High alcohol intake more frequent after early LT in alcohol-related hepatitis
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High alcohol intake was more frequent following early liver transplant vs. standard transplant in patients with severe alcohol-related hepatitis, according to research published in The Lancet Gastroenterology and Hepatology.
“Patients with severe alcohol-related hepatitis who do not respond to medical management and have around 80% risk of 6-month mortality can now be identified with prognostic scores such as the Lille model,” Alexandre Louvet, MD, professor of hepatology at the University Hospital of Lille in France, and colleagues wrote. “Because these patients are at a therapeutic end and there is improved prediction of mortality, the French consensus on liver transplantation has recommended investigating early access to liver transplantation without a period of at least 6 months of abstinence. A pilot study reported a significant benefit to survival following early liver transplantation in highly selected patients, which has been confirmed by several other studies.”
Seeking to evaluate the risk of alcohol relapse in patients who received early LT for alcohol-related hepatitis vs. patients who received LT after 6 months or more of alcohol abstinence, Louvet and colleagues conducted a prospective, nonrandomized controlled trial in 19 French and Belgian hospitals. They recruited patients who did not respond to medical treatment and who were eligible for early transplant (early LT group), patients who were listed for transplant after a 6-month abstinence period (standard LT group) and patients who did not respond to medical treatment and who were not eligible for early LT. Researchers also recruited a control group of participants with severe alcohol-related hepatitis who were unresponsive to therapy and not transplanted.
Studied endpoints included risk assessment of alcohol relapse and survival rates 2 years post-transplant in the early LT and standard LT groups and 2-year overall survival in the early LT group compared with patients not eligible for early LT and non-transplanted controls.
Among 149 patients with severe alcohol-related hepatitis, researchers placed 102 in the early LT group, 129 in the standard LT group and 47 in the group not eligible for early LT. Sixty-eight patients in the early LT group and 93 in the standard LT group received transplants.
According to study results, 34% of patients in the early LT group relapsed vs. 25% in the standard LT group, which was not statistically significant (P = .45). Compared with the standard LT group, the early LT group demonstrated an increased rate of 2-year high alcohol intake (absolute difference: 16.7%; 95% CI, 5.8-27.6).
Though researchers noted similar 2-year post-transplant survival rates between these two groups (HR = 0.87; 95% CI, 0.33-2.26), the rate of 2-year overall survival was higher in the early LT group vs. those not eligible for early LT (HR = 0.27; 95% CI, 0.16-0.47) and controls (HR = 0.21; 95% CI, 0.13-0.32).
“The present study did not establish the non-inferiority of early liver transplantation for severe alcohol-related hepatitis with regards to alcohol relapse after transplantation and confirms the important survival benefit related to early liver transplantation for severe alcohol-related hepatitis,” Louvet and colleagues concluded. “The study also proposes a reproducible approach to select patients for early liver transplantation. Further progress is required to improve addiction management after liver transplantation.”
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Shreya Sengupta, MD
This study once again demonstrates the significant survival benefit of those offered early LT compared with those with severe alcohol-related hepatitis for whom medical therapy failed and who were not transplant candidates.
It also highlights the importance of good patient selection for early LT in alcohol-related hepatitis. Alcohol-related liver disease is the No. 1 cause of LT in the U.S., and rates of alcohol use and related liver disease are rising globally, particularly among patients in their 20s to 40s. The lesson from this article should be that there is survival benefit and similar rates of survival between patients who are transplanted early and at the standard 6-month mark, but that patients in the early LT group need more support to prevent alcohol use after transplant. The increased rate of consumption of alcohol in the early LT group highlights the need for standardized, multidisciplinary care in the pre- and post-transplant setting that addresses both liver disease and alcohol use disorder, addiction and co-existing mental health conditions.
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