Liver transplantation for alcoholic hepatitis: Being consistent about where to set the bar

The 2011 article by Mathurin et al. on early liver transplantation for patients with severe alcoholic hepatitis (SAH) caused a significant stir in the hepatology and liver transplantation communities; not because it showed excellent outcomes in patients with liver failure, but because of the nature of the recipient group. A 6-month abstinence rule has been applied either formally or informally in virtually all countries where liver transplantation is undertaken. The rationale behind the 6-month rule is the perception that 6 months of pretransplant abstinence predicts posttransplant abstinence, as well as allowing determination of recoverability of the liver disease. However, in patients with SAH, 40% of all patients and up to 70% of those with an adverse Lille score after 7 days of prednisolone treatment will have died by 6 months, making the current abstinence month rule of no use. In an article in this issue of Liver Transplantation, Antonini et al. conducted a survey to explore how the initial article by Mathurin et al. had translated into clinical practice by surveying hepatologists, surgeons, anesthetists, and addiction psychiatrists at liver transplant units in France. The results are both fascinating and instructive. First, they demonstrate that transplantation for SAH is now much more widely practiced in France than it was before and that the majority of clinicians, particularly hepatologists and addiction specialists, are highly supportive in selected patients. This was even though over half of the respondents thought that accepting certain patients with alcoholic hepatitis would adversely affect the survival chances for patients with other indications on the transplant waiting list. The article by Antonini et al. also suggests a spillover of positive attitudes more broadly to transplantation for alcoholrelated cirrhosis with an observed increase after 2011 in most centers. The 6-month abstinence rule has been relaxed in three-quarters of centers in “highly selected patients. ” Although this survey has not been verified against transplant registry data, taken on face value it shows both a significant change and marked variation in routine clinical practice. Although 12% of transplant centers in France are performing more than 5 transplants per year for SAH, a similar proportion, 13%, are not undertaking any. This suggests a marked inequity of access to this potentially lifesaving procedure, which potentially creates a “postcode lottery” scenario where the likelihood of being listed for transplantation is related to the place you live and the policy of the local transplant center. In most clinical decision making, such a marked variation in practice would be unacceptable, therefore dictating the need for agreed national, rather than local, criteria for transplant listing in SAH. Variations in practice may be explained by a number of factors, including uncertainty around prognosis in SAH, risk of disease recurrence, and stigmatization of patients with alcohol use disorders. The article by Mathurin et al. showed excellent outcomes for early LT, but only 2% of all SAH patients seen during the study underwent transplantation. Stringent criteria were used to narrow down those individuals who had a poor prognosis without transplantation, but yet would have a good longterm prognosis with transplantation, particularly in terms of returning to drinking. Current prognostic scoring tools do not reliably discriminate those patients with a high ( 90%) mortality Abbreviations: ARLD, alcohol-related liver disease; HCV, hepatitis C virus; SAH, severe alcoholic hepatitis.