Liver Transplantation in Patients With Alcoholic Liver Disease

A Retrospective Study

Gabriele A. Vassallo; Claudia Tarli; Maria M. Rando; Carolina Mosoni; Antonio Mirijello; Adwoa Agyei-Nkansah; Mariangela Antonelli; Luisa Sestito; Germano Perotti; Daniela Di Giuda; Salvatore Agnes; Antonio Grieco; Antonio Gasbarrini; Giovanni Addolorato

Disclosures

Alcohol Alcohol. 2018;53(2):151-156. 

In This Article

Abstract and Introduction

Abstract

Aim Alcoholic liver disease (ALD) is the most common liver disease in the Western World. Liver transplantation (LT) is the treatment for end-stage ALD. However, many transplant centers are still reluctant to transplant these patients because of the risk of alcohol relapse, recurrence of the primary liver disease and associated post-transplant complications. We examined survival rate, prevalence of primary liver disease recurrence, re-transplantation and post-transplant complications among transplanted patients for alcoholic cirrhosis compared with those transplanted for viral cirrhosis.

Methods data about patients transplanted for alcoholic and viral cirrhosis at the Gemelli Hospital from January 1995 to April 2016 were retrospectively collected. Survival rate was evaluated according to the Kaplan–Meier method. Recurrence was defined as histological evidence of primary liver disease. Data on the onset of complication, causes of death and graft failure after liver transplant were analyzed.

Results There was no statistically significant difference regarding survival rate between the two groups. Only patients transplanted for viral cirrhosis presented with primary liver disease recurrence. There was a higher rate of cancer development in patients transplanted for alcoholic cirrhosis. Cancer was the major cause of death in this population. Risk factors associated with the onset of cancer were a high MELD score at the transplant time and smoking after transplantation.

Conclusion ALD is a good indication for LT. Patients transplanted for alcoholic cirrhosis should receive regular cancer screening and should be advised against smoking.

Short Summary No difference was found between patients transplanted for alcoholic cirrhosis and viral cirrhosis in term of survival rate. Only patients transplanted for viral cirrhosis presented primary liver disease recurrence. A higher rate of cancer development was found in patients transplanted for alcoholic cirrohosis. This complication was associated with post-trasplant smoking.

Introduction

Alcohol use disorders (AUD) represents the most common cause of liver disease in the Western countries (Tilg and Day, 2007). The development of alcoholic liver disease (ALD) is influenced by environmental and host factors other than alcohol consumption per se. The duration of alcohol abuse, the drinking pattern and the amount of alcohol consumed have been reported as the most important factors for ALD progression. Moreover, recent studies have suggested that gut flora could play an important role in the pathophysiology of alcoholic liver injury (Vassallo et al., 2015). ALD ranges from simple steatosis (fatty liver) to steatohepatitis, cirrhosis and hepatocellular carcinoma (Tilg and Day, 2007). Independently from the stage of disease, total alcohol abstinence represents the cornerstone of the management of ALD (Addolorato et al., 2016b). Alcohol abstinence may reduce the disease progression; several studies indicate that a stable liver function and recovery from advanced liver failure may be achieved with alcohol abstinence in AUD patients with advanced ALD (Lucey, 2009). At present, the psychosocial approaches combined with pharmacotherapies seem effective to help these patients to achieve and maintain alcohol abstinence (Addolorato et al., 2013a). When liver function fails to improve with abstinence, liver transplantation (LT) is the treatment of choice for end-stage ALD (Addolorato et al., 2016a). However, concerns persist about LT in patients with AUD, related to the risk of alcohol relapse, the consequent recurrence of liver disease, poor compliance with post-LT management by AUD patients, the presence of extra-hepatic alcohol-related disease and post-transplant complications (Vassallo et al., 2013). AUD is still often considered a 'self-inflicted disease', and part of the society considers alcoholic individuals as patients not deserving LT (Neuberger et al., 1998). Viral cirrhosis is the leading indication for LT in the Western World (O'Leary et al., 2008; Song et al., 2014), with cirrhosis due to hepatitis C being the most frequent indication. Prior to the introduction of new direct-acting antiviral agents, recurrence of HCV infection after LT was present in all liver transplant recipients who demonstrated hepatitis C viremia at the time of transplantation (Gruener et al., 2004). Progression to HCV-related cirrhosis was estimated to reach 20–30% at 5-year follow-up after LT, resulting in the need for re-transplantation, worse outcomes and greater health care costs (Gruener et al., 2004). Despite the high risk of HCV recurrence after LT prior to the introduction of these new direct-acting antiviral agents, it was rare for LT to be denied to an HCV-infected patient with end-stage liver disease on the grounds of HCV alone. In AUD patients with an adequate therapeutic approach for maintaining alcohol abstinence, it is possible to prevent relapse and alcohol-related liver damage after LT (Gallegos-Orozco and Charlton, 2016). The treatment of hepatitis C virus infection has been advancing at breakneck speeds over the past few years with a very high cure rates ranging from 95–100%. Although these drugs may not be universally available in the short or medium-term, the high cure rate will radically change the need for liver transplant, with ALD becoming the leading indication for LT. For this reason, it is crucial to identify the best post-transplant management to improve the risk of post-transplant complications in this population. The aim of this study was therefore to assess survival rate, prevalence of primary liver disease recurrence, re-transplantation and post-transplant complications comparing transplanted patients for alcoholic cirrhosis with those transplanted for viral cirrhosis. Moreover, risk factors for post-transplant complications were analyzed.

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