Agree, they must pay.

There are 2 aspects to it [1] Medical aspect, [2] Social aspect. Viewing from medical side, of course patient has to buy the transplant if he has financial capability. From social aspect the matter is more complicated as it involves cost, organ availability and ethical issues. If cost [including live donor] is borne by the family, their financial status further worsens as most family with alcoholics are. If cost [including organ availability and transplant] is borne by public sector, there are important ethical issues of loss of valuable organs [especially in resource constrained countries with organ shortage] and the whole cost from recidivism and relapse which is common in such cases. The whole matter will actually depend on socioeconomic scenario of the country, availability of organs, patient profile and cost.

Post-translant, provided by the public purse, what is chance or likelihood that the alcoholic patient will not drink again? Is there any study on this aspect?

Of late there have been published studies from USA, Italy, France and India Brazil including metanalysis [can be easily found on Pubmed with serach term "liver transplantation for alcoholic liver disease]. But I feel many studies are biased.

The chances that the alcohol-dependent patients will not drink alcohol post-transplant are close to zero. I have worked in the Gastro-Enterology and Hepatology Unit at AIIMS, New Delhi, and, I know what I am saying from first-hand experience.

The sobbing of the wives of male alcohol-dependent pre-terminal decompensated patients still rings in my years.

I totally agree with you.

When we serve with full efforts to murderers

then why not for alcoholics

Good question.

Let the members take it up.

If there is even a single such case, it should be brought to attention to animate the discussion.

Approximately one third of the patients to be transplanted in Italy have a more or less recent past of abuse of alcohol or drugs. Criteria necessary to start the pre liver transplantation assessment is the abstinence certified by the SERD (Service Dependencies) of minimum 6 months.

And to evaluate a psychological path to consolidate the condition of abstinence by strengthening the patient's personal motivation, also performing toxicological checks to verify the persistence of abstinence, discussing the cases at risk in team with hepatologist and psychiatrist.

That is indeed a great program.

Kindly comment on the success rate of such expected abstinence.

The outcome depends on the strength of interdisciplinary counselling, monitoring, follow up and of course the attitude of patient and care givers.

Perhaps you might offer some figures that are representative in general to guide us in the future.

I think liver transplantation should not be provided as these patients usually return to drink alcohol again

We should give a chance to our colleagues to return with some solid figures. This is important because eventually international bodies that recommend such procedures will have to take a call and the issue is both sensitive and expensive to the public Exchequer.

There are a lot of studies tah show that full recovery is possible in at least the 50% of these patients. So my answer is clearly YES.

The problem is not full recovery post-transplant. The problem is a fresh assault to the transplanted liver by resumption of alcohol consumption.

Please provide reference with your answers.

You can obtain a complete abstinence at least for six months before including these patients in the transplantation list

How?

With a strict surveillance and rigid periodic control

Even in the well-controlled environs of a hospital with video-cameras, strict surveillance may not deter the alcoholic patient --- alcohol dependence is just like any other drug dependence. "Rigid periodic control" -- GGT elevations can remain long after alcohol consumption. What are we going to control?

I have no dispassion for the alcohol-dependent patient. We are just discussing the practical aspects. As therapists, we are on the same side as well on the side of the alcohol-dependent patient.

Looks like there is an interesting dichotomy of opinions here. You will find excellent information on the subject in the EASL guidelines with a huge amount of references as well with regards to abstinence, the medical and psychological support for this and outcomes.

https://www.journal-of-hepatology.eu/article/S0168-8278(12)00288-7/pdf

What I find a bit disturbing is the nearly punitive undertone of some in this discussion.

Alcoholism is a disease. There are genetic and epigenetic factors that influence it. It affects rich and poor. The religious and devout as well as the agnostic. People who are well seated in society and those at the fringes. It is a disease with treatments and relapses in some.

Would you consider liver transplantation to patients with NASH. Isn't dietary over intake not also self-inflicted? What about the person that went into fulminant liver failure as a result of an overdose in suicidal intention ? Self inflicted as well and a high chance of chronic mental illness. Away from the subject of transplantation - What about the mountaineer who ends up in multiple organ failure after an accident when pursuing their hobby. Wouldn't you offer them all available care even though it is self inflicted? What about the kid joy racer that crashes? Good chance both will continue their "hobby".

Best wishes,

Immo

Here are some figures from an older metaanalysis on relapse rates post transplant:

Average alcohol relapse rates (examined only in liver studies) were 5.6 cases per 100 patients per year (PPY) for relapse to any alcohol use and 2.5 cases per 100 PPY for relapse with heavy alcohol use. Illicit drug relapse averaged 3.7 cases per 100 PPY, with a significantly lower rate in liver vs. other recipients (1.9 vs. 6.1 cases).

Article Meta-Analysis of Risk for Relapse to Substance Use After Tra...

@Immo

Thank you for some wonderful discussion.

I think there might be a distinct difference between "punitive" and "public or tax-payer moneys".

Hawaiian Airlines has decided to punish or charge (euphemism) flyers arriving to or departing from Pago Pago International Airport (PPG) in American Samoa not allowed to select their seats online or at check-in. Instead, flyers’ seats are selected for them because the airline says they are contending with heavier passengers aboard the flight. According to a statement from Hawaiian Airlines, the policy allows the airline to redistribute weight in order to meet manufacturer guidelines on the Boeing 767 aircraft that fly the route.

Hawaiian Airlines passengers are asked to be weighed. Obesity in American Samoa has been a growing problem noted in research papers. NPR reports that one in three residents of the island nation currently contends with Type 2 diabetes as a result of diet and weight issues.

Hawaiian Airlines’ issue with weight is not the first time an airline has addressed the concern of heavier flyers. Last year, Uzbekistan Airways announced they would begin weighing passengers prior to boarding, while Southwest Airlines maintains a “Customer of Size” policy for large flyers.

The era of free expansion of body weight and for making society pay for one's inclinations or excesses is steadily drawing to a close.

If the mountaineer can pay for her/his hobby, why not for the treatment?

There are only limited dollars that can go around, for therapy or research all over the world. Why should society pay for others' recreation/hobby/inclination/joyful pursuits/suicidal tendency? You would rob Peter (society) to pay (treat) Paul (the hobbyist)? This is a mega-question that will refuse to die out. Along with health care or any other social care comes responsibility.

We want no responsibility but all facilities.

The "Michelin Man" has disappeared from check-in counters of flights.

Then there is health insurance and the legalities linked to it. A huge and separate question by itself.

Suffice is it to say here the Richard Clayderman, a world famous pianist, insured his own fingers for a sum of 20 million pounds. Nobody came in to pitch for Richard. So, what is the issue here? Please, somebody explain!!!

When you wear a helmet (and or other form of high-tensile guards to sensitive parts of the body) while joy racing or speed cycling or cruising at high speed in a motorbike or mountaineering or while boxing or playing rugby or in any another contact sport or a high-velocity projectile sport such as cricket, you automatically acknowledge the risk involved. Who will or should pick up the tab for the risk you are taking???

If the patient is aware of their addiction and undergoes a multidisciplinary therapeutic program (sodium oxybate or acamprosate therapy, or  nalmefene) and psycho-therapy, good results can be obtained (drug free even for a few years). Clearly the risks of relapse are always present and must be monitored over time

@Giuseppe

Perhaps we have some studies on the lines suggested by you.

DRUG DISCOVERY

17 APRIL 2018

Booze-busting nanopills to help the liver

Miniature capsules deliver enzymes that quickly cut blood-alcohol levels.

A pair of nanocapsules serve as an alcohol antidote by ferrying detoxifying enzymes to the liver.

Yunfeng Lu at the University of California, Los Angeles, Cheng Ji at the University of Southern California, also in Los Angeles, and their colleagues devised two types of nanopill. One holds a pair of enzymes that transform alcohol into the compound acetaldehyde; the second contains an enzyme that processes the acetaldehyde to a less-toxic molecule, acetate. In combination, the enzymes mimic the activity of those that dismantle alcohol in liver cells.

When the scientists injected the nanopills into mice, the capsules travelled to the animals’ livers. Four hours after intoxicated mice received the pills, the rodents’ blood-alcohol levels were nearly 45% lower than those of mice dosed with a control solution.

The pills, which could reduce liver damage, are now the subject of pre-clinical studies. The researchers say they will seek federal approval for their remedy.

Best.

I fully agree with the comments of Prof. Giuseppe da rosa

@Luis

Let us see what data can be available on these lines.

I would be personally gratified if we could help this particular section (or any other section) of potential liver transplant recipients.

We should agree with data, not opinions.

"Can" and "should" do not constitute evidence.

May agree if offering him LDLT

LDLT poses a risk to the donor. The number of LDLT procedures performed in the United States peaked at 519 in 2001 and then decreased to approximately 320 per year starting in 2003 as enthusiasm for the procedure was tempered by concerns about complications. (Pomfret EA, Fryer JP, Sima CS, et al. Liver and intestine transplantation in the United States, 1996-2005. Am J Transplant 2007; 7:1376.)

Yet again, the issue with the alcohol-dependent is not the liver donation.

Data on the matter in question may relate to many factors e.g. magnitude of alcohol related problems in a country [data from countries where alcohol is social or religious taboo will be very different from those that are not], alcohol related diseases [psychiatric, injuries, liver etc] alcohol related liver disease [which further include decompensated liver disease, acute on chronic liver failure, alcoholic hepatitis etc] and each of which will be different in different regions of the world. Added to this it must remembered that the above mentioned points may occur in unison which also affect outcomes depending on the multidisciplinary medical infrastructure in a country devoted to diagnosing and treating alcohol related problems [which is dismal in India] Alcohol problems are also under reported most times.

Considering liver disease, data in meagre in India [for relapse rates check article: Narendra S. Choudhary, Naveen Kumar, Sanjiv Saigal,⁎ Rahul Rai, Neeraj Saraf, and Arvinder S. Soin. Liver Transplantation for Alcohol-Related Liver Disease. J Clin Exp Hepatol. 2016 Mar; 6(1): 47–53.] Data will vary according to nature of alcohol related liver disease that is being treated. I also personally feel that much of these data are biased in favour of selection of patients who have chance of better outcome on pretransplant check up. Also the follow up period is very variable and most studies do not report long term outcome.

@Gautam

"Data will vary according to nature of alcohol related liver disease that is being treated."

Would transplant not be considered for the end-stage alcohol related cirrhotic and contracted liver with a rather uniform histopathology?

Please explain why nature of terminal alcohol-related liver disease will or can vary?

Decompensated liver disease, acute on chronic liver failure due to alcohol, alcoholic hepatitis are different entities. Decompensated liver disease is terminal and best suited for transplant. Pure alcoholic hepatitis does not have cirrhotic background and patient may recover spontaneously. In ACLF the disease is chronic but stable with recent decompensation due to an acute insult like virus, hypotension, alcohol and so may or may not recover without transplant. All however require abstinence which again depends on multimodality support from counsellors, family, physicians [from societal aspect] and genetic background, nature and duration of addiction, comorbidities and will for abstinence [patient aspect]

If the clinical situation must be maintained and a time of at least 6 months without drinking alcohol must be confirmed before the final decision

The decompensation is not at the level of the liver, it is at the level of the brain/mind that is willing to perpetuate deliberate self-harm to death. How can we manage the mind intoxicated with alcohol and distressed by absence of the intoxication, if ever. Are there any guidelines?

It takes time enough and good clinical care during at least 6 months before complete liver recovery and to get complete abstinence during this time

@Luis Rodrigo

Let us outline the "good clinical care".

There are countries where alcohol and tobacco are heavily taxed, and all that money is the major income (and much more than) for that country to provide free healthcare and education for everyone. So they can ask the question who has already paid all that expense behalf of everyone in advance.

Yes, if they fulfill standard abstinence criteria and show no harmful drinking tendencies of recidivism. Moreover, interestingly it is acceptable for people to eat themselves into cirrhosis (NASH) but wrong for them to drink themselves into it!