Alcohol Use Surpasses Hepatitis C as Reason for Liver Transplants
Proportion of transplants related to alcohol doubles in 15 years, study says.
By Don Rauf
January 28, 2019
For decades, chronic hepatitis C has been the leading reason for liver transplant in the United States. Improved hepatitis treatment and evolving attitudes toward alcohol-related liver disease may be changing that.
New research spanning from 2002 to 2016 shows that alcohol-related liver disease (ALD) has now emerged as the most common reason for transplant, rising most quickly from 2012 to 2016.
“Our study strongly suggests that shifting attitudes of transplant providers to allow earlier liver transplant for ALD are an important part of the increase,” says study author Brian Lee, MD, a gastroenterology and hepatology fellow at the University of California in San Francisco. “The rise can also be explained by declining transplants for hepatitis.”
The scientific paper, published January 22, 2019, in the journal JAMA Internal Medicine, based its findings on information from more than 50,000 liver transplant recipients in the United Network for Organ Sharing (UNOS) database, including those with hepatitis C virus.
The proportion of those with alcohol-related liver disease who received a transplant climbed from 15.3 percent in 2002 to 18.6 percent in 2010 and then escalated to 30.6 percent in 2016. The increase over 15 years was double, although transplant rates varied in different regions of the country.
Antivirals Eliminate Hep C
While this research did not specify proportions of non-ALD diagnoses, Dr. Lee says that a study published in August 2018 in the journal Clinical Gastroenterology and Heptaology showed that the proportion of hepatitis C-related liver transplants decreased from 30 percent in 2012 to 18 percent in 2016.
Other reasons for transplant include fatty liver disease, hepatitis B virus, autoimmune hepatitis, primary biliary cholangitis, primary sclerosing cholangitis, cryptogenic cirrhosis, and other more rare liver diseases.
David Bernstein, MD, chief of hepatology at Northwell Health in Manhasset, New York, says that new antiviral therapies have provided a cure for many cases of hepatitis C. These drugs include Mavyret (glecaprevir and pibrentasvir), Epclusa (sofosbuvir and velpatasvir), and Harvoni (ledipasvir and sofosbuvir).
“For those patients who have not yet developed liver failure from hepatitis C, we can intervene and prevent them from progressing to a point where they need a transplant,” says Dr. Bernstein, who was not involved in the study.
Changing Attitudes About Alcohol-Related Liver Disease
The American Liver Foundation reported that 7,496 liver transplants were performed in 2016, and about 17,000 people are on the wait list to receive the organ.
For those with ALD, doctors have commonly required a six-month alcohol-free period to be eligible for a transplant. The concern has been that if people drank and got a transplant, they might go back to drinking and wouldn’t do well with the new liver, according to Bernstein.
This study notes a growing movement away from that practice.
“With more data showing that post-transplant abstinence is dependent on other factors, providers are changing their attitudes,” says Lee. “This means that more patients with ALD are now eligible for transplant, as more liver transplant providers believe that it is justified to pursue earlier liver transplant for alcohol-related liver disease.”
This investigation suggests that provider attitudes and policies regarding pretransplant abstinence vary, and patients with alcohol-related liver disease may face inequity in getting access to a transplant.
“Given that increases in transplant for ALD were very different across regions, there could be value in a national policy to guide the selection process,” says Lee.
Alcohol Consumption Is Rising
Another reason for the spike in transplants for those with alcohol-related illness may be the fact that more Americans are drinking to excess.
A study published in September 2017 in the journal JAMA Psychiatry found that alcohol consumption rose substantially between 2003 and 2013, especially among women, minorities, and older adults.
Although transplants have increased for those with ALD, five-year survival rates for ALD transplants were 11 percent lower compared with transplants without ALD, according to the study.
“Given the lower survival with alcohol-related disease, and other studies showing recurrent alcohol use, malignancy, and infections to be important causes of late death after liver transplantation, we need more research to specifically investigate these areas to improve outcomes for patients with ALD after liver transplant,” says Lee.
He adds that because the study relied on previously recorded data, the conclusions were made by association and did not show cause and effect.