HCV 71.7%, p = 0.03). Overall, elderly ALD LT recipients had higher long-term post-LT survival than NASH and HCV (Figure). Conclusion: The number of elderly LT recipients continues to rise, particularly within the elderly NASH LT population. Although elderly NASH LT recipients demonstrated a higher 5-year post-transplant survival compared to HCV, the large age-specific survival disparity within NASH necessitate further analysis to improve recipient selection.Figure 1Figure 2

Alcoholic liver damage–toxicity, autoimmunity and allergy

Retrospective-prospective study of safety and efficacy of sofosbuvir-based direct-acting antivirals in HIV/HCV-coinfected participants with decompensated liver disease pre- or post-liver transplant.

Liver transplantation in patients with alcohol-related liver disease: current status and future directions

Liver transplantation for alcoholic hepatitis in the United States: Excellent outcomes with profound temporal and geographic variation in frequency.

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