Liver Transplantation in Patients With Alcoholic Liver Disease

Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin, Madison, WI 53792, USA.
Liver Transplantation (Impact Factor: 3.79). 07/2011; 17(7):751-9. DOI: 10.1002/lt.22330
Source: PubMed

ABSTRACT Although alcoholic liver disease (ALD) is one of the most common indications for liver transplantation (LT), there are still unresolved controversies about the goals of treatment, the referral, evaluation, and selection of patients with ALD for LT, and their care after LT. It is uncertain whether there is a large unmet need for LT among patients with ALD because of the unmeasured effects of recent drinking, relapse, and recovery with abstinence in this population. A careful assessment of the extrahepatic effects of alcohol-related end-organ damage is needed for ALD patients who are referred for an LT evaluation. Although there clearly is a relationship between the length of sobriety and future abstinence, the present methods for predicting future drinking are inexact. The survival of ALD patients after LT is as good as the survival of non-ALD patients, although patients with coincident ALD and hepatitis C virus have higher mortality and morbidity rates. After LT, ALD patients have an increased risk of developing malignancies and cardiovascular disease. These risks appear to be linked to cigarette smoking. Covert drinking occurs both before and after transplantation, and approximately 20% of patients return to harmful drinking after LT. Harmful drinking after LT (instead of slips) causes liver damage and reduces survival. Better therapies for controlling addictions to alcohol and nicotine are needed for ALD patients both before and after LT.

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    ABSTRACT: Alcoholic hepatitis is an acute manifestation of alcoholic liver disease with mortality as high as 40-50 % in severe cases. Patients usually have a history of prolonged alcohol abuse with or without a known history of liver disease. Although there is significant range in severity at presentation, patients with severe alcoholic hepatitis typically present with anorexia, fatigue, fever, jaundice, and ascites. The use of either pentoxifylline or corticosteroids in those with severe disease (Maddrey's discriminate function >32) has significant mortality benefit. The addition of N-acetylcysteine to corticosteroids decreases the incidences of hepatorenal syndrome, infection, and short-term mortality, but does not appear to significantly affect 6-month mortality. Nutritional support with high-calorie, high-protein diet is recommended in all patients screening positive for malnutrition. Liver transplantation for a highly selected group of patients with severe alcoholic hepatitis may be an option in the future, but is not currently recommended or available at most transplant institutions.
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May 29, 2014