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Review article: Current indications and selection criteria for early liver transplantation in severe
Carolina Ramirez-Cadiz1, Hanna Blaney2, Natalia Kubanek3
1Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada.
Insights
Early liver transplantation for severe alcohol-associated hepatitis (AH) shows survival benefits, but patient selection criteria need refinement. An integrated approach is crucial for managing alcohol use disorder risks.
Area of Science:
- Hepatology
- Transplantation Surgery
- Addiction Medicine
Background:
- Alcohol-associated hepatitis (AH) is a severe, high-mortality liver disease.
- Early liver transplantation is an emerging option for severe AH.
- Referral and selection criteria for early liver transplantation are debated.
Purpose of the Study:
- To review the natural history of severe AH.
- To outline diagnostic criteria for AH.
- To discuss indications for early liver transplantation in AH.
Main Methods:
- PubMed database search conducted through August 2023.
- Key search terms included 'alcoholic hepatitis,' 'abstinence,' and 'liver transplantation.'
- Narrative review methodology employed.
Main Results:
- Historically, a six-month abstinence period was required for liver transplantation in alcohol-associated liver disease (ALD).
- Selected patients receiving early transplants demonstrate significantly higher survival rates (77%) compared to non-transplanted patients (23%).
- Early transplantation is controversial due to the risk of alcohol relapse without prior alcohol use disorder treatment.
Conclusions:
- Early liver transplantation offers survival advantages for severe AH.
- Many candidates for early transplantation may not have undergone alcohol use disorder treatment.
- An integrated evaluation approach is necessary for candidacy in early liver transplantation.
Background:
Alcohol-associated hepatitis (AH) is a severe inflammatory form of alcohol-associated liver disease (ALD) that carries a high mortality rate. Early liver transplantation for severe AH is increasingly available. However, specific criteria for referral and selection remain a subject of debate.
Aims:
To provide a narrative review of the natural history, diagnostic criteria and indications for referral for early liver transplantation for severe AH.
Methods:
We searched PubMed for articles published through August 2023. Key search terms were 'alcoholic hepatitis,' 'alcohol-associated hepatitis,' 'abstinence,' 'alcohol relapse,' and 'liver transplantation.'
Results:
Previously, a six-month period of alcohol abstinence was required before patients with ALD were considered for liver transplantation. However, studies in recent years have demonstrated that, among carefully selected patients, patients who received early transplants have much higher survival rates than patients with similarly severe disease who did not undergo transplants (77% vs. 23%). Despite these successes, early liver transplantation remains controversial, as these patients have typically not undergone treatment for alcohol use disorder, with the ensuing risk of returning to alcohol use.
Conclusions:
While early liver transplantation for AH has survival benefits, many patients would not have received treatment for alcohol use disorder. An integrated approach to evaluating candidacy for early liver transplantation is needed.
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