Abstract
Purpose of Review
Early liver transplantation (ELT) refers to transplantation for alcohol-related liver disease (ALD) that takes place before 6 months of sobriety. We provide a summary of recent literature as well as a detailed analysis of various ethical issues in ELT.
Recent Findings
Literature continues to show that survival rates between ELT and standard liver transplantation (SLT) are comparable. Discussions of post-transplant sobriety are becoming more nuanced, with not all alcohol use being seen as equally problematic. Nevertheless, there continues to be controversy around ELT.
Summary
Data continues to show that the 6-month rule does not further the goal of promoting patient and graft survival. Instead, it perpetuates stigma toward those who consume alcohol and inappropriately singles out ALD as morally exceptional. Further work in transplant should focus on promoting the health and well-being of all transplant patients, including those who consume alcohol, supporting the transplant teams who take on this responsibility, and rooting out disparities and structural injustice in liver transplantation.
Similar content being viewed by others
Data Availability
Data sharing is not applicable to this article as no new data were created or analyzed in this study.
References
Papers of particular interest, published recently, have been highlighted as: • Of importance
Louvet A, Labreuche J, Moreno C, Vanlemmens C, Moirand R, Féray C, Dumortier J, Pageaux G-P, Bureau C, Chermak F, Duvoux C, Thabut D, Leroy V, Carbonell N, Rolland B, Salamé E, Anty R, Gournay J, Delwaide J, et al. Early liver transplantation for severe alcohol-related hepatitis not responding to medical treatment: a prospective controlled study. The Lancet Gastroenterol Hepatol. 2022;7:416–25. https://doi.org/10.1016/S2468-1253(21)00430-1.
Bangaru S, Pedersen MR, MacConmara MP, Singal AG, Mufti AR. Survey of liver transplantation practices for severe acute alcoholic hepatitis. Liver Transpl. 2018;24:1357–62. https://doi.org/10.1002/lt.25285.
Mitchell J, Herrick-Reynolds K, Motter JD, et al. Transplant center attitudes toward early liver transplant for alcohol-associated liver disease. Transplant Direct. 2023;9(9): e1532. https://doi.org/10.1097/TXD.0000000000001532.
Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 8th ed. New York: Oxford University Press. 2019.
Department of Health Education, and Welfare. National commission for the protection of human subjects of biomedical and behavioral research. The Belmont Report. Ethical principles and guidelines for the protection of human subjects of research. J Am Coll Dent. 2014;81(3):4–13.
Musto J, Stanfield D, Ley D, Lucey MR, Eickhoff J, Rice JP. Recovery and outcomes of patients denied early liver transplantation for severe alcohol-associated hepatitis. Hepatol (Baltimore, Md). 2022;75:104–14. https://doi.org/10.1002/hep.32110.
Germani G, Angrisani D, Addolorato G, Merli M, Mazzarelli C, Tarli C, Lattanzi B, Panariello A, Prandoni P, Craxì L, Forza G, Feltrin A, Ronzan A, Feltracco P, Grieco A, Agnes S, Gasbarrini A, Rossi M, De Carlis L, et al. Liver transplantation for severe alcoholic hepatitis: a multicenter Italian study. Am J Transplant. 2022;22:1191–200. https://doi.org/10.1111/ajt.16936.
Ethics - ethical principles in the allocation of human organs - OPTN. https://optn.transplant.hrsa.gov/professionals/by-topic/ethical-considerations/ethical-principles-in-the-allocation-of-human-organs/. Accessed 25 Sep 2023
Herrick-Reynolds KM, Punchhi G, Greenberg RS, Strauss AT, Boyarsky BJ, Weeks-Groh SR, Krach MR, Anders RA, Gurakar A, Chen P-H, Segev DL, King EA, Philosophe B, Ottman SE, Wesson RN, Garonzik-Wang JM, Cameron AM. Evaluation of early vs standard liver transplant for alcohol-associated liver disease. JAMA Surg. 2021;156:1026–34. https://doi.org/10.1001/jamasurg.2021.3748.
Lee BP, Im GY, Rice JP, Lazar A, Weinberg E, Han H, Maddur H, Ghobrial RM, Therapondos G, Hsu C, Fix OK, Eswaran S, Shetty K, Chhatwal J, Dalgic OO, Jakhete N, Mobley C, Victor DW, Mehta N, et al. Patterns of alcohol use after early liver transplantation for alcoholic hepatitis. Clin Gastroenterol Hepatol. 2022;20:409-418.e5. https://doi.org/10.1016/j.cgh.2020.11.024.
Ntandja Wandji, L. C., Ningarhari, M., Lassailly, G., Dharancy, S., Boleslawski, E., Mathurin, P., & Louvet, A. Liver Transplantation in alcohol-related liver disease and alcohol-related hepatitis. J Clin Exp Hepatol. 2023;13;127–138. https://doi.org/10.1016/j.jceh.2022.06.013This is a review of LT for ALD and is a particularly good source for understanding LT outcomes. Ntandja Wandji et al. are firmly opposed to the 6 months rule and are interested in exploring alternatives for selection criteria.
Faure S, Herrero A, Jung B, Duny Y, Daures J-P, Mura T, Assenat E, Bismuth M, Bouyabrine H, Donnadieu-Rigole H, Navarro F, Jaber S, Larrey D, Pageaux G-P. Excessive alcohol consumption after liver transplantation impacts on long-term survival, whatever the primary indication. J Hepatol. 2012;57:306–12. https://doi.org/10.1016/j.jhep.2012.03.014.
Mathurin, P., & Lucey, M. R. Liver transplantation in patients with alcohol-related liver disease: current status and future directions. The Lancet Gastroenterol Hepatol. 2020;5;507–514. https://doi.org/10.1016/S2468-1253(19)30451-0Mathurin and Lucey explore the current landscape of LT for ALRD and call for a more nuanced discussion of post-LT relapse and alcohol consumption in general. In particular, they call for hepatology/hepatologists to consider revising their approach to alcohol to be more in line with current approaches in psychotherapy and pharmacotherapy.
Shenoy, A., Dienstag, A., Dienstag, P., Ford, L., Schubert, E., Wankoff, M., Mohan, K., Mirza, O., Bhardwaj, M., & Im, G. Scoring systems to assess relapse risk in alcohol use disorder presenting for early liver transplantation: a systematic review. General Hospital Psych. 2021;72;23–30. https://doi.org/10.1016/j.genhosppsych.2021.06.012This is a systematic review of scoring systems to predict post-LT alcohol relapse. Shenoy et al. conclude that while some tools have high negative predictive values for relapse, there remains no gold standard tool for predicting post-LT relapse.
Zambrano, A. Why alcoholics ought to compete equally for liver transplants. Bioethics 2016;30;689–697. https://doi.org/10.1111/bioe.12274This is the most recent paper in the sphere of LT for ALD that has been published from the ethics side of the field (as opposed to the medical side). Zambrano argues that if one accepts that LT allocation policy should embrace liberal neutrality, then allocation policy must also refrain from discriminating against ALD patients.
Hause, J., & Rice, J. P. Transplants for acute alcoholic hepatitis: controversies and early successes. Clinics in Liver Disease, 2021;25;229–252. https://doi.org/10.1016/j.cld.2020.08.010Hause and Rice give a brief history of ELT (and LT for ALD in general) and outline current controversies. They assert that despite critics’ concerns about ELT, the 6-month rule (and mandatory sobriety periods in general) cannot be defended, and the way forward is to continue to improve ELT.
Kherbache A, Mertens E, Denier Y. Moral distress in medicine: an ethical analysis. J Health Psychol. 2022;27(8):1971–90. https://doi.org/10.1177/13591053211014586.
Morley G, Field R, Horsburgh CC, Burchill C. Interventions to mitigate moral distress: a systematic review of the literature. Int J Nurs Stud. 2021;121: 103984. https://doi.org/10.1016/j.ijnurstu.2021.103984.
Amos VK, Epstein E. Moral distress interventions: an integrative literature review. Nurs Ethics. 2022;29(3):582–607. https://doi.org/10.1177/09697330211035489.
Thakral, N, Deutsch-Link, S, Singal, AK Therapeutic pipeline in alcohol-associated liver disease. Seminars in Liver Disease 2022. https://doi.org/10.1055/s-0042-1759614
Thornton V. Who gets the liver transplant? The use of responsibility as the tie breaker. J Med Ethics. 2009;35:739–42.
Im GY, Vogel AS, Florman S, Nahas J, Friedman SL, Aqui S, Ford L, Mirza O, Kim-Schluger L, Schiano TD. Extensive health care utilization and costs of an early liver transplantation program for alcoholic hepatitis. Liver Transpl: Off Pub Am Assoc Stud Liver Dis Int Liver Transplant Soc. 2022;28:27–38. https://doi.org/10.1002/lt.26215.
Funding
No funding was received for this article.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Human and Animal Rights and Informed Consent.
This article does not contain any studies with human or animal subjects performed by any of the authors.
Conflict of Interest
The authors declare no competing interest.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Brundage, J., Kates, O.S. Outcomes, Attitudes, and Updated Ethical Analysis of Early Liver Transplantation for Severe Alcoholic Hepatitis. Curr Transpl Rep 10, 167–172 (2023). https://doi.org/10.1007/s40472-023-00417-1
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s40472-023-00417-1