Liver Transplantation for Alcoholic Liver Disease: A Consideration of Reasons For and Against

Orthotopic liver transplantation is a clinical procedure that has been accepted widely as the treatment of choice for individuals with advanced chronic liver disease. As such, its application to the important clinical problem of alcoholic liver disease is inevitable. The arguments for and against liver transplantation for individuals with advanced alcoholic liver disease are presented.     

Effect of Alcohol Use on Allograft Rejection Rates after Liver Transplantation for Alcoholic Liver Disease

Alcoholic liver disease is a major cause of liver disease and has become an ever-increasing indication for liver transplantation (LTx). Follow-up studies have reported a higher rate of alcohol recidivism in patients transplanted for alcoholic hepatitis, compared with those transplanted for endstage alcohol-associated cirrhosis. It is assumed widely that recurrent alcohol use is associated with reduced compliance with immune suppression and, as a result, an increased risk of graft rejection and loss. To assess this question, 209 alcoholic patients transplanted for either alcoholic hepatitis with cirrhosis or cirrhosis alone between January 1, 1986 and December 31, 1991 were followed, with a mean follow-up of 4.4 ± 0.6 years. There were 175 episodes of acute cellular rejection (ACR) that occurred in 137 patients, for an overall rejection rate of 83.7% or at a rate of 1.25 episodes/patient with rejection. The rate of ACR was three times as great in those who remained alcohol-abstinent (2.24 episodes/patient), compared with those who admitted to continued alcohol use (0.75 episodes/patient) ( p < 0.01). A total of 33 episodes of chronic rejection occurred in 26 patients, for an overall rate of 12.4%. As was the case for ACR, the chronic rejection rate was greater among those who were continuously alcohol-abstinent, compared with those who intermittently used alcohol after successful LTx.
There were no differences in the mean FK 506 or cyclosporin A levels in the groups with and without a rejection episode at the time the rejection episode was documented by liver biopsy. Contrary to generally accepted opinion, these data suggest that continued use of alcohol by liver transplant recipients is associated with a reduction, not an increase, in the rate of rejection.     

Comparison of Quality of Life Between Alcoholic and Nonalcoholic Patients After Liver Transplantation

Alcoholic (n = 18) and nonalcoholic (n = 85) recipients of a liver transplant were compared 1–3 years post-surgery on the Quality of Life Inventory. No differences between groups were observed on any of the 26 domains of health, behavior, and psychosocial functioning. These results indicate that quality of life is similar for alcoholic and nonalcoholic patients after liver transplantation surgery.     

脂肪性肝病的肝移植

随着肥胖症发病率在美国乃至全球的持续上升,非酒精性脂肪性肝病（NAFLD）和非酒精性脂肪性肝炎（NASH）的诊断日益增多,并被认为是终末期肝病（ESLD）的病因之一。     

Nonalcoholic Fatty Liver Disease: Implications for Alcoholic Liver Disease Pathogenesis

This article represents the proceedings of a symposium at the 2000 ISBRA Meeting in Yokohama, Japan. The presentation was Nonalcoholic fatty liver disease: Implications for alcoholic liver disease pathogenesis, by Anna Mae Diehl.     

酒精性肝病诊疗指南（2010年1月修订）

酒精性肝病（alcoholic liver disease,ALD）是长期大量饮酒所致的一种肝脏疾病,初期常表现为脂肪肝,可进展为酒精性肝炎、酒精性肝纤维化和酒精性肝硬化,严重酗酒者可诱发广泛肝细胞坏死甚或肝功能衰竭.本病在我国常见,严重危害人民健康.为进一步规范ALD的诊疗流程.中华医学会肝病学分会脂肪肝和酒精性肝病学组组织国内相关专家,在参考国内外最新研究成果和相关诊疗共识的基础上,对2006年制订的〈酒精性肝病诊疗指南〉进行了修改和补充.     

酒精性肝病的诊断

酒精性肝病的致病因素是单一的，即长期大量的酒精摄入，但其病理过程却十分复杂。长期大量酒精摄入可以造成肝脏的几种不同病变，轻者只有脂肪变性，重者形成酒精性肝炎和肝纤维化，再发展则导致不可逆转的肝硬化。这些病变主要是以组织学的改变为依据命名，但临床上这些病变多为混合存在。     

酒精性肝病的治疗

酒精性肝病(ALD)是西方国家最常见的肝硬化病因，也是十大常见死因之一。ALD包括轻度酒精性肝损伤、酒精性脂肪肝、急性酒精性性肝炎和酒精性肝硬化等。戒酒或显著减少酒精摄入可显著改善所有阶段患者的组织学改变和生存率。因此，戒酒是ALD治疗的关键因素。根据治疗开始时疾病所处的阶段，     

Liver Transplantation for Alcoholic Liver Disease: Survival of Patients Transplanted with Alcoholic Hepatitis Plus Cirrhosis as Compared with Those with Cirrhosis Alone

From January 1986 through December 1991, a total of 221 patients with alcoholic liver disease received liver transplantation. In 147 of these cases, complete pretransplant histopathologic, demographic, and laboratory data (minimum of CBC, AST, ALT, total bilirubin, albumin, and prothrombin time) were available for review. Forty-five (30%) of the 147 recipients had alcoholic hepatitis plus cirrhosis (AH), whereas 70% had cirrhosis (CIRR) alone. Age and sex were similar in the subgroups, but the patients with CIRR had a greater AST/ALT ratio, longer protime, and lower platelet count (all p < 0.01). Coexistent hepatitis B (4.7%) or hepatitis C (4.1%) was similar in both groups. Current survival is 80% for patients with AH and 84% for those with CIRR (NS). Overall, survivors were younger (43.4 ±1.7 years) than nonsurvivors (53.6 ± 3.2) (p < 0.01), an age influence that was significant in the CIRR group (p <; 0.01) but not in the AH group. Inexplicably, the AST/ALT ratio was greater in AH survivors (1.5 ± 0.2) than it was in nonsurvivors (0.4 ± 0.1) (p < 0.01). In patients with CIRR, the platelet count was greater in survivors (252 ± 29 vs. 86 + 11 ± 10⁹ cells/liter).
The data support the clinical impression that patients with chronic decompensated cirrhosis referred for liver transplantation had more severe complications of their liver disease than did those with AH. Survival in both subgroups was similar, but overall the survivors are nearly a decade younger than the nonsurvivors. Because the diagnosis of AH implies a briefer period of alcohol abstention, it was interesting to note that liver transplantation could be accomplished as successfully with AH as with CIRR.