Early liver transplantation for alcoholic hepatitis: Ready for primetime?

With advances in the prevention and therapy of viral hepatitis, the percentage of patients with alcohol-associated liver disease (ALD) and non-alcoholic fatty liver disease (NAFLD) requiring liver transplantation is increasing and, in the future, they will represent the vast majority of listed patients. Unfortunately, the promise of new therapies has not been realized for ALD. While two centuries have elapsed since René Laënnac described the association between excessive alcohol consumption and cirrhosis, ALD has eluded effective treatment, accounting for half of all deaths associated with cirrhosis. Moreover, severe alcohol-associated hepatitis (AH), the most serious form of ALD, carries a six-month mortality rate as high as 40%. Even with intensive nutritional support and medical therapies such as corticosteroids and N-acetylcysteine, the short-term prognosis of AH remains grim. The only potentially life-saving measure, liver transplantation, is denied to the majority of patients with AH, because treatment guidelines adopted by most liver transplantation centers require a six-month period of alcohol abstinence and counseling prior to candidacy for liver replacement. Most patients with severe AH do not have the luxury of waiting, and are unlikely to survive six months. In fact, a small number of transplantation programs have already abandoned the six-month sobriety period as a prerequisite for liver transplantation. Still, most centers continue to maintain a highly exclusionary approach to early liver transplantation for AH. This transplantation guideline, however, is being challenged by emerging data that raise questions about current practice and support the benefits of early liver transplantation, without a waiting period of abstinence, in patients with AH.