[Liver transplantation: which indications? which results?].

UNLABELLED: THE ONLY TREATMENT: Liver transplantation (LT) is currently the final treatment for most types of end-stage liver diseases including alcoholic cirrhosis, so far alcoholic cirrhosis has become the first indication for LT in France and other western countries, accounting for 25% of all procedures. However due to ethical issues and also the discrepancy between the theoretical number of candidates and available organs, indications for LT in alcoholic cirrhosis must be rigorously defined.

INDICATIONS: On the average, candidates are 50 years old, males in two-thirds of the cases, with pre-terminal liver disease combining advanced-stage liver dysfunction (PT < 40%, bilirubin > 50 mumol/l, albumin < 30 g/l) and intractable ascitis. The gain in survival being best in patients with severe cirrhosis (Child-Pugh grade C), these patients should be given priority when liver function fails to improve despite prolonged abstention. For less advanced diseases (Child-Pugh B or A), LT can be considered after failure of symptomatic medical treatments or in case a small hepatocellular carcinoma develops.

CONTRAINDICATIONS: The list includes presence of extrahepatic organ failure, generally related to alcohol-tobacco abuse (cardiomyopathy, pancreatitis, neuropathy, squamous cell carcinoma ...) and precarious psychosocial situations exposing the patient to the risk of recurrent alcoholism and non-compliance after transplantation. Predictive factors of after recidivism after transplantation are preoperative abstinence of less than 6 months duration, denial of alcoholism, lack of familial and occupational support, antisocial behavior and a history of psychiatric disorders or drug abuse. Patients with several of these risk factors cannot reasonably be considered as candidates for LT. Inversely, transplantation should be proposed for patients with no or few risk factors due to the excellent physical and social outcome observed. Generally, a full 6 months of preoperative abstinence is required by most transplantation centers. The aim is to avoid underestimation for liver function recovery and to limit the risk of recurrent alcoholism.

RESULTS: Using the above criteria, LT for alcoholic cirrhosis can restore a satisfactory quality of life and provides a 5-year survival to the order of 65%, similar to results obtained in other indications for LT. Recurrent pathological consumption of alcohol occurs in 10 to 15% of the cases, generally with moderate effects on the liver graft.

PRACTICAL ATTITUDE: Using the currently accepted selection criteria, less than 5% of the patient with alcoholic cirrhosis actually undergo transplantation. For these patients, LT enables to treat both cirrhosis and alcoholic disease in 80% of the cases. Based on these results, segregating among patients with severe alcoholic cirrhosis considered as reasonable candidates for LT after a complete pluridisciplinary preoperative work-up must be avoided.