Photo Credit: SvetaZi

Emerging data on living donor transplant for alcohol-associated hepatitis shows the procedure offers a survival benefit over medical management alone.

Studies have shown that managing alcohol-associated hepatitis (AH) with corticosteroid therapy and aggressive nutritional intervention results in a less than 50% improvement in survival. Liver transplant (LT), however, has been shown to increase the survival rate for patients with AH beyond what can be expected with nonsurgical management. 

Transplant Concerns

There are several concerns regarding LT for patients with AH. For example, 6 months of complete abstinence from alcohol is recommended before embarking on an LT. The dire state of health of patients with AH, however, may not allow this time. In this case, an early LT can be enacted, which waves the 6-month alcohol-free period. This may not be detrimental as studies have shown that pre-LT alcohol abstinence is a poor predictor of continued alcohol restraint post-LT.

The availability of deceased donor LT (DDLT) is limited. Although this transplantation method has several advantages, including the availability of whole allograft and a more straightforward procedure, living donor LT (LDLT) is considered a viable option with its own benefits, including offering a lower cold ischemia time and greater control over surgery timing.

Despite its increasing use in treating AH, little research has been conducted on early LDLT in this patient group. To bridge this education gap, Therese Bittermann, MD, and colleagues developed a literature review to explore the challenges and advantages of LDLT in patients with AH. Their findings were published in Liver Transplantation.

Dr. Bittermann spoke with Physician’s Weekly (PW) about the review.

PW: What prompted this research?

Dr. Bittermann: Over the past 10 years, there has been a significant increase in the number of LTs performed for alcohol-associated liver disease. Patients with severe alcohol-associated hepatitis have a high risk of mortality, but LTation is increasingly being acknowledged as an effective treatment for this condition. Much of the data supporting this has originated from the US and Europe in patients receiving deceased donor LTs.

However, there are many countries in the world where deceased donor LT is not an option, and living donor LT is the sole pathway. Given the ongoing shortage of deceased donor organs, living donor LT may also be a relevant option in the US. It is, therefore, important to understand the benefits and risks of living donor LT for severe alcohol-associated hepatitis.

Which findings are most important to emphasize? 

Living donor LT is increasingly considered a pathway for patients with alcohol-associated hepatitis worldwide. The existing data suggest that living donor LT, similar to transplantation with a deceased donor, offers a vital survival benefit over medical management alone. While absolute numbers remain low, there are unique medical, surgical, and ethical considerations for recipients and donors alike in this setting, which our manuscript helps summarize.

What would you like future research to focus on?  

In this manuscript, we highlight the available literature, which primarily originated from countries where deceased donor LT is not an option. Many unanswered questions remain, and the number of studies available is small.

Areas that still need to be clarified include the role and outcomes of living donor LT for candidates with alcohol-associated hepatitis in the US. It would be important to understand in what circumstances living donor transplantation offers an advantage over receiving a deceased donor for this indication and whether the risks of alcohol relapse after LT differ between the two recipient types.

There are also many unknowns related to living donor health outcomes (ie, medical, psychosocial) and safety in this setting, including a lack of data on living donors’ perspectives and long-term consequences.