Long-term liver transplant survival worse with alcoholic liver disease

Last Updated: 2019-01-23

By Anne Harding

NEW YORK (Reuters Health) - Alcoholic liver disease (ALD) has become the leading indication for liver transplant in the U.S., but late posttransplant survival is inferior to survival after transplant for other indications, a new study shows.

"The findings suggest that early liver transplant for alcoholic hepatitis may be leading to broader acceptance of ALD for liver transplant," but the inferior survival suggests "a need for future studies to identify patient profiles associated with best outcomes," Dr. Norah Terrault of the University of California, San Francisco, and her colleagues wrote January 22 online in JAMA Internal Medicine.

Traditionally, ALD patients had to be sober for at least six months in order to receive a liver transplant. But attitudes toward mandatory pre-transplant sobriety periods are changing, the authors note. A 2011 pilot study found transplants extended survival in patients with severe alcoholic hepatitis with no sobriety period, although these patients had been carefully selected.

For the new analysis, the authors used data from the United Network for Organ Sharing on 32,913 patients who received new livers between 2002-2016, including 9,438 with ALD as the primary indication. The study cohort did not include patients with hepatitis C virus (HCV) or hepatocellular carcinoma.

In 2002, 24.2% of the transplants were in patients with ALD, which increased to 27.2% in 2010 and 36.7% in 2016. (If recipients with HCV infection had been included, the proportion of transplants for ALD would have been 15.3%, 18.6%, and 30.6%, respectively, according to the researchers.)

While the authors say the increase in the proportion of transplants for ALD can largely be attributable to the decrease in transplants for HCV over the same period, they also point out that "the most significant increases occurred after . . . the landmark trial of early liver transplant for severe alcoholic hepatitis."

Five-year unadjusted posttransplant survival was 79% with ALD versus 80% without ALD, while 10-year survival was 63% and 68%, respectively. ALD was independently associated with an increased risk of late death (adjusted hazard ratio 1.11).

"Patient and graft survival among patients with ALD were comparable with those among patients without ALD but with an increase in late deaths, which may be clinically significant given the increased focus on long-term outcomes in liver transplant recipients," Terrault and her team write. "Future studies focused on improving disparities in access to liver transplant for ALD and optimizing short- and long-term survival among transplant recipients with ALD should be encouraged."

Care for these patients must include management of ALD and surveillance for cancer and infections, Dr. Mack C. Mitchell of the University of Texas Southwestern Medical Center in Dallas told Reuters Health in a telephone interview. Mitchell co-authored a commentary accompanying the study.

"There's somebody taking care of these people long-term and they need to be empowered with better ways of managing these patients," he said. "There's a lot of unmet needs in this area of how to treat alcohol use disorders."

Rather than focus on length of sobriety before transplant, Mitchell added, factors such as a person's level of social support, perceived ability and willingness to comply with medical treatments and treatment for alcohol use disorder should be taken into account. "The idea that there is some arbitrary fixed time frame for abstinence from alcohol that will separate those who relapse from those who won't is not correct," he said. "There just isn't a way to do it based on time frame alone."

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JAMA Intern Med 2019.