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Liver Transplantation and Alcoholic Liver Disease: History, Controversies, and Considerations

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Liver Transplantation and Alcoholic Liver Disease: History, Controversies, and Considerations Submit a Manuscript: http://www.f6publishing.com World J Gastroenterol 208 July 4; 24(26): 0000-0000 DOI: 0.3748/wjg.v24.i26.0000 ISSN 007-9327 (print) ISSN 229-2840 (online) REVIEW Liver transplantation and alcoholic liver disease: History, controversies, and considerations Claudio A Marroni, Alfeu de Medeiros Fleck Jr, Sabrina Alves Fernandes, Lucas Homercher Galant, Marcos Mucenic, Mario Henrique de Mattos Meine, Guilherme Mariante-Neto, Ajacio Bandeira de Mello Brandão Claudio Augusto Marroni, Sabrina Alves Fernandes, Lucas Correspondence to: Claudio Augusto Marroni, MD, Homercher Galant, Guilherme Mariante Neto, Ajacio PhD, Professor, Graduate Program in Medicine: Hepatology, Bandeira de Mello Brandão, Graduate Program in Medicine: Universidade Federal de Ciências da Saúde de Porto Alegre Hepatology, Universidade Federal de Ciências da Saúde de Porto (UFCSPA), Rua José Kanan Aranha, 102, Jardim Isabel, Porto Alegre (UFCSPA), Porto Alegre 90430-080, RS, Brazil Alegre 91760-470, RS, Brazil. [email protected] Telephone: +55-51-999638306 Claudio Augusto Marroni, Alfeu de Medeiros Fleck Junior, Fax: +55-51-32483202 Sabrina Alves Fernandes, Lucas Homercher Galant, Marcos Mucenic, Mario Henrique de Mattos Meine, Guilherme Received: April 3, 2018 Mariante Neto, Ajacio Bandeira de Mello Brandão, Peer-review started: April 4, 2018 Liver Transplant Adult Group, Irmandade da Santa Casa de First decision: April 27, 2018 Misericórdia de Porto Alegre, Porto Alegre 90035-072, RS, Revised: May 23, 2018 Brazil Accepted: June 16, 2018 Article in press: June 16, 2018 Sabrina Alves Fernandes, Nutrition at the Centro Universitário Published online: June 28, 2018 Metodista (IPA), Porto Alegre 90420-060, RS, Brazil ORCID number: Claudio Augusto Marroni (0000-0002-1718-6548); Alfeu de Medeiros Fleck Jr (0000-0002-0424-6919); Sabrina Alves Fernandes (0000-0001-8504-603X); Lucas Homercher Galant Abstract (0000-0002-4333-1403); Marcos Mucenic (0000-0001-9389-2236); Alcohol consumption accounts for 3.8% of annual global Mario Henrique de Mattos Meine (0000-0001-9914-6381); mortality worldwide, and the majority of these deaths Guilherme Mariante Neto (0000-0002-1580-3725); Ajacio Bandeira are due to alcoholic liver disease (ALD), mainly alcoholic de Mello Brandão (0000-0001-8411-5654). cirrhosis. ALD is one of the most common indications for liver transplantation (LT). However, it remains a Author contributions: All authors reviewed and analyzed complicated topic on both medical and ethical grounds, the literature and contributed to the writing of the manuscript; Marroni CA also provided the overarching intellectual input into as it is seen by many as a “self-inflicted disease”. One of the study design and edited the final version of the manuscript. the strongest ethical arguments against LT for ALD is the probability of relapse. However, ALD remains a common Conflict-of-interest statement: No potential conflicts of indication for LT worldwide. For a patient to be placed on interest. No financial support. an LT waiting list, 6 mo of abstinence must have been achieved for most LT centers. However, this “6-month rule” Open-Access: This article is an open-access article which was is an arbitrary threshold and has never been shown to selected by an in-house editor and fully peer-reviewed by external affect survival, sobriety, or other outcomes. Recent studies reviewers. It is distributed in accordance with the Creative have shown similar survival rates among individuals who Commons Attribution Non Commercial (CC BY-NC 4.0) license, undergo LT for ALD and those who undergo LT for other which permits others to distribute, remix, adapt, build upon this chronic causes of end-stage liver disease. There are work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and specific factors that should be addressed when evaluating the use is non-commercial. See: http://creativecommons.org/ LT patients with ALD because these patients commonly licenses/by-nc/4.0/ have a high prevalence of multisystem alcohol-related changes. Risk factors for relapse include the presence of Manuscript source: Invited manuscript anxiety or depressive disorders, short pre-LT duration of WJG|www.wjgnet.com July 4, 208|Volume 24|Issue 26| Marroni CA et al . Liver transplantation and alcoholic liver disease sobriety, and lack of social support. Identification of risk patients with liver failure in end-stage liver disease, and it factors and strengthening of the social support system is their only chance of survival. As patients on LT waiting may decrease relapse among these patients. Family lists outnumber the number of LTs performed, and counseling for LT candidates is highly encouraged to due to the high waiting list mortality rate, prioritization prevent alcohol consumption relapse. Relapse has been of individuals who are most likely to die without LT is associated with unique histopathological changes, graft needed. Access based on who is most likely to benefit damage, graft loss, and even decreased survival in some from organ donation requires a legal, fair and ethical studies. Research has demonstrated the importance of basis for the allocation[1-3]. a multidisciplinary evaluation of LT candidates. Complete Alcohol consumption accounts for 3.8% of global abstinence should be attempted to overcome addiction mortality and 4.6% of disability-adjusted life-years issues and to allow spontaneous liver recovery. Abstinence [4] (DALYs) lost due to premature death . Among the is the cornerstone of ALD therapy. Psychotherapies, various harmful effects of alcohol, alcoholic liver disease including 12-step facilitation therapy, cognitive-behavioral (ALD) induces a wide spectrum of liver abnormalities, therapy, and motivational enhancement therapy, help support abstinence. Nutritional therapy helps to reverse including simple steatosis, alcoholic hepatitis (AH) or muscle wasting, weight loss, vitamin deficiencies, and steatohepatitis, progressive fibrosis, and ultimately trace element deficiencies associated with ALD. For alcoholic cirrhosis (AC) and/or hepatocellular carcinoma [5] muscular recovery, supervised physical activity has been (HCC) . shown to lead to a gain in muscle mass and improvement One of the common causes of chronic liver disease, of functional activity. Early LT for acute alcoholic hepatitis for which LT is potentially lifesaving, is ALD. This has has been the subject of recent clinical studies, with been highly controversial from the beginning. The ever- encouraging results in highly selected patients. The increasing shortage of organs has accentuated the low survival rates after LT for ALD are comparable to those of priority given to patients with ALD, which is considered patients who underwent LT for other indications. Patients a “self-inflicted” condition. However, by improving the that undergo LT for ALD and survive over 5 years have a long-term survival rates (thereby making them similar higher risk of cardiorespiratory disease, cerebrovascular to those for LT patients with other indications) and events, and de novo malignancy. recognizing that alcoholism is a primary disease, ALD has become one of the most common indications for Key words: Alcoholic liver disease; Alcoholic hepatitis; LT in Europe and North America, a situation thought Alcoholic cirrhosis; Alcoholism; Liver transplantation; unfathomable 30 years ago. Unfortunately, there are still Alcoholic recurrence; Controversies; Alcoholic abstinence; many issues with the use of LT for ALD. Relapse; Selection criteria LT for ALD used to be associated with many ethical dilemmas, but this has recently changed as alcoholism is © The Author(s) 2018. Published by Baishideng Publishing now understood to be a chronic, recurrent neurological Group Inc. All rights reserved. disease process with a clear biological basis. Alcoholism is no longer primarily viewed to be a result of moral Core tip: Alcohol consumption accounts for 3.8% of annual global mortality worldwide. Cirrhosis is a common weakness and self-destructive behavior, but an addiction and dependence that should be considered from other complication of alcoholic liver disease (ALD) and when [5] end-stage liver disease is reached, the only chance of perspectives . survival is liver transplantation (LT). There are contro- ALD progression is dependent on patient charac- versies and ethical dilemmas associated with LT for teristics, as well as drinking patterns. Abstinence is ALD. This study reviews the history and controversies fundamental to the treatment of all forms of ALD, and and considers the development of, indications for, and the alcohol consumption relapse rate is lower than that outcomes of LT in ALD, including severe acute alcoholic expected in alcoholics. The consequences of excessive hepatitis. Relapse, therapeutic options, and outcomes are drinking after LT range from asymptomatic biochemical emphasized. and histological abnormalities to graft failure and death. Marroni CA, de Medeiros Fleck A Jr, Fernandes SA, Galant LH, HISTORICAL PERSPECTIVE, Mucenic M, de Mattos Meine MH, Mariante-Neto G, de Mello CONTROVERSIES, AND Brandão AB. Liver transplantation and alcoholic liver disease: History, controversies and considerations. World J Gastroenterol CONSIDERATIONS 2018; 24(26): 0000-0000 Available from: URL: http://www. History wjgnet.com/1007-9327/full/v24/i26/0000.htm DOI: http://dx.doi. LT for ALD has been a controversial situation from the org/10.3748/wjg.v24.i26.0000 beginning
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