T oday, there are nearly 12,000 patients per year dying of end-stage alcoholic liver disease (ALD); with only 4,000 hepatic donor organs available per year, it is clear that all patients with ALD cannot be saved by liver transplantation. 1 Which of these patients with ALD is selected for liver transplantation remains one of the most controversial areas in medicine today. 2 This controversy continues to be fueled by increasing numbers of patients with ALD undergoing liver transplantation in the face of an ever-increasing donor shortage. Furthermore, many questions remain regarding the impact of pretransplantation abstinence on recidivism, long-term compliance, long-term quality of life, ability to return to work, cost, and the overall social worth of performing liver transplantation for alcoholic patients.
Although 1-year patient survival and quality of life in select patients with end-stage ALD have been comparable to other indications for liver transplantation, medium-and long-term follow-up data are sparse. [3][4][5][6] Furthermore, the potential adverse impact of alcohol-related comorbid conditions on long-term outcome has not been fully assessed.
In this study, we used the National Institute of Diabetes and Digestive and Kidney Diseases Liver Transplantation Database (NIDDK-LTD) to assess long-term outcomes of a large, select group of patients undergoing liver transplantation for endstage ALD with or without associated hepatitis C. We compared these outcomes with those of patients undergoing liver transplantation for nonalcoholic indications. Clinical outcomes analyzed include patient and graft survival, quality of life, ability to work after transplantation, posttransplantation complications, resource utilization, and the incidence of recidivism.
Methods
The NIDDK-LTD 7 is a 7-year prospective study of patients undergoing liver transplantation at three centers: Mayo Clinic Foundation, Rochester, MN; University of Nebraska, Omaha, NE; and University of California, San Francisco, CA. All patients were evaluated for liver transplantation at these three centers and gave written, informed consent to participate in the database study. Detailed clinical information was obtained at initial evaluation, at transplantation, and at specified postoperative intervals. Information was collected according to a preestablished format and included demographic features, medical history, symptoms, signs, biochemical laboratory test results, serology, and radiological and histological results, as well as information on the transplantation procedure itself. Detailed information on the donor was also obtained, including age, sex, race, cause of death, condition and treatments, and available laboratory test results. Data were entered into a computerized database maintained by the Coordinating Center at the University of Pittsburgh, Graduate School of Public Health, Pittsburgh, PA.
During the accrual phase of the study between April 15, 1990, and December 31, 1993, a total of 1,346 adult patients with end-stage liver disease were evaluated for liver transplantation at the three participating institutions. Of this group, 1,230 patients had a well-defined drinking history, and 1,196 had a diagnosis that did not involve either hepatitis B or malignancy. Of these 1,196 patients, 342 had a diagnosis of ALD, and 139 of these 342 patients eventually underwent liver transplantation. When the 342 patients with a diagnosis of ALD were clinically evaluated, 56 were found not to be sick enough to warrant liver transplantation, and 118 were found to have a medical, financial, or psychological contraindication to liver transplantation. The 139 patients who underwent liver transplantation because of ALD included 51 who also had chronic hepatitis C. The majority (n 5 121) of these 139 patients were abstinent for 6 months or more, whereas 13 patients were abstinent for less than 6 months. The duration of abstinence could not be ascertained for the 5 remaining patients.
The transplant control population consisted of 486 adult liver transplant recipients with a nonalcoholic indication for liver transplantation. Patients undergoing liver transplantation