Patterns of alcohol consumption after liver transplantation
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Background —Uncertainty exists about the extent and consequences of a return to alcohol consumption after liver transplantation for alcoholic liver disease (ALD). Aims —To determine the prevalence and consequences of alcohol consumption in patients transplanted for ALD. Methods —A retrospective case controlled study of all patients transplanted for ALD at the Queen Elizabeth Hospital, Birmingham, between 1987 and 1996. Results —Seventy patients with ALD were transplanted, of which 59 survived more than three months; 56 were interviewed. Twenty eight had consumed some alcohol after transplantation; for the nine “heavy drinkers” (HD), the median time to resumption of alcohol intake was six months and for the 19 “moderate drinkers” (MD) it was eight months. There was no significant difference in episodes of acute rejection or compliance with medication between those who were abstinent, MD, or HD. Histological evidence of liver injury was common in ALD patients who had returned to drink. Mild fatty change was found in 1/11 biopsy specimens from abstinent patients but moderate to severe fatty change and ballooned hepatocytes were seen in 3/5 MD and 2/5 HD specimens. Two HD patients had early fibrosis. One HD patient has died of alcohol related complications. Conclusions —Moderate to heavy alcohol consumption occurs in patients transplanted for ALD. Patient recall of abstinence advice is unreliable, and patients return to alcohol mainly within the first year after liver transplantation. Return to alcohol consumption after liver transplantation is associated with rapid development of histological liver injury including fibrosis.Keywords:
Liver disease
Although alcoholic liver disease (ALD) is an accepted indication for liver transplantation (LT), there are several controversial issues. The aim of this study is to examine the applicability of the 6-month abstinence rule prior to LT and to evaluate the results in living donor LT for patients with ALD.A retrospective study of 102 patients with ALD referred for LT was performed. Clinical data, including alcohol consumption history, were analyzed. A period of abstinence from drinking alcohol of at least 6 months was strictly required.Among 102 patients, 21 abstained from drinking for at least 6 months. Of these, 13 patients (12%) underwent LT, five patients (5%) recovered without LT and three patients (3%) were listed for deceased donor LT. LT was not indicated for the remaining 81 patients (80%). Eight patients died within 6 months of referral to our program. The Child-Pugh score was higher in these eight patients than in the 21 who achieved 6-month abstinence, although the alcohol consumption history variables did not significantly differ between the two groups. The 5-year overall survival rates after LT in 13 patients with ALD (91%) were similar to those in 387 non-ALD patients (83%). The rate of alcohol consumption relapse after LT was 8% (n = 1/13).Living donor LT for patients with ALD who complied with the 6-month abstinence rule provides sufficient survival benefit with good compliance, compensating for the potential risks to the donors.
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Although alcoholic liver disease (ALD) is regarded as a common indication for liver transplantation (LT), debatable issues exist on the requirement for preceding alcoholic abstinence, appropriate indication criteria, predictive factors for alcoholic recidivism, and outcomes following living-donor LT. In most institutions, an abstinence period of six months before LT has been adopted as a mandatory selection criterion. Data indicating that pre-transplant abstinence is an associated predictive factor for alcoholic recidivism supports the reasoning behind this. However, conclusive evidence about the benefit of adopting an abstinence period is yet to be established. On the other hand, a limited number of reports available on living-donor LT experiences for ALD patients suggest that organ donations from relatives have no suppressive effect on alcoholic recidivism. Prevention of alcoholic recidivism has proved to be the most important treatment after LT based on the resultant inferior long-term outcome of patients. Further evaluations are still needed to establish strategies before and after LT for ALD.
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Alcoholic liver disease(ALD) is the second most common diagnosis among patients undergoing liver transplantation(LT).The recovery results of patients transplanted for ALD are often at least as good as those of patients transplanted for other diagnoses and better than those suffering from hepatitis C virus, cryptogenic cirrhosis, or hepatocellular carcinoma.Inthe case of medically non-responding patients with severe acute alcoholic hepatitis or acute-on chronic liver failure, the refusal of LT is often based on the lack of the required alcohol abstinence period of six months.The obligatory abidance of a period of abstinence as a transplant eligibility requirement for medically non-responding patients seems unfair and inhumane, since the majority of these patients will not survive the six-month abstinence period.Data from various studies have challenged the 6-mo rule, while excellent survival results of LT have been observed in selected patients with severe alcoholic hepatitis not responding to medical therapy.Patients with severe advanced ALD should have legal access to LT.The mere lack of pre-LT abstinence should not be an obstacle for being listed.
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Although alcoholic liver disease(ALD) is regarded as a common indication for liver transplantation(LT), debatable issues exist on the requirement for preceding alcoholic abstinence, appropriate indication criteria, predictive factors for alcoholic recidivism, and outcomes following living-donor LT. In most institutions, an abstinence period of six months before LT has been adopted as a mandatory selection criterion. Data indicating that pre-transplant abstinence is an associated predictive factor for alcoholic recidivism supports the reasoning behind this. However, conclusive evidence about the benefit of adopting an abstinence period is yet to be established. On the other hand, a limited number of reports available on living-donor LT experiences for ALD patients suggest that organ donations from relatives have no suppressive effect on alcoholic recidivism. Prevention of alcoholic recidivism has proved to be the most important treatment after LT based on the resultant inferior long-term outcome of patients. Further evaluations are still needed to establish strategies before and after LT for ALD.
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SummaryThe purpose was to study the features of clinical and laboratory manifestations ofalcoholic liver disease at the cirrhosis stage associated with non-alcoholic fatty liverdisease.Material and methods. Clinical, laboratory and instrumental examinations wereperformed for 204 patients with hepatic cirrhosis. 78 persons had alcoholic liver disease(Group I) and 126 persons had a combination of alcoholic liver disease with nonalcoholic fatty liver disease (Group II). Group I included 24 women and 54 men(53.2±7.6) years old; 22 women and 104 men (47.8±6.4) years old belonged to GroupII. Patients of Groups I and II were allocated to subgroups according to the classes ofhepatic cirrhosis compensation according to the Child-Pugh criteria: IA (17 patients),IB (38 patients), IC (23 patients); IIA (44 patients), ІІВ (48 patients), ІІС (34 patients).Results and discussion. It was found that the signs of astheno-vegetative, pain,dyspeptic, hepatorenal, hepatopulmonary syndromes, jaundice, medically uncontrolledascites, and manifestations of hepatic encephalopathy were shown more often amongpatients in combination with non-alcoholic fatty liver disease. Somatometric indicessignificantly differed among all patients depending on the degree of compensation. Thethickness of the skin and fat fold are reliable indicators that reflect the state of the fatdepot of the body; the circumference of shoulder muscles is a reliable indicator of thereduction of the somatic protein pool, accompanied by a decrease in the syntheticfunction of the liver and a decrease in the somatic protein pool, especially amongpatients associated with non-alcoholic fatty liver disease.Conclusions. During examining patients with liver cirrhosis, the study of the trophicstatus, synthetic function, and functional state of the liver are recommended for timelycorrection of the revealed disorders.
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The dietary intake of eight alcoholic patients with liver cirrhosis following complete abstinence was compared with that of non-alcoholic cirrhotics. Protein and lipid amounts actually ingested were much lower, even following abstinence, in alcoholic cirrhotics than in non-alcoholic cirrhotics, suggesting that dietary customs of alcoholics with liver disease do not change easily. Therefore, dietary education is necessary for abstaining alcoholics and should be aggressively applied in the out-patient clinic.
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Alcoholism is the leading cause of end-stage liver failure in the United States, but the application of liver transplantation to the treatment of alcoholic liver disease remains controversial because of medical and ethical concerns. Information about the outcome of patients who undergo transplantation for alcoholic cirrhosis would help to resolve these concerns.The results of 41 patients (Group 1) with alcoholic liver disease were compared with those of patients who underwent liver transplantation for other medical problems (group 2) at this center. Thirty of the 32 survivors from group 1 and 30 matched subjects from group 2 were interviewed to assess substance dependence, recidivism, and activity level.Compared with control subjects, patients with alcoholic liver disease had equivalent patient and graft survival rates and achieved an equal level of postoperative health. These results were achieved even though patients with alcoholic liver disease had significantly worse liver failure and more morbidity before surgery, and one third of the patients in this group were not abstinent before transplantation.We conclude that patients with alcoholic liver disease merit equal consideration for liver transplantation compared with other causes of liver failure. Treatment of the addictive disorder should be included before and after surgery.
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Alcoholic liver cirrhosis is a leading cause of liver transplantation around the world. Nevertheless, selection of alcoholic candidates remains controversial. We estimate that 20–50% of patients who receive a liver transplant because of end-stage alcoholic liver disease acknowledge some alcohol use in the first 5 years after liver transplantation, whereas 10–15% will resume heavy drinking. Currently, the majority of alcoholic patients who are placed on the liver transplant waiting list have established extended periods of abstinence from alcohol prior to evaluation. This chapter looks at assessment of the alcoholic patient before the decision to undertake liver transplantation is made, and the management and outcome of liver transplantation in this population, including specific issues related to alcohol use.
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