Alcoholic Liver Disease : Pretransplant Evaluation

by National Institute of Health

(Page 2 of 7)

To identify alcoholic patients suitable for OLT, Beresford and colleagues proposed a selection method that included measures of the likelihood of abstinence, such as the extent to which alcohol dependence was recognized by the patient and his or her family, the patient's degree of social stability, and the nature and extent of lifestyle changes conducive to long-term abstinence. Using this selection method, Lucey and colleagues reported on a multidisciplinary collaboration of transplant hepatologists, surgeons, and psychiatrists that identified psychosocial predictors of long-term sobriety and compliance after OLT in alcoholics. (These predictors are summarized in the University of Michigan Alcoholism Prognosis Scale, which is discussed later.) These researchers reported that ALD patients judged suitable using these criteria had outcomes after OLT that were similar to outcomes for transplant patients with non-alcohol-related liver disease (non-ALD). People who were judged suitable for OLT included patients with severe end-stage liver disease without an available alternative therapy, who showed a clear understanding of the risks and benefits of the procedure, had a favorable psychiatric assessment including acceptance of alcoholism, and had favorable prognostic factors for future sobriety.

The minimal listing criteria established by the United Network for Organ Sharing (UNOS) in 1996 do not include an absolute requirement for a 6-month period of abstinence before ALD patients are listed as candidates for OLT. Furthermore, a 1996 NIH workshop on OLT for patients with ALD concluded that liver transplantation provides a good outcome in alcoholic patients and that relapse rates after OLT were lower if the patients had successfully completed conventional alcohol rehabilitation programs prior to OLT.

ALD now is widely accepted by many transplant centers as a valid indication for OLT, provided the transplant team caring for the patient can reasonably expect him or her to remain abstinent after the transplant.

Current Status

According to the UNOS database, 41,734 liver transplants using organs from dead donors (cadaveric transplants) were performed in the United States between 1992 and 2001. Of those, 12.5 percent were performed in patients with ALD, and 5.8 percent were performed in patients with ALD and a concurrent infection with the hepatitis C virus (HCV). (Infection with HCV [as well as with other related viruses, such as the hepatitis B virus] can lead to chronic inflammation of the liver [hepatitis], which eventually can cause complete liver failure and death.) This makes ALD the second most frequent indication (after HCV infection alone) for which OLT was performed during this period. As of November 2002, 17,646 patients in the United States were on the waiting list for a cadaveric liver transplant; of these, about 14.1 percent had ALD, and 6.2 percent had combined ALD and HCV infection.

Overall, the number of liver transplants performed annually for ALD has been relatively constant for many years (see the accompanying figure), but the number performed because of chronic HCV infection has increased annually, as has the number of liver transplants for combined ALD and HCV infection.

Pretransplant Evaluation of Patients With ALD

To ensure the success of liver transplantation, ALD patients are required to undergo a thorough evaluation to determine whether they are suitable candidates. This evaluation addresses any coexisting medical problems that might influence the outcome of the transplant and includes a psychological evaluation to identify those patients who are most likely to remain abstinent and comply with the medical regimen after the procedure.

Coexisting Medical Problems

Alcohol affects many organ systems in addition to the liver. For example, as described by Keeffe and Neuberger and colleagues, alcohol abuse can lead to:

• Damage of the heart muscles (cardiomyopathy) and skeletal muscles (skeletal myopathy).
• Inflammation of the pancreas (pancreatitis).
• Malnutrition.
• Central and peripheral nervous system dysfunction.
• "Soft" bones that lack minerals for stability (osteopenia/osteoporosis).
• Cancers of the airways and digestive tract.

These conditions, particularly if they are severe, can complicate the management of patients with ALD both before and after OLT, and some may even be contraindications for OLT. However, some of these alcohol-induced conditions (cardiomyopathy and acute pancreatitis) can be reversed by abstinence, and when such a reversal occurs, these conditions do not affect the decision on a patient's suitability for a transplant.

The clinical approach to evaluating a patient for OLT also may be markedly altered by other disorders that can coexist with ALD, such as infection with hepatitis viruses, particularly HCV, and the presence of liver cancer. The impact of all these coexisting conditions is discussed in the sections to follow.

Cardiomyopathy. The exact prevalence of heart disease in patients with end-stage ALD is unknown. Overall, cardiomyopathy is far more common in actively drinking alcoholics than in abstinent alcoholics. In general, alcohol-related cardiomyopathy rarely is a reason for refusing liver transplantation. Anecdotal evidence suggests that coronary artery disease (CAD) may be more prevalent than cardiomyopathy in patients with ALD. To identify either condition in liver transplant candidates, many transplant centers routinely assess cardiac function through noninvasive tests (electrocardiography, echocardiography, and stress tests) as part of their pretransplant evaluations. A more invasive technique, coronary angiography, uses X rays to visualize the structure of the heart and blood vessels following the injection of a contrast medium, and can identify more patients with CAD than the various noninvasive cardiac tests used. Although CAD is not a reason to refuse a patient a transplant because it usually can be reversed by abstinence, the condition can create problems if it has not been identified prior to the OLT.

About the Author

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