Liver transplant viable, more accepted in alcoholic hepatitis

WASHINGTON — Patients with acute alcoholic hepatitis fare well after liver transplant and should be considered for the procedure more than they currently are, according to a presenter at The Liver Meeting 2017.

“Patients with acute alcoholic hepatitis have comparable early post-transplant outcomes to those transplanted for fulminant hepatic failure,” George Cholankeril, MD, from Stanford University School of Medicine, said in his presentation. “However, there is no consensus in national guidelines for liver transplantation within this patient population, which is much needed. It is also thought that this is only a solution for a minority of patients amid the rising epidemic of alcohol intoxication in the United States.”

Cholankeril explained they used the UNOS database from 2011 to 2016, looking at all adult transplant candidates and recipients listed for acute alcoholic hepatitis (AAH, n = 193) and compared them to the candidates and recipients listed as status 1A for drug-induced liver injury due to acetaminophen (DILI-APAP, n = 314) and non-DILI (n = 1,405). UNOS defines status 1A as: “acute (sudden and severe onset) liver failure and a life expectancy of hours to a few days without a transplant.”

In the waitlist demographics shown, AAH and non-DILI patients were older than DILI-APAP and patients with AAH were more likely to be white (79.3%). Patients with AAH had an average MELD of 32 vs. 34 for DILI-APAP and 21 for non-DILI. Bilirubin in AAH was at 20 compared to 5.8 and 8.4 in DILI-APAP and non-DILI, respectively. Additionally, 18.8% of patients with AAH had severe hepatic encephalopathy compared to 13% of patients listed as non-DILI and 60.2% of patients with DILI-APAP.

Cholankeril called attention to the seemingly higher level of acceptance of patients with alcoholic hepatitis in transplant centers.

“In 2011, there were 14 patients listed for alcoholic hepatitis and within this last year, in 2016, it’s increased three-fold to 58. DILI and non-DILI are relatively stable throughout these years. So, there’s a growing indication for transplant for alcoholic hepatitis. Similarly, we noticed an eight-fold increase in the number of transplant centers willing to accept patients for transplant for alcoholic hepatitis,” Cholankeril said, showing that in 2011, just three centers listed for this indication while in 2016, 26 centers accepted these patients.

In looking at 90-day waitlist mortality, the researchers found that 61.1% of AAH patients, 63.8% of DILI-APAP and 36% of non-DILI patients died while awaiting transplant.

Of those who received a liver transplant, patients with AAH (n = 126) had a median MELD of 33 and a median total bilirubin of 21.2 while 10.3% were on mechanical ventilator, 35.7% were on dialysis and 25.4% had severe hepatic encephalopathy. Those patients transplanted for non-DILI indications had median MELD of 25, median total bilirubin of 12 and 8.2% were on a mechanical ventilator, 19.9% were on dialysis and 15.7% had severe hepatic encephalopathy.

Following liver transplantation, patients with AAH showed a 93.3% 1-year and 3-year survival rates. Comparatively, patients with DILI-APAP had an 87.7% 1-year post-transplant survival and 80.8% 3-year post-transplant survival. Patients with non-DILI indications showed an 88.4% 1-year survival and 81.4% 3-year survival (P < .001 for both groups).

“A significant proportion of patients with severe alcoholic hepatitis may not survive 6 months to complete sobriety, which is needed to become an acceptable candidate for liver transplantation,” Cholankeril said. “We must consider that alcoholic liver disease is an orphan disease and still an unmet need as it continues to grow and become a burden in our allocation system.” – by Katrina Altersitz

Reference:

Cholankeril G, et al. Abstract 32. Presented at: The Liver Meeting; Oct. 20-24, 2017; Washington, D.C.

Disclosure: Cholankeril reports no relevant financial disclosures.