Liver Transplants Double for Alcohol-related Liver Disease in U.S

Highlights:

• Liver transplants performed to treat alcohol-associated liver disease (ALD) have doubled in the last 15 years in the United States
• ALD has replaced Hepatitis C as the most common reason for liver transplants
• New research also highlights geographic variations in transplant rates for ALD patients

In the U.S, the proportion of liver transplants that are being performed to treat alcohol-related liver disease (ALD) has doubled in the last 15 years.

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The Liver Transplant Scenario

A research team from the University of California- San Francisco has made an observation that this could partly be attributed to wider acceptance of the waiver of the mandated sobriety period before transplants in the ALD group. The study has also highlighted that there are regional geographic variations in the liver transplant rates for alcohol-related liver disease patients, which might indicate inequity in access to treatment.

Dr. Brian P. Lee, a Gastroenterology and Hepatology Fellow at UCSF and the lead author of the study has said that, “This study suggests that there may be value in a national policy for liver transplant in alcohol-associated liver disease, to eliminate any potential inequity in health care access for liver transplant related to the patient's geography and the transplant center's policy on alcohol abstinence prior to transplant.” He added that, “The liver transplant landscape is changing and multiple factors must be taken into account when considering future trends and policy.”

In recent times ALD has replaced hepatitis C to become the most common source for liver transplants in the U.S. Factors such as flexibility around the six-month abstinence rule are most likely to have caused this change in scenario. On the other hand, hepatitis C rates have significantly declined after adopting antiviral therapy.

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Alcoholism in the U.S

A 2017 national epidemiology study in the Journal of the American Medical Association (JAMA) showed that the prevalence of harmful drinking among Americans had increased considerably. The disorder was more pronounced in women and disadvantaged socioeconomic populations. This is also an indicator of the escalation of many chronic comorbidities like ALD where alcohol use plays a substantial role.

In general, a candidate needing a transplant is required to abstain from alcohol for a minimum of six months to be considered eligible for surgery. The practice of following the ‘six-month rule,’ though common, but subjective, has declined since 2011. Dr. Lee explains that this happened following a breakthrough European study showing that liver transplants for patients with severe alcoholic hepatitis could still be successful without the minimum sobriety period.

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The Study

Dr. Lee and his team analyzed 32,913 liver transplant recipients from 2002 to 2016 in the United Network for Organ Sharing (UNOS) database. Of this, 9,438 were ALD patients and 23,475 were non-ALD. Between 2002 and 2010 (a year before the European study), the share of ALD transplants had increased from 24.2 percent to 27.2 percent respectively.

Further, in 2016, it had gone up to 36.7 percent. The proportions of transplant for ALD, including the hepatitis C virus recipients were: 15.3 percent in 2002, 18.6 percent in 2010 and 30.6 percent in 2016, which is a 100 percent increase.

Geographical Variations in ALD Transplants

The research team has also identified variations in regional increases in transplants for ALD among the 11 UNOS regions. All of these regions witnessed increases in the proportion of liver transplant for ALD between 2010 and 2016.

• Region 2, comprising of Delaware, D.C., Maryland, New Jersey, Pennsylvania, West Virginia, Northern Virginia and Region 4 - Oklahoma, Texas saw the largest increase in ALD transplant.
• The smallest of increases were noticed in Region 3: Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, Puerto Rico and Region 10 - Indiana, Michigan.

Findings and Recommendations

The research team has observed that despite the significant increase in liver transplants for ALD, when it comes to access to transplants, these patients are still at a disadvantage. About 48 percent of liver-related deaths are a result of ALD, a number that is still higher than the proportion of liver transplants.

Dr. Lee mentions that for ALD patients the survival rates beyond five years were 11 percent lower, despite the short-term rates being the same as that of the non-ALD transplants.

Dr. Noah Terrault, a UCSF Health Hepatologist and Professor of Medicine at UCSF and the senior author of the study has remarked: “Early liver transplant for ALD recipients without a mandated sobriety period leads to a higher proportion of patients with ALD being prioritized for transplant over non-ALD patients.”

She added, “Since liver transplant policy is decided at a center level and may be incentivized by regional competition, there can be significant regional disparities, potentially leading to inequity to transplant access. We hope our results encourage action towards a national transplant policy for ALD.”

Besides this study, as part of another multicenter research, Dr. Lee and his team at UCSF have developed a new tool referred to as the ‘SALT’ acronym for Sustained Alcohol use post-Liver Transplant. With 95 percent effectiveness, ‘SALT’ could be used to identify suitable candidates for transplant, ideally patients with alcoholic hepatitis who were at low risk for sustained alcohol use after transplant.

References:

1. Liver Transplants Double for Alcohol-Related Liver Disease - (https://www.ucsf.edu/news/2019/01/413096/liver-transplants-doubles-alcohol-related-liver-disease)

Source-Medindia