Liver transplant for acute alcoholic hepatitis

James Trotter, MDBaylor University Medical Center

Dallas, Texas

OLT – acute alcoholic hepatitis• background

• outcomes

• current guidelines

• future

Alcoholic liver disease

• acute alcoholic hepatitis– young, < age 40– active drinking, acutely very ill– high inpt mortality rate

• alcoholic cirrhosis– usually older > 50 y– ascites, jaundice, non-bleeding varices– variable mortality rate

Alcoholic liver disease - OLT

• “they did it to themselves”– other illness are self-induced (HCV, fatty liver)– “disease paradigm” of alcoholism

• “they will just go back to drinking again”– many have long-established sobriety– most don’t drink after OLT– excellent post-OLT survival

Current criteria – OLT EtOH cirrhosis

• alcoholic cirrhosis• 6 months sobriety• “proves” sobriety commitment• weak supporting data

Current criteria – 6 m sobriety rule

• some patients recover – no OLT

• some patients die

• alcoholic hepatitis resolves

OLT – alcoholic cirrhosis

57-year-old alcoholic cirrhosis sober for 8 yrslong-term clinic patient.

diet-controlled DM

bili – 4.1 Cr – 1.2 INR – 2.3 MELD – 23anticipated wait time to transplant 6 – 12 m

OLT – alcoholic cirrhosis

57-year-old alcoholic cirrhosis sober for 8 yrslong-term clinic patient.- employed, insured- married, family- proven long-term clinic compliance- no psych, drug or legal problems

New criteria – acute EtOH hepatitis

• acute illness, very sick, short evaluation• no sobriety period• recidivism predicted from risk factors• based on French study in NEJM

OLT – acute alcoholic hepatitis

27-year-old WM presents with decompensation

EtOH level – 178 on admission

dx alc liver disease 2 yrs ago, continued to drink

bili – 24.1 Cr – 1.2 INR – 4.3 MELD – 37

anticipated wait time to transplant 6 – 12 d

OLT – acute alcoholic hepatitis

27-year-old WM presents with decompensation

OLT – acute alcoholic hepatitis

27-year-old WM presents with decompensation

- recently fired, paying monthly for insurance- no insight about EtOH causing illness- unmarried, parents “fighting for patient”- failed EtOH rehab, 2 DUI’s- prior psych rx, never followed up

Acute hepatitis vs. cirrhosis

alc hepatitis cirrhosisfollow-up none long-termduration acute chronicsobriety no yesseverity very high highevaluation hours-days weekswait time days months

OLT – acute alcoholic hepatitis• scientific

• sociologic

• transplant

Criteria- nonresponse to medical therapy - first liver-decompensating event- supportive family members- absence of psychiatric disorder- agreement to adhere to lifelong total abstinence

2 % of all patients with acute alcoholic hepatitis

12 % recidivism rate

Clinical experience – no uniform selection criteria

28 % recidivism rate

Post-OLT recidivism – risk factors

• >10 drinks/d at initial hospitalization (+4 pts)

• multiple prior rehabilitation attempts (+4 pts)

• prior alcohol-related legal issues (+2 pts)

• prior illicit substance abuse (+1 pt)

Hepatology 2018

Death rates attributed to alcohol

MMWR, 2017

Transplant factors• decline of hepatitis C

• organ competition

• “need” for healthy, high-MELD patients

1. 1st presentation with decompensated liver disease

2. OLT medical eligibility3. assessment w SW and

addiction specialist.4. < 1 prior failed rehab5. lack of other substance use/

dependency/psyc disease6. patient insight

7. 2 close, supportive family members or caregivers 8. post LT care with addiction specialist in LT clinic 9. transplant team facilitating alcohol use treatment 10. EtOH monitoring owith ETG and PEtH for at least 2 yrs

PRO – acute alcoholic hepatitisAbstinence duration not relevantNon-transplant outcomes poorInitial outcomes are favorableGrowing number of young, sick patients

CON – acute alcoholic hepatitisUS patients poorly selected

Higher rates of recidivism

Displacing more qualified patients

Transplant centers “redefining” alcoholism for their own purposes

Criteria- nonresponse to medical therapy - first liver-decompensating event- supportive family members- absence of psychiatric disorder- agreement to adhere to lifelong total abstinence

2 % of all patients with acute alcoholic hepatitis