Alcoholic Liver Disease: Liver Transplantation

by National Institute of Health

In many patients, long-term heavy drinking leads to chronic liver disease, liver failure, and even death. Orthotopic liver transplantation (OLT) is the only definitive treatment for end-stage liver disease, including alcoholic liver disease (ALD). Because of a shortage of donor organs, OLT for ALD patients remains controversial out of concerns that patients may resume drinking, thereby harming the transplanted organ. Therefore, transplant centers conduct careful screening procedures that assess patients' coexisting medical problems and psychosocial status to identify those patients who are medically most suited for the procedure and who are most likely to remain abstinent after OLT. Studies assessing the outcomes of ALD patients after OLT found that the survival rates of the transplanted organ and the patient were comparable to those of patients with nonalcoholic liver disease and that relapse rates among the ALD patients were low. Similarly, ALD patients and patients with other types of liver disease had comparable rates of compliance with complex medication regimens after OLT. Enhanced efforts to identify risk factors for relapse among OLT candidates with ALD and to target interventions specifically to those patients who are at high risk of relapse may further improve patient outcome and enhance the acceptance of OLT for alcoholic patients in the general population.

Population-based surveys indicate that 68 percent of adult Americans drink at least one alcoholic beverage per month. About 10 percent consume more than two drinks per day, which is a commonly used definition of "heavy drinking". However, substantial differences exist in the prevalence of heavy drinking among population subgroups. For example, 18 percent of men but only 3 percent of women are classified as heavy drinkers, and heavy drinking is more common among Whites than among African Americans or Hispanics. Heavy drinking and its consequences are important public health problems, as illustrated by the following statistics:

Five percent of the deaths occurring annually in the United States are either directly or indirectly attributable to alcohol abuse.

Only about 10 percent of all drinkers account for 50 percent of the total alcohol consumption in the United States per year.

About 13.8 million people in the United States meet the diagnostic criteria for alcohol abuse or dependence specified in the fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders.

About 15 percent of U.S. alcoholics eventually will develop alcoholic liver disease (ALD), a broad spectrum of liver injuries - ranging from asymptomatic fatty liver (steatosis) or abnormalities of liver enzymes to end-stage liver disease - that result from alcohol ingestion. Women in general show greater susceptibility to ALD than men, and African Americans show greater susceptibility than Whites.

Among heavy drinkers, liver disease is highly prevalent. Thus, 90 to 100 percent of heavy drinkers have steatosis, 10 to 35 percent have alcohol-induced inflammation of the liver (alcoholic hepatitis), and 8 to 20 percent have alcoholic cirrhosis.

The 5-year and 10-year survival rates for patients with alcoholic cirrhosis are 23 percent and 7 percent, respectively. These rates are significantly worse than survival rates for patients whose cirrhosis was not caused by alcohol.

Alcohol consumption is one of the leading causes of chronic liver disease in the United States and worldwide. In Western countries, alcohol is the major causative factor in about 50 percent of deaths from end-stage liver disease . To date, liver transplantation (also known as orthotopic1 liver transplantation [OLT]) is the only definitive treatment for end-stage liver disease. (Orthotopic means "in the normal or usual place.") However, OLT for patients with ALD continues to be controversial because of the ever-increasing demand for donor organs and the inadequate rate of organ donation, combined with concerns that alcoholic patients might relapse to drinking, thereby damaging the transplanted liver.

This review discusses the patterns and controversies relating to liver transplantation in patients with ALD. After providing some historical perspective and summarizing the current status of OLT in these patients, the article discusses elements of the pretransplantation evaluation that can help identify suitable patients for the procedure. Outcomes for ALD patients who have received liver transplants are reviewed, and the ethical issues surrounding this procedure in alcoholic patients are discussed. This article concludes by summarizing future research directions that might improve the outcomes of liver transplants in alcoholics and thereby resolve some of the ethical concerns.

Historical Perspective and Current Status of OLT in Alcoholic Patients

Historical Perspective

Before the National Institutes of Health Consensus Conference on Liver Transplantation in 1983, OLT rarely was performed in patients with ALD. The Consensus Conference concluded that ALD is an appropriate indication for OLT if the patient is judged likely to abstain from alcohol after transplantation . This conclusion, which was adopted by many transplant centers, led to an increase in the number of transplants performed for ALD. A report by Starzl and colleagues made the most convincing argument for OLT for ALD patients, demonstrating that 73 percent of ALD patients who had received a liver transplant still were alive 1 year after the procedure, and that only 3 percent of those patients had relapsed to alcoholism. Based on these findings, in 1991 the Health Care Financing Administration (HCFA) identified ALD as one of the seven conditions for which it approved payment for OLT, but the HCFA recommended a "significant" period of abstinence for alcoholics before undergoing the procedure as well as the availability of a reasonable social support system.

About the Author

NIH is the nation's medical research agency - making important medical discoveries that improve health and save lives. The National Institutes of Health (NIH), a part of the U.S. Department of Health and Human Services, is the primary Federal agency for conducting and supporting medical research.