Alcoholic Liver Disease and Transplantation : Liver Damage

by National Institute of Health

(Page 6 of 7)

Based on long-term studies of alcoholism remissions and relapses, Vaillant proposed four prognostic factors that indicate a favorable outcome: the patient's involvement in activities that can substitute for alcohol, a caring relationship with another person, a source of hope or improved self-esteem, and negative behavioral reinforcement for subsequent drinking (the development of acute pancreatitis). When at least two of these factors are present, the patient is likely to remain abstinent for 3 or more years. If none of these factors or only one of them applies, the patient is likely to relapse within 2 years.

Individual transplant centers also assess long-term abstinence among their patients. Based on their findings, UNOS developed the following guidelines for considering individual alcoholic patients for liver transplantation: a few months of sobriety as a test of short-term compliance (UNOS does not require a 6-month period of abstinence), presence of a supportive social network at home, absence of comorbid risk factors, a clinical impression that the patient has been compliant in the past.

Some transplant centers have used contingency contracting as a method to improve long-term abstinence. With this approach, the patient and the center enter a formal agreement that specifies the consequences of certain actions of both parties. No studies to date have assessed the efficacy of this strategy, however.

Several investigators have proposed additional risk factors for an alcohol relapse. A study by Platz and colleagues suggested that these risk factors include being female, having a poor social environment, having poor personal stability as assessed by a psychologist, and completing less than 6 months of abstinence. DiMartini and colleagues identified a history of other drug use, a family history of alcoholism, and previous experience with alcoholism treatment as risk factors associated with a higher incidence of alcohol relapse. These investigators did not find any relationship between a prior psychiatric disorder and abstinence at 6 months after the transplant.

Types of Liver Damage During an Alcohol Relapse

Although it is not necessary to take a tissue sample (biopsy) of the liver to make a diagnosis of recurrent ALD in patients who have relapsed to alcohol use, researchers have examined changes in liver structure (histological changes) that occur in these patients. These analyses found that the histological features of recurrent ALD that affect the transplanted liver are similar to those of ALD in the native liver. The major histological changes seen with recurring ALD in transplant patients are steatosis, which is found in 83 percent; steatosis accompanied by inflammation (steatohepatitis), found in 10 percent of cases; fibrosis in certain areas of the liver, which occurs in 28 percent of patients; and cirrhosis, found in 23 percent of patients. Other less commonly seen changes include enlarged mitochondria5 in 14 percent of cases, excess levels of iron (siderosis) in the liver cells in 24 percent of cases, and interruption of the bile flow within the liver. (5 The mitochondria are membrane-enclosed components of the cell that are responsible for most of the cell's energy production.) These changes are not specific for ALD, and the physician therefore must exclude the presence of other diseases (viral infection).

Management of Alcoholic Patients After an OLT

With the exception of patients who are dependent on other drugs in addition to alcohol, ALD patients do not have a higher incidence than non-ALD patients of pre- or postoperative psychiatric problems that would necessitate additional treatment. However, ALD patients at high risk for relapse should be followed closely, and regular psychiatric followup should be considered in such cases.

To date, no controlled studies have evaluated specific treatment methods for managing relapse after liver transplantation. The alcoholism treatment approaches used in the general population are probably applicable to these patients as well, with close monitoring by the transplant psychiatrist/psychologist and physician. Several studies have demonstrated that the involvement of a transplant psychiatrist or psychologist both before and after OLT reduces the alcohol relapse rate after transplantation.

Several investigators have attempted to study the effectiveness of motivational enhancement therapy in patients who relapse after liver transplantation. The results of such studies are unclear, however, because few patients enroll in these studies and because other problems are associated with the care of such patients.

Another approach to achieving abstinence in alcoholic patients, administering the medication disulfiram, which serves to deter people from drinking by causing unpleasant effects when combined with alcohol, is not recommended in patients after OLT because disulfiram has toxic effects on the liver.

Ethical Issues Associated With OLT for ALD Patients

Although most people in the population consume alcohol at least occasionally, alcoholism and the diseases caused by it continue to carry a stigma among the general public. This is true particularly for ALD, and no other alcohol-induced organ damage is viewed so negatively. Many people have a bias against liver transplants in alcoholics, resulting at least in part from the continued organ shortage and ever-increasing demand for donor organs, which necessitates rationing of the donor organs. For example, some people consider ALD a self-inflicted disease and therefore propose that ALD patients have lower priority on transplant waiting lists. This attitude is reflected in an opinion poll conducted in Great Britain, which showed that both the general public and family physicians believed that alcoholic patients should have a lower priority than others for OLT. Similar results were reported in Oregon, where the general public was asked to allocate priorities for 714 disorders or treatments. The respondents rated the priority of OLT for non-ALD patients at a moderate level, but gave a very low priority to OLT for ALD. Transplant psychiatrists and psychologists, however, have a more favorable opinion on OLT for alcoholics. For example, in a survey of these health care professionals from 14 academic liver transplant centers in the United States, a consensus favored offering further alcoholism treatment to patients who continued to use alcohol rather than refusing OLT outright.

About the Author

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