Liver Transplantation for Decompensated Alcohol-Related Chronic Liver Disease

In Australia, more than one-in-ten adult liver transplants occur for alcohol-related liver disease and this trend is expected to increase. Liver transplantation is an effective treatment for end-stage liver disease from alcohol, with improved 5-year survival outcomes. Six months of alcohol abstinence is currently considered mandatory for patients where alcohol is a significant contributor to liver injury or alcohol use disorder is raised as a concern.  

Australian guidelines for liver transplantation use this “six-month rule” to determine both transplant need and the risk for recidivism, however, guidelines extend to potentially exclude patients who are considered to have an “unfavourable” recidivism risk even with six-months abstinence. In general, patients with chronic liver disease who have the Model for End Stage Liver Disease (MELD) score of >14 may be considered for liver transplant assessment. Six months of abstinence allows time to determine a baseline of liver function in the absence of persisting alcohol injury to ensure transplantation is required. In addition to the ability to maintain pre-transplant abstinence, several other features may impact transplant outcomes including social isolation or integration; the candidate’s acceptance of AUD as a comorbid lifelong problem that requires long term treatment; any prior treatment for an AUD including inpatient rehabilitation and other comorbid psychiatric disorders. 

Many patients with decompensation recover (“re-compensate”) with abstinence to the point where transplantation is not required or can be deferred. Some patients with AUD will not be able to maintain abstinence. Unfortunately, many patients with decompensated liver disease will continue to deteriorate despite abstinence due to progressive liver disease, portal hypertensive complications or liver cancer.