Introduction
The global mortality rate is significantly influenced by alcohol usage, with a predominant cause of death being alcoholic liver disease (ALD), specifically alcoholic cirrhosis. Autoimmune liver disease (ALD) is widely recognized as a prevalent indication for liver transplantation (LT). Nevertheless, the subject remains intricate from both medical and ethical perspectives, as it is a self-induced ailment. The liver transplantation (LT) for alcoholic liver disease (ALD) is the concern regarding the likelihood of relapse.
What Is Liver Transplantation?
A liver transplantation procedure involves the surgical removal of a malfunctioning liver, typically due to liver failure, and the subsequent replacement with a healthy liver obtained from either a donor who died or a living donor's partial liver.
What Is Alcoholic Liver Disease?
Alcoholic liver disease refers to the medical condition characterized by liver damage resulting from excessive alcohol consumption. The accumulation of lipids, inflammatory response, and fibrotic tissue formation can be induced.
How Should Alcohol Be Used After Transplantation?
The anticipation of abstinence following liver transplantation; however, there exists a variety of alcohol consumption patterns. The standardization of quantifying alcohol use following liver transplantation remains lacking despite the existence of various terminologies employed to characterize alcohol use.
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Abstinence refers to the complete avoidance of alcohol consumption.
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Relapses - Infrequent intake of restricted quantities of alcohol accompanied by prompt actions to reinstate abstinence.
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Harmful and excessive drinking, also referred to as relapses, is characterized by the consumption of more than 40 grams of alcohol per day, the intake of four or more drinks within a single day, or the continuation of drinking for a minimum of four consecutive days.
What Does Pre-Transplant Management Include?
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The timely initiation of the transplantation process is crucial in achieving favorable outcomes. Therefore, it is strongly advised that individuals diagnosed with alcohol-associated liver disease who meet the criteria for transplantation be promptly referred for examination to assess their eligibility for transplantation. The patient's chances of surviving the evaluation and waiting period may be compromised due to delayed referral, as the waiting times for a suitable donor liver are progressively increasing.
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The mere existence of cirrhosis does not provide adequate justification for the need for transplantation. The consideration of transplantation typically arises when a patient has either a problem related to portal hypertension or a symptom of impaired hepatic function. The indications for liver transplantation are addressed distinctly.
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The achievement of early referral for liver transplantation is often hindered, perhaps due to ongoing alcohol consumption or the belief held by referring specialists that liver transplantation is not a feasible alternative. Nevertheless, the frequency at which patients eligible for transplantation are not being recommended for assessment remains uncertain.
What Are the Factors Contributing to Alcohol Relapse?
Various patient-related factors influence the probability of alcohol relapse after transplantation.
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One of the risk factors for alcohol relapse is the absence of social support.
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The presence of a psychiatric disorder, whether it is ongoing or has occurred in the past, increases the likelihood of alcohol relapse following liver transplantation. Evaluating to detect any coexisting psychiatric conditions can assist in identifying patients who are at a higher risk for relapse.
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The presence of a familial background of alcohol dependency is associated with an increased likelihood of alcohol relapse. However, it is important to note that the magnitude of this association is rather small.
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Noncompliance with post-transplantation office visits was found to be a non-significant risk factor for alcohol relapse among patients with alcohol-associated liver disease who received liver transplantation.
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Hepatitis C virus (HCV) infection is a frequently observed cause of liver disease in individuals who also consume alcohol. However, it is important to note that the presence of HCV does not contribute to an increased likelihood of alcohol relapse after undergoing transplantation.
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The correlation between a younger age and a higher rate of alcohol relapse is not consistently seen.
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The length of abstinence before transplantation has been observed to have a negative correlation with the likelihood of alcohol relapse.
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A composite measure has been devised to evaluate multiple variables (such as age at liver transplantation, nonalcohol-related criminal record, pre-transplantation alcohol abstinence, and daily alcohol consumption) and has demonstrated potential in identifying patients who are more likely to experience a relapse in alcohol consumption.
What Are the Outcomes Following Organ Transplantation?
Mortality and graft survival - The acute-term survival rates of patients and grafts who have undergone liver transplantation for alcohol-associated liver disease are comparable to those who have undergone transplantation for nonalcohol-related conditions. Nevertheless, these patients and grafts have a lower ten-year survival rate.
1. Patient Survival: Compared to patients with nonalcohol-associated disease, patients with alcohol-associated liver disease exhibited comparable rates of survival at one and five years. Nevertheless, patients diagnosed with alcohol-associated liver disease had a lower 10-year survival rate than those with diagnoses unrelated to alcohol.
2. Graft Survival: Patients diagnosed with alcohol-associated liver disease exhibited comparable graft survival rates at one and five years in comparison to those with nonalcohol-associated disease. On the contrary, patients diagnosed with alcohol-associated liver disease had a reduced graft survival rate at ten years (60 percent) than those with a nonalcohol-related diagnosis (63 percent).
3. Recurrent Detrimental Alcohol Consumption: Notwithstanding thorough pre-transplant assessment and compliance with the six-month rule as mandated by the majority of medical facilities, certain patients may revert to consuming alcohol after undergoing liver transplantation.
Rejection, loss, and recurrence of alcohol-associated liver disease are all possible complications associated with an alcohol relapse following liver transplantation. There is a potential risk of rapidly progressive liver injury, allograft failure, and fatal alcohol-associated hepatitis (AH) associated with excessive consumption following liver transplantation.
Patients who continue to consume alcohol following liver transplantation may face an elevated risk of being lost to follow-up, which could result in an underestimation of the true consequences of alcohol use on health outcomes.
Patients who have previously experienced alcohol-associated liver disease are monitored for recurrent alcohol use after liver transplantation. This is achieved through clinical interviews and urine ethyl glucuronide (uEtG) testing at each follow-up outpatient visit and at random occurrences when necessary.
4. Prevention and Treatment: Before liver transplantation, patients with acute severe alcohol-associated liver disease (AH) or AH who did not complete an alcohol treatment program are required to execute a patient contract. After undergoing transplantation, they are also required to complete an alcohol therapy program when medically appropriate.
Conclusion
Alcoholic liver disease is a suitable indication for liver transplant. Accurate classification of probable candidates is required to identify those who are most likely to remain abstinent following liver transplant. The survival rate of transplanted individuals with alcoholic cirrhosis is equivalent to that of other types of liver disease. Patients who have had a liver transplant for alcoholic cirrhosis should be followed by AUD specialists at the Liver Transplantation Centre to help them avoid relapse and the recurrence of the initial liver disease. Following liver transplant, patients should have regular cancer screenings, including chest radiography, upper digestive endoscopy, and clinical pharyngolaryngeal examination. Finally, they should be instructed to stop smoking following liver transplant.
