A 31-year-old man with a wife and three-month-old baby lay in New York University Langone Medical Center this week with acute alcoholic hepatitis, a liver-ravaging disease that will likely kill him if he doesn’t stop drinking.
“No one told him that alcohol was bad and he had been doing it since college,” said Dr. Lewis Teperman, director of transplantation at NYU.
“He is a big finance guy and wound up in the hospital for a month, super sick, with his liver quitting on him,” he said. “He had never stopped the booze before.”
More than 16,000 Americans are waiting for a liver transplant, according to federal data from the Organ Procurement and Transport Network.Only 6,000 organs are available a year and nearly 2,000 people will die waiting for one to become available.
Should Teperman’s patient, who is committed to abstinence from alcohol and has the family support to keep his promise, be allowed an early transplant, before his liver is fatally scarred by cirrhosis? Even as thousands of others who have not abused their bodies with alcohol or drugs await a new liver.
“This is a truly controversial subject,” said Teperman. “But I believe people deserve a second chance. You just have to figure out the right patient population.”
Now, a new study by French researchers released Wednesday concludes that early liver transplantation can improve survival in patients with a first episode of severe alcoholic hepatitis who aren’t responding to medical therapy.
A six-month abstinence from alcohol is usually required before patients with acute alcoholic hepatitis are considered for liver transplantation, but some doctors want to rethink the rule.
Only 30 percent of those who do not respond to treatment live beyond six months and most die within two months, according to the study published Nov. 9 in the New England Journal of Medicine.
With supportive families, no other severe medical conditions and a commitment to future abstinence, patients can do well, the study revealed.
But study authors say that although early liver transplantation is “attractive,” many doctors are reluctant to treat patients with alcoholism because they are “responsible for their illness” and are likely to resume drinking.
Teperman said his patient, who is now responding to steroid medications, had never had proper counseling or treatment, but he would have been a “perfect” candidate for a transplant.
“He’s holding down a job and no one ever addressed it appropriately with him,” said Teperman. “People who are consistently drinking and having repeat DWI after DWI would not be.”
“It should be done in certain rare circumstances,” he said. “We need a good system to predict which of these people are going to get better…We can’t just open the door to this for everyone – there aren’t enough organs to go around.”
The liver is one of the largest and most complex organs, protecting the body from disease and breaking down and removing harmful toxins. It is especially vulnerable to alcohol.
Alcoholic hepatitis, or inflammation of the liver, is a potentially fatal condition that can be a “red flag” that cirrhosis of the liver may soon follow, according to the National Institute on Alcohol and Alcoholism (NIAAA).
Up to 70 percent of all alcoholic hepatitis patients will develop cirrhosis, a scarring of the liver that is a major cause of death in the United States, according to NIAAA.
But those who stop drinking can have a complete recovery from alcoholic hepatitis and a liver transplant can save their lives.
Acute Alcoholic Hepatitis Patients Improved After Transplant
The study involved patients selected from seven centers for early liver transplantation. All had no prior episodes of alcoholic hepatitis and were assessed at having a high risk of death.
Twenty-six of patients at risk of death were placed on a list for liver transplant. The cumulative six-month survival rate was higher in those who had undergone transplant surgery. Follow-up showed this was maintained for two years.
Three patients resume drinking alcohol: one at 720 days and one at 740 days and one at 1,140 days after transplantation. Two patients died from infection.
About 50 percent of all liver transplants are related to alcohol-induced disease, according to Dr. David Cronin, director of liver transplants at Froedtert and the Medical College of Wisconsin.
“The dilemma is that livers that are available for transplants in a limited supply,” said Cronin. “Many people on the list have — in quotes — paid their dues. They have done what they were supposed to do to get evaluated. They have changed their social behavior and are waiting.”
The question of “worthy” must be considered with the one of “utility,” he said.
Patients should have an 85 percent chance of expected success. “This is not a salvage operation,” said Cronin. “The sicker you are, the higher rate of dying.”
Alcoholics with chronic liver disease may not be good transplant patients.
“Substance abuse is associated with self-destructive behavior and noncompliance,” he said. “If you give them a liver transplant, they won’t maintain employment and show up for visits and take their medications and the graft ends up failing.”
But in patients with acute alcoholic hepatitis, which can also be caused by a one-time event like a virus or eating mushrooms or other drugs, the success rate may be higher.
Cronin, as the study concludes, said it takes a “highly selected” type of patient, with strong family support to keep them off alcohol.
“We will take a chance with this group,” he said. “If they don’t get a transplant, a certain subset in the group will die… We are in the life-preserving game. We should always — physicians and society — strive to preserve life… That is our duty.”
Cronin said the liver transplant can be a “life-changing event” for those who realize “they made a mistake.”
Such was the case with another one of Teperman’s liver transplant patients in 1997 at New York University — a woman who in her 20s who had acute alcoholic hepatitis.
“She was young and there were some emotional issues that had taken place,” he said. “But she had the belief and support of her family and a rehab doctor and a psychiatrist who said this had caused a wonderful woman just to over the deep end. They were all behind her.”
Now, more than decade later, she is healthy and thriving – without alcohol.