Potosky: Liver transplantation for alcoholic liver disease

Today we are pleased to post the parting lecture that Darryn R. Potosky, MD gave to the attendants of the December 2016 UMMC Critical Care conference. Dr. Potosky was an undergrad, medical student, resident, and fellow of the University of Maryland system. During his tenure as staff at UMMC, Dr. Potosky was the director of Hepatology and Assistant Professor of Medicine. In addition, he has published numerous articles in peer-reviewed publications on liver transplantation, spoken at national and international meetings including the American Association for the Study of Liver Diseases (AASLD). Today he is breaking down a problem plaguing ICUs around the country: the massive influx of pre-transplant liver failure patients. This is an issue I can assure you is not just effecting the doctors here in Baltimore!

Clinical Pearls

  • Basic statistics:
    • Alcoholic liver disease is a common indication for liver transplantation
    • Over 7000 liver transplants were done in United States in 2015
      • 359 (~5%) are living donors
    • Over 14000 patients are listed for a transplant (half availability)
  • How do you get a new liver?
    • The Evaluation process is done by a team which includes (hepatology, transplant surgery, social work, nutrition, and transplant coordinator)
    • Work-up:
      • Stress test (+/- cardiac cath), liver imaging, serological eval, etc.
        • And re-evaluated every 2 years
    • MELD score ≥15 + signs of liver disease is an indication for liver transplant evaluation
      • Patients will be placed on the active transplant list ONLY if deemed to be a good candidate
        • NOTHING is a definitive criteria
      • Higher the MELD the more often the patient will need lab work done for monitoring
    • MELD-Na score is an updated scoring system that was implemented in the past 6 months.
      • Hyponatremia increases MELD score significantly
    • MELD exceptions
      • HCC: score is immediately 28 points after 6 months
      • HPS: score is 22 points at listing with documentation of shunt
      • Review board appeals (region pending)
    • Allocation Priority: Status 1 (OPO then region), MELD > 35 (OPO then region), MELD 29-34 (OPO), Liver-intestine candidates Nationally, MELD 15-28 (OPO)
      • Time on wait list only matters if 2 patients have same MELD
  • Alcoholic hepatitis:
    • Labs
      • Alcoholic hepatitis is associated with mild elevation in transaminases (usually < 500)
        • AST: ALT ratio of roughly 2:1 or greater
      • Its common to see significant leukocytosis with alcoholic hepatitis without evidence of active infection (up to 50K)
    • Exam
      • AKI, ascites, jaundice, encephalopathy, enlarged/fatty liver, cirrhosis
    • Medical treatment is limited to glucocorticoids and pentoxifylline
      • STOPAH study (multicenter, double blinded, randomized) showed that prednisone and pentoxifylline was not associated with significant mortality reduction

    • Acute alcoholic hepatitis has a high mortality (85% 6-month mortality if no response to steroids) and these patients won’t make it for 6 months
      • Survival rate with liver transplant for alcoholic hepatitis is higher than liver transplant for viral hepatitis or cryptogenic cirrhosis
        • Early liver transplant for acute alcoholic hepatitis who didn’t respond to steroid was associated with significant improvement in survival but the study’s sample was small
      • ELTR data shows higher survival rates than viral or cryptogenic failure
        • Viral disease was an independent risk factor for mortality
      • Mathurin et. al. evaluated early transplant in severe alcoholic hepatitis (with extremely strict psychosocial criteria)
        • Evaluated responders to steroids vs. non-responders who were transplanted vs. pts who were not transplanted (with a decent percentage of pts who relapsed):

    • Prediction models:
      • Maddrey’s Discriminant Function (DF) score of > 32 will benefit from steroids
        • DF = [4.6 x increase in PT (sec)] + bilibrubin (mg/dl)
      • The Lille model
        • A new tool for therapeutic strategy in patients with severe alcoholic hepatitis treated with steroids with no response + DF > 32 to predict survival and management plan
      • Its proven to be better than other scoring systems like MELD
    • The 6-month rule:
      • One is required to be abstinent from alcohol x 6 months in order to be consider for liver transplant
      • Based on limited data and there are other factors more important than length of abstinence
        • Length of pre-transplant abstinence has been repetitively shown to be a poor predictor of post-transplant abstinence
          • Majority of patients will not live through the 6 months
      • The following factors predict Recidivism and not necessarily length of alcohol abstinence:
        1. Lack of insight into addiction
        2. Social isolation (no job, no home, no companion)
        3. Co-morbid psychiatric illness (includes poly substance abuse)
        4. Multiple failed rehab attempts
      • Majority of patients remained abstinent post-transplant (69%) and 21% relapse in heavy drinker and 10% occasional drinking
        • Recurrent heavy alcohol use can impair graft survival

Suggested Reading

  1. DiMartini A, Day N, Dew MA, Javed L, Fitzgerald MG, Jain A, Fung JJ, Fontes P. Alcohol consumption patterns and predictors of use following liver transplantation for alcoholic liver disease. Liver Transpl. 2006 May; 12(5):813-20. [Pubmed Link]
  2. Burra, P., Senzolo, M., Adam, R. et al, Liver transplantation for alcoholic liver disease in Europe: a study from the ELTR (European Liver Transplant Registry). Am J Transplant. 2010; 10:138-48. [Pubmed Link]
  3. Louvet A, Naveau S, Abdelnour M, Ramond MJ, Diaz E, Fartoux L, Dharancy S, Texier F, Hollebecque A, Serfaty L, Boleslawski E, Deltenre P, Canva V, Pruvot FR, Mathurin P. The Lille model: a new tool for therapeutic strategy in patients with severe alcoholic hepatitis treated with steroids. Hepatology. 2007 Jun; 45(6):1348-54 [Pubmed Link]
About the Author

Jim Lantry

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Just your average critical care doc: Wandering the ED and ICUs for the USAF down in the San Antonio Military Medical Center, traveling the globe to cannulate for ECLS wherever the need arises, and trying to keep up with great minds of today. E: JlantryMD@gmail.com

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