LIVER-TRANSPLANTATION FOR ALCOHOLIC LIVER-DISEASE - EVALUATION OF A SELECTION PROTOCOL

We have used a formal transplant protocol to select patients with alco holic liver disease (ALD) for transplantation. We retrospectively anal yzed all the patients with ALD who were referred specifically for tran splantation to our Liver Unit between 1987 and 1994. Patients were sel ected for liver transplantation if they had end-stage liver disease an d had remained abstinent from the time they were medically advised to stop alcohol intake. Of the 180 patients referred for transplantation, 43 (none of whom were transplanted) had case records insufficiently c omplete for full analysis; this may bias the analysis. Of the remainin g 137 patients, 39 were transplanted and 4 were awaiting transplantati on at the time of analysis. Of the patients who were not accepted for transplantation 13 died during the assessment, 7 were considered to be unlikely to survive the procedure, 29 were found to be medically unsu itable, 16 psychologically unsuitable, 7 patients refused the offer of transplantation, and an additional 19 either showed clinical improvem ent or were considered too well for transplantation. Special investiga tions, such as brain computerized tomography (CT) scan and echocardiog raph, changed the clinical decision to transplant in only a small numb er of cases (4% and 5%, respectively). Nine of the transplanted patien ts died and the remaining were followed up for a median of 25 (range, 7-63) months. One year actuarial survival for the transplanted patient s was 79%, for those considered too sick was 0%, for medically unsuita ble patients was 44%, for psychologically unsuitable patients was 65% and for those considered too well was 94%. Only 5 of the transplanted patients (13%) reverted to drinking. The observed actuarial survival o f nontransplanted patients was compared with the expected survival cal culated by 'the Beclere model.' The observed actuarial survival in the nontransplanted groups was much better than anticipated from the Becl ere model, which therefore, is not applicable to our patients. The pro portional hazards regression analysis of our nontransplanted patients identified serum bilirubin, serum albumin, blood urea, ascites, and sp ontaneous bacterial peritonitis as factors significantly predictive of their probability of survival. Using a model based on these parameter s, the expected survival of our transplanted patients was calculated. Although we applied the model to a different population, the observed actuarial survival in the transplanted patients was found to be better than their expected survival (P less than or equal to .001). Our prot ocol was useful in selecting suitable patients with ALD for liver tran splantation, which resulted in significant survival advantage with low recidivism rate.