Dr Arab discusses his address from Digestive Disease Week 2023 on determining appropriate candidates among patients with alcohol-related liver disease, including hepatitis, for liver transplantation.

Juan Pablo Arab, MD, is a transplant hepatologist and an associate professor of medicine in the Division of Gastroenterology, Department of Medicine, and the Department of Epidemiology and Biostatistics at Schulich School of Medicine, Western University, London, Ontario, Canada.

--

TRANSCRIPT:

Dr. Juan Pablo Arab:

Good morning everyone. I'm Juan Pablo Arab. I'm a transplant hepatologist at Western University in London, Ontario, Canada. We are here at the DDW. I just presented regarding who should be referred for liver transplantation when they have alcohol related liver disease, specifically with alcohol associated hepatitis. As you may know, 90% of the subjects that drinks alcohol heavily will develop hepatic steatosis, this is fatty liver. But some of them, between 20 to 40%, if they continue drinking heavily, they will develop a more advanced form of the disease. That could be with fibrosis or cirrhosis and all the complications. But also alcohol associated hepatitis, which is the inflammatory form of the disease, can have a very high mortality, up to 50% at three months.

So in some patients that are very sick, we need to think about a more definitive treatment. And sometimes that treatment is liver transplantation. For patients with cirrhosis, we use the same criteria that we use for all other etiologies of liver disease, which is a MELD score more than 15, or any complication of portal hypertension or any other complication of the cirrhosis, including hepatocellular carcinoma.

The problem is with the patient with severe alcohol associated hepatitis, nowadays, the treatment is very limited. So we use steroids, in particular prednisolone or prednisone in a subgroup of patients. But the response to steroids is no more than 50 or 60%, and only in a subgroup of patients.

We have previously identified that that sub group of patients are those patients with a MELD score between 25 and 39, for the maximum benefit of a difference of survival of at least 20%, up to 30%.

So liver transplantation may be a great option for patients with severe alcohol-associated hepatitis that are not responding to steroids. The problem is how we select these patients, because we don't have an infinite supply of organs. We need to use the organs wisely because there is no organs for everyone. So how we select these patients in a fair manner, and also we do some justice in giving this organ to someone that is going to have a good graft survival and good patient survival. So that's what we want to know.

So the first experience for early liver transplantation in severe alcohol-associated hepatitis was in France, by Dr. Philippe Mathurin. This was published in the New England Journal of Medicine in 2011, and they found excellent outcomes after liver transplantation in these patients. Then there have been more experience. They accelerate ADH consortium in the United States, showed also excellent results.

But how we can select this patient because the main concern is relapse? So the data has been evolving and now we know that there are some criteria that can help us to identify who are going to be good candidates, patient with good social support, patient with the first episode of liver decompensation, a patient that does not have other psychiatric comorbidities that are untreated. So those patients are most likely going to do well post-transplant.

And the post-transplant relapse is frequent, up to 30% in some cohorts. However, the early heavy alcohol relapse that is going to be sustained is only around eight to 10%, and not necessarily is going to impact the graft. So even if they relapse, most of the time the outcomes in the long term are going to be good. Indeed, the patient survival in the patients with ALD is better than other etiologies.

So the message for the GI providers that are not hepatologists, is when to refer these patients. So from one side, if they are cirrhotics, MELD more than 15, complications of portal hypertension or complication of cirrhosis, including hepatocellular carcinoma. If they have a severe alcohol-associated hepatitis, we should consider in those patients that are not responding to steroid based on the Lille score at day seven, or they are too sick to be considered for steroids, we should think on those patients as candidates for liver transplantation. Especially if they have good social support, this is the first episode, they have good insight, and they don't have other psychiatric comorbidities or other organ comorbidities that can preclude liver transplantation. Thank you very much.

--