Researchers at Keck Medicine of USC say these patients can do well and the established waiting list inclusion/exclusion criteria warrant a closer look.
A recent Keck Medicine of USC study shows that liver transplant patients with established alcohol abuse issues prior to transplantation can do as well as, or better than, others who receive new livers — a finding that challenges longstanding selection criteria.
“The assumption has been that liver failure patients who continue to use alcohol are poor transplant candidates because they aren’t motivated to take care of the donor organ,” said senior author Brian Lee, MD, a liver transplant hepatologist at Keck Medicine of USC. “However, that view is not supported by the data.”
The study, which ran in the American Journal of Gastroenterology, acknowledges that the persistent scarcity of donor organs means that doctors must make difficult decisions while screening potential transplant candidates for those most likely to thrive. However, some seemingly common-sense inclusion or exclusion criteria are not backed by hard data, Lee said.
For example, many centers mandate six months of sobriety before transplantation, even though research shows such abstinence is no guarantee against post-transplant drinking.
Doctors also view strong support networks as a plus when evaluating transplant candidates, though research hasn’t confirmed the importance of that factor.
Keck Medicine of USC does not mandate six months of sobriety. Such a delay in transplantation can be a death sentence for some patients, Lee said, including those who have no serious symptoms before being diagnosed with end-stage liver disease.
“With the extraordinary rise in both listings and completed transplants for alcohol-associated hepatitis in the setting of the COVID-19 pandemic, the need to explore the appropriateness of selection criteria is more relevant than ever,” Lee said. “This study will ideally serve as a foundation for ongoing debate among liver transplant providers and teams to improve selection and post-transplant practices as well as encourage a revision to national transplant policies.”
This study looked at 241 liver transplant patients, including 31 who continued using alcohol against doctors’ advice after being diagnosed with alcohol-related hepatitis. The other 210 patients received transplants for sudden, unexpected liver failure resulting from heavy drinking.
“The conventional wisdom was that these patients who continued drinking were more at risk for bad outcomes and were possibly more likely to return to drinking after transplant,” said first author Matthew Dukewich, MD, a gastroenterology fellow at USC. “Perhaps they had more recalcitrant addiction, which would be difficult to overcome after transplant.”
Drinking after a liver disease diagnosis
The researchers found a higher risk of death and resumption of drinking among transplant patients who continued drinking after a liver disease diagnosis. However, three-year survival rates were still high in both groups: 78% for those with a history of continued drinking after liver disease diagnosis, versus 85% for those with sudden liver failure. Most patients in both groups were able to stop drinking completely after transplant.
These survival rates are similar to those of patients transplanted for liver cancer, who account for 25% of total liver transplant recipients in the United States.
“We know that these patients are sick enough that if they weren’t transplanted, only 30% would have survived three months,” said Dukewich. “The study supports the idea that liver transplant, even in this patient population that was deemed high-risk, is life-saving, has merit, and should be studied further.”
USC is the coordinating center for ACCELERATE-AH, the American Consortium of Early Liver Transplantation for Alcohol-Associated Hepatitis. The consortium of 12 centers, started by Lee and colleague Norah Terrault, MD, chief of the Division of GI and Liver at the Keck School of Medicine of USC, is the largest longitudinal cohort of patients transplanted for alcohol-associated hepatitis (AH) without mandated sobriety.
In addition to Lee, Dukewich and Terrault, other study authors are Hyosun Han of USC; Ethan M. Weinberg of the University of Pennsylvania; Neha Jakhete, Kirti Shetty and Elizabeth Stonesifer of the University of Maryland; Gene Im, Stephanie Rutledge and Sander Florman of the Icahn School of Medicine at Mount Sinai; Michael Lucey and John Rice of the University of Wisconsin; David Victor, Mark Ghobrial and Akshay Shetty of Houston Methodist Hospital; Christine Hsu of Georgetown University; and Mohamed Shoreibah, Mahmoud Aryan and Babak Orandi of the University of Alabama.