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Immediate Versus Later Listing for Liver Transplantation for Alcoholic Cirrhosis
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What is the problem and what is known about it so far?
Alcoholic cirrhosis is damage to the liver from heavy alcohol use. The condition sometimes improves when the patient stops drinking, but it can progress through several stages to end-stage liver disease. The stages of alcoholic cirrhosis are Child–Pugh stage A (least severe), stage B (medium), and stage C (most severe). Liver transplantation is a surgical procedure that takes a liver from someone who just died to replace the sick liver in someone with end-stage liver disease. Liver transplantation benefits patients with Child–Pugh stage C disease. Some think that it might make sense to do liver transplantation in patients before they reach the most severe stage of disease, such as patients with Child–Pugh stage B alcoholic cirrhosis.
Why did the researchers do this particular study?
To find out whether patients with Child–Pugh stage B alcoholic cirrhosis have better outcomes if they are immediately put on the liver transplant waiting list or if listing is postponed until they develop Child–Pugh stage C disease.
Who was studied?
120 French patients who had Child–Pugh stage B alcoholic cirrhosis and had no other liver disease, no cancer, and no condition that made them ineligible for transplantation. Some of the patients were still drinking when they entered the study.
How was the study done?
The researchers assigned patients to either immediate listing for a liver transplant or to usual care, which meant waiting until they developed more severe Child–Pugh stage C disease to be put on the transplant list. The researchers followed patients for 5 years to see who got a liver transplant, who died, and who developed cancer. Cancer is an important outcome because liver cancer is a complication of both cirrhosis and the drugs that people must take after liver transplantation.
What did the researchers find?
It is important to note that not all patients assigned to immediate listing got a liver transplant. A liver never became available for some patients, and others developed conditions that made them ineligible for a transplant. Some patients assigned to usual care did get a liver transplant because their disease worsened over the course of the study. After 5 years, 68% of patients assigned to immediate listing and 25% of those assigned to usual care got a liver transplant. The researchers found no difference in death rates between patients assigned to immediate listing and those assigned to usual care. More patients assigned to immediate listing developed cancer than did those assigned to usual care.
What were the limitations of the study?
Other countries require patients with alcoholic cirrhosis to be sober for longer periods than 6 months to be eligible for transplantation. Results might be different in those places or if the patients were followed for more than 5 years.
What are the implications of the study?
Immediate listing for a liver transplant for patients with Child–Pugh stage B alcoholic cirrhosis does not improve patient outcomes compared with care that requires more severe disease before being put on the waiting list.
Article and Author Information
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The summary below is from the full report titled “Immediate Listing for Liver Transplantation Versus Standard Care for Child–Pugh Stage B Alcoholic Cirrhosis. A Randomized Trial.” It is in the 3 February 2009 issue of Annals of Internal Medicine (volume 150, pages 153-161). The authors are C. Vanlemmens, V. Di Martino, C. Milan, M. Messner, A. Minello, C. Duvoux, T. Poynard, J.M. Perarnau, M.A.A. Piquet, G.P. Pageaux, S. Dharancy, C. Silvain, S. Hillaire, G. Thiefin, J.P. Vinel, P. Hillon, E. Collin, G. Mantion, J.P. Miguet, and the TRANSCIAL Study Group.
