Comments on Aasld Practice Guidelines for Alcoholic Liver Disease
Authors: Ashwani K. Singal
Journal: Hepatology (2010)

We read with great interest the article by O'Shea et al. in the January issue of HEPATOLOGY, regarding the American Association for the Study of Liver Diseases (AASLD) Practice Guidelines on alcoholic liver disease.1 The article is well written and informative. However, we would like to bring some points to your kind attention which may be of interest to the physicians, gastroenterologists, and hepatologists. In Table 2, the authors described how to calculate the quantity of alcohol in a standard drink. This is an important piece of information when taking a history of alcohol intake from the patients. However, what constitutes one drink should also be described as patients describe their history of alcohol intake as the amount (in milliliters) of wine, beer, or hard liquor. It is defined that 12 ounces of beer (360 mL), 4 ounces of wine (120 mL), and 1.5 ounces of hard liquor (45 mL) constitutes one drink.2 Antioxidants have been used in the treatment of alcoholic liver disease, based on data from animal models as well as in patients with alcoholic liver disease.3, 4 The authors did discuss the current status of vitamin E supplementation. However, another powerful antioxidant, N-acetylcysteine (NAC), has been studied. A randomized controlled study reported in abstract form at the AASLD 2009 meeting showed benefit of NAC in the treatment of severe acute alcoholic hepatitis (AH). Patients with AH treated with a combination of steroids and NAC (n = 85) compared to patients with AH treated with steroids alone (n = 89) had a lower mortality at month 2 (15% versus 33%; P = 0.007) and lower complication rate at month 6 (19% versus 42%; P = 0.001).5 If these results are confirmed in subsequent studies from other centers, a combination of steroids and NAC may be a potential option to improve the outcome of patients with severe AH. While discussing the role of liver transplantation (LT) in AH, the authors did point out the requirement of 6 months of abstinence from alcohol to be eligible for LT. However, in an acute setting such as AH, this may not be possible and 30%-40% of patients with nonresponse to steroids (Lille score ≥0.45) succumb to their illness.6 Louvet et al., in a case-control study reported at the AASLD 2009 meeting in patients with nonresponse to steroids at 1 week showed improved survival at 6 months after LT (n = 18) as compared to matched controls (n = 18) (83% ± 9% versus 44% ± 12%; P = 0.009).7 All the patients in the LT group underwent transplantation within 9 (range 5-13) days of classifying them as nonresponders to steroids. At 1 year, none of the transplanted patients relapsed for alcohol intake. Although we are far from making any firm recommendations on LT in patients with AH, this study is stimulating and challenges the current requirement of 6 months of abstinence. Furthermore, the bibliography list has 276 references in the article. However, we could see 262 references cited in the text. If this observation is correct, the authors may like to submit correction as an erratum. Ashwani K. Singal M.D.*, * Division of Gastroenterology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX.