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Immediate listing for liver transplantation versus standard care for Child-Pugh stage B alcoholic cirrhosis: a
Claire Vanlemmens1, Vincent Di Martino, Chantal Milan
1Centre Hosptialier Universitaire Jean Minjoz, Besançon, France.
Insights
Immediate liver transplantation for alcoholic cirrhosis (Child-Pugh stage B) did not improve survival and increased cancer risk. Standard care with delayed transplantation is recommended for these patients.
Area of Science:
- Hepatology
- Transplantation Surgery
- Gastroenterology
Background:
- Liver transplantation enhances survival for end-stage alcoholic cirrhosis (Child-Pugh stage C).
- The benefit of liver transplantation for Child-Pugh stage B alcoholic cirrhosis remains uncertain.
- Alcoholic cirrhosis is a leading indication for liver transplantation worldwide.
Purpose of the Study:
- To compare outcomes of immediate liver transplantation versus standard care for Child-Pugh stage B alcoholic cirrhosis.
- To evaluate the impact of early listing on survival and cancer risk.
- To determine optimal management strategies for alcoholic cirrhosis patients not yet at end-stage.
Main Methods:
- Randomized controlled trial involving 120 patients with Child-Pugh stage B alcoholic cirrhosis.
- Patients were assigned to immediate liver transplantation listing (60) or standard care (60).
- Primary endpoints were overall and cancer-free survival over 5 years.
Main Results:
- Immediate listing resulted in 68% receiving transplants versus 25% in the standard care group.
- No significant difference in 5-year all-cause or cirrhosis-related mortality between groups (58% vs. 69% survival).
- Immediate listing increased the risk of extrahepatic cancer (5-year cancer-free survival 63% vs. 94%).
Conclusions:
- Immediate liver transplantation listing does not offer a survival advantage for Child-Pugh stage B alcoholic cirrhosis.
- Early listing for liver transplantation is associated with a higher risk of developing extrahepatic cancers.
- Management should focus on factors like alcohol abstinence and baseline disease severity for long-term survival.
Background:
Liver transplantation improves survival of patients with end-stage (Child-Pugh stage C) alcoholic cirrhosis, but its benefit for patients with stage B disease is uncertain.
Objective:
To compare the outcomes of patients with Child-Pugh stage B alcoholic cirrhosis who are immediately listed for liver transplantation with those of patients assigned to standard treatment with delay of transplantation until progression to stage C disease.
Design:
Randomized, controlled trial.
Setting:
13 liver transplantation programs in France.
Patients:
120 patients with Child-Pugh stage B alcoholic cirrhosis and no viral hepatitis, cancer, or contraindication to transplantation.
Interventions:
Patients were randomly assigned to immediate listing for liver transplantation (60 patients) or standard care (60 patients).
Measurements:
Overall and cancer-free survival over 5 years.
Results:
Sixty-eight percent of patients assigned to immediate listing for liver transplantation and 25% of those assigned to standard care received a liver transplant. All-cause death and cirrhosis-related death did not statistically differ between the 2 groups: 5-year survival was 58% (95% CI, 43% to 70%) for those assigned to immediate listing versus 69% (CI, 54% to 80%) for those assigned to standard care. In multivariate analysis, independent predictors of long-term survival were absence of ongoing alcohol consumption (hazard ratio, 7.604 [CI, 2.395 to 24.154]), recovery from Child-Pugh stage C (hazard ratio, 7.633 [CI, 2.392 to 24.390]), and baseline Child-Pugh score less than 8 (hazard ratio, 2.664 [CI, 1.052 to 6.746]). Immediate listing for transplantation was associated with an increased risk for extrahepatic cancer: The 5-year cancer-free survival rate was 63% (CI, 43% to 77%) for patients who were immediately listed and 94% (CI, 81% to 98%) for those who received standard care.
Limitation:
Restriction of the study sample to alcoholic patients may limit the generalizability of results to other settings.
Conclusion:
Immediate listing for liver transplantation did not show a survival benefit compared with standard care for Child-Pugh stage B alcoholic cirrhosis. In addition, immediate listing for transplantation increased the risk for extrahepatic cancer.
Funding:
The French National Program for Clinical Research.
