Liver transplantation for alcoholic liver disease: Executive statement and recommendations

A lcoholic liver disease (ALD) is a major cause of cirrhosis and a leading cause of death of end-stage liver disease in the United States and most of the Western world. The only means of restoring health in patients with end-stage liver disease at present is orthotopic liver transplantation. In the United States, between 3,000 and 4,000 liver transplants are performed each year, and a similar number are done yearly in Western Europe. Of the total, 20% to 25% are performed for ALD. The increasing demand for liver transplantation and lack of a similar increase in the supply of donor livers make it important to reassess the use of this precious resource on a regular basis. What criteria should be used in selecting patients with ALD for liver transplantation? How can survival and quality of life after liver transplantation for ALD be made optimal? These issues were addressed in a focused 2-day workshop, ‘‘Liver Transplantation for Alcoholic Liver Disease,’’ held under the auspices of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and the National Institute for Alcohol Abuse and Alcoholism (NIAAA) in Bethesda, Maryland, December 6-7, 1996. This executive statement summarizes the issues raised at this conference and provides overall recommendations regarding treatment of patients with ALD who require liver transplantation. Most importantly, this summary focuses on important needs and directions for clinical research in liver transplantation for ALD. Alcohol is used by a majority of adults in the Western world. Population-based surveys indicate that 68% of adult Americans drink at least one alcoholic beverage per month, and 10% drink two or more per day, the usual definition used for ‘‘heavy drinking.’’ Heavy drinking is more common among men (18%) than women (3%) and among whites than blacks or Hispanics. Alcohol use is a major cause of morbidity and mortality; in the United States, 5% of deaths, approximately 100,000 per year, are either directly or indirectly attributable to alcohol abuse. Why some individuals are able to drink alcohol without dependence while others cannot is unknown. Among the factors associated with the development of alcoholism, both social and genetic factors are important. A family history of alcoholism is perhaps the major risk factor for developing alcohol dependence or abuse. The recent identification of genetic linkages to alcohol-seeking activity in laboratory animals promises to provide critical information on the genetic basis of alcoholism. Research into the nature of addiction is of central importance for the future of prevention and treatment of alcoholism. Encouragement of temperance and moderation should be the cornerstone to societal attempts to decrease alcoholism. ALD is perhaps the most widely recognized complication of chronic alcohol abuse. Nevertheless, only 15% to 20% of alcoholic subjects develop cirrhosis. The disease is more common in men than in women, and the average age of onset is in the mid-40s, typically after 10 to 20 years of heavy alcohol use. The average intake of alcohol in patients with ALD is more than 100 g of alcohol (approximately 8 drinks) per day, but the lower