Alcoholic liver disease: to transplant or not to transplant?

Liver transplantation for patients with alcoholic liver disease remains very controversial. We review recent data which suggest that, contrary to earlier reports, many alcoholic patients with end-stage liver disease are able to meet stringent selection criteria and that these selected alcoholics achieve a good result from a liver transplant. Conversely, non-selected alcoholics have a significantly poorer survival. This raises the question as to what is the most appropriate method to select alcoholic patients for liver transplantation. We advocate a selection process which considers the potential recipients' medical, surgical and psychiatric suitability rather than their diagnosis. We outline how we have arrived at this approach in part because of the heterogeneity of patients who carry the diagnosis 'alcoholic liver disease'. We describe how we try to estimate prognosis for future abstinence, which is based on a profile of historical features rather than a fixed period of sobriety. Using this approach, the incidence of recidivism in the first 2 years after transplantation has been low. Prospective longitudinal studies are needed to improve methods of selection for the management of alcoholic patients undergoing liver transplantation.