Immediate Listing for Liver Transplantation for Alcoholic Cirrhosis: Curbing Our Enthusiasm

Liver transplantation has become the standard of care for end-stage liver disease, with 5-year survival rates approaching 70% to 80%. In the United States, allocation and timing of liver transplantation were first based on both waiting time and the Child–Pugh system. The Child–Pugh system characterizes disease severity by a scoring system involving laboratory and clinical features, as well as the physician's subjective assessment of the magnitude of ascites and encephalopathy, which are important components of the final score. In 2000, the Institute of Medicine recommended that disease severity, not time spent on the waiting list, should determine organ allocation in the United States. This recommendation created the need for an objective, even-handed method for measuring disease severity, which led to the introduction of the Model for End-Stage Liver Disease (MELD) in place of the Child–Pugh score in 2002 (1). This mathematical model characterizes disease pretransplantation severity on a scale of 6 (healthiest) to 40 (sickest) and estimates 3-month mortality rates. Some countries have replaced the Child–Pugh score with MELD to rank patients according to mortality risk, but most countries do not use a national–regional allocation system based on disease severity. In most countries, physicians determine priority for receiving an organ by waiting list time (seniority) and clinical judgment about disease severity (2–4).

Patients with decompensated cirrhosis from alcoholic liver disease (ALD) are unique among patients with liver disease because their condition often improves markedly when they stop drinking and get expert medical care (5). Because the Child–Pugh stage …