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Milestones in liver transplantation for alcoholic liver disease
Milestones in Liver Transplantation for Alcoholic Liver Disease Emmet B. Keeffe
L
iver transplantation in humans was first performed in 1963 by Starzl and colleagues, but it took 20 years of further experience before the procedure was recognized at the Consensus Development Conference sponsored by the National Institutes of Health (NIH) in 1983 as an appropriate treatment for advanced liver disease, including alcoholic liver disease (ALD).1 The NIH conference assumed that a minority of alcoholic patients would meet the rigorous medical and psychosocial criteria required to be candidates for transplantation. In fact, at the time of the conference only 25 of 540 patients (4.6%) had received transplants for ALD, and the survival rate was an unacceptable 20%.2 The next milestone occurred in 1988 with the publication by Starzl et al3 of an experience from the University of Pittsburgh showing that the posttransplant survival of 42 patients with ALD was equal to that of patients with end-stage liver disease attributable to other causes and that a minority of patients (2 of 35) returned to drinking. Over the next 6 to 8 years, the cumulative experience at other transplant centers, as reported individually and compiled by the United Network for Organ Sharing, confirmed that the posttransplant survival rates of patients with alcoholic cirrhosis and other types of cirrhosis were indeed comparable and also established that the alcohol relapse rate averaged 15%, with relatively few patients returning to troublesome drinking.4,5 Another important milestone resulted from the collaboration of transplant hepatologists and surgeons with psychiatric colleagues to define psychosocial predictors of long-term sobriety and compliance after liver transplantation.6 Although 6 months of sobriety has evolved as a reasonable, easily identified, and objective requirement for candidacy for liver transplantation, the importance of psychosocial parameters, in combination with a defined period of sobriety, was emphasized in this publication and has been confirmed using slightly modified criteria in other programs.7 Since the publication of these studies, the relative percentage of transplants performed for ALD
has increased substantially to account for approximately 20% of all transplants currently performed in the United States,4 but the supply of donor organs does not begin to approach the potential demand for transplantation. By extrapolation of data from various sources, it is estimated that only 6% (700 patients) of patients expected to die annually of alcoholic cirrhosis in the United States (11,000 patients) actually undergo liver transplantation.5 Another 20% to 30% of liver transplantations are performed for chronic hepatitis C, including a substantial percentage of patients with end-stage liver disease due to a combination of viral and alcoholic liver disease. With this discrepancy between supply and demand, the timing was appropriate to convene a multidisciplinary conference on liver transplantation as the most current milestone in this area. The reports that appear in this issue were presented at a 2-day meeting on ‘‘Liver Transplantation for Alcoholic Liver Disease’’ sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases and the National Institute for Alcohol Abuse and Alcoholism at the NIH in Bethesda, Maryland, December 6-7, 1996. The strength of this meeting was the diversity of interests and backgrounds of the speakers and the wide range of topics presented around the central theme of liver transplantation for ALD. The conference organizers met immediately after the conference and prepared a summary of the information presented during this meeting, which appears as the final report in this issue. Taken together, the reports in this issue of Liver Transplantation and Surgery define the current field of liver transplantation for ALD and identify the areas requiring future outcomes research. From the Stanford University Medical Center, Stanford, California. Address reprint requests to Emmet B. Keeffe, MD, Stanford University Medical Center, 750 Welch Rd, Suite 210, Palo Alto, CA 94304-1509. Copyright r 1997 by the American Association for the Study of Liver Diseases 1074-3022/97/0303-0001$3.00/0
Liver Transplantation and Surgery, Vol 3, No 3 (May), 1997: pp 197-198
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Emmet B. Keeffe
References 1. National Institutes of Health Consensus Development Conference statement: Liver transplantation—June 2023, 1983. Hepatology 1984;4(suppl):107S-110S. 2. Scharschmidt BF. Human liver transplantation: Analysis of data on 540 patients from four centers. Hepatology 1984;4(suppl):95S-101S. 3. Starzl TE, Van Thiel D, Tzakis AG, Iwatsuki S, Todo S, Marsh JW, et al. Orthotopic liver transplantation for alcoholic cirrhosis. JAMA 1988;260:2542-2544. 4. Belle SH, Beringer KC, Detre KM. Liver transplantation in the United States: Results from the national Pitt-UNOS liver transplant registry. In: Terasaki PI, Cecka JM, (eds).
Clinical transplants 1994. Los Angeles: UCLA Tissue Typing Laboratory, 1995:19-35. 5. Keeffe EB. Assessment of the alcoholic patient for liver transplantation: comorbidity, outcome and recidivism. Liver Transplant Surg 1996;2:12-20. 6. Lucey MR, Merion RM, Henley KS, Campbell DA Jr, Turcotte JG, Nostrant TT, et al. Selection for and outcome of liver transplantation in alcoholic liver disease. Gastroenterology 1992;102:1736-1741. 7. Gish RG, Lee AH, Keeffe EB, Rome H, Concepcion W, Esquivel CO. Liver transplantation for patients with alcoholism and end-stage liver disease. Am J Gastroenterol 1993;88:1337-1342.
L
iver transplantation in humans was first performed in 1963 by Starzl and colleagues, but it took 20 years of further experience before the procedure was recognized at the Consensus Development Conference sponsored by the National Institutes of Health (NIH) in 1983 as an appropriate treatment for advanced liver disease, including alcoholic liver disease (ALD).1 The NIH conference assumed that a minority of alcoholic patients would meet the rigorous medical and psychosocial criteria required to be candidates for transplantation. In fact, at the time of the conference only 25 of 540 patients (4.6%) had received transplants for ALD, and the survival rate was an unacceptable 20%.2 The next milestone occurred in 1988 with the publication by Starzl et al3 of an experience from the University of Pittsburgh showing that the posttransplant survival of 42 patients with ALD was equal to that of patients with end-stage liver disease attributable to other causes and that a minority of patients (2 of 35) returned to drinking. Over the next 6 to 8 years, the cumulative experience at other transplant centers, as reported individually and compiled by the United Network for Organ Sharing, confirmed that the posttransplant survival rates of patients with alcoholic cirrhosis and other types of cirrhosis were indeed comparable and also established that the alcohol relapse rate averaged 15%, with relatively few patients returning to troublesome drinking.4,5 Another important milestone resulted from the collaboration of transplant hepatologists and surgeons with psychiatric colleagues to define psychosocial predictors of long-term sobriety and compliance after liver transplantation.6 Although 6 months of sobriety has evolved as a reasonable, easily identified, and objective requirement for candidacy for liver transplantation, the importance of psychosocial parameters, in combination with a defined period of sobriety, was emphasized in this publication and has been confirmed using slightly modified criteria in other programs.7 Since the publication of these studies, the relative percentage of transplants performed for ALD
has increased substantially to account for approximately 20% of all transplants currently performed in the United States,4 but the supply of donor organs does not begin to approach the potential demand for transplantation. By extrapolation of data from various sources, it is estimated that only 6% (700 patients) of patients expected to die annually of alcoholic cirrhosis in the United States (11,000 patients) actually undergo liver transplantation.5 Another 20% to 30% of liver transplantations are performed for chronic hepatitis C, including a substantial percentage of patients with end-stage liver disease due to a combination of viral and alcoholic liver disease. With this discrepancy between supply and demand, the timing was appropriate to convene a multidisciplinary conference on liver transplantation as the most current milestone in this area. The reports that appear in this issue were presented at a 2-day meeting on ‘‘Liver Transplantation for Alcoholic Liver Disease’’ sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases and the National Institute for Alcohol Abuse and Alcoholism at the NIH in Bethesda, Maryland, December 6-7, 1996. The strength of this meeting was the diversity of interests and backgrounds of the speakers and the wide range of topics presented around the central theme of liver transplantation for ALD. The conference organizers met immediately after the conference and prepared a summary of the information presented during this meeting, which appears as the final report in this issue. Taken together, the reports in this issue of Liver Transplantation and Surgery define the current field of liver transplantation for ALD and identify the areas requiring future outcomes research. From the Stanford University Medical Center, Stanford, California. Address reprint requests to Emmet B. Keeffe, MD, Stanford University Medical Center, 750 Welch Rd, Suite 210, Palo Alto, CA 94304-1509. Copyright r 1997 by the American Association for the Study of Liver Diseases 1074-3022/97/0303-0001$3.00/0
Liver Transplantation and Surgery, Vol 3, No 3 (May), 1997: pp 197-198
197
198
Emmet B. Keeffe
References 1. National Institutes of Health Consensus Development Conference statement: Liver transplantation—June 2023, 1983. Hepatology 1984;4(suppl):107S-110S. 2. Scharschmidt BF. Human liver transplantation: Analysis of data on 540 patients from four centers. Hepatology 1984;4(suppl):95S-101S. 3. Starzl TE, Van Thiel D, Tzakis AG, Iwatsuki S, Todo S, Marsh JW, et al. Orthotopic liver transplantation for alcoholic cirrhosis. JAMA 1988;260:2542-2544. 4. Belle SH, Beringer KC, Detre KM. Liver transplantation in the United States: Results from the national Pitt-UNOS liver transplant registry. In: Terasaki PI, Cecka JM, (eds).
Clinical transplants 1994. Los Angeles: UCLA Tissue Typing Laboratory, 1995:19-35. 5. Keeffe EB. Assessment of the alcoholic patient for liver transplantation: comorbidity, outcome and recidivism. Liver Transplant Surg 1996;2:12-20. 6. Lucey MR, Merion RM, Henley KS, Campbell DA Jr, Turcotte JG, Nostrant TT, et al. Selection for and outcome of liver transplantation in alcoholic liver disease. Gastroenterology 1992;102:1736-1741. 7. Gish RG, Lee AH, Keeffe EB, Rome H, Concepcion W, Esquivel CO. Liver transplantation for patients with alcoholism and end-stage liver disease. Am J Gastroenterol 1993;88:1337-1342.