remains clear is the definitive treatment for ALD.
Thomas Starzl, the father of modern transplantation, first de-
scribed LT as a treatment modality for patients with cirrhosis due
to alcohol in a series written in 1988. 13. It has been widely adopted
since that time and remains a valuable therapy for those patients
in need.
DIAGNOSIS
The diagnosis of ALD is based on a combination of features, in-
cluding a history of significant alcohol intake, clinical evidence
of liver disease, and supporting laboratory abnormalities. Unfor-
tunately, the ability to detect these is constrained by patient and
physician factors, as well as diagnostic laboratory shortcomings.
Denial of alcohol abuse and underreporting of alcohol intake are
common in this population, and physicians tend to underestimate
alcohol-related issues and rarely make specific recommendations.
Both the physical exam findings and laboratory evidence for ALD
may be non-diagnostic, especially in patients with mild ALD or
early cirrhosis, but the clinician must have a low threshold to raise
the issue of possible ALD and stress the importance of abstinence
from alcohol. The gold standard for diagnosis remains a liver bi-
opsy, but is rarely needed given an appropriate history, imaging
characteristics and elimination of other etiologies of end-stage
liver disease.
THE COMPLEXITY OF ALCOHOL
More importantly, about one in five patients will return to harmful
levels of drinking, and a third of those will progress to allograft
cirrhosis. 17-18. Recurrent cirrhosis due to alcohol after liver trans-
plant tends to eliminate patients from consideration for re-trans-
plantation and outcomes are poor. 18. There are various risk scores
and tools under investigation in an attempt to predict which pa-
tients will return to harmful drinking after LT.
TREATMENT
ABSTINENCE At the Trager Transplant Center in Louisville, liver transplant re-
ferral patients are evaluated by a multidisciplinary team includ-
ing hepatologists, surgeons, nurse coordinators, dietitians, social
workers, and psychologists. Patients are discussed weekly at a Pa-
tient Selection Committee which ultimately decides on transplant
candidacy. We do require six months of sobriety prior to listing
for transplantation and patients undergo random drug and alco-
hol screens to assure compliance with their sobriety. Patients are
also encouraged to take part in either Alcoholics Anonymous or
another intensive outpatient program (IOP), but this is not a re-
quirement prior to transplant as long as they demonstrate a com-
mitment to sobriety. Many of our patients have had excellent suc-
cess with The Healing Place, a local, nationally recognized, long-
term social model recovery program. After LT, we do not have
any required drug screens or sobriety program involvement, but
patients are intensively followed with regular outpatient visits,as
are all post-LT patients.
Abstinence is the most important therapeutic intervention for pa-
tients with ALD. Abstinence has been shown to improve the out-
come histological features of hepatic injury, decrease progression
to cirrhosis, and to improve survival at all stages in patients with
ALD. This can be relatively rapid, and in 66% of patients abstain-
ing from alcohol, significant improvement was observed in three
months. 14 There is a concern that a large number of patients with ALD
are never referred for transplant evaluation and are essentially
“ruled out” for their drinking history. Therefore the depths of the
problem with ALD may be vastly under reported. Our center does
not require six months of sobriety prior to evaluation and will
work with patients on seeking appropriate addiction resources to
reach the requisite sobriety point before listing.
It is for that reason that most liver transplant programs in the
United States have adopted a “six month rule,” which requires pa-
tients with alcoholic cirrhosis to demonstrate six months of so-
briety prior to undergoing transplantation. There are centers that
will offer liver transplantation to selected patients with severe al-
coholic hepatitis in the acute setting who are unlikely to survive
to the six month mark. It should be noted that sobriety is not a
requirement for listing or liver transplant by the United Network
for Organ Sharing (UNOS); that decision is left to the discretion
of the listing transplant center. ETHICS
OUTCOMES AND RECIDIVISM
Post-transplant outcomes for those patients with ALD are compa-
rable to those who have undergone LT for other etiologies. Relapse
to alcohol use and abuse after transplant is a unique challenge to
this population. Between 10-90% of patients return to some form
of alcohol use depending on how the researchers defined “use.” 16.
The ethical debate surrounding LT for ALD remains a point of
contention nationwide. Some argue that given the limited resourc-
es surrounding organ availability, that use for ALD is not appro-
priate. A potential drop in donations with greater publicity of ALD
transplants is often suggested as an argument against transplant
for this disease, but this has never been supported.
STIGMA AND PERSONAL RESPONSIBILITY FOR HEALTH
Transplantation for patients with ALD has generated widespread
debate among the general public, health care professionals, pa-
tients, living donors, and family members. A commonly expressed
concern pertains to a patient’s personal responsibility for his or
her own health. Specifically, opponents argue that, in ALD, liv-
er damage is self-induced—alcoholism leading to end-stage liver
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