THE COMPLEXITY OF ALCOHOL
ALCOHOL, LIVER DISEASE AND TRANSPLANTATION
AUTHORS Christopher M. Jones, MD, and Dylan Adamson, MD
PREVALENCE
Alcoholic liver disease (ALD) may well rep-
resent the oldest form of self-inflicted liver
injury known to humankind. Evidence sug-
gests that fermented beverages existed at
least as early as the Neolithic period (circa
10,000 B.C.), 1 and liver disease related to
it, almost as long. Alcohol remains a ma-
jor cause of liver disease worldwide. More recently, ALD became
the number one indication for liver transplant (LT) in the United
States in 2016, surpassing Hepatitis C, which had long held that
distinction. 2. ALD encompasses both cirrhosis and acute alcoholic
hepatitis.
RISK FACTORS
Possible factors that affect the development of liver injury include
the dose, duration and type of alcohol consumption; drinking pat-
terns; sex; ethnicity; and associated risk factors including obesity,
iron overload, concomitant infection with viral hepatitis, and pos-
20
LOUISVILLE MEDICINE
sible genetic factors. Geographic variability exists in the patterns
of alcohol intake throughout the world, with approximately two-
thirds of adult Americans consuming some alcohol. 3-4 The major-
ity drink small or moderate amounts and do so without evidence
of clinical disease. 5-7 A population of drinkers, however, do so
excessively and develop alcohol dependence, defined by physical
tolerance and withdrawa. 8. A second subset of alcohol abusers and
problem drinkers engage in harmful use of alcohol, defined by the
development of negative social and health consequences of drink-
ing (e.g., unemployment, loss of family, organ damage, accidental
injury, or death). 9. Failure to recognize alcoholism remains a sig-
nificant problem and impairs efforts at both the prevention and
management of patients with ALD. 10-11. Population level mortality
from ALD is related to per capita alcohol consumption obtained
from national alcoholic beverage sales data. One epidemiologic
study has estimated that for every 1-liter increase in per capita al-
cohol consumption (independent of type of beverage), there was
a 14% increase in cirrhosis in men and 8% increase in women. 12
These data must be considered in the context of the limitations
of measuring alcohol use and defining ALD. Nonetheless, what