liver transplant for acute alcoholic hepatitis · 2019. 7. 22. · alcoholic liver disease •acute...
TRANSCRIPT
Liver transplant for acute alcoholic hepatitis
James Trotter, MDBaylor University Medical Center
Dallas, Texas
OLT – acute alcoholic hepatitis• background
• outcomes
• current guidelines
• future
Alcoholic liver disease
• acute alcoholic hepatitis– young, < age 40– active drinking, acutely very ill– high inpt mortality rate
• alcoholic cirrhosis– usually older > 50 y– ascites, jaundice, non-bleeding varices– variable mortality rate
Alcoholic liver disease - OLT
• “they did it to themselves”– other illness are self-induced (HCV, fatty liver)– “disease paradigm” of alcoholism
• “they will just go back to drinking again”– many have long-established sobriety– most don’t drink after OLT– excellent post-OLT survival
Current criteria – OLT EtOH cirrhosis
• alcoholic cirrhosis• 6 months sobriety• “proves” sobriety commitment• weak supporting data
Current criteria – 6 m sobriety rule
• some patients recover – no OLT
• some patients die
• alcoholic hepatitis resolves
OLT – alcoholic cirrhosis
57-year-old alcoholic cirrhosis sober for 8 yrslong-term clinic patient.
diet-controlled DM
bili – 4.1 Cr – 1.2 INR – 2.3 MELD – 23anticipated wait time to transplant 6 – 12 m
OLT – alcoholic cirrhosis
57-year-old alcoholic cirrhosis sober for 8 yrslong-term clinic patient.- employed, insured- married, family- proven long-term clinic compliance- no psych, drug or legal problems
New criteria – acute EtOH hepatitis
• acute illness, very sick, short evaluation• no sobriety period• recidivism predicted from risk factors• based on French study in NEJM
OLT – acute alcoholic hepatitis
27-year-old WM presents with decompensation
EtOH level – 178 on admission
dx alc liver disease 2 yrs ago, continued to drink
bili – 24.1 Cr – 1.2 INR – 4.3 MELD – 37
anticipated wait time to transplant 6 – 12 d
OLT – acute alcoholic hepatitis
27-year-old WM presents with decompensation
OLT – acute alcoholic hepatitis
27-year-old WM presents with decompensation
- recently fired, paying monthly for insurance- no insight about EtOH causing illness- unmarried, parents “fighting for patient”- failed EtOH rehab, 2 DUI’s- prior psych rx, never followed up
Acute hepatitis vs. cirrhosis
alc hepatitis cirrhosisfollow-up none long-termduration acute chronicsobriety no yesseverity very high highevaluation hours-days weekswait time days months
OLT – acute alcoholic hepatitis• scientific
• sociologic
• transplant
Criteria- nonresponse to medical therapy - first liver-decompensating event- supportive family members- absence of psychiatric disorder- agreement to adhere to lifelong total abstinence
2 % of all patients with acute alcoholic hepatitis
12 % recidivism rate
Clinical experience – no uniform selection criteria
28 % recidivism rate
Post-OLT recidivism – risk factors
• >10 drinks/d at initial hospitalization (+4 pts)
• multiple prior rehabilitation attempts (+4 pts)
• prior alcohol-related legal issues (+2 pts)
• prior illicit substance abuse (+1 pt)
Hepatology 2018
Death rates attributed to alcohol
MMWR, 2017
Transplant factors• decline of hepatitis C
• organ competition
• “need” for healthy, high-MELD patients
1. 1st presentation with decompensated liver disease
2. OLT medical eligibility3. assessment w SW and
addiction specialist.4. < 1 prior failed rehab5. lack of other substance use/
dependency/psyc disease6. patient insight
7. 2 close, supportive family members or caregivers 8. post LT care with addiction specialist in LT clinic 9. transplant team facilitating alcohol use treatment 10. EtOH monitoring owith ETG and PEtH for at least 2 yrs
PRO – acute alcoholic hepatitisAbstinence duration not relevantNon-transplant outcomes poorInitial outcomes are favorableGrowing number of young, sick patients
CON – acute alcoholic hepatitisUS patients poorly selected
Higher rates of recidivism
Displacing more qualified patients
Transplant centers “redefining” alcoholism for their own purposes
Criteria- nonresponse to medical therapy - first liver-decompensating event- supportive family members- absence of psychiatric disorder- agreement to adhere to lifelong total abstinence
2 % of all patients with acute alcoholic hepatitis