Smarter Decisions,
Better Care

UpToDate synthesizes the most recent medical information into evidence-based practical recommendations clinicians trust to make the right point-of-care decisions.

  • Rigorous editorial process: Evidence-based treatment recommendations
  • World-Renowned physician authors: over 5,100 physician authors and editors around the globe
  • Innovative technology: integrates into the workflow; access from EMRs

Choose from the list below to learn more about subscriptions for a:


Subscribers log in here


Liver transplantation in alcoholic liver disease

INTRODUCTION

After initial reluctance to transplant patients with alcoholic liver disease, it is now clear that transplantation offers an excellent survival advantage in appropriately selected patients, equal to that for other disease indications. The original reluctance stemmed from the perception that the disease was self-inflicted and from the possible presence of alcohol-mediated damage to sites outside the liver [1,2]. There was also concern that compliance with postoperative recommendations would be suboptimal and that recidivism would lead to graft failure. Opposing opinions and accumulated data have addressed these reservations [3]. Liver transplantation appears to be cost-effective for alcoholic liver disease, albeit possibly less so than for transplantation for some other indications such as primary biliary cirrhosis and primary sclerosing cholangitis [2,4-6].

However, the shortage of livers limits the availability of liver transplantation for patients with advanced liver disease. An increase in mortality related to cirrhosis in recent years is troubling and underscores the need for more formal programs to reduce alcohol intake [7-11].

This topic will review liver transplantation for alcoholic liver disease. Other aspects related to alcohol induced liver injury are discussed elsewhere. (See "Pathogenesis of alcoholic liver disease" and "Clinical manifestations and diagnosis of alcoholic fatty liver disease and alcoholic cirrhosis" and "Prognosis and management of alcoholic fatty liver disease and alcoholic cirrhosis".)

EFFICACY OF LIVER TRANSPLANTATION

End-stage alcoholic liver disease was responsible for 18 percent of all orthotopic liver transplants between 1992 and 2001 in the United States [12]. The first large experience with liver transplantation for alcoholic cirrhosis was reported from Pittsburgh, where survival among 42 patients was equal to that for other forms of liver disease [13]. Similar data have now been accumulated from several other centers [14-21]. In one report, for example, actuarial one-, five-, and seven-year patient and graft survival rates among 123 patients were 84 and 81 percent (one year), 72 and 66 percent (five years), and 63 and 59 percent (seven years), respectively [19]. Without transplant, five-year survival is as low as 23 percent. Full integration into society is likely following liver transplantation in appropriately screened and managed alcoholic patients [22].

An important determinant of success is that clinicians caring for patients with end-stage alcoholic liver disease consider transplantation as a potential option and refer their patients early to a transplant center for evaluation. With progressively increasing waiting times until donor organs become available, delayed referral may prevent the patient from surviving the evaluation and waiting period [23,24].

         

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2014. | This topic last updated: Dec 4, 2013.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2014 UpToDate, Inc.
References
Top
  1. Moss AH, Siegler M. Should alcoholics compete equally for liver transplantation? JAMA 1991; 265:1295.
  2. Lucey MR. Liver transplantation in patients with alcoholic liver disease. Liver Transpl 2011; 17:751.
  3. Cohen C, Benjamin M. Alcoholics and liver transplantation. The Ethics and Social Impact Committee of the Transplant and Health Policy Center. JAMA 1991; 265:1299.
  4. Longworth L, Young T, Buxton MJ, et al. Midterm cost-effectiveness of the liver transplantation program of England and Wales for three disease groups. Liver Transpl 2003; 9:1295.
  5. O'Grady JG. Liver transplantation alcohol related liver disease: (deliberately) stirring a hornet's nest! Gut 2006; 55:1529.
  6. De Gottardi A, Dumortier J. Transplantation for alcoholic liver disease. Gut 2007; 56:735.
  7. Room R. British livers and British alcohol policy. Lancet 2006; 367:10.
  8. Leon DA, McCambridge J. Liver cirrhosis mortality rates in Britain from 1950 to 2002: an analysis of routine data. Lancet 2006; 367:52.
  9. Ponicki WR, Gruenewald PJ. The impact of alcohol taxation on liver cirrhosis mortality. J Stud Alcohol 2006; 67:934.
  10. Andreasson S, Holder HD, Norström T, et al. Estimates of harm associated with changes in Swedish alcohol policy: results from past and present estimates. Addiction 2006; 101:1096.
  11. Gelson W, Hoare M, Dawwas MF, et al. The pattern of late mortality in liver transplant recipients in the United Kingdom. Transplantation 2011; 91:1240.
  12. United Network for Organ Sharing (UNOS). Public data from UNOS/OPTN scientific registry http://www.unos.org (Accessed on March 01, 2007).
  13. Starzl TE, Van Thiel D, Tzakis AG, et al. Orthotopic liver transplantation for alcoholic cirrhosis. JAMA 1988; 260:2542.
  14. Gish RG, Lee AH, Keeffe EB, et al. Liver transplantation for patients with alcoholism and end-stage liver disease. Am J Gastroenterol 1993; 88:1337.
  15. Berlakovich GA, Steininger R, Herbst F, et al. Efficacy of liver transplantation for alcoholic cirrhosis with respect to recidivism and compliance. Transplantation 1994; 58:560.
  16. Osorio RW, Freise CE, Ascher NL, et al. Orthotopic liver transplantation for end-stage alcoholic liver disease. Transplant Proc 1993; 25:1133.
  17. Lucey MR, Merion RM, Henley KS, et al. Selection for and outcome of liver transplantation in alcoholic liver disease. Gastroenterology 1992; 102:1736.
  18. Stefanini GF, Biselli M, Grazi GL, et al. Orthotopic liver transplantation for alcoholic liver disease: rates of survival, complications and relapse. Hepatogastroenterology 1997; 44:1356.
  19. Bellamy CO, DiMartini AM, Ruppert K, et al. Liver transplantation for alcoholic cirrhosis: long term follow-up and impact of disease recurrence. Transplantation 2001; 72:619.
  20. Young TA, Neuberger J, Longworth L, et al. Survival gain after liver transplantation for patients with alcoholic liver disease: a comparison across models and centers. Transplantation 2003; 76:1479.
  21. Webb K, Shepherd L, Day E, et al. Transplantation for alcoholic liver disease: report of a consensus meeting. Liver Transpl 2006; 12:301.
  22. Cowling T, Jennings LW, Goldstein RM, et al. Societal reintegration after liver transplantation: findings in alcohol-related and non-alcohol-related transplant recipients. Ann Surg 2004; 239:93.
  23. Everhart JE, Lombardero M, Detre KM, et al. Increased waiting time for liver transplantation results in higher mortality. Transplantation 1997; 64:1300.
  24. Watt KD, McCashland TM. Transplantation in the alcoholic patient. Semin Liver Dis 2004; 24:249.
  25. Julapalli VR, Kramer JR, El-Serag HB, American Association for the Study of Liver Diseases. Evaluation for liver transplantation: adherence to AASLD referral guidelines in a large Veterans Affairs center. Liver Transpl 2005; 11:1370.
  26. Vanlemmens C, Di Martino V, Milan C, et al. Immediate listing for liver transplantation versus standard care for Child-Pugh stage B alcoholic cirrhosis: a randomized trial. Ann Intern Med 2009; 150:153.
  27. Lucey MR, Brown KA, Everson GT, et al. Minimal criteria for placement of adults on the liver transplant waiting list: a report of a national conference organized by the American Society of Transplant Physicians and the American Association for the Study of Liver Diseases. Liver Transpl Surg 1997; 3:628.
  28. Keeffe EB. Assessment of the alcoholic patient for liver transplantation: comorbidity, outcome, and recidivism. Liver Transpl Surg 1996; 2:12.
  29. Vaillant GE. The natural history of alcoholism and its relationship to liver transplantation. Liver Transpl Surg 1997; 3:304.
  30. Hoofnagle JH, Kresina T, Fuller RK, et al. Liver transplantation for alcoholic liver disease: executive statement and recommendations. Summary of a National Institutes of Health workshop held December 6-7, 1996, Bethesda, Maryland. Liver Transpl Surg 1997; 3:347.
  31. O'Shea RS, Dasarathy S, McCullough AJ, et al. Alcoholic liver disease. Hepatology 2010; 51:307.
  32. Webzell I, Ball D, Bell J, et al. Substance use by liver transplant candidates: an anonymous urinalysis study. Liver Transpl 2011; 17:1200.
  33. Kumar S, Stauber RE, Gavaler JS, et al. Orthotopic liver transplantation for alcoholic liver disease. Hepatology 1990; 11:159.
  34. Osorio RW, Ascher NL, Avery M, et al. Predicting recidivism after orthotopic liver transplantation for alcoholic liver disease. Hepatology 1994; 20:105.
  35. Bird GL, O'Grady JG, Harvey FA, et al. Liver transplantation in patients with alcoholic cirrhosis: selection criteria and rates of survival and relapse. BMJ 1990; 301:15.
  36. Tandon P, Goodman KJ, Ma MM, et al. A shorter duration of pre-transplant abstinence predicts problem drinking after liver transplantation. Am J Gastroenterol 2009; 104:1700.
  37. Weinrieb RM, Van Horn DH, McLellan AT, Lucey MR. Interpreting the significance of drinking by alcohol-dependent liver transplant patients: fostering candor is the key to recovery. Liver Transpl 2000; 6:769.
  38. Everhart JE, Beresford TP. Liver transplantation for alcoholic liver disease: a survey of transplantation programs in the United States. Liver Transpl Surg 1997; 3:220.
  39. Rodrigue JR, Hanto DW, Curry MP. Substance abuse treatment and its association with relapse to alcohol use after liver transplantation. Liver Transpl 2013; 19:1387.
  40. Carbonneau M, Jensen LA, Bain VG, et al. Alcohol use while on the liver transplant waiting list: a single-center experience. Liver Transpl 2010; 16:91.
  41. Georgiou G, Webb K, Griggs K, et al. First report of a psychosocial intervention for patients with alcohol-related liver disease undergoing liver transplantation. Liver Transpl 2003; 9:772.
  42. Pfitzmann R, Schwenzer J, Rayes N, et al. Long-term survival and predictors of relapse after orthotopic liver transplantation for alcoholic liver disease. Liver Transpl 2007; 13:197.
  43. De Gottardi A, Spahr L, Gelez P, et al. A simple score for predicting alcohol relapse after liver transplantation: results from 387 patients over 15 years. Arch Intern Med 2007; 167:1183.
  44. Mathurin P, Moreno C, Samuel D, et al. Early liver transplantation for severe alcoholic hepatitis. N Engl J Med 2011; 365:1790.
  45. Singal AK, Bashar H, Anand BS, et al. Outcomes after liver transplantation for alcoholic hepatitis are similar to alcoholic cirrhosis: exploratory analysis from the UNOS database. Hepatology 2012; 55:1398.
  46. Brown RS Jr. Transplantation for alcoholic hepatitis--time to rethink the 6-month "rule". N Engl J Med 2011; 365:1836.
  47. John S, Chung RT. Early liver transplantation for severe alcoholic hepatitis. N Engl J Med 2012; 366:478; author reply 479.
  48. Tamura S, Sugawara Y, Kukudo N. Early liver transplantation for severe alcoholic hepatitis. N Engl J Med 2012; 366:477.
  49. Di Martino V, Sheppard F, Vanlemmens C. Early liver transplantation for severe alcoholic hepatitis. N Engl J Med 2012; 366:478.
  50. Schiano TD, Kim-Schluger L, Gondolesi G, Miller CM. Adult living donor liver transplantation: the hepatologist's perspective. Hepatology 2001; 33:3.
  51. Miller CM, Gondolesi GE, Florman S, et al. One hundred nine living donor liver transplants in adults and children: a single-center experience. Ann Surg 2001; 234:301.
  52. Bramstedt KA, Jabbour N. When alcohol abstinence criteria create ethical dilemmas for the liver transplant team. J Med Ethics 2006; 32:263.
  53. Fábrega E, Crespo J, Casafont F, et al. Alcoholic recidivism after liver transplantation for alcoholic cirrhosis. J Clin Gastroenterol 1998; 26:204.
  54. Dew MA, DiMartini AF, Steel J, et al. Meta-analysis of risk for relapse to substance use after transplantation of the liver or other solid organs. Liver Transpl 2008; 14:159.
  55. Miguet M, Monnet E, Vanlemmens C, et al. Predictive factors of alcohol relapse after orthotopic liver transplantation for alcoholic liver disease. Gastroenterol Clin Biol 2004; 28:845.
  56. Foster PF, Fabrega F, Karademir S, et al. Prediction of abstinence from ethanol in alcoholic recipients following liver transplantation. Hepatology 1997; 25:1469.
  57. McCallum S, Masterton G. Liver transplantation for alcoholic liver disease: a systematic review of psychosocial selection criteria. Alcohol Alcohol 2006; 41:358.
  58. Keeffe EB, Esquivel CO. Controversies in patient selection for liver transplantation. West J Med 1993; 159:586.
  59. Jauhar S, Talwalkar JA, Schneekloth T, et al. Analysis of factors that predict alcohol relapse following liver transplantation. Liver Transpl 2004; 10:408.
  60. Kelly M, Chick J, Gribble R, et al. Predictors of relapse to harmful alcohol after orthotopic liver transplantation. Alcohol Alcohol 2006; 41:278.
  61. Boffetta P, Hashibe M. Alcohol and cancer. Lancet Oncol 2006; 7:149.
  62. Gerhardt TC, Goldstein RM, Urschel HC, et al. Alcohol use following liver transplantation for alcoholic cirrhosis. Transplantation 1996; 62:1060.
  63. Schmeding M, Heidenhain C, Neuhaus R, et al. Liver transplantation for alcohol-related cirrhosis: a single centre long-term clinical and histological follow-up. Dig Dis Sci 2011; 56:236.
  64. Rice JP, Eickhoff J, Agni R, et al. Abusive drinking after liver transplantation is associated with allograft loss and advanced allograft fibrosis. Liver Transpl 2013; 19:1377.
  65. Conjeevaram HS, Hart J, Lissoos TW, et al. Rapidly progressive liver injury and fatal alcoholic hepatitis occurring after liver transplantation in alcoholic patients. Transplantation 1999; 67:1562.
  66. Pageaux GP, Bismuth M, Perney P, et al. Alcohol relapse after liver transplantation for alcoholic liver disease: does it matter? J Hepatol 2003; 38:629.
  67. Cuadrado A, Fábrega E, Casafont F, Pons-Romero F. Alcohol recidivism impairs long-term patient survival after orthotopic liver transplantation for alcoholic liver disease. Liver Transpl 2005; 11:420.
  68. Jain A, DiMartini A, Kashyap R, et al. Long-term follow-up after liver transplantation for alcoholic liver disease under tacrolimus. Transplantation 2000; 70:1335.
  69. DiMartini A, Javed L, Russell S, et al. Tobacco use following liver transplantation for alcoholic liver disease: an underestimated problem. Liver Transpl 2005; 11:679.
  70. Muñoz SJ. Tobacco use by liver transplant recipients: grappling with a smoking gun. Liver Transpl 2005; 11:606.
  71. Bataller R. Time to ban smoking in patients with chronic liver diseases. Hepatology 2006; 44:1394.
  72. Ehlers SL, Rodrigue JR, Widows MR, et al. Tobacco use before and after liver transplantation: a single center survey and implications for clinical practice and research. Liver Transpl 2004; 10:412.
  73. Björnsson E, Olsson J, Rydell A, et al. Long-term follow-up of patients with alcoholic liver disease after liver transplantation in Sweden: impact of structured management on recidivism. Scand J Gastroenterol 2005; 40:206.
  74. Bathgate AJ, UK Liver Transplant Units. Recommendations for alcohol-related liver disease. Lancet 2006; 367:2045.
  75. Kotlyar DS, Burke A, Campbell MS, Weinrieb RM. A critical review of candidacy for orthotopic liver transplantation in alcoholic liver disease. Am J Gastroenterol 2008; 103:734.