Liver transplantation in alcoholic liver disease
- Scott L Friedman, MD
Scott L Friedman, MD
- Fishberg Professor of Medicine
- Icahn School of Medicine at Mount Sinai
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 . 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 . 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 . 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 . 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 .
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].
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