In a recent report on the outcome of liver transplantation in a small series of cases suffering acute alcoholic hepatitis and requiring liver transplantation, Lee et al. (2017) commented on two patients who died following severe alcohol drinking relapse. These two cases had significant repercussions on the morale of our transplant team, and should serve as cautionary tales for any center considering implementation of such a program. They had used both their clinical data and a previously published scale (Yates et al., 1993) on alcohol relapse that were based, unfortunately, on general outpatient alcoholism treatment rather than clinical experience specific to alcoholic transplant recipients, available for many years (Beresford et al., 1990). While, any scale in any setting aims at gauging a clinical phenomenon, most often applying the attributes of a collection of symptoms—that is, a syndrome—to specific persons can be challenging. If there is a single lesson in the reports in this Special Issue, kindly published by the editors of Alcohol and Alcoholism, in providing a life-saving treatment for liver failure in a setting where no alternative treatment exists, it may be this. The field requires a complex clinical art—collecting as much relevant data as possible and then looking for the patterns that occur in each case assessed individually—as much as it does a clinical science—wherein statistical significance points us to probabilities that guide the field more generally. Each of the contributions published here serve one or the other of these twin components in clinical medicine, regardless of specialty or discipline, and most offer service to both. The first two reports—our own and that by Parker and Holt—present two such. The first is in essence a ‘what to do and how to do it’ discussion aimed at promoting a uniformity of clinical approach across programs. Nonetheless, it refers to quantitative data, such as that differentiating relatively simple or primary alcoholism versus polydrug dependence that includes alcoholism with a very different, much more indurated natural course. Parker and Holt take this same diagnostic sensitivity and contrast it to the array of services in the UK examining at the level of an integrated national health system how services, whether for evaluation or for transplant itself, distribute with respect to need in providing a unified approach to care. The next section of three studies—two from individual clinical centers and one, a meta-analysis across several centers, strike the themes again. All three notice the same relatively high-abstinence rates among alcoholics after transplants that gives statistical weight to the outcome of providing an expensive and availability limited, procedure that saves lives. But, they each point to the need for improved and standardized assessments across centers. The challenge of furthering the differentiation of alcoholism types as well as adding other factors—such as tobacco use that appears to have prognostic value beyond the first 5 years following transplant—outlines one of the frontiers in the field. The third section contains four reports that, as a group, widen the field of vision of the transplant domain itself. Mellinger and Volk take the reader into the realm of ethics in their synthesis of what-we-ought-to-do with what-we-can-do in addressing their main topic on how a limited resource—the supply of viable liver grafts—can be distributed fairly. They go on to review the burgeoning interest in providing liver grafts for those suffering from alcoholic hepatitis with its course that is less predictable than is Laennec’s cirrhosis. Braun and Ascher take the readers to another frontier, that of providing liver lobe tissue donated by living persons for use in transplantation, and in doing so widen the discussion to Asian cultures that view living donations as preferable to cadaveric grafts. Ursec Bedoya and colleagues address a question that many transplant teams do not consider—alcohol use in the non-alcoholic cases post-transplant and how to care for them. Last in this group, Wieland and Everson take the topic down to a microbiological scale in considering the impact of the new treatments for Hepatitis C in the interest of liver health post-transplant as well as their impact in lessening the pressure on the finite supply of available graft organs. Last, on a molecular level, we present a basic science line of inquiry that has emanated directly from the transplant experience itself as many teams have noted the ubiquity of high-abstinence rates after transplants in alcoholics. With neither viable explanation of this from selection nor from psychological factors, our biological investigations have pointed to a possible effect of the anti-immune medications themselves. This report provides further evidence for a brain effect. It offers the possibility of a new medicinal approach for treating alcoholism itself, perhaps resembling—if only by analogy—the medicinal effects on Hepatitis C. Recalling the comment of Lee et al. (2017) with which this introduction began, and now taking into consideration the breadth of this Special Issue on what at first glance may appear a very narrow clinical topic, we hope the discussions will assist and improve the morale of all the programs that may find useful discussions in these pages. In this as in many specialty fields, it is most important that we find ways to talk with each other—for out patients’ benefit and for our own morale. The Special Issue editors, and indeed the Alcohol and Alcoholism editors, all convey as many thanks as possible to the contributors to this discussion of alcohol and liver transplantation. We offer our gratitude for Dr Seitz’s thoughtful Commentary on the contents of the Special Issue and his example of how to go about talking with each other. We welcome anyone of any specialty, discipline, or viewpoint who may wish to explore its pages, correspond with its authors, or join in the discussion that enlightens not only the transplant field itself, but the larger, implicated areas of medicine broadly considered. And we thank our readers for their interest. FUNDING No grant funds were expended in writing this report. Dr Beresford receives salary support from the US Department of Veterans Affairs. CONFLICT OF INTEREST STATEMENT None declared. DISCLAIMER The contents do not represent the views of the US Department of Veterans Affairs or the US Government. REFERENCES Beresford TP, Turcotte JG, Merion R, et al. . ( 1990) A rational approach to liver transplantation for the alcoholic patient. Psychosomatics 31: 241– 54. Google Scholar CrossRef Search ADS PubMed Lee BP, Chen PH, Haugen C, et al. . ( 2017) Three-year results of a pilot program in early liver transplantation for severe alcoholic Hepatitis. Ann Surg 265: 20– 9. Google Scholar CrossRef Search ADS PubMed Yates WR, Booth BM, Reed DA, et al. . ( 1993) Descriptive and predictive validity of a high-risk alcoholism relapse model. J Stud Alcohol 54: 645– 51. Google Scholar CrossRef Search ADS PubMed Medical Council on Alcohol and Oxford University Press 2018. This work is written by (a) US Government employee(s) and is in the public domain in the US.
Alcohol and Alcoholism – Oxford University Press
Published: Mar 1, 2018
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