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World J Gastroenterol. Oct 21, 2015; 21(39): 10994-11002
Published online Oct 21, 2015. doi: 10.3748/wjg.v21.i39.10994
Liver transplantation for alcoholic liver disease: Lessons learned and unresolved issues
José Ursic-Bedoya, Stéphanie Faure, Hélène Donnadieu-Rigole, Georges-Philippe Pageaux
José Ursic-Bedoya, Stéphanie Faure, Georges-Philippe Pageaux, Liver Transplantation Unit, Digestive Department, Saint Eloi University Hospital, University of Montpellier, 34295 Montpellier Cedex 5, France
Hélène Donnadieu-Rigole, Addictology Department, Saint Eloi University Hospital, University of Montpellier, 34295 Montpellier Cedex 5, France
Author contributions: Ursic-Bedoya J reviewed the literature and wrote the manuscript; Faure S, Donnadieu-Rigole H and Pageaux GP advised on the literature search and critically revised the manuscript.
Conflict-of-interest statement: The authors declare no conflict of interests.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Georges-Philippe Pageaux, MD, PhD, Liver Transplantation Unit, Digestive Department, Saint Eloi University Hospital, University of Montpellier, 34295 Montpellier Cedex 5, France. gp-pageaux@chu-montpellier.fr
Telephone: +33-4-67337077 Fax: +33-4-67337077
Received: April 28, 2015
Peer-review started: May 6, 2015
First decision: June 2, 2015
Revised: July 10, 2015
Accepted: September 2, 2015
Article in press: September 2, 2015
Published online: October 21, 2015
Processing time: 174 Days and 3.5 Hours
Abstract

The use of liver transplantation (LT) as a treatment for alcoholic liver disease (ALD) has been highly controversial since the beginning. The ever increasing shortage of organs has accentuated the low priority given to patients suffering from ALD, which is considered a “self-inflicted” condition. However, by improving the long-term survival rates, making them similar to those from other indications, and recognizing that alcoholism is a primary disease, ALD has become one of the most common indications for LT in Europe and North America, a situation thought unfathomable thirty years ago. Unfortunately, there are still many issues with the use of this procedure for ALD. There are significant relapse rates, and the consequences of excessive drinking after LT range from asymptomatic biochemical and histological abnormalities to graft failure and death. A minimum three-month period of sobriety is required for an improvement in liver function, thus making LT unnecessary, and to demonstrate the patient’s commitment to the project, even though a longer abstinence period does not guarantee lower relapse rates after LT. Recent data have shown that LT is also effective for severe alcoholic hepatitis when the patient is unresponsive to corticosteroids therapy, with low relapse rates in highly selected patients, although these results must be confirmed before LT becomes a standard procedure in this setting. Finally, LT for ALD is accompanied by an increased risk of de novo solid organ cancer, skin cancer, and lymphoproliferative disorders, which has a large impact on the survival rates.

Keywords: Liver transplantation; Alcoholic liver disease; Cirrhosis; Alcoholic hepatitis; Survival rates; Relapse; Six-month rule; Sobriety; Solid organ cancer

Core tip: Alcoholic liver disease (ALD) has become one of the leading indications for liver transplantation (LT) over the last twenty years. In the context of scarcity of organs, the excellent survival and compliance rates of LT for ALD make this a favorable procedure. However, there are considerable relapse rates, which can have dire consequences, such as graft loss and death. Other issues have also emerged: increased risk of malignancy, concomitant hepatitis C virus infection, and LT for alcoholic hepatitis. This review will first discuss the highly controversial history of LT for ALD and then focus on the main questions that remain unanswered in 2015.