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• W2034549443 abstract "1. IntroductionAlcoholic liver disease (ALD) is now the commonest indication for liver transplantation and has accounted for 5716 transplants in Europe between January 1988 and June 2000 [[1]European Liver Transplant Registry (http://www.eltr.com).Google Scholar]; however, it remains controversial. The proportion of patients grafted for ALD in Europe is overall 17%; however, both the proportion of patients grafted for alcohol-related liver disease and the absolute number of patients grafted has risen; there is great variation between countries (from 0% (in Poland) to 30% (in Spain)) (Fig. 1). Survival after transplantation for ALD is possible (5 and 10-year survival rates are 67 and 55% (graft survival) and 71 and 59% (patient survival)) [[1]European Liver Transplant Registry (http://www.eltr.com).Google Scholar] which is similar to those for other indications although this does not necessarily imply that the outcome is as good in the two groups since there may be considerable differences in case-mix. There is no doubt that a small proportion of patients return to a damaging pattern of drinking but the number of grafts lost through a return to drinking is, at least according to published reports, small [[2]Neuberger J. Transplantation for alcoholic liver disease: a perspective from Europe.Liver Transpl Surg. 1998; 4: S51-S57PubMed Google Scholar].The European Association for the Study of the Liver (EASL) and European Liver Transplant Registry (ELTR) organised a workshop to draw up guide-lines to clarify the role of liver transplantation in the management of patients with ALD. In this report from the workshop, we describe the patterns of alcohol use, those factors which may affect susceptibility as well as the indications for liver transplantation in patients with ALD and discuss the need and extent of abstinence required before transplantation. In order to manage patients optimally and to make most effective use of the scarce availability of donor livers, it is important that transplant clinicians understand and agree the patterns, causes and extra-hepatic consequences of alcohol excess and the possible role of therapies.2. Alcohol use, alcohol abuse and alcohol dependenceWhile there is some evidence that modest alcohol consumption may be beneficial for survival, excessive alcohol consumption is associated with not only significant morbidity and mortality but also with physical, psychological and social disability [[3]Keller M. A historical overview of alcohol and alcoholism.Cancer Res. 1979; 39: 2822-2829PubMed Google Scholar]. Classification of the pattern of alcohol abuse is important for appropriate assessment and management of the potential liver transplant candidate.Alcohol consumption can be classified into none, light, moderate and heavy. Heavy consumers can be considered as either abusers or dependent [[4]Skinner H.A. Spectrum of drinkers and intervention opportunities.Can Med Assoc J. 1990; 143: 1054-1059Google Scholar]. Abuse runs a different course to dependence and there is no evidence that abuse leads to dependence [5Hasin D. Paykin A. Endicott J. Grant B. The validity of DSM-IV alcohol abuse.J Stud Alcohol. 1999; 60: 746-755PubMed Google Scholar, 6Hasin D. Van Rossem R. McCloud S. Endicott J. Alcohol dependence and abuse diagnoses: validity in community sample heavy drinkers.Alcohol Clin Exp Res. 1997; 21: 213-219PubMed Google Scholar]. There is a close relationship between alcohol dependence and psychiatric problems, although it is not clear whether this represents a causal relationship, a common basis or an independent effect. Antisocial personality disorder, depression, anxiety and psychotic syndromes are common. Several typologies for alcohol dependent/abusing patients have been developed, but empirical support for these classifications remains contradictory.It is important to define relapse or recidivism: some Units will define relapse as any alcohol consumed, others define relapse as consuming over a set amount (such as 21 units/week for males and 14 units/week for females). In the non-transplant setting, addiction specialists define a relapse as more than 4 units/day or any alcohol consumed daily on 4 or more consecutive days. A return to alcohol consumption at a lower rate is defined as a ‘slip’.There are two major diagnostic systems used to define alcohol dependence, ICD-10 and DSM-IV. While there is reasonably good agreement between the two systems for the classification of alcohol dependence, there is poor agreement with respect to abuse or harmful use [7Rounsaville B.J. Bryant K. Babor T. Kranzler H. Kadden R. Cross system agreement for substance use disorders: DSM-III-R, DSM-IV and ICD-10.Addiction. 1993; 88: 337-348Crossref PubMed Scopus (90) Google Scholar, 8Schuckit M.A. Hesselbrock V. Tipp J. Anthenelli R. Buchholz K. Radziminski S. A comparison of DSM-III-R, DSM-IV and ICD-10 substance use disorders diagnoses in 1922 men and women subjects in the COGA study.Addiction. 1994; 89: 1629-1638Crossref PubMed Scopus (75) Google Scholar, 9Hasin D. McCloud S. Li Q. Endicott J. Cross-system agreement among demographic subgroups: DSM-III, DSM-III-R, DSM-IV and ICD-10 diagnoses of alcohol use disorders.Drug Alcohol Depend. 1996; 41: 127-135Abstract Full Text PDF PubMed Scopus (59) Google Scholar]. Attempts to define the severity of alcohol dependence have been largely unsuccessful and the severity criteria present in DSM-IIIR have been removed from DSM-IV.3. Natural history of alcohol excessIt is assumed by many that the natural history of people with alcohol dependence is one of progressive alcohol consumption: however, this view is not supported by the data available:I. Treatment for alcoholism can be effective: a meta-analysis of 44 methodologically sound studies on the treatment of alcoholism showed a success rate of 34–48% [10Fromme K. D'Amico E.J. Neurobiological bases of alcohol's psychological effects.in: Leonard K.E. Blane H.A.T. Psychological theories of drinking and alcoholism. Guilford Press, New York, NY1999: 422-455Google Scholar, 11Cook C.C.H. Gurling H.M.D. The genetic aspects of alcoholism and substance abuse: a review.in: Edwards G. Lader M. The nature of drug dependence. Oxford University Press, Oxford1990: 75-111Google Scholar, 12Anthenelli R.M. Schuckit M.A. Genetics.in: Lowinson J.H. Ruiz P. Millman R.B. Langrod J.G. Substance abuse. A comprehensive textbook. Williams & Wilkins, Baltimore, MD1997: 41-51Google Scholar, 13Vaillant G. The natural history of alcoholism revisited. Harvard University Press, Cambridge, MA1995Google Scholar, 14Süß H. Zur Wirksamkeit der Therapie bei Alkoholabhängigen: Ergebnisse einer Meta-Analyse.Psychol Rundschau. 1995; 46: 248-266Google Scholar].II. Relapse is common: relapse usually occurs within the first 6 months with only about half of the patients achieving 1 year of continuous abstinence [[15]Moore D.P. Jefferson J.W. Handboof of medical psychiatry. Mosby, St. Louis, MO1996Google Scholar].III. Natural recovery may occur: this may arise with or without support. In most cases where natural recovery occurs, there is a return to low risk drinking in up to 75% [[16]Sobell L.C. Ellingstad T.P. Sobell M.B. Natural recovery from alcohol and drug problems: methodological review of the research with suggestions for future directions.Addiction. 2000; 95: 749-764Crossref PubMed Scopus (282) Google Scholar]. Indeed, recovery may occur without formal help and is the most frequent way out of alcohol dependency for 60–80% patients [17Sobell L.C. Cunningham J.A. Sobell M.A. Recovery from alcohol problems without treatment: prevalence in two population surveys.Am J Public Health. 1996; 86: 966-972Crossref PubMed Scopus (326) Google Scholar, 18Dawson D.A. Correlates of past-year status among treated and untreated persons with former alcohol dependence: United States, 1992.Alcohol Clin Exp Res. 1996; 20: 771-779Crossref PubMed Scopus (111) Google Scholar, 19Rumpf H.J. Meyer C. Hapke U. Bischof G. John U. Inanspruchnahme suchtspezigischer Hilfen von Alkoholabhängigen und –mißbrauchern: Ergebnisse der TACOS-Bevölkerungsstudie.Sucht. 2000; 46: 9-17Crossref Scopus (83) Google Scholar]. Contrary to what might be predicted, those who were likely to remit were more seriously dependent, experienced less social pressure to stop but did have a more stable employment situation [[20]Bischoff G. Rumpf H.J. Hapke U. Meyer C. John U. Remission ohne formelle Hilfe und Inanspruchnahme stationärer Behandlung bei Alkoholabhängigen – Ein Vergleich auslösender Faktoren.Sucht. 2000; 46: 54-61Google Scholar].Thus, in many cases there is a wide discrepancy between clinicians' beliefs and reality (Table 1) and clarification of misconceptions will help inform the debate as to the appropriateness and the indications for orthotopic liver transplantation in patients with ALD.Table 1Some common misconceptions about alcohol dependencyBeliefRealityAlcoholism is a problem of current timesAlcoholism has been present throughout historyAlcoholics are social drop-outsOnly 5% alcoholics conform to this phenotypeAlcoholism is self-inflictedStrong evidence for genetic and environmental influencesAlcoholics have specific personality traitsAlcoholics have a varied profileAlcoholics will be detected and treated by the medical systemPatients with alcohol dependence are usually undetected and not treatedThere is a low probability of recoveryThere is a natural recovery of more than 60%Relapse rates increase with timeRelapse is most common in the first yearTo recover, absolute abstinence is neededThere is evidence that dependency may be overcome without total abstinence Open table in a new tab There are several approaches to help the patient become and stay abstinent and selection of the most appropriate approach is important in determining the outcome. Several factors have been identified which help predict abstinence (Table 2).Table 2Predictors of relapseAffectiveNegative mood statesBehaviouralPoor coping skillsPoor social skillsCognitiveNegative attitude for recoveryPoor self perceptionPoor perception of illnessLow level of cognitive functioningInterpersonalLack of social supportSocial pressuresLack of involvement in leisure activitiesLack of productive workPhysiologicalCraving for alcoholChronic illness and/or painPsychiatricCo-morbiditySpiritualExcessive guiltLack of purposeTreatmentNegative attitude of care-giversInadequate after-careLack of integrated services for support Open table in a new tab 4. Risk factors for the development of ALDWhile it is clear that there is a close correlation between both the amount of alcohol consumed and the duration of alcohol consumption and the probability of developing severe liver damage within a population, between individuals, there is a great variation. Both the risk of developing alcohol dependence and progressive liver damage are multi-factorial.4.1 Pattern of drinkingThe pattern of drinking influences the probability of developing liver disease. The development of liver disease is more common when drinking outside meal times (RR 3.4), multiple drinks (RR 23) [[21]Bellentani S. Saccoccio G. Costa G. Tiribelli C. Manenti F. Sodde M. et al.Drinking habits as cofactors of risk for alcohol induced liver damage The Dionysos Study Group.Gut. 1997; 41: 845-850Crossref PubMed Scopus (502) Google Scholar] and daily compared to week-end drinking (RR 2.5) [[22]Corrao G. Arico S. Alcohol and cirrhosis: old questions and weakly explored opportunities.Addiction. 2000; 95: 1267-1270Crossref PubMed Scopus (5) Google Scholar].4.2 GenderFemales are more susceptible than males, reasons for which are not clear but may be related to the effects of oestrogen on intestinal permeability to endotoxin.4.3 DietObesity itself is a major factor for ALD; there is an increased risk in obese drinkers (BMI>25 for females and >27 for males) (RR2.15 for cirrhosis) [[23]Naveau S. Giraud V. Bortto E. Aubert A. Capron F. Chaput J.C. Excess weight risk factor for alcoholic liver disease.Hepatology. 1997; 25: 108-111Crossref PubMed Scopus (528) Google Scholar]. The reasons for this are unclear but most likely reflect the close association between obesity and steatosis [[24]Day C. James O.F.W. Steatohepatitis: a tale of two ‘hits’?.Gastroenterology. 1998; 114: 842-845Abstract Full Text Full Text PDF PubMed Scopus (3404) Google Scholar]. Data largely derived from animal studies suggest that diets that are low in carbohydrate, high in polyunsaturated fat and iron and/or deficient in antioxidant vitamins and trace elements may all lead to an increased susceptibility to ALD.4.4 GeneticStudies of alcoholism and ALD in twins have shown a clear genetic component to susceptibility with a concordance rate increased two- to three-fold higher in monozygotic compared to dizygotic twin pairs [[25]Hrubec Z. Omenn G.S. Evidence of genetic predisposition to alcoholic cirrhosis and psychosis: twin concordance for alcoholism and its biological end-points by zygosity among male veterans.Alcohol Clin Exp Res. 1981; 5: 207-215Crossref PubMed Scopus (333) Google Scholar]. Relevant genes have not yet been identified.Thus, both environmental and genetic factors are implicated in susceptibility to ALD: some can be altered by the individual, other factors may be altered by transplantation and others will remain host dependent. Knowledge of these various factors may help the patient manage their risk factors better after transplantation.5. Indications for transplantation for patients with alcohol related chronic liver diseaseThe indications for transplantation for the patient with cirrhosis of any aetiology have been identified by several groups (see Minimal Listing Criteria [[26]Lucey M.R. Brown K.A. Everson G.T. Fung J.J. Gish R. Keefe E.B. et al.Minimal listing criteria for placement of adults on the liver transplant waiting list: a report of a national conference organised by the American Society of Transplant Physicians and the American Association for the Study of Liver Disease.Transplantation. 1998; 66: 956-962Crossref PubMed Scopus (83) Google Scholar], BSG Guidelines [[27]Devlin J. O'Grady J. Indications for referral and assessment in adult liver transplantation: a national guide-line. British Society of Gastroenterology.Gut. 1999; 45: VL1-VI22Google Scholar]). Development of the clinical or serological features of end-stage disease are now relatively well defined and include such general features as Child grade B or C, intractable encephalopathy or variceal bleeding; while most centres give for indications a poor quality of life (because of liver disease) or anticipated length of life less than 1 year, it is clear from modelling evaluations both in France and in the UK that for most patients with ALD, the anticipated survival without transplantation is between 50 and 80% at 1 year [28Poynard T. Naveau S. Doffoel M. Boudjema K. Vanlemmens C. Mantion G. et al.Evaluation of efficacy of liver transplantation in alcoholic cirrhosis using matched and simulated controls: 5-year survival.J Hepatol. 1999; 30: 1130-1137Abstract Full Text Full Text PDF PubMed Scopus (100) Google Scholar, 29Anand A.C. Ferraz-Neto B.H. Nightingale P. Mirza D.F. White A. McMaster P. Neuberger J. Liver transplantation for alcoholic liver disease: evaluation of a selection protocol.Hepatology. 1997; 25: 1478-1484Crossref PubMed Scopus (71) Google Scholar]; indeed it is not until 3 or more years after transplantation that there is a clear survival benefit, and as might be anticipated, survival benefit is greatest in those who are the sickest. Thus, either the models are inaccurate or further work is needed to define when transplantation is required in this group of patients.6. Alcoholic hepatitisA particular problem exists for patients with alcoholic hepatitis: these patients are often very sick with renal failure and malnutrition; the probability of survival without transplantation is very low. The Maddrey Discriminant function [[30]Maddrey W.C. Alcoholic hepatitis: clinicopathologic features and therapy.Semin Liver Dis. 1988; 8: 91-102Crossref PubMed Scopus (40) Google Scholar] will help identifying those with a poor prognosis: those values that predict a poor survival without transplantation (serum bilirubin and clotting time) are also associated with a poor outcome after transplantation. There is only limited experience of transplantation in such patients: although there have been isolated cases where there has been excellent survival [[31]Mutimer D.J. Burra P. Neuberger J. Hubscher S.H. Buckels J.A. Mayer A.D. et al.Managing severe alcoholic hepatitis complicated by renal failure.Q J Med. 1993; 86: 649-656Crossref PubMed Scopus (36) Google Scholar] and some [32Bonet H. Manez R. Kramer D. Wright H.I. Gavaler J.S. Baddour N. Van Thiel D.H. Liver transplantation for alcoholic liver disease: survival of patients transplanted with alcoholic hepatitis plus cirrhosis as compared to those with cirrhosis alone.Alcohol Clin Exp Res. 1993; 17: 1102-1106Crossref PubMed Scopus (36) Google Scholar, 33Shakil A.O. Pinna A. Demetris A.J. Lee R.G. Fung J.J. Rakela J. Survival and quality of life after liver transplantation for acute alcoholic hepatitis.Liver Transpl Surg. 1997; 3: 240-244Crossref PubMed Google Scholar] have reported good outcomes, although others [[34]Conjeeveram H.S. Hart J. Lossoos T.W. Schiano T.D. Dasgupta K. Befeler A.S. et al.Rapidly progressive liver injury and fatal alcoholic hepatitis occurring after liver transplantation in alcoholic patients.Transplantation. 1999; 67: 1562-1568Crossref PubMed Scopus (82) Google Scholar] have suggested that there may be a rapid return to a damaging pattern of alcohol consumption. Until more patients have been studied, we feel that this is not a routine indication for transplantation outside a controlled study.7. Alcohol excess and other liver diseasesPatients with ALDs often have co-existing liver disease: this increased association may reflect a common behavioural pattern (such as other substance abuse leading to chronic viral infection), or this may reflect the increased susceptibility to alcohol in patients with chronic liver disease (such as chronic hepatitis B or C viral infection or genetic haemachromatosis, or, more rarely, porphyria cutanea tarda). Where other causes for liver disease are present, appropriate additional investigations may be warranted.7.1 Hepatitis C viral (HCV) infection and alcoholThe liver disease most commonly associated with ALD is chronic HCV infection. Those with HCV who drink more than 50 g alcohol/day develop cirrhosis more rapidly than those with a lower alcohol consumption [[35]Poynard T. Bedossa P. Opolon P. Natural history of liver fibrosis progression in patients with chronic hepatitis C.Lancet. 1997; 349: 825-832Abstract Full Text Full Text PDF PubMed Scopus (2755) Google Scholar]. Clinically, those with both HCV and ALD tend to resemble those with ALD alone rather than HCV alone (Table 3) with respect to age, gender and severity of disease, although liver cell cancer is more common in those with HCV alone or HCV and ALD compared to those with ALD alone. In general, however, liver allograft recipients with a combined cause for end-stage liver disease tend to be considered as HCV rather than ALD. Post-transplant, the survival of patients grafted for ALD appears, at least in the short-term (<4 years), similar to those grafted for ALD and HCV [[36]Wiesner R.H. Lombardero M. Lake J.R. Everhart J. Detre K.M. Liver transplantation for end-stage alcoholic liver disease: an assessment of outcomes.Liver Transpl Surg. 1997; 3: 231-239Crossref PubMed Scopus (76) Google Scholar]. However, those with combined ALD and HCV have considerably more graft fibrosis (Fig. 2) [54Pera M. Garcia-Valdecasas J.C. Grande L. Rimola A. Fuster J. Lacy A. et al.Liver transplantation for alcoholic cirrhosis with anti-HCV antibodies.Transpl Int. 1997; 10: 289-292Crossref PubMed Google Scholar, 55Burra P. Mioni D. Ceccetto A. Cillo U. Zanus G. Fagiuoli S. et al.Histological features after liver transplantation in alcoholic cirrhotics.J Hepatol. 2001; 34: 716-722Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar] and therefore the long-term graft survival is likely to be less in these patients; indeed, some centres are already observing this.Table 3Pre-transplant clinical variables in patients with ALD, chronic HCV associated liver disease and bothaData from Hospital La Fe, Valencia, Spain. 1991–2000 (unpublished). Ages are shown as median (range). HCC, hepatocellular carcinoma. P values: 1 vs. 2: P NS; 2 vs. 3: P<0.0001; 1 vs. 3: P<0.0001; 4 vs. 5: P NS; 5 vs. 6: P<0.0001; 4 vs. 6: P<0.0001; 7 vs. 8: P NS; 8 vs. 9: P=0.08; 7 vs. 9: P NS; 10 vs. 11: P=0.01; 11 vs. 12: P NS; 10 vs. 12: P<0.0001.ALD aloneALD+HCVHCV aloneN13138238Age (years)50 (30–64)150 (31–64)257 (25–67)3Male (%)85.5492555.56Child class C (%)34.57408289HCC (%)111026112812a Data from Hospital La Fe, Valencia, Spain. 1991–2000 (unpublished). Ages are shown as median (range). HCC, hepatocellular carcinoma. P values: 1 vs. 2: P NS; 2 vs. 3: P<0.0001; 1 vs. 3: P<0.0001; 4 vs. 5: P NS; 5 vs. 6: P<0.0001; 4 vs. 6: P<0.0001; 7 vs. 8: P NS; 8 vs. 9: P=0.08; 7 vs. 9: P NS; 10 vs. 11: P=0.01; 11 vs. 12: P NS; 10 vs. 12: P<0.0001. Open table in a new tab Fig. 2Prevalence of severe hepatic fibrosis in patients at 1 and 5 years after liver transplantation for HCV infection, ALD or both (data (unpublished) from Hospital La Fe, Valencia, Spain.View Large Image Figure ViewerDownload (PPT)8. Abstinence and liver transplantationThe greatest concerns about transplanting patients with ALD are related to abstinence before and after transplantation: in particular, there are concerns that the patient will return to the previous pattern of alcohol abuse which could result in graft loss or patient death because of, for example, non-compliance with immunosuppressive therapy, a direct hepatotoxic effect of alcohol on the graft or extra-hepatic alcohol-induced organ damage. There are, however, few reports in the literature of graft loss for these reasons. The two concerns are primarily whether there is a need for the patient to be abstinent pre-transplantation and if so, for how long, and whether the patient should be abstinent after transplantation.9. Need for abstinence pre-transplantation?Most centres in Europe and in North America have adopted a rule requiring 6 months abstinence before patients are accepted for listing, although relatively few centres follow their own guidance in all instances [2Neuberger J. Transplantation for alcoholic liver disease: a perspective from Europe.Liver Transpl Surg. 1998; 4: S51-S57PubMed Google Scholar, 44Osorio R.W. Ascher N.L. Avery M. Bacchetti P. Roberts J.P. Lake J.R. Predicting recidivism after orthotopic liver transplantation for alcoholic liver disease.Hepatology. 1994; 20: 105-110PubMed Google Scholar, 51Bird G.L. O'Grady J.G. Harvey F.A. Calne R.Y. Williams R. Liver transplantation in patients with alcoholic cirrhosis: selection criteria and rates of survival and relapse.Br Med J. 1990; 301: 15-17Crossref PubMed Scopus (162) Google Scholar, 52Kumar S. Stauber R.E. Gavaler J.S. Basista M.H. Dindzans V.J. Schade R.R. et al.Orthotopic liver transplantation for alcoholic liver disease.Hepatology. 1990; 11: 159-164Crossref PubMed Scopus (195) Google Scholar]. The rationale for this approach is that a period of abstinence pre-transplant will1.Ensure the patient will, with abstinence, recover adequate liver function: studies have indicated that a significant proportion of patients referred for liver transplantation may, with abstinence, regain sufficient liver function and a quality of life that makes transplantation unnecessary [[29]Anand A.C. Ferraz-Neto B.H. Nightingale P. Mirza D.F. White A. McMaster P. Neuberger J. Liver transplantation for alcoholic liver disease: evaluation of a selection protocol.Hepatology. 1997; 25: 1478-1484Crossref PubMed Scopus (71) Google Scholar]. It is not possible, at present, to identify reliably those patients who will not need transplantation. Premature listing and transplantation, may, therefore lead to unnecessary transplantation.2.Identify those patients who are likely to relapse and so avoid inappropriate transplantation: when a patient presents with decompensated alcohol liver disease, it may not be possible to determine whether the patient is at risk of relapse after transplantation, because of, for example, encephalopathy: while ‘death-bed repentance’ may reflect the true ambitions of the patient, intentions may not be translated into reality after transplantation. Some studies have suggested that relapse is commoner in those who have not had a 6-month period of abstinence.3.Allow time for adequate rehabilitation and treatment for alcohol dependence: as indicated above, relapse is most common within the first year of stopping alcohol consumption.However, more recently, the need for a set period of abstinence has been questioned on the basis of a number of observations:I. There is no clear rationale for this rule and published data are conflicting. The 6-month period is not based on prospectively gathered data but rather on custom and practice.II. Patients who would be abstinent post-transplant may die before the fixed period of abstinence is finished.III. The length of wait for a liver often exceeds 6 months and therefore the patient can ‘work out the period of abstinence’ during this time. The time on the waiting list is one when the patient can be followed, and when indicated, offered support and treatment.IV. Pre-transplant abstinence does not reliably predict post-transplant abstinence or compliance [43Berlakovich G.A. Steininger R. Herbst F. Barlan M. Mittlbock M. Mulbacher M. Efficacy of liver transplantation for alcoholic cirrhosis with respect to recidivism and compliance.Transplantation. 1994; 58: 560-565Crossref PubMed Scopus (133) Google Scholar, 44Osorio R.W. Ascher N.L. Avery M. Bacchetti P. Roberts J.P. Lake J.R. Predicting recidivism after orthotopic liver transplantation for alcoholic liver disease.Hepatology. 1994; 20: 105-110PubMed Google Scholar, 45Gledhill J. Burroughs A. Rolles K. Davidson B. Blizard B. Lloyd G. Psychiatric and social outcomes following liver transplantation for alcoholic liver disease: a controlled study.J Psychosom Res. 1999; 46: 359-368Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar, 61Neuberger J. Tang H. Relapse after transplantation: European studies.Liver Transpl Surg. 1997; 3: 275-279Crossref PubMed Scopus (37) Google Scholar, 62Foster P. Fabrega F. Karademir S. Sankary H. Mital D. Williams J. Rediction of abstinence from ethanol in alcoholic recipients following liver transplantation.Hepatology. 1997; 25: 1469-1477Crossref PubMed Scopus (132) Google Scholar, 63Gerhardt T.C. Goldstein R.M. Urschel H.C. Tripp L. Levy M. Husberg B. et al.Alcohol use following liver transplantation for alcoholic cirrhosis.Transplantation. 1996; 62: 1060-1063Crossref PubMed Scopus (80) Google Scholar, 64DiMartini A. Jain A. Irish W. Fitzgerald M. Fung J.J. Outcome of liver transplantation in critically ill patients with alcoholic cirrhosis.Transplantation. 1998; 66: 298-302Crossref PubMed Scopus (46) Google Scholar].V. Most centres do not routinely follow the 6 months rule [[2]Neuberger J. Transplantation for alcoholic liver disease: a perspective from Europe.Liver Transpl Surg. 1998; 4: S51-S57PubMed Google Scholar].VI. Although many patients do return to some form of alcohol consumption after liver transplantation, there is little evidence that this has a major impact on either patient or graft survival [53Berlakovich G.A. Langer F. Freundorfer E. Windhager T. Rockenschaub S. Sporn E. et al.General compliance after liver transplantation for alcoholic cirrhosis.Transpl Int. 2000; 13: 129-135PubMed Google Scholar, 58Lucey M.R. Carr K. Beresford T.P. Fisher L.R. Shieck V. Brown K.A. Campbell D.A. Alcohol use after liver transplantation in alcoholics: a clinical follow-up study.Hepatology. 1997; 25: 1223-1227Crossref PubMed Scopus (150) Google Scholar, 59Pageaux G.P. Michel J. Coste V. Perney P. Possoz P. Perrigault P.F. et al.Alcoholic cirrhosis is a good indication for liver transplantation even for cases of recidivism.Gut. 1999; 45: 421-426Crossref PubMed Scopus (136) Google Scholar, 60Everson G. Bharadhwaj G. House R. Talamantes M. Bilir B. Shrestha R. et al.Long-term follow-up of patients with alcoholic liver disease who underwent hepatic transplantation.Liver Transpl Surg. 1997; 3: 263-275Crossref PubMed Scopus (67) Google Scholar]; however, as discussed below, these observations do not mean that a return to drinking is free of adverse effects on the liver.Thus, while most guide-lines suggest that there should be a fixed period of abstinence it is clear that the basis for this is not firm. A reasonable practice is to wait until the patient can be fully evaluated by a multi-disciplinary team to ensure that there is a minimal risk of relapse and that suitable support will be provided, and to ensure that, with abstinence, the patient will not improve to an extent that transplantation is no longer needed.10. Investigation of patients with ALD for liver transplantationAlcohol will not only affect the liver but also other organs including heart, central and peripheral nervous system, the bone marrow and pancreas. Whether additional investigations are required for potential liver allograft recipients remains uncertain. There are few prospective data on the prevalence of significant extra-hepatic alcohol-related organ damage in candidates for" @default.
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• W2034549443 title "Transplantation for alcoholic liver disease" @default.
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