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Invited Commentary
January 22, 2019

Changing Times in Liver Transplantation for Alcohol-Associated Liver Disease

Author Affiliations
  • 1Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
JAMA Intern Med. 2019;179(3):348-350. doi:10.1001/jamainternmed.2018.6532

How times have changed in the evaluation of patients for liver transplant. In the early days, a diagnosis of alcohol-associated liver disease (ALD) was a reason not to consider transplant. Today, ALD has ascended to the top of the list of indications for transplant. What has changed in our approach to evaluating candidates for this surgery?

Shortly after the first National Institutes of Health Consensus Development Conference on Liver Transplantation in 1983, the question of whether to allocate transplants to patients with ALD was discussed. A group of senior hepatologists informally suggested a period of abstinence for 6 months before a patient with ALD should be listed. The recommendation was based in part on the belief that a significant period of abstinence might allow decompensated disease to stabilize, thereby obviating the need for transplant. The group also expressed concern that the public might be less likely to donate organs if they perceived that most of the recipients had a self-inflicted disease. Although the 6-month time frame was arbitrary, the expert panel noted that a requirement for abstinence would encourage patients to engage in treatment of their alcohol use disorder (AUD), thereby reducing relapse to drinking after transplant. During the past 30 years, several studies1 have found that the likelihood of relapse to drinking in patients who received a transplant for ALD is related to factors other than a specific duration of abstinence. These data have diminished but not completely eliminated a bias against ALD as an indication for liver transplant.

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