Transplantation for alcoholic liver disease: 6-month rule or death sentence?

Liver transplantation for alcoholic liver disease has been controversial since the advent of the procedure. The perception that alcohol-related liver disease is self-inflicted combined with concerns of a high risk of recidivism to alcohol use, recurrent alcoholic liver disease, and non-compliance post-transplant has led a lack of support for transplantation for alcoholic patients in the public and among physicians. After initially avoiding transplants in this group of patients, the majority of programs now restrict transplants to those meeting a requirement of a six-month period of abstinence from alcohol. Based on little data, this “6-month” rule has led to needless deaths and needs to be revisited.

Though longer periods of abstinence from alcohol do predict a higher rate of being able to remain abstinent, it is only one of many factors. Insight into alcoholism, strong family support, and the absence of untreated psychiatric illness also can predict abstinence. Six months is also not a magic number, as longer periods would do better and shorter periods only marginally worse. To make life or death decisions on arbitrary limits without basis in data is capricious and wrong. If we truly began to accept alcoholism as a disease rather than a habit, we would use hard data and sound medical decision making to assess the likelihood of achieving long-term abstinence from alcohol and the likelihood of a successful transplant, not an arbitrary hurdle. We do this with other diseases, why not alcoholism?

The argument that alcohol is a self-inflicted disease is not truly a valid one. When one looks at the other causes of liver disease (or most human diseases) many could be perceived as self-inflicted; whether it be due to prior drug use and resultant viral hepatitis or obesity leading to non-alcoholic fatty liver disease. We even offer transplant to patients who take intentional overdoses of acetaminophen leading to liver failure. Alcoholism is a disease, and it should not be used to exclude patients per se from transplantation if transplant will be successful, just like we don’t exclude patients with diabetes for example. It only when we view alcoholism as a volitional habit, rather than a disease, that it becomes socially unacceptable.

Due to the scarcity of organs, many transplant professionals say we cannot risk choosing candidates in a way that is arbitrary and cannot be defended in the public eye. They say this argument as a defense for not transplanting patients with alcoholism when the denial is very embodiment of that arbitrary distinction. As a transplant community, we need to do a better job of educating the public on the nature of alcoholism as a disease and the ability to successfully rehabilitate patients while saving lives with liver transplantation. The time has come to stop judging and treat all patients and diseases with compassion.

Robert S. Brown, Jr. is a transplant hepatologist and a professor of medicine, Weill Cornell Medical College, New York, NY.

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