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Over the past 15 years, opinion regarding the suitability of alcoholic patients for liver transplantation has fluctuated from overt disapproval to optimism that liver transplantation might have a beneficial effect on alcoholic behaviour. The former view was evaluated by an opinion survey among the general population, general practitioners and hospital specialists in Great Britain, in which the vignette of an alcoholic in need of liver transplant was consistently rated as justifying a low priority.1 The origin of optimism about the salutary effects of transplantation on alcoholic relapse came from Thomas Starzl, who coined the aphorism that, “liver transplantation was the ultimate sobering experience”.2The current status of liver transplantation for alcoholic liver disease rests somewhere between these two extremes.
Alcoholic liver disease is a common diagnosis among patients selected for liver transplantation in North America and Europe. It often occurs in conjunction with chronic hepatitis C infection. All transplant programmes try to identify patients who will remain abstinent, although how best to achieve this end is less certain. The study by Pageauxet al, in this issue (see page 421), is unusual in not including psychiatry as part of the pretransplant assessment.4 The requirement for a fixed period of abstinence, the so called six month rule, as a predictor of future abstinence is in widespread use among transplant centres in North America and Europe.4 Many addiction specialists remain skeptical about the usefulness of the six month rule, both because it ignores the complexity of addictive behaviour, and because it does not successfully predict future drinking by alcoholic candidates for liver transplantation.5-8
Initial patient and graft survival for alcoholic patients after transplantation is similar to that in patients transplanted for other forms of chronic liver diseases.3 ,9 Quality of life measures, such as rate of returning to work, are similar in alcoholic and non-alcoholic liver transplant recipients. However, data from one of the few prospective studies show that patient survival curves decline more rapidly after two years in alcoholic recipients compared with non-alcoholics.9 Given that the rate of retransplantation is lower in alcoholics than in non-alcoholic recipients, these data may reflect a greater reluctance on the part of transplant programmes to retransplant alcoholics.
The greatest area of controversy concerns alcoholic relapse after liver transplantation. This topic is confounded by difficulty in determining accurate data on drinking behaviour, and a more fundamental conflict on the meaning of alcohol relapse when it occurs in alcoholics. Addiction specialists and transplanters use different interpretations of relapse into alcohol use. Addiction specialists eschew the term recidivism with its connotations of blame, and refer to minor, isolated drinking episodes as slips.5 Indeed, a slip may serve a useful purpose by indicating to the alcoholic that they need more support or treatment for their alcoholism. Conversely, liver transplanters tend to regard any use of alcohol as a failure of compliance, which should have serious consequences, such as removal from the waiting list. These dichotomous views on the nature of alcoholism were highlighted by a conference on Liver Transplantation in Alcoholics held under the auspices of the National Institutes of Health in 1997 which served to bring clinical researchers in liver transplantation and addiction medicine together for the first time.3-5 ,9
Despite difficulty in getting robust data and differences in accepting a model of addiction which distinguishes slips (minor, isolated drinking) from relapses (prolonged and harmful drinking), liver transplanters and addiction specialists are finding common ground in the consistent results regarding alcohol use which are coming to light. In this issue Pageaux et al present a retrospective data analysis regarding alcohol use and other parameters of clinical well-being in 54 alcoholic liver transplant recipients. Their data are broadly consistent with at least 17 other published reports on the outcome of liver transplantation in alcoholic patients.10 Typically, roughly one third to one half of alcoholic liver transplant recipients will report some use of alcohol in the first five years after transplantation. Although many studies suggest that the consequences of alcohol use are minimal for many recipients, perhaps because alcohol is consumed in small amounts on infrequent occasions, there are few good data to be certain. Conversely, between 10 and 20% of alcoholic liver transplant recipients will drink excessively, yet over five years, few of these patients develop significant liver injury. The major deleterious effects of heavy alcohol use in the first five years after liver transplantation are on extrahepatic health, thereby emphasising that the injurious effects of alcohol are multisystemic.7 ,8
What do these observations teach us about alcoholism and the urge to drink excessively? Like the cliché about the glass being half full or half empty, the data on alcohol relapse after liver transplantation can be viewed as surprisingly good or disappointingly bad. Compared with the outcome of other forms of intervention against alcoholism, a rate of sobriety of 50% at five years is at least as good as most alcoholism treatment programmes. Indeed, such data may overestimate significant drinking, as some of the patients who are classified as relapsers report occasional slips which would not be considered treatment failures in today’s standard alcoholism literature. However, it is noteworthy that many alcoholic patients return to alcohol use after liver transplantation despite the devastating effects of alcohol on their lives, and despite evidence of continuing alcoholic injury. Our goal should be to reduce further the frequency of relapses to excessive, harmful drinking. In order to achieve this goal, it will be necessary to understand the factors that promote or inhibit a return to drinking, and how relapsers contrast with those who establish long term sobriety. It is naive to presume that paradigms drawn from alcoholism treatment programmes will translate directly into the liver transplant population. Alcoholic liver transplant candidates are less likely to consider themselves in need of treatment for alcoholism than matched controls in an alcoholism treatment programme.11Similarly, after transplantation, alcoholic patients frequently lack motivation for alcoholism treatment. Enhancing the sense of commitment to treatment may be an important component in improving control of alcoholism in the 50% of recipients in danger of relapse in the first five years after liver transplantation. Although much has been learnt about alcoholics and alcoholism from retrospective audits of transplant databases, future advances will require hypothesis testing by means of longitudinal, prospective studies.