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

Discussion

This study shows that patients who underwent LT for alcoholic cirrhosis have a higher survival rate than patients transplanted for viral cirrhosis. These findings are in line with previous studies (Mackie et al., 2001; Burra et al., 2010), confirm and further support that LT is an appropriate indication for ALD (European Association for the Study of Liver, 2012). Nonetheless, public opinion and even some medical professionals continue to question the appropriateness of using resource for patients with ALD due to the consideration that this is a 'self-inflicted disease'. A UK study showed that general physicians believed that, given the shortage of organs, alcoholic patients should take lower priority than other candidates, even when the latter had less chance of a successful outcome from transplantation (Neuberger et al., 1998). Other issues on the appropriateness of LT for patients with ALD are related to the risk of alcohol relapse. A previous study showed that patients transplanted for alcoholic cirrhosis have a lower prevalence of relapse and mortality rate if they are selected and managed by a team working in an Alcohol Addiction Unit within the Liver Transplantation Center (Addolorato et al., 2013b).

In this study, primary liver disease recurrence was present only in patients transplanted for HCV-related cirrhosis. Recurrence of hepatitis C is particularly aggressive in transplanted patients, with a rapid evolution towards cirrhosis, resulting in graft loss (Rowe et al., 2008) and re-transplantation. (Firpi et al., 2009). In this study, five patients were re-transplanted because they developed graft failure after recurrence of hepatitis C. Many physicians are concerned about re-transplantation due to organ shortages, economic implications and the poorer survival rates in re-transplanted patients. Interestingly, no patients belonging to the alcoholic cirrhosis group developed recurrence, and only two were re-transplanted due to graft failure from surgical complication. The transplanted patients that reported at least an episode of alcohol relapse during follow-up were promptly treated with multimodal treatment to prevent organ damage. The absence of recurrence in this group of patients could be partially related to the prevention and prompt treatment of alcohol relapse by the team of the Alcohol Addiction Unit within the Liver Transplantation Center (Addolorato et al., 2013b).

This study shows that patients transplanted for alcoholic cirrhosis are more prone to the onset of de novo cancer. Those patients developed de novo cancer of the upper airways and gastrointestinal tract. These data are in line with previous literature (Saigal et al., 2002; Burra et al., 2010; Nure et al., 2013). Moreover, this study revealed that cancer is a relevant cause of death in this population. The risk factors associated with the onset of this complication are post-transplant use of tobacco and a high MELD score at the time of transplantation. These risk factors act synergistically to increase post-transplantation immunosuppression. The effect is probably due to reduced immunosuppression and the activation of oncogenic viruses. However, in this study the effect of immunosuppressive drugs were not considered for the high risk of bias due to frequent change in immunosuppressive therapy during follow-up. Tobacco is used in a high percentage of patients transplanted for alcoholic cirrhosis and many patients resume smoking habits early after transplantation (Dumortier et al., 2007) and physicians do not typically encourage enough smoking cessation in this population. Use of tobacco is a well established and recognized factor for the onset of de novo cancer in transplanted patients (Dumortier et al., 2007) and is also associated with an increased mortality and morbidity from hepatic artery thrombosis and cardiovascular disease in this population (Pungpapong et al., 2002). For these reasons, all transplanted patients should be encouraged to stop smoking (Lucey, 2014) and treatments for smoking cessation should be offered (Lee and Leggio, 2015). Regarding alcohol relapse after transplantation, our study did not show any correlation with the onset of cancer. Similarly, a previous study indicated that alcohol relapse did not increase the risk of malignancy (Watt et al., 2009). In our study, this finding could be explained by the low rate (19%) of alcohol relapse compared with other studies (Mackie et al., 2001). Furthermore, it may be critical to implement screening programs in transplanted patients, that include periodic upper digestive endoscopy, chest radiography and clinical pharyngo-laryngeal examination. Moreover, it is crucial to prevent alcohol relapse, encourage smoking cessation and avoid excessive immunosuppressive therapy.

There were no differences between the two groups on the other post-transplant complications, possibly because of the small sample size. Previous studies showed an increased incidence of cardiovascular events (Burra et al., 2010) and infections in patients transplanted for alcoholic cirrhosis compared to those transplanted for other etiologies, whilst rate of rejection was lower (Farges et al., 1996).

The main limitations of this study were small sample size, monocentric and retrospective design. Moreover, it was not possible discriminate among relapsing patients after LT those who presented only an episode of lapse.

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