Liver transplantation for severe alcoholic hepatitis-The CON view

In patients with severe alcoholic hepatitis (AH) who have failed medical therapy, liver transplantation (LT) remains a controversial therapeutic option. This is exemplified by the fact that most of these patients will not have had a period of abstinence prior to consideration for transplantation. Both abstinence before transplantation and the duration of abstinence are important predictors of post-transplant relapse. Furthermore, relapse after transplantation has been associated with accelerated graft injury and increase mortality. Recent pilot studies have demonstrated a benefit in short-term survival with early transplantation in highly selected small number of patients compared to matched controls. The results of these studies raises the possibility of extending graft allocation to these subjects. Despite stringent assessment and a multi-tiered approach to selecting out patients for transplantation, the relapse rate was not insignificant at 12%. As the long-term outcome remains unclear, further relapses with time can still occur. These studies also highlight the fact that the overwhelming majority of subjects with severe AH who are non-responsive to medical therapy are not suitable for LT. Indeed, further large-scale multicentre prospective studies with long-term follow-up are required to confirm the preliminary findings.