Lecture : Acute alcoholic hepatitis is a distinct entity from the chronic liver disease associated with heavy alcohol intake where liver fibrosis occurs gradually over time. Although both occur in the setting of prolonged alcohol use, acute alcoholic hepatitis presents acutely with a clinical syndrome of jaundice and signs of liver failure. The development of severe acute alcoholic hepatitis (SAH), most commonly defined by a Maddrey discriminant function score of at least 32 or the presence of hepatic encephalopathy, portends a particularly poor prognosis (mortality rate up to 40% at 6 months) in the absence of effective therapy. Treatment of severe alcoholic hepatitis with corticosteroids or pentoxifylline is recommended by current clinical practice guidelines, including the American Association for the Study of Liver Disease and the European Association for the Study of the Liver. Managing steroid non-responders and patients in whom steroids are contraindicated remains a challenge and unsolved medical problem. The therapeutic armamentarium at disposal, leaves no other option other than orthotopic liver transplantation (OLT). With death staring at these patients, whether rescue OLT should be offered has been a matter of debate.
Problems with liver transplantation for patients with AH are manifold. Beginning with, whether a patient with self-inflicted disease deserves the available liver graft which is a scarce resource. Second, recidivism and relapse are major concerns in these patients. Third, the fact that alcoholism is multisystem disease which precludes good result from surgery along with the risk of poor compliance in these patients.36 Fourth and the most debatable is the proper selection of patients who should be transplanted: the ones who are likely to die without a liver transplant and those who are unlikely to return to drinking.37 About 25% of the steroid null-responders will eventually recover with medical management and if transplanted at early stage would lead to wastage of precious liver grafts. The public perceptions of use of organs for patients with alcoholism complicate the issue further.
We used data from the Korean Network for Organ Sharing (KONOS) database, which contains comprehensive national data on waiting lists, organ donations, and transplantations.
The study population included deceased donor liver transplantation (DDLT) between June 2014 and May 2018 in Korea. All patients were followed until death, drop out on the waiting list, or 31 June 2018. In June of 2016, the KONOS implemented the MELD score to prioritize liver allocation. Outcome data were collected from June 2014 to May 2016 (the 24 months prior to MELD implementation), and from June 2016 to May 2018 (the 24 months after MELD implementation). Among total 1684 liver recipients from deceased donor, patient with alcohol related liver disease were 660. The Survival rate after LT in MELD era, was higher in these patients than non-alcohol liver disease such as viral hepatitis and HCC.
In present liver allocation system, alcoholic hepatitis is favored to receive deceased donor liver. Because of scared organs, patients with non-alcohol liver disease have few chance to undergo liver transplantation. This problem should be considered and allocation system must be improved.