Liver Transplantation for Alcoholics with Terminal Liver Disease
David H Van Thiel, Alcohol Health & Research World
Most candidates for liver transplantation have irreversible cirrhosis caused by years of heavy alcohol consumption. Arguments against liver transplantation for alcoholics include the presumption of relapse to heavy drinking, which might damage the new liver or lead to its rejection. Corresponding ethical arguments focus on the presumption that alcoholics brought their condition upon themselves and should not compete with nonalcoholics for scarce donor livers. However, experimental data demonstrate that carefully selected alcoholics can survive liver transplantation and return to the workplace as productive citizens. Moreover, it has never been considered ethical for clinicians to refuse treatment to patients for diseases that are partly or wholly preventable. KEY WORDS: liver; organ transplantation; alcoholic liver disorder; alcoholic liver cirrhosis; mortality; ethics; treatment complications; public policy; patient treatment matching; prognosis
Alcoholic liver disease is one of the most serious medical consequences of long-term alcohol use. Moreover, long-term heavy alcohol use is the most prevalent single cause of illness and death from liver disease in the United States. More than 25,000 Americans died of liver cirrhosis in 1991, making it the eleventh most frequent cause of death that year (National Center for Health Statistics 1994). Approximately one-half of cirrhosis deaths have been attributable to alcohol consumption (see sidebar) (National Institute on Alcohol Abuse and Alcoholism [NIAAA] 1993).
The only effective treatment for patients whose liver disease (usually cirrhosis) has become terminal and irreversible is transplantation. Because most cases of terminal liver disease are related to heavy alcohol consumption (Senior et al. 1988), the majority of potential candidates for liver transplants are alcoholics. However, some transplant centers in the United States have been unwilling to provide the procedure to people with alcohol-induced liver injury (Kumar et al. 1990). This article explores the reasons for and against liver transplantation for patients with alcoholic liver disease and provides evidence suggesting that alcoholics should be eligible for this life-saving treatment.
NORMAL LIVER FUNCTION
The liver is the largest organ of the body, located in the upper right section of the abdomen. As well as being involved in many of the body's metabolic systems, the liver assists in digesting, absorbing, and processing food. A versatile organ, the liver stores vitamins, synthesizes cholesterol, controls blood fluidity, and regulates blood-clotting mechanisms. It also filters circulating blood, removing and destroying toxic substances. Thus, liver disease compromises the body's ability to perform multiple functions essential to life.
ALCOHOLIC LIVER DISEASE
Alcohol-related liver damage includes fatty liver, alcoholic hepatitis, and cirrhosis. A single episode of heavy drinking is sufficient to cause some deposition of fat in the liver, which, however, rarely causes illness (NIAAA 1993).
Long-term heavy drinking may lead to alcoholic hepatitis, a severe inflammation of the liver characterized by nausea, weakness, pain, loss of appetite, weight loss, and fever (Senior et al. 1988). Alcoholic cirrhosis is the most advanced form of alcoholic liver injury, characterized by progressive development of scar tissue that constricts blood vessels and distorts the liver's internal structure, impairing liver function. Approximately 10 to 20 percent of heavy drinkers develop cirrhosis (NIAAA 1993).
A patient may have only one of these three conditions or any combination of them. Traditionally, alcoholic liver disease has been conceptualized as progressing from fatty liver to alcoholic hepatitis to cirrhosis. However, cirrhosis may appear insidiously, without any previous stage resembling hepatitis, and alcoholic hepatitis can be fatal by itself without leading to cirrhosis (Senior et al. …