Histological features after liver transplantation in alcoholic cirrhotics

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Abstract

Background/Aims: Though alcoholic cirrhosis is a common indication for liver transplantation, it carries the risk of alcohol recidivism and consequent graft failure. This study aims to evaluate the effect of alcohol recidivism on survival rates and histological parameters in patients transplanted for alcoholic cirrhosis, with and without hepatitis C virus (HCV) infection.

Methods: Fifty-one out of 189 consecutive transplanted patients underwent psychosocial evaluation and liver biopsy at 6 and 12 months, then yearly after transplantation.

Results: The cumulative 84 month survival rate was identical in patients transplanted for alcoholic (51%) and non-alcoholic cirrhosis (52%). No difference emerged between anti-HCV negative vs. positive alcoholic cirrhosis patients. Psycho-social evaluation revealed alcohol recidivism in 11/34 long-term survivors, but this did not affect overall survival rate in patients with or without HCV. In anti-HCV negative cases, fatty changes and pericellular fibrosis were significantly more common in heavy drinkers than in occasional drinkers and abstainers. When HCV status was considered regardless of alcohol intake, fibrosis was significantly more frequent in patients with HCV.

Conclusion: Alcohol recidivism after transplantation in alcoholic cirrhosis patients does not affect survival, irrespective of HCV status. Fatty changes and pericellular fibrosis are the most relevant histological signs of heavy alcohol intake.

Introduction

Alcoholic cirrhosis has become a common indication for liver transplantation since many centers have reported encouraging results in terms of patient and graft survival [1], [2], [3], [4], which is similar to the situation described in patients transplanted for non-alcoholic liver disease [5], [6], [7], [8]. One problem with alcoholic cirrhotic patients is the risk of recidivism, the actual incidence of which is difficult to establish due to centers using different evaluation methods [9], [10], [11], [12]. Another problem concerns the risk of poor compliance with immunosuppressive therapy. Both problems can result in graft failure. The effect of alcohol recidivism in terms of histological liver damage has been reported in a few studies [13], [14], [15], [16], [17], [18], with conflicting results in terms of severity, which ranges from mild fatty changes with neither fibrosis nor cirrhosis [18] to rapidly developing liver injury including fibrosis [16], and fatal alcoholic hepatitis [13] or cirrhosis as early as 6–21 months after transplantation [15], [19]. Moreover, the histological changes are difficult to interpret in anti-hepatitis C virus (HCV) positive patients transplanted for alcoholic cirrhosis who resume alcohol abuse and carry a concomitant risk of recurrent HCV infection [20], [21], [22] or acute allograft rejection [23], [24], [25].

The aim of this study was to evaluate the effect of alcohol recidivism on survival rates and liver histopathological parameters in patients undergoing liver transplantation for alcoholic cirrhosis, with or without concomitant HCV infection.

Section snippets

Study population

Fifty-one consecutive adult patients were enrolled in this prospective study. All patients underwent liver transplantation for alcoholic cirrhosis between November 1990 and October 1998. They represented 27% of a larger group consisting of 189 patients with chronic or acute end-stage liver disease who underwent 209 transplantations during said period. The etiology of liver disease in the 138 patients with non-alcoholic cirrhosis was HCV- or hepatitis B virus (HBV)-related cirrhosis in 68,

Study population

At the time of liver transplantation, 33 (65%) of the 51 patients had alcoholic cirrhosis with negative viral markers, 16 (31%) were anti-HCV positive, 2 (4%) were HBsAg positive but HBeAg and HBV-DNA negative. Two out of 51 patients had hepatocellular carcinoma, one diagnosed before surgery who was anti-HCV positive, the other incidentally during surgery, who was anti-HCV negative.

Causes of death and survival

During an overall 84 months of follow-up, 17/51 (33%) patients transplanted for alcoholic cirrhosis (Table 1) and

Discussion

In the long term, alcohol recidivism (detected by psychosocial interview) was recorded in one in three patients transplanted for alcoholic cirrhosis.

The rate of recidivism is similar to the one reported by various authors [1], [2], [7], [30], [31], [32], [33], [34] and differences depend on the alcohol abuse screening programs adopted at different liver transplant centers.

We established very restrictive selection criteria at our unit in an attempt to predict long-term abstinence and we followed

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