To the Editor:
As physicians and members of the Council of the Liver Intensive Care Group of Europe (LICAGE), we read with great concern the poem by Dr. Hester recently published in Anesthesiology.1
It is our strong opinion that such a contribution has nothing to do with “Creative writing that explores the abstract side of our profession and our lives.”
We think that Dr. Hester’s paper ignores not only the suffering of our patients or the transplant community’s efforts to offer them a reliable and long-lasting treatment, but also the current evidence and practice. In fact, liver transplantation is the only cure for end-stage alcoholic liver disease, which remains a common indication for this procedure worldwide.2–7 Transplant centers commonly require at least 6 months of alcohol abstinence before patients can be listed for liver transplantation. In fact, the 1993 Consensus Conference of Paris recognized an abstinence of 3 to 6 months as a good predictor of alcohol relapse avoidance.2 This period not only gives physicians a possibility to review if the patient’s liver resumes function on its own in the absence of alcohol, but also is an opportunity for the patient to demonstrate how strong their intention is to stay sober after the surgery.
We have evidence that excellent results can occur when liver transplantation is performed after 6 months of alcohol abstinence.5 However, for patients whose hepatitis did not respond to standard medical therapy, the 6-month survival rate was approximately 30%, with most of the alcoholic hepatitis deaths occurring within 2 months.5 Mathurin et al.7 evaluated if early liver transplantation (with alcohol abstinence less than 6 months) is associated with survival benefits among patients with severe alcoholic hepatitis. Twenty-six patients with severe alcoholic hepatitis, at high risk of death (median Lille score, 0.88), were transplanted. The cumulative 6-month survival rate was higher among patients who received early liver transplantation in comparison to controls who did not receive liver transplantation (77% ± 8% vs. 23% ± 8%, P < 0.001). This benefit of early transplantation was maintained through 2 years of follow-up (hazard ratio, 6.08; P = 0.004). Three patients resumed drinking alcohol, one at 720 days, one at 740 days, and one at 1,140 days after transplantation. The authors concluded that the low rate of alcohol relapse was probably related to the careful selection of recipients. More recently, Im et al.4 performed a similar study in the United States. Early liver transplantation, in selected patients with severe alcoholic hepatitis, resulted in improved outcomes. Also, Lee et al.,3 in a retrospective analysis of 147 patients who underwent early liver transplantation for severe alcoholic liver disease, found patient survival for 1 (94%) and 3 yr (84%) similar to that for patients receiving liver transplantation for other indications. The authors stated that the alcohol use after liver transplantation was infrequent but associated with increased mortality, supporting the use of liver transplantation as a treatment for severe alcoholic liver disease.
Liver transplantation for alcoholic liver disease has always remained a complicated topic from both medical and ethical points of view, as it is seen for many a “self-inflicted disease,” where the main concerns remain the chance of alcohol intake relapse after liver transplantation, which has been reported to be from 7 to 95%.5 The significant differences among data can be explained by differences in the use of terms “recidivism” and “relapse,” which some studies utilize to define any alcohol intake, and heavy drinking. Relapse to “harmful drinking” has been reported in 8 to 21% of liver transplantation recipients, and occasional drinks may not cause significant graft damage. However, with a history of alcoholism, it would be difficult to predict an outcome and magnitude of posttransplant alcohol abuse.5 Nevertheless, it is clear that, due to the current organ shortage, priority should be given to patients with high probability of success. For alcoholic liver disease, abstinence before and after liver transplantation may be reinforced by the implementation of strict clinical and laboratory screening for alcohol relapses as well as strong support groups, along with strong social support and closer follow-up. The selection criteria should strongly emphasize the importance of the family environment, good social structure, and family counseling.5 We think that all of these patients and families deserve the same respect as any other patient while they walk the hard road to redemption from alcohol abuse.
Several questions remain to be answered regarding liver transplantation for alcoholic liver disease.2 We strongly believe that physicians should address these questions with compassion, with empathy, and based on the available evidence.
Dr. Reyntjens is a member of the KOL Group on perioperative temperature management. The other authors declare no competing interests.