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


Alcohol Alcohol. 2018;53(2):151-156. 

In This Article

Materials and Methods

Between January 1995 and April 2015, 400 patients with liver cirrhosis underwent LT at the Liver Transplantation Center of the Gemelli Hospital, Rome (Italy). The diagnosis of cirrhosis was based on physical examination, biochemical laboratory tests and diagnostic imaging. Severity of cirrhosis was classified according to the Child-Pugh score. From 2003 the model of end-stage liver disease (MELD) score was used to determine which patients required LT and the priority to be attributed to their clinical status.


From a total of 400 consecutive transplanted patients, only patients with alcoholic or viral cirrhosis (HCV-related cirrhosis, HBV-related cirrhosis, combined hepatitis B and C related cirrhosis) were considered for the analysis.

Patients Transplanted for Combined Alcoholic and Viral Cirrhosis Were Excluded

Patients with cholestatic (Primary Biliary Cholangitis and Primary Sclerosing Cholangitis), genetic, autoimmune liver diseases, cryptogenic cirrhosis, and hepatocellular carcinoma were excluded from analysis. Patients with acute liver failure (viral acute liver failure, paracetamol or mushroom poisoning, etc.) or receiving simultaneous multi-organ transplants were also excluded from the analysis. The medical records retrospectively analyzed included demographic data, Body Mass Index, Child-Pugh score, MELD, type of graft, type of immunosuppression, smoking habits and presence of diabetes. Patients were observed until their death, loss to follow-up, or graft loss. Follow-up data was collected until January 2017 for patients that were still alive. Survival of the graft was evaluated according to the Kaplan–Meier method, considering as event the death of the patients or graft loss.

Primary Liver Disease Recurrence and Re-transplantation

Data on recurrence of primary liver disease after LT and re-transplantation were evaluated. All transplanted patients periodically had abdominal ultrasound scanning and blood tests. When clinically indicated, liver biopsies were performed. Histological grading according to the Ishak and Metavir classification system was used. In the group of transplanted patients for alcoholic cirrhosis, recurrence was defined as histological feature of ALD and alcohol relapse after LT. As total alcohol abstinence is required after LT (European Association for the Study of Liver, 2012; Addolorato et al., 2016a), alcohol relapse was defined as any alcohol intake after LT. Alcohol intake was evaluated at each follow-up visit after LT using a clinical interview based on patients' self-report, Timeline Follow-Back and interview with family members. Moreover, biomarkers of alcohol consumption (γ-glutamyltransferase, mean cellular volume, aspartate aminotransferase/alanine aminotransferase >2), breath-alcohol concentration (BAC) and, starting from 2007, carbohydrate-deficient transferrin were evaluated in all patients transplanted for alcohol cirrhosis after LT. All AUDs patients received treatment including counseling and psychosocial support; baclofen was utilized as anti-craving medications from 2007 (Addolorato et al., 2007).

In the group of patients transplanted for virus-related cirrhosis recurrence was defined as a histological evidence of viral hepatitis and positive viremia (serum HCV RNA or HBV DNA) after LT. In case of recurrence, patients were managed by the hepatologists of the Liver Disease Centre at Gemelli Hospital. Antiviral treatment was initiated with any degree of fibrosis or fibrosing cholestatic hepatitis if the clinical conditions were sufficient to undergo antiviral therapy.

Re-transplantation were performed in patients with irreversible graft failure. Patients relisted for early complication (e.g. primary non-function or hepatic artery thrombosis), developing within 30 days after LT, were excluded from the statistical analysis.

Complications After LT

The onset of complication and the causes of death or graft failure after LT were collected. Only data about acute rejection, de novo cancer (lymphoproliferative disorders and solid tumor except for non-melanoma skin tumors), hepatic artery stenosis/thrombosis, infection, metabolic (for instance, new onset of diabetes mellitus), cardiovascular and cerebrovascular disease were considered for statistical analysis. The other data about surgical complications, portal venous thrombosis, renal and hematological complications, neuropsychiatric disorder were not considered for the statistical analysis because of the poor number of events.