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Romance and reality: clinical science in liver transplant for alcoholism

Many view organ transplantation as one of the miracles of modern medicine: preserving a person’s life by providing a new liver, heart, lung, kidney, or other organ where the original vital organ has failed. One sees the transplant surgeon as the proverbial knight in shining armor riding a white horse and impaling the demons of death and disease on the end of his sharp-pointed lance. In this view, the patient receiving the organ graft is naturally worthy, good-hearted, and grateful for the new hope of a long life that is used to pass along the gift from the knight and his or her retainers—in our day called the transplant team. What wonderful contributions in modern medicine from organ donors and their families, the recipients, and the medical professionals themselves.

So far, all is well and good. Enter the alcoholic with severe liver failure due in part to drinking, a condition that will claim his or her life—with “end stage” liver disease for which there is no medical alternative for a cure. An alcoholic? Give an alcoholic a new liver when they have destroyed with drink the one Nature already provided? Graft a new liver in someone who will destroy the graft with their uncontrolled drinking? Some estimate that one in every two households has direct experience with an alcoholic relative, and very unpleasant experiences when they are drinking. Throw a liver away on someone like that? Surely this will tarnish the reputation—and perhaps the shining armor—of the knight.

Is it really the case of an idealized knight-provider and a mythological fiend in human form who can’t be trusted? Clinical science argues no. The knight does not merely aim a lance and spur the charger on to certain victory. In a field in which the need for donated organs overwhelms the supply of viable donor organs, the knight must decide where best to allocate the resource, not merely charge ahead.

The alcoholic with liver disease has a liver from birth that is genetically vulnerable in some way to the ravages of drink. Only about 15% of heavy drinkers develop alcoholic liver disease. The other 85% of heavy drinkers will never need a transplanted liver. Should the 15% die because of their genetic vulnerability to alcoholism—a treatable condition in which large numbers recover every year?

“Should the 15% die because of their genetic vulnerability to alcoholism—a treatable condition in which large numbers recover every year?”

And again, for reasons no one understands exactly, women are more vulnerable to alcoholic liver disease than men. They can acquire it by drinking more alcohol than is good for their liver but not enough for their brain to lose the ability to control alcohol use—the principal characteristic of alcoholism. Should women with alcoholic liver disease—but without alcoholism—die each year because of their gender and the genetics associated with it—confusing liver disease with brain alcohol addiction? Rather, clinical science brings its principles and its need for evidence, rather than surface biases, to bear in finding appropriate answers.

Over thirty years ago, a judge in the US state of Michigan held that alcoholism alone was not sufficient grounds for denying liver transplant. Transplant programs must provide rational criteria that can be fairly applied in deciding how to allocate a precious resource. The transplant surgeons and the internal medicine liver specialists then turned to a humble, itinerant psychiatrist to assist with this along the lines the Court guided. In a field full of biases, including for wishful cures, guidance came from the work of George Vaillant and his landmark studies in The Natural History of Alcoholism and its second Revisited edition.

There followed a clarification of the factors leading to sustained abstinence from alcohol that could be assessed in liver transplant candidates. As alcoholic candidates received life saving liver grafts, outcome studies across many centers demonstrated that alcoholic recipients fared as well or better than those receiving new livers for non-alcohol related conditions. Striking among them were the high rates of abstinence, again documented across centers. Findings such as this now drive pursuit of further scientific understanding.

Much research and discussion has since centered on transplant candidate evaluation and selection, as well as patient/candidate subgroups including those suffering from intractable alcoholic hepatitis. Long-term post-transplant outcomes among alcoholics receiving liver grafts have further informed candidate selection. Clinical observations have opened a door to basic research on the role of immunosuppressants found to decrease alcohol use in rodents.

Scientific findings such as these point to a miracle, not in the wishful sense of shining knights and storm-ridden demons, but rather of persistent searches for evidence by all who examine biases and pre-ordained conclusions in this multi-faceted topic.

Featured image credit: High magnification micrograph of a liver with cirrhosis. Trichrome stain. The most common cause of cirrhosis in the Western world is alcohol abuse – the cause of cirrhosis in this case. Image by nephron. CC BY-SA 3.0 via Wikimedia Commons

Recent Comments

  1. LL

    This post is timely with the recent movements in Canada and policy changes in the US at UCM and other transplant centers. #End6MonthWait

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