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Early liver transplantation for alcoholic hepatitis: Ready for primetime?

  • Maddie Kubiliun
    Affiliations
    Digestive and Liver Diseases Division, Department of Medicine, University of Texas Southwestern, Dallas, TX, USA
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  • Suraj J. Patel
    Affiliations
    Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA

    Harvard Medical School, Boston, MA, USA
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  • Chin Hur
    Affiliations
    Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA

    Harvard Medical School, Boston, MA, USA
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  • Jules L. Dienstag
    Affiliations
    Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA

    Harvard Medical School, Boston, MA, USA
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  • Jay Luther
    Correspondence
    Corresponding author. Address: Gastrointestinal Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA, Harvard Medical School. Tel.: +1 617 724 6004; fax: +1 617 724 6832.
    Affiliations
    Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA

    Harvard Medical School, Boston, MA, USA
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Published:November 23, 2017DOI:https://doi.org/10.1016/j.jhep.2017.11.027
      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.

      Linked Article

      • Reply to: “Assessment of the risk of alcohol relapse following liver transplantation for alcoholic hepatitis using a meta-analysis approach”
        Journal of HepatologyVol. 68Issue 6
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          We commend Deltenre et al. for their work examining the likelihood of recurrent alcohol use following liver transplantation in patients with severe alcoholic hepatitis.1 Their analysis further underscores the uncertain validity – and limited predictive value for post-transplantation alcohol abstinence – of the “six-month rule,” which, we believe, discriminates unfairly against a selected subset of patients with severe alcoholic hepatitis who may benefit from liver transplantation. Moreover, their analysis demonstrates that the likelihood of alcohol relapse in such patients undergoing liver transplantation for severe acute alcoholic hepatitis is as low as 14% to 22% and indistinguishable from that in alcoholic cirrhotic patients who undergo liver transplantation after a documented six-month period of sobriety.
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      • Reply to: “Primed for the spotlight: Transplantation for alcohol-associated liver disease”
        Journal of HepatologyVol. 69Issue 1
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          We appreciate the comments by Dr. Im and agree fully with the issues raised, including the negative effect terms like “alcoholic” and “recidivism” have on society’s view of alcohol-related diseases. Similarly, we too endorse the need for more research aimed at optimizing candidate selection for liver transplantation in patients with severe alcohol-related hepatitis. It was emphasized both in Dr Im’s letter and our editorial that fears about the impact of offering donated liver allografts to those with severe alcohol-related hepatitis – that i) donors would be discouraged by the policy and ii) that such patients would compete for and reduce the availability of donor organs to patients with other liver disorders – have not been realized, as supported by recent data.
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      • Assessment of the risk of alcohol relapse following liver transplantation for alcoholic hepatitis using a meta-analysis approach
        Journal of HepatologyVol. 68Issue 6
        • Preview
          We read with interest the editorial from Dr. Kubiliun and colleagues about early liver transplantation for alcoholic hepatitis (AH).1 We would like to add some recent data to complete their excellent overview on this highly debated topic.
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      • Primed for the spotlight: Transplantation for alcohol-associated liver disease
        Journal of HepatologyVol. 69Issue 1
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          I applaud the editorial by Kubiliun et al., entitled “Early liver transplantation for alcoholic hepatitis: Ready for primetime?” for its insightful examination of this controversial and emerging indication for liver transplantation (LT).1 I would like to highlight several issues.
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      References

      1. National Institute of Justice. https://www.nij.gov/topics/corrections/recidivism/Pages/welcome.aspx (accessed March 10, 2017).

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