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Perceptions of liver transplantation for ALD are evolving

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Attitudes are changing, commentators report

One of the most significant findings of the study by Brian P. Lee, MD, and his colleagues is the major shift in attitudes surrounding the eligibility criteria for patients with ALD to undergo liver transplantation.

More than 3 decades ago, a group of surgical experts gathered together to discuss evaluation criteria for candidacy of individuals to undergo liver transplantation. They recommended that patients with ALD be required to restrict alcohol consumption for 6 months prior to being listed eligible for surgery. The group presumed that a period of complete avoidance may induce some degree of disease remission, circumventing the need for transplant altogether.

However, these suggestions were given without the use of evidence, formed largely on the basis of opinion, and recent data dispute these recommendations. On the contrary, relapse rates for alcohol use disorder has been shown to be due to factors other than length of abstinence. While these findings have lessened bias surrounding ALD and liver transplantation, the assumption still remains prevalent in clinical practice today.

These results highlight the unanswered question of how to best approach treatment of individuals with ALD, and whether the recent rise of patients undergoing liver transplantation for ALD, without a continued duration of abstinence, should be a concern of clinicians.

Mack C. Mitchell, MD, is affiliated with the department of internal medicine at the University of Texas in Dallas. Dr. Mitchell reported having financial affiliations with the National Institute of Alcohol and Alcohol Abuse. These comments are adapted from his accompanying editorial (JAMA Intern Med. 2019 Jan 22. doi: 10.1001/jamainternmed.2018.6532 ).



In recent years, the proportion of patients undergoing liver transplantation for alcohol-associated liver disease (ALD) has doubled, suggesting a major shift in attitudes related to transplant indication, according to an analysis of registry data.

An operation in the OR VILevi/Thinkstock

“The findings suggest that early liver transplant for alcoholic hepatitis may be leading to broader acceptance of ALD for liver transplant,” Brian P. Lee, MD, of the University of California, San Francisco, and his colleagues wrote in JAMA Internal Medicine.

The researchers conducted a prospective cohort study of 9,438 patients with ALD who received a liver transplant from 2002 to 2016. Data were obtained from the United Network for Organ Sharing national database.

Study participants were evaluated for patterns, both nationally and regionally, related to liver transplant for the treatment of ALD. In addition, Dr. Lee and his colleagues completed a sensitivity analysis, which evaluated specific clinical parameters, including patient and graft survival, hepatocellular carcinoma (HCC), and hepatitis C viral (HCV) infection.

“Because there is no national policy regarding early liver transplant, we hypothesized that changes may vary regionally as liver transplant programs shifted their attitudes toward increased acceptance of early liver transplant for alcoholic hepatitis and ALD,” the researchers wrote.

After analysis, the researchers found that liver transplantation for patients with ALD increased proportionally from 24.2% to 36.7% from 2002 to 2016, respectively. With HCV-infected recipients included, the proportion of liver transplants rose from 15.3% to 30.6% over the same period, representing a twofold increase of transplants received for this indication.

The degree of increase was reported to vary based on geographic region and was linked with differences in patient-specific factors.

“There may be regional disparities in access to liver transplant for ALD; whether this is related to different attitudes toward ALD and requirements for sobriety is unknown,” they added.

The researchers acknowledged that a key limitation of the study was the use of registry data. As a result, Dr. Lee and his colleagues reported that all conclusions are not causal, but rather only by association.

The study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases UCSF Liver Center. The authors reported no conflicts of interests.

SOURCE: Lee BP et al. JAMA Intern Med. 2019 Jan 22. doi: 10.1001/jamainternmed.2018.6536.

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