Mistakes in ... Booklet 2020 - 13

ueg education

Mistakes in... 2020

Mistakes in liver transplantation and how to avoid them
Patrizia Burra and Alberto Zanetto
Since it was first performed by Thomas Starlz in 1963, liver transplantation has become
a viable treatment option for patients with acute and chronic liver failure whatever the
aetiology (figure 1).1-3 Over the years, the outcomes of liver transplant recipients have
improved significantly,1 owing to continuous advances in surgical techniques and organ
preservation, optimization of intensive care, and management of immunosuppressive
therapy.4 New strategies to enlarge the donor pool and to maximize survival after liver
transplantation have also been introduced, which is essential particularly given the rise
in cases of nonalcoholic steatohepatitis (NASH) and its emergence as a leading indication
for liver transplantation.5 That the field is continually evolving poses unique challenges
to clinical practice, and these challenges may increase the risk of making mistakes. By
definition, patients on the waiting list for liver transplantation do not have a therapeutic
alternative, so any mistakes can have an ominous impact on their prognosis.
Here, we highlight 10 mistakes that can frequently be made when managing liver
transplant candidates or recipients, and provide an evidence- and experience-based
approach to avoiding them. Much of the discussion is based on the European Association
for the Study of the Liver (EASL) clinical practice guidelines.2,6-12
Mistake 1 Basing eligibility for
transplantation in patients with alcoholrelated liver disease solely on duration of
pre-transplant abstinence

Figure 1 | Main indications for liver transplantation in
Europe. Data from the 2008 Annual Report of the
European Liver Transplant Registry (ELTR).1

or with acute-on-chronic liver failure due to
alcoholic hepatitis may be candidates for a new
liver. Indeed, ALD is one of the main indications
for liver transplantation.13 Outcomes for ALD
patients are excellent and comparable to other
indications, with a 5-year survival rate of 76-86%.14
Nonetheless, liver transplantation for patients
with ALD still generates a lot of discussion, due to
the perception that ALD is self inflicted and
concerns regarding alcohol relapse after liver
transplantation. As patients with a history of
alcohol abuse are believed to be poor transplant
candidates, many of those eligible for referral
for liver transplantation are not referred. In the
United States alone, lack of referral may be
associated with as many as 12,000 deaths
per year.15
In our opinion, patients should not be excluded
from liver transplantation based on preconceived
ideas, lack of evidence and presumed lack of
resources, even if they are actively drinking at the
time of decompensation.16 Most important is the
selection of candidates, balancing the needs of
the individual and the claim that other potential
recipients may have on each donated organ.17
In our experience, this balance can be achieved
via a strict selection process that takes a
multidisciplinary approach, involving transplant
hepatologists and surgeons, psychiatrists,
addiction specialists, psychologists and/or social
workers (figure 2). Identifying patients at risk of
severe alcohol relapse after transplantation is of
utmost importance, as only severe relapse has

been shown to have a negative impact on long-term
survival.18,19
Traditionally, most transplant centres
require a 6-month period of abstinence before
considering a patient with ALD suitable for liver
transplantation. The so-called 6-month rule was
introduced more than 20 years ago, when a group
of experts formulated the minimal criteria for
listing patients with ALD.20 The rationale
behind this rule was twofold-to prevent liver
transplantation in patients whose liver function
will recover with abstinence alone and to
identify patients at high risk of relapse after liver
transplantation (for whom liver transplantation
should be contraindicated).
Although some studies have demonstrated
that the maximum benefit of abstinence is
observed within the first 3-6 months, it's very
hard to establish whether the length of
pre-transplantation abstinence is really helpful
when assessing the risk of post-transplantation
relapse.2,9,21,22 Assessing the real likelihood of
abstinence post-transplantation is extremely
complex, and both the European and American
guidelines state that the 6-month rule should no
longer be used to assess whether a patient can be
accepted as a liver transplantation candidate.2,3,9 In
particular, liver transplantation may be indicated
even without 6 months of abstinence when liver
function deteriorates rapidly.23
The seminal study by Mathurin et al.
provides further evidence that good results can
be achieved in patients transplanted for alcoholic

© (2020) Burra and Zanetto.
Cite this article as: Burra P and Zanetto A. Mistakes in liver
transplantation and how to avoid them. UEG Education 2020;
2020: 1-6.

Patrizia Burra and Alberto Zanetto are at the Multivisceral
Transplant Unit, Gastroenterology, Department of Surgery, Oncology
and Gastroenterology, Padua University Hospital, Padua, Italy.
Illustrations: J. Shadwell.

Correspondence to: burra@unipd.it.
Conflict of interest: The authors declare there are no conflicts of
interest.
Published online: May 14, 2020.

Gastroenterologists and hepatologists frequently
encounter patients with alcoholic liver disease
(ALD), and those with decompensated cirrhosis

13%

19%

6%
4%
9%

22%
10%
15%

Alcoholic cirrhosis
Virus-related
cirrhosis
Combined viral and
alcoholic cirrhosis
Hepatocellular
carcinoma

2%
Cholestatic liver
disease
Acute hepatic
failure
Biliary atresia
Metabolic disease
Other

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