New top cause for liver trans­plant

Al­co­hol-linked dis­ease over­takes hep­ati­tis C, ac­cord­ing to re­search

Baltimore Sun Sunday - - MARYLAND - By Rachel Bluth

An es­ti­mated 17,000 Amer­i­cans are on the wait­ing list for a liver trans­plant, and there’s a strong chance that many of them have al­co­hol-as­so­ci­ated liver dis­ease.

ALD now edges out hep­ati­tis C as the No. 1 rea­son for liver trans­plants in the U.S., ac­cord­ing to re­search re­cently pub­lished in JAMA In­ter­nal Medicine.

One rea­son for the shift, re­searchers said, is that hep­ati­tis C, which used to be the lead­ing cause of liver trans­plants, has be­come eas­ier to treat with drugs.

An­other could be an in­creas­ing open­ness within the trans­plant com­mu­nity to a can­di­date’s his­tory of al­co­hol and ad­dic­tion and when a can­di­date com­bat­ing these is­sues can qual­ify for a liver.

For years, con­ven­tional wis­dom sug­gested that peo­ple with a heavy drink­ing past who did not have a pe­riod of so­bri­ety un­der their belts would not be good can­di­dates to re­ceive a new liver. But of al­most 33,000 liver trans­plant pa­tients since 2002 who were stud­ied, re­searchers from the Univer­sity of Cal­i­for­nia at San Fran­cisco found that 36.7 per­cent of them had ALD in 2016, up from 24.2 per­cent in 2002.

“Across the coun­try, and we show in a prior study, peo­ple are chang­ing their minds,” said Dr. Brian P. Lee, the study’s lead au­thor and a UCSF gas­troen­terol­ogy and hep­a­tol­ogy fel­low. “More and more providers are will­ing to trans­plant pa­tients with ALD.”

The de­bate, roil­ing for decades, cul­mi­nated in 1997 when a group of doc­tors and med­i­cal so­ci­eties and the U.S. sur­geon gen­eral pub­lished a pa­per that rec­om­mended pa­tients with al­co­holic liver dis­ease be sober at least six months be­fore they could be con­sid­ered for trans­plant.

This “six-month rule” be­came the gold stan­dard. The idea was that a pa­tient who could stay sober for that long had a lower chance of re­turn­ing to harm­ful drink­ing be­hav­ior. There was also con­cern that the pub­lic would stop do­nat­ing or­gans if they thought liv­ers would be go­ing to peo­ple with al­co­hol ad­dic­tions.

“Nei­ther of those at­ti­tudes are based on any facts or data,” said Dr. Robert Brown, di­rec­tor of the Cen­ter for Liver Dis­ease and Trans­plan­ta­tion at Weill Cor­nell and New York Pres­by­te­rian.

The chang­ing at­ti­tude plays out at many trans­plant cen­ters where what once was viewed as a hard-and-fast re­quire­ment for six months of so­bri­ety is now more nu­anced. Specif­i­cally, a team of doc­tors, psy­chol­o­gists and so­cial work­ers looks at a range of fac­tors, in­clud­ing fi­nan­cial sta­bil­ity and fam­ily sup­port, to de­ter­mine whether a pa­tient will re­lapse af­ter the trans­plant.

An anal­y­sis pub­lished in 2010 by re­searchers from the Univer­sity of Pitts­burgh and a 2011 study in France showed that, in any given year, there was lit­tle ev­i­dence to sug­gest that six months of ab­sti­nence be­fore the trans­plant de­creased the chance of re­lapse.

The cen­tral point, ex­perts say, does not nec­es­sar­ily come down to a pa­tient’s record of so­bri­ety be­fore the pro­ce­dure. Fore­most is de­ter­min­ing that a pa­tient is un­likely to drink again af­ter re­ceiv­ing a new liver — that he or she is “com­mit­ted to life­long ab­sti­nence,” said Lee.

Five years af­ter trans­plan­ta­tion, pa­tients who were ab­sti­nent for six months and those who weren’t had about the same sur­vival rates, ac­cord­ing to Lee’s re­search. Af­ter 10 years, the pa­tients who didn’t have six months of so­bri­ety be­fore the pro­ce­dure had slightly worse sur­vival rates. Lee said more re­search is needed to find out ex­actly why.

There is noth­ing mag­i­cal about six months, ac­cord­ing to Dr. Michael Lucey, med­i­cal di­rec­tor of the Univer­sity of Wis­con­sin liver trans­plant pro­gram. He said it shows a poor un­der­stand­ing of al­co­hol abuse as a “very com­plex be­hav­ioral dis­or­der.”

“Drink­ing isn’t a sta­ble phe­nom­e­non,” Lucey said. “Peo­ple with ALD may have long pe­ri­ods of drink­ing and ab­sti­nence.”

Al­though ad­vo­cates are glad that pol­icy is chang­ing, it didn’t change swiftly enough to save Chelsea Oesterle. Oesterle, who was 24 and had bat­tled al­co­hol ad­dic­tion since age 16, went to than emer­gency room in Peo­ria, Ill., in 2013, al­ready in liver fail­ure. Doc­tors told her in the first few days that sur­vival de­pended on a trans­plant.

When it be­came clear she wasn’t go­ing to get that trans­plant, her mother, Terri Oesterle, had her daugh­ter trans­ferred to an­other hos­pi­tal, and be­tween both fa­cil­i­ties she spent six weeks hos­pi­tal­ized. In that time, she was never put on a trans­plant list.

The stigma around her daugh­ter’s con­di­tion was pal­pa­ble, her mother said. Doc­tors and nurses lec­tured her about quit­ting drink­ing. “They kept telling her she had to go to re­hab,” Terri Oesterle said. “She couldn’t even leave the hos­pi­tal; how on earth was she sup­posed to go to a re­hab pro­gram?”

One doc­tor point-blank asked Terri Oesterle why she thought her daugh­ter de­served a liver over some­one else. “She was dis­missed from the get-go,” Terri Oesterle said. “It’s just heart-wrench­ing be­cause she was such a sen­si­tive soul. She was so scared and hope­ful.”

Chelsea Oesterle died in the hos­pi­tal July 4, 2013.

Al­co­hol use dis­or­der has of­ten been thought of as a “self-in­flicted” dis­ease that re­sults from bad habits or moral fail­ing, Lucey said. That at­ti­tude is chang­ing in the med­i­cal com­mu­nity, but ves­tiges re­main.

“For some peo­ple, it’s not ac­cept­ing that al­co­hol use dis­or­der is an ill­ness,” Lucey said.

While sup­port for the chang­ing ap­proach is grow­ing, Lee, the new study’s lead au­thor, said it con­tin­ues to be a po­lar­iz­ing is­sue.

“There are still de­trac­tors and still strong op­po­si­tion,” he said. “Our study sug­gests that is cer­tainly present, be­cause re­gional dif­fer­ences are dis­parate.”

That trou­bles Lee, be­cause it means a pa­tient’s life is de­pen­dent on the at­ti­tudes of lo­cal providers, cre­at­ing an unequal sys­tem.

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