Gastroenterology

Gastroenterology

Volume 155, Issue 2, August 2018, Pages 422-430.e1
Gastroenterology

Original Research
Full Report: Clinical—Liver
Outcomes of Early Liver Transplantation for Patients With Severe Alcoholic Hepatitis

https://doi.org/10.1053/j.gastro.2018.04.009Get rights and content

Background & Aims

The American Consortium of Early Liver Transplantation for Alcoholic Hepatitis comprises 12 centers from 8 United Network for Organ Sharing regions studying early liver transplantation (LT) (without mandated period of sobriety) for patients with severe alcoholic hepatitis (AH). We analyzed the outcomes of these patients.

Methods

We performed a retrospective study of consecutive patients with a diagnosis of severe AH and no prior diagnosis of liver disease or episodes of AH, who underwent LT before 6 months of abstinence from 2006 through 2017 at 12 centers. We collected data on baseline characteristics, psychosocial profiles, level of alcohol consumption before LT, disease course and treatment, and outcomes of LT. The interval of alcohol abstinence was defined as the time between last drink and the date of LT. The primary outcomes were survival and alcohol use after LT, defined as slip or sustained.

Results

Among 147 patients with AH who received liver transplants, the median duration of abstinence before LT was 55 days; 54% received corticosteroids for AH and the patients had a median Lille score of 0.82 and a median Sodium Model for End-Stage Liver Disease score of 39. Cumulative patient survival percentages after LT were 94% at 1 year (95% confidence interval [CI], 89%–97%) and 84% at 3 years (95% CI, 75%–90%). Following hospital discharge after LT, 72% were abstinent, 18% had slips, and 11% had sustained alcohol use. The cumulative incidence of any alcohol use was 25% at 1 year (95% CI, 18%–34%) and 34% at 3 years (95% CI, 25%–44%) after LT. The cumulative incidence of sustained alcohol use was 10% at 1 year (95% CI, 6%–18%) and 17% at 3 years (95% CI, 10%–27%) after LT. In multivariable analysis, only younger age was associated with alcohol following LT (P = .01). Sustained alcohol use after LT was associated with increased risk of death (hazard ratio, 4.59; P = .01).

Conclusions

In a retrospective analysis of 147 patients who underwent early LT (before 6 months of abstinence) for severe AH, we found that most patients survive for 1 year (94%) and 3 years (84%), similar to patients receiving liver transplants for other indications. Sustained alcohol use after LT was infrequent but associated with increased mortality. Our findings support the selective use of LT as a treatment for severe AH. Prospective studies are needed to optimize selection criteria, management of patients after LT, and long-term outcomes.

Section snippets

Study Population

Twelve LT centers provided detailed retrospective data on all patients receiving transplants for severe acute AH. Sites were queried about specific selection criteria, the process of selection, and post-transplantation care (Supplementary Table 1). Inclusion criteria were age older than 18 years, presentation with clinically diagnosed severe acute AH (ie, jaundice, prolonged international normalized ratio, chronic and recent alcohol use), no prior diagnosis of chronic liver disease or episodes

Cohort Selection

A total of 147 patients from 12 LT centers across 8 UNOS regions met inclusion and exclusion criteria; 26 of 147 patients were described in prior publications,16, 17 with updated follow-up data included in the current study. Nine of 12 centers, contributing 126 of 147 (86%) patients reliably obtained selection committee data. Of 432 patients with severe AH, 155 (35.9%) were listed and 126 (29.1%) underwent LT (20 died on waitlist, and 9 were delisted due to clinical improvement). The range of

Discussion

The ACCELERATE-AH study includes 12 LT programs in 8 UNOS regions, providing a comprehensive description of the US LT landscape for severe AH. Prior studies were from single centers, thus not necessarily representative of general experience, and lacked sample size to evaluate factors associated with post-LT outcomes. In severe AH, where 6-month mortality can reach 70%, our study shows that early LT is used across the United States as rescue therapy. Indeed, it seems incontrovertible that this

Acknowledgments

Author contributions: Brian Lee: study concept and design, acquisition of data, analysis and interpretation of data, drafting of manuscript, revision of manuscript, statistical analysis. Neil Mehta: study concept and design, analysis and interpretation of data, revision of manuscript. Laura Platt: acquisition of data, analysis and interpretation of data, revision of manuscript. Ahmet Gurakar: acquisition of data, analysis and interpretation of data, revision of manuscript. John Rice:

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    Conflicts of interest The authors disclose no conflicts.

    Funding Supported by grants from the National Institute of Diabetes and Digestive and Kidney Diseases: UCSF Liver Center P30 DK026743 and T32 DK060414 to Brian P. Lee.

    This article has an accompanying continuing medical education activity, also eligible for MOC credit, on page e21. Learning Objective: Upon completion of this CME activity, successful learners will be able to determine if a patient with severe alcoholic hepatitis is appropriate for consideration of early liver transplantation and identify expected outcomes after transplantation

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