Alcoholic hepatitis: How long “off the wagon” is enough before liver transplantation?

Early transplantation for alcoholic hepatitis improved survival (Image source: Thinkstock)

How long should patients with alcoholic hepatitis be sober before a transplant is allowed? Six months is the current rule, though that time is arbitrary. If too much time elapses, there`s a good chance the patient will die. In their article “Early Liver Transplantation for Severe Alcoholic Hepatitis” published last week in the New England Journal of Medicine, Dr. Philippe Mathurin (Hôpital Claude Huriez, Services Maladies de l`Appareil Digestif and INSERM Unité 995, Université Lille Nord de France) et al. studied patients from seven transplant centers who had severe alcoholic hepatitis, had rapidly worsening liver function, were not responsive to medical therapy, and had a higher risk of death without transplantation. Patients also had to have supportive families, have no psychiatric disorder, and agree to be abstinent from alcohol for the rest of their lives. This cohort was matched to other patients who did not undergo early transplantation. Listing patients for transplantation was made soon after non-response to medical therapy was determined (13 days median) and transplantation was performed 9 days later (median).

Six-month survival (77%) was higher for transplant patients compared to control patients who did not respond to medical therapy (23%). Six-month survival of transplant patients was no different from the survival rate of the control group. Ninety percent of deaths in control patients who did not respond to medical therapy occurred two months after determination of non-response to medical therapy. No transplant patient resumed alcohol consumption within six months after transplant, though 3/26 later did: 2 within 2 years and 1 after 3 years. None of the three had graft dysfunction.

Livers available for transplant are relatively scarce. There is a public outcry when celebrity alcoholics, e.g., Mickey Mantle, receive a transplant. This outcry, however, does not occur when a transplant is provided for voluntary overdose of acetaminophen, or for intravenous drug abusers with acute hepatitis B or hepatitis C infection who have a risk for continuing IV drug use. This was a relatively small study and more prospective larger studies of alcoholics are needed.