Early liver transplant in severe alcoholic hepatitis shows benefit

WASHINGTON — Early liver transplant in patients with severe alcoholic hepatitis demonstrated acceptable short-term survival, according to results from the multi-center ACCELERATE-AH study presented at The Liver Meeting 2017.

“Early transplant can be lifesaving, but most U.S. centers adhere to a 6-month rule where patients are required to be abstinent from alcohol for at least 6 months prior to transplant,” Brian Lee, MD, of the University of California, San Francisco, said during his presentation.

Lee, however, noted that the problem with requiring patients to remain abstinent from alcohol for 6 months could be costly, because approximately 70% of patients with severe alcoholic hepatitis die during the abstinence period.

“To have informed debate on national policy on such a controversial use of a scarce organ, we need a better understanding of a broad experience,” he said. “And that’s why this project was initiated.”

Lee and colleagues conducted a retrospective cohort study of 147 patients (median age, 43 years; 73% men; 83% white) across 12 medical centers (range, 3-40 per center).

Investigators from each center completed standardized data collection forms encompassing patient characteristics, as well as alcohol related outcomes.

More than half of the cohort (56%) were employed, 66% of the cohort had a form of private medical insurance, and 31% had a history of psychiatric or co-morbid disease.

Thirty-nine percent had a family history of alcoholism, 30% had a history of a failed rehab attempt, and 12% had a history of illicit drug use.

Sixty-nine percent of the cohort were thought to have completely accepted their diagnosis of alcohol use disorder after social work assessment.

The median alcohol consumption per day was 10 units with 15 years of heavy drinking.

Researchers included transplant recipients with clinician-diagnosed alcoholic hepatitis. Patients were excluded, however, if they had other co-existing liver disease, HIV infection and other severe co-morbid medical conditions.

Survival and alcohol use post-transplant served as the primary endpoints.

The researchers differentiated between a “slip” and sustained alcohol use post-transplant. They categorized a slip as a sign of alcohol use among individuals who had stopped drinking at last follow-up. They defined patients still drinking at most recent follow-up as sustained.

Additionally, the researchers made note of binge drinking vs. frequent drinking. Binge drinking occurred if men consumed six units of alcohol during a sitting, or if women consumed four units of alcohol. Frequent drinking occurred if a recipient consumed alcohol 4 days or more in a week.

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Patients spent a median 7 days on the wait list with a median pre-transplant abstinence of 55 days. With a median follow-up of 1.6 years, probability of 1-year survival was 94%, and 84% at 3 years. Eighteen patients died during study – nine during the first 90 days. The remaining deaths occurred more than 1 year after transplant.

Twenty-seven percent of patients demonstrated signs of alcohol use post-transplant with a median time to use of 160 days. Probability of alcohol use at 1-year post-transplant was 25%, and 34% at 3 years.

Fifteen patients had sustained use and the remaining 25 were considered slips and had recovered to sobriety at most recent follow-up.

Individuals who were younger (OR = 1.05; 95% CI, 1.01-1.09) and those who lacked an acceptance of a diagnosis during social worker assessment (OR = 2.36; 95% CI, 1.1-5.08) were most likely to use alcohol post-transplant. Race, medical insurance, co-morbid psychiatric disease and employment rate were not correlated to drinking post-transplant.

Drinking 10 or more united of alcohol per day at presentation was one predictor of post-transplant death (OR = 3.17; 95% CI, 1.04-9.67).

“Our next steps need to address how best to select these candidates and the optimal means for monitoring alcohol use post-transplant, as well as strategies to prevent and intervene in patients with alcohol abuse,” Lee said.

Since 2011, Lee said, there has been a steady rise in the application of early transplant for severe alcoholic hepatitis, increasing from four centers to 12 centers and from five transplants per year to 39 per year. And although the data from the ACCELERATE-AH study shows concern with post-transplant drinking, Lee said he still sees the need for early liver transplant.

“This data highlights a very significant problem – that alcohol use post-transplant was responsible for the majority of deaths beyond the perioperative period in this patient population,” he said. “This is not new. ... There’s several papers that have shown a return to heavy drinking post-transplant is associated with [life loss]. Despite all these findings, the data in terms of interventions to intervene on alcohol use post-transplant is embarrassingly scarce and I’m not discouraged by this, [but] it is the honest truth that we don’t know what to do with these patients. But, I think that our group is motivated, and we share your concerns and we’re actively studying this.” – by Ryan McDonald

Reference:

Lee BP, et al. Abstract 12. Presented at: The Liver Meeting; October 20-24, 2017; Washington, D.C.

Disclosures: Lee reports no relevant financial disclosures.

Editor's note: This has been updated with clarification from the presenter.