Potosky: Liver transplantation for alcoholic liver disease

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