Alcohol relapse adversely affects liver transplant survival

A new study on how alcohol relapse affects survival rates after liver transplants found that it adversely affected survival rates only after 10 years. The decrease in survival rates may, however, be due to other alcohol-related diseases.

The results of this study appear in the April 2005 issue of Liver Transplantation, the official journal of the American Association for the Study of Liver Diseases (AASLD) and the International Liver Transplantation Society (ILTS). The journal is published on behalf of the societies by John Wiley & Sons, Inc. and is available online via Wiley InterScience.

Alcoholic liver disease (ALD) is the second most common indication for liver transplants in the U.S. and Europe. Although reported survival rates after transplantation were similar between alcoholics and non-alcoholics (up to 60 percent at 7 years following transplant), concerns about alcohol relapse post-transplant have made the practice somewhat controversial, especially in light of the shortage of donor organs. To offset this risk, it is common practice to establish a 6 month period of abstinence from alcohol before listing a patient for liver transplant. Not only may improvement in liver function result, but higher rates of relapse have been reported in patients who have abstained for less than 6 months before undergoing transplantation. Although several previous studies analyzed the rate of alcohol relapse after liver transplantation and its influence on patient survival and transplant success, researchers had previously not studied patients for a longer follow-up period.

Led by Antonio Cuadrado, M.D. of the Gastroenterology and Hepatology Unit of the University Hospital "Marqués de Valdecilla" in Santander, Spain, the study expanded on a 1977 study involving 44 patients who underwent liver transplants for ALD and 17 controls who were followed up for a mean period of 39.5 months. This group was enlarged for the present study to 54 patients in total, including those analyzed in the previous study. Before transplantation was undertaken, a 6-month period of abstinence from alcohol was required. Patients were all given the same immunosuppressive regimen, consisting of cyclosporine A, steroids and azathioprine. By the end of the third month following transplant, azathioprine was stopped and prednisone was progressively tapered over the first year. Follow-up periods ranged from 14 to 155 months, with a mean of 99.2 months.

After their transplants, 14 patients resumed alcohol consumption. None of these patients had serious medical complications as a result of their alcohol intake, and no significant differences were found in terms of graft evolution (i.e. liver function) when compared to those who did not resume alcohol consumption. Survival rates for 1 and 5 years were similar between the two groups, but differed significantly at the ten year mark: 45.1 percent in the relapse group versus 85.5 percent in the abstinent group. "This unexpected finding could be explained by the higher mortality rate observed in the first group, mainly due to cancer and different cardiovascular events," state the authors. They note that alcoholism is associated with an increased risk for several malignancies in the non-immunosuppressed population and that tobacco consumption increased in alcohol relapsers, which may account for the higher rate of these types of diseases and subsequent mortality in those who resumed alcohol consumption. In addition, although there was a lower incidence of acute rejection in patients who had alcohol relapse, it was not statistically significant and may be attributable to an inhibitory effect of alcohol on various aspects of the immune system, as suggested by previous studies.

"In conclusion, we have observed a significant decline in 10-year survival rates in patients transplanted for ALD who relapse into alcohol use, as compared with those who remain abstinent," the authors state. They add that more studies with longer follow-up periods in a larger number of patients are needed in order to corroborate these results, and that risk-reducing measures, such as quitting smoking and abstaining from alcohol, should be encouraged in these patients.