Timing of liver transplantation in alcoholic cirrhosis

Our review has considered liver transplantation as part of a continuum of care for patients with alcoholic liver disease. Evaluation of patients with alcoholic liver disease for liver transplantation and determination of the optimal time for transplantation usually takes place in a multidisciplinary model. Currently, the majority of alcoholic patients who are placed on the liver transplant waiting list have established extended periods of abstinence from alcohol prior to evaluation. While this subset of alcoholics may be more resistant to the idea that alcoholism is a problem requiring continuing medical and psychological attention, the absence of recent alcohol use in this group makes judgment of the optimal time for liver transplant a medical decision similar to that in non-alcoholic disease. The data of Poynard would suggest that the best results are achieved when liver transplantation is confined to patients with advanced liver failure. The adoption of the MELD score ensures that cadaveric donor organs will be allocated to alcoholic patients with advanced decompensation. There remains the group of patients with more recent alcohol use. Up to now, these patients have been precluded from liver transplantation. We lack good data to determine whether some of these patients would benefit from transplantation. Similarly, we do not know how to recognize which patients with recent alcohol use to select nor how long to wait to see whether medical management will allow resolution of acute alcoholic hepatitis and restoration of liver function. In the absence of such data, the '6-month' rule has become standard, with possible dire consequences for some patients. Consideration of patients with acute alcoholic hepatitis has not been carried out in a systematic or protocolized fashion. The introduction of the MELD system to allocate livers, and the growth of living donor liver transplantation may challenge this orthodoxy.