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Early transplant for severe alcoholic hepatitis boosts survival, alcohol intake

Lancet Gastroenterology and Hepatology
Reuters Health – 11/03/2022 - For patients with severe alcohol-related hepatitis, early liver transplantation improves survival, but also boosts the likelihood of alcohol relapse, researchers say. 

To compare the effects of early transplant versus transplantation for alcohol-related cirrhosis after at least 6 months of abstinence, Dr. Philippe Mathurin of Centre Hospitalier Universitaire de Lille, and colleagues conducted a multicenter, non-randomized, non-inferiority, study in 19 French and Belgian hospitals. 

Three groups of patients (median age, about 55; about 70%, men) were included: 68 with severe alcohol-related hepatitis unresponsive to medical treatment receiving early liver transplantation; 93 with alcohol-related cirrhosis receiving standard transplantation; and 47 with severe alcohol-related hepatitis not eligible for early transplantation. 

A historical control group with unresponsive severe alcohol-related hepatitis who were not transplanted was also included. 

The primary outcome – non-inferiority of the alcohol relapse rate at 2 years posttransplant, as measured by the alcohol timeline follow back (TLFB) tool – was not met, as 34% of patients relapsed in the early group, and 25% in the standard group. 

Further, the 2-year rate of high alcohol intake was greater in the early group (absolute between-group difference, 16.7%). While the time spent drinking alcohol was not different between the groups (standardized difference 0.24), the time spent drinking a large quantity of alcohol was higher in the early group (SD, 0.50). 

Two-year post-transplant survival was similar in the two groups, but it was higher in the early transplantation group compared to those not eligible for early transplant and historical controls (HR 0.27 and 0.21, respectively). 

The authors conclude that while high alcohol intake is more frequent after early liver transplantation, the approach confers a survival benefit for severe alcohol-related hepatitis. 

Dr. Gerald Winder of Michigan Medicine in Ann Arbor, coauthor of a related editorial, commented in an email to Reuters Health, "Alcohol relapses after liver transplant (LT) are emotionally radioactive for many clinicians in the field of hepatology and LT." 

"The argument can be made that most of us will be more incredulous, angry, and judgmental toward the alcohol liver patient who drinks after their liver transplant than the metabolic-associated fatty liver disease patient who returns to a diet of cheeseburgers and milkshakes post-transplant." 

"Yet, these hypothetical cases are foundationally similar in that the recipients are engaging in nonadherent and risky health behaviors and are not being good stewards of their organ," he said. "We clinicians need to come to terms with how we feel about these patients since it can affect how we engage with them, discuss their treatment, and follow-up on their care." 

"If our therapeutic alliances with (these) patients weaken because of how we think and talk about them, they are only less likely to tell us if they need help, which just accentuates the downstream risk of negative outcomes, which then just fuels the field’s frustration with this patient population," he said. "A spiral could ensue." 

Dr. Kirti Shetty, Medical Director of Liver Transplantation at the University of Maryland School of Medicine, also commented by email, "This study is particularly timely and relevant since the burden of alcoholic liver disease has intensified since the start of the COVID-19 pandemic. It has now become the most common reason for LT listing in the U.S., accounting for 40% of all LT listings since the start of the pandemic." 

"Of note, this is the first prospective controlled trial in the field that systematically recorded alcohol relapse after transplantation using the validated TLFB tool," she said. 

However, she added, the study was carried out at European transplant centers, which differ from U.S. centers in several important ways: 

- In Europe, the LT selection process for early LT is rigorous and uniform across centers. In the US, there are no formalized policy guidelines regarding early LT. While consensus conferences have generated guidelines, these are open to interpretation and implementation at the transplant center level. For example, the "6-month rule" of alcohol abstinence used as a standard in this study is not strictly used at most U.S. transplant centers. 

- The population undergoing early LT in the U.S. is more likely to have underlying cirrhosis. 

In addition, she noted, "this study did not utilize biochemical tests for alcohol use, relying on patient reporting, and so the extent of alcohol relapse may have been underestimated." 

Nonetheless, she added, the study "will aid us in the decision-making process as we work to develop consensus in this area, with the aim of ensuring equitable access to donor organs, as well as optimized outcomes." 

Dr. Mathurin did not respond to requests for a comment. 

SOURCE: https://bit.ly/3CBAoS2 and https://bit.ly/3CD3Sic Lancet Gastroenterology and Hepatology, online February 21, 2022. 

By Marilynn Larkin 

© 2023 The Author(s). Published by Medicom Medical Publishers.
User license: Creative Commons Attribution – NonCommercial (CC BY-NC 4.0)

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