Limits...
Managing alcoholic liver disease.

Shah VH - Clin Mol Hepatol (2015)

Bottom Line: Alcoholic liver disease continues to be a significant cause of liver-related morbidity and mortality throughout the world.A number of diagnostic and prognostic models have been developed in the management of this condition, although specific roles for liver biopsy still remain particularly in the setting of alcoholic hepatitis.Owing in part to a great deal of attention from governmental funding sources, a number of new treatment approaches are undergoing rigorous evaluation, hopefully providing future treatment options in this very severe condition.

View Article: PubMed Central - PubMed

Affiliation: Gastroenterology Research Unit, Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.

ABSTRACT
Alcoholic liver disease continues to be a significant cause of liver-related morbidity and mortality throughout the world. A number of diagnostic and prognostic models have been developed in the management of this condition, although specific roles for liver biopsy still remain particularly in the setting of alcoholic hepatitis. Despite a large number of recent treatment trials, the ideal pharmacotherapy approach remains undefined. Most essential is the supportive care and focus on abstinence and nutrition. Owing in part to a great deal of attention from governmental funding sources, a number of new treatment approaches are undergoing rigorous evaluation, hopefully providing future treatment options in this very severe condition.

No MeSH data available.


Related in: MedlinePlus

Team-based management to avoid recidivism. Duration of abstinence (6-month rule) is not the driving factor for transplant determination but provides a window of time for viewing maximal recovery opportunity and attempts at treating alcoholism.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
getmorefigures.php?uid=PMC4612281&req=5

Figure 2: Team-based management to avoid recidivism. Duration of abstinence (6-month rule) is not the driving factor for transplant determination but provides a window of time for viewing maximal recovery opportunity and attempts at treating alcoholism.

Mentions: Liver transplantation has recently been proposed for patients with alcoholic hepatitis and supported by a large well-conducted trial.29 However, the reality of the current era is that there are not adequate organs available for large populations of patients with alcoholic hepatitis. The study was published in the New England Journal of Medicine and showed that individuals who did not respond to corticosteroids after one week of attempted treatment will have markedly improved survival if they undergo liver transplantation. Transplantation was carried out quite quickly in this study within weeks, and they had two to three-fold improvement in survival compared to individuals who did not respond to steroids and did not undergo liver transplantation.29 Again, when the community is surveyed about liver transplantation for alcoholic hepatitis, approximately 30% of transplant centers have transplanted a patient for alcoholic hepatitis (A. Singal, personal communication - manuscript submitted). The information shows that approximately 50 liver transplants have been done for this indication in the United States, and the outcomes are quite reasonable with 90% one-year survival and the rate of alcohol relapse of less than 20%. Additionally, studies have recently shown that the outcomes of patients who undergo liver transplantation for alcoholic cirrhosis, as compared to those who have hepatitis on their explant is quite similar, again suggesting that hepatitis may have good outcomes after liver transplantation and similar to alcohol-related cirrhosis.30 The key factor is identifying the right patients who could undergo such an aggressive intervention and, in fact, very few individuals fall into this group. This requires coordinated interactions between a number of physicians in the team including the hepatologist, psychiatrist, surgeon, as well as the broader team including the social worker, addiction counselor, and the nurse coordinator (Fig. 2). Often times, a contract is pursued with the patient and a detailed psychosocial assessment is also performed. It's controversial whether patients should wait six months prior to undergoing liver transplantation. This delay can allow assessment of whether a patient will recover spontaneously and might not require liver transplantation.31 However, in the setting of alcoholic hepatitis, most individuals with severe disease will not survive six months and therefore attempts to treat their alcoholism during this time, which is another goal of the six-month delay, also cannot be pursued. Therefore, transplantation for alcoholic hepatitis probably is medically effective and patients would certainly have better outcomes than if they did not undergo transplantation. In the broader arena of alcoholic liver disease, a delay prior to transplant is useful to see the natural history of whether the patient may recover spontaneously with abstinence and also to undergo alcohol addiction treatment. However, in alcoholic hepatitis, a delay is probably not feasible. Overall relapse rates have been described with great heterogeneity, but probably occurring in about 1 in 5.31 However, the risk of graft loss from relapse is quite low. It's very important to select the right psychosocial patients and, in the setting of alcoholic hepatitis where alcohol consumption has occurred until very recently, there is very few of those individuals who will indeed qualify for this aggressive-type treatment. There are also a number of societal and logistical issues relating to the number of organs available and the high prevalence of alcohol-related liver disease, and societal perceptions may also be relevant since the majority of organs come from donated organs from the broader society. In summary, a very small percent of the total alcoholic hepatitis population of patients should be considered for such an aggressive treatment such as liver transplantation in the acute setting. These will be individuals with therapy failure, remarkably strong social support, positive factors for predicting long-term abstinence, and a lack of psychiatric co-morbidities.


Managing alcoholic liver disease.

Shah VH - Clin Mol Hepatol (2015)

Team-based management to avoid recidivism. Duration of abstinence (6-month rule) is not the driving factor for transplant determination but provides a window of time for viewing maximal recovery opportunity and attempts at treating alcoholism.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4612281&req=5

Figure 2: Team-based management to avoid recidivism. Duration of abstinence (6-month rule) is not the driving factor for transplant determination but provides a window of time for viewing maximal recovery opportunity and attempts at treating alcoholism.
Mentions: Liver transplantation has recently been proposed for patients with alcoholic hepatitis and supported by a large well-conducted trial.29 However, the reality of the current era is that there are not adequate organs available for large populations of patients with alcoholic hepatitis. The study was published in the New England Journal of Medicine and showed that individuals who did not respond to corticosteroids after one week of attempted treatment will have markedly improved survival if they undergo liver transplantation. Transplantation was carried out quite quickly in this study within weeks, and they had two to three-fold improvement in survival compared to individuals who did not respond to steroids and did not undergo liver transplantation.29 Again, when the community is surveyed about liver transplantation for alcoholic hepatitis, approximately 30% of transplant centers have transplanted a patient for alcoholic hepatitis (A. Singal, personal communication - manuscript submitted). The information shows that approximately 50 liver transplants have been done for this indication in the United States, and the outcomes are quite reasonable with 90% one-year survival and the rate of alcohol relapse of less than 20%. Additionally, studies have recently shown that the outcomes of patients who undergo liver transplantation for alcoholic cirrhosis, as compared to those who have hepatitis on their explant is quite similar, again suggesting that hepatitis may have good outcomes after liver transplantation and similar to alcohol-related cirrhosis.30 The key factor is identifying the right patients who could undergo such an aggressive intervention and, in fact, very few individuals fall into this group. This requires coordinated interactions between a number of physicians in the team including the hepatologist, psychiatrist, surgeon, as well as the broader team including the social worker, addiction counselor, and the nurse coordinator (Fig. 2). Often times, a contract is pursued with the patient and a detailed psychosocial assessment is also performed. It's controversial whether patients should wait six months prior to undergoing liver transplantation. This delay can allow assessment of whether a patient will recover spontaneously and might not require liver transplantation.31 However, in the setting of alcoholic hepatitis, most individuals with severe disease will not survive six months and therefore attempts to treat their alcoholism during this time, which is another goal of the six-month delay, also cannot be pursued. Therefore, transplantation for alcoholic hepatitis probably is medically effective and patients would certainly have better outcomes than if they did not undergo transplantation. In the broader arena of alcoholic liver disease, a delay prior to transplant is useful to see the natural history of whether the patient may recover spontaneously with abstinence and also to undergo alcohol addiction treatment. However, in alcoholic hepatitis, a delay is probably not feasible. Overall relapse rates have been described with great heterogeneity, but probably occurring in about 1 in 5.31 However, the risk of graft loss from relapse is quite low. It's very important to select the right psychosocial patients and, in the setting of alcoholic hepatitis where alcohol consumption has occurred until very recently, there is very few of those individuals who will indeed qualify for this aggressive-type treatment. There are also a number of societal and logistical issues relating to the number of organs available and the high prevalence of alcohol-related liver disease, and societal perceptions may also be relevant since the majority of organs come from donated organs from the broader society. In summary, a very small percent of the total alcoholic hepatitis population of patients should be considered for such an aggressive treatment such as liver transplantation in the acute setting. These will be individuals with therapy failure, remarkably strong social support, positive factors for predicting long-term abstinence, and a lack of psychiatric co-morbidities.

Bottom Line: Alcoholic liver disease continues to be a significant cause of liver-related morbidity and mortality throughout the world.A number of diagnostic and prognostic models have been developed in the management of this condition, although specific roles for liver biopsy still remain particularly in the setting of alcoholic hepatitis.Owing in part to a great deal of attention from governmental funding sources, a number of new treatment approaches are undergoing rigorous evaluation, hopefully providing future treatment options in this very severe condition.

View Article: PubMed Central - PubMed

Affiliation: Gastroenterology Research Unit, Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.

ABSTRACT
Alcoholic liver disease continues to be a significant cause of liver-related morbidity and mortality throughout the world. A number of diagnostic and prognostic models have been developed in the management of this condition, although specific roles for liver biopsy still remain particularly in the setting of alcoholic hepatitis. Despite a large number of recent treatment trials, the ideal pharmacotherapy approach remains undefined. Most essential is the supportive care and focus on abstinence and nutrition. Owing in part to a great deal of attention from governmental funding sources, a number of new treatment approaches are undergoing rigorous evaluation, hopefully providing future treatment options in this very severe condition.

No MeSH data available.


Related in: MedlinePlus