Should alcoholics be eligible for lifesaving liver transplants?

Should alcoholics who have blown out their livers be eligible to receive new livers from organ donors?

The answer has been no – at least not until these patients have demonstrated that they won’t squander a new organ. Patients with severe alcoholic hepatitis are usually required to go six months without a drink in order to get on the transplant list. But this requirement, while understandable given the scarcity of livers for patients in need, amounts to a death sentence for 70% to 80% of these patients; most of them don’t even last two months without a new liver.

A group of researchers in France and Belgium wanted to see what would happen to these patients if they were allowed to qualify for liver transplants sooner.

They identified 26 such patients who had failed to respond to standard drug treatment and placed them on the transplant list. These candidates (all between the ages of 34 and 60) also pledged not to drink and had supportive families. The research team also found 26 control patients who had the same severity of disease but did not go on the transplant list.

Joining the transplant list right away was certainly a boon to the patients, according to results published in Thursday’s edition of the New England Journal of Medicine. Of the 26 who got liver transplants as part of the study, 20 (or 77%) were still alive six months later. Among the 26 matched controls, only six (or 23%) were still alive six months after joining the study. In fact, of the 20 who died, 18 passed away within the first two months after failing to respond to drug treatment.

Not surprisingly, the patients who became eligible for early transplants were also much more likely to be alive after two years, according to the study.

None of the patients who got new livers suffered an alcoholic relapse during the first six months after their transplants. However, three of the patients did resume drinking eventually – one started one year and 255 days after transplant; another resumed two years and 10 days later; and a third lasted for three years and 45 days before drinking again. All three received counseling from an addiction specialist, and one of them cut back to drinking an average of only 10 grams per week. The other two were still drinking daily – one was drinking 30 grams per day (about two average-sized drinks) and the other drank more than 50 grams per day.

The results underscore the ambivalence many people feel about putting alcoholics on the transplant list in the first place. As the researchers put it: “Reluctance to perform transplantation in patients with alcoholism is often based on the view that they are responsible for their illness and are likely to resume alcohol use after transplantation.”

But previous studies have shown that focusing on a long sobriety period isn’t always the best way to predict which patients will relapse, the researchers note. And besides, the six-month cutoff is rather arbitrary -- if you force patients to wait even longer (say, a year or two), you can do an even better job of predicting which are most likely to relapse, according to Dr. Robert S. Brown Jr., a liver disease and transplantation expert from Columbia University who wrote an editorial that accompanies the study.

“Alcoholism is a disease, and it should not be used to exclude patients from transplantation,” Brown writes. “This study highlights the need to rethink our approach to transplantation for alcoholic liver disease.”

A summary of the study is available online here. (The full study is available only to New England Journal of Medicine subscribers.) The first part of the editorial is online here.

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