Heavy drinkers who have severe liver inflammation are much more likely to survive if they get a prompt liver transplant than if they wait a few months, new research finds. Allowing some alcoholics with a potentially lethal form of liver disease to move up the waiting list for a transplant — a controversial area of transplant policy — would save lives, researchers suggest in the Nov. 10 New England Journal of Medicine.
About 10 to 15 percent of donor livers go to people whose liver disease stems directly from alcohol, says Robert Brown, a hepatologist at Columbia University in New York City who wasn’t involved in the new study. But the number is an estimate at best since many people who qualify for a transplant because of liver damage from other causes might also drink, he says.
In the United States, transplant guidelines require that alcoholics stay sober for six months before they can be placed on the waiting list for a liver transplant. Six months of abstinence and medication improve the health of many people with alcohol-related liver disease, but the delay can be fatal for those with a form of alcohol-induced liver inflammation that doesn’t respond to routine medication. About 70 to 80 percent of people with this condition, called severe alcoholic hepatitis, die within six months.
For the new study, physician Philippe Mathurin of the Claude Huriez Hospital in Lille, France, and his colleagues chose 26 patients to get a liver transplant within a few weeks of being diagnosed with alcoholic hepatitis. The patients had failed to respond to medication such as steroids, the typical treatment for the condition. The researchers also monitored 26 similar patients who didn’t receive transplants.
Six months after surgery, six of the 26 transplant patients had died, compared with 20 of the 26 who didn’t get a liver transplant.
These findings challenge the notion that transplant eligibility for all alcoholism-related liver patients must be linked to a prescribed abstinence period, Mathurin argues. But changing transplant guidelines takes years, he acknowledges, and the new data will need to be reproduced by other scientists. Ultimately, he says, patients on the waiting list for donor organs “need to be ranked by sickest-first and according to the severity of their disease, regardless of the cause.”
Underlying the U.S.’s six-months-sober policy is the assumption that alcohol-related liver disease is a self-inflicted problem, Brown says. “There is an inherent bias against alcohol as a reason for transplant.” He acknowledges that consuming alcohol is a deliberate act but notes that other factors that contribute to liver disease — obesity, smoking, sedentary lifestyle, hepatitis C — could also be seen as self-inflicted. In the study, three of the 26 transplant patients reported drinking at some point during the two years after the operation.
Surgeons have to make difficult assessments when determining how urgently a patient needs a transplant, Brown says, and the new data should be factored in. “When the likelihood of dying is 70 percent, the default has to be to transplant,” he says. Patients with severe alcoholic hepatitis who don’t respond to medication would constitute only a few percent of total liver transplants, he estimates.
The true prevalence of alcoholic hepatitis is unknown, but by some estimates it comprises 10 to 35 percent of all alcohol-related liver disease.