From the Guidelines
Upfront liver transplantation is recommended for selected patients with severe alcoholic hepatitis who have failed medical therapy and meet strict selection criteria, as determined by the latest guidelines from the Journal of Hepatology 1. The standard initial approach involves medical management with corticosteroids (typically prednisolone 40mg daily for 28 days) and supportive care.
- Key considerations for transplantation include:
- Non-response to steroids, often assessed using the Lille score at day 7
- Strong social support
- Absence of severe coexisting psychiatric conditions
- Commitment to lifelong abstinence
- Completion of a thorough psychosocial evaluation The traditional 6-month abstinence rule has been reconsidered in some centers for highly selected patients with their first episode of alcoholic hepatitis who have favorable psychosocial profiles, as supported by recent studies 1.
- A multidisciplinary approach involving hepatologists, transplant surgeons, addiction specialists, psychiatrists, and social workers is essential to ensure appropriate patient selection and optimize outcomes.
- The latest evidence suggests that early liver transplantation can improve both short and long-term survival of patients with severe alcohol-related hepatitis, with 1-year survival rates of up to 83.9% compared to 7.9% for non-transplanted patients 1.
- However, the risk of recidivism and the potential for de novo cancer and cardiovascular complications must be carefully considered, as highlighted in previous studies 1.
- The selection process for liver transplantation in patients with severe alcoholic hepatitis should be rigorous and multidisciplinary, taking into account factors such as the patient's medical and psychiatric history, social support, and commitment to abstinence.
From the Research
Upfront Liver Transplant in Severe Alcoholic Hepatitis
- The decision to perform an upfront liver transplant in patients with severe alcoholic hepatitis is a complex one, with various studies suggesting that it can be a lifesaving intervention 2, 3, 4, 5, 6.
- Traditionally, liver transplantation for alcoholic liver disease was only considered in patients who had achieved 6 months of abstinence, due to social and ethical concerns regarding the use of a limited resource 2, 4, 6.
- However, recent studies have demonstrated that early liver transplantation in carefully selected patients with severe alcoholic hepatitis who fail medical therapy can provide a significant survival benefit, with 6-month survival rates ranging from 77% to 100% 4, 5.
- Selection criteria for patients with severe alcoholic hepatitis undergoing liver transplantation have evolved and become more permissive, with the period of sobriety becoming less important in the evaluation process 2, 3.
- Factors such as disease process insight, older age at the time of transplant, and the presence of social support have been identified as important predictors of lower rates of return to alcohol use after liver transplantation 2.
- Despite the potential benefits of upfront liver transplantation, there are still concerns about the risk of alcohol relapse post-transplant, which can contribute to graft loss and mortality 4, 5, 6.
- Further research is needed to refine inclusion criteria, address post-transplant relapse prevention interventions, and monitor long-term outcomes in patients with severe alcoholic hepatitis undergoing liver transplantation 3, 5, 6.