Confronting life-or-death decisions on liver transplant recipients

Surgeons encounter a difficult dilemma regarding liver transplants. The availability of donor organs is limited, and the determination of who will receive one is a matter of life and death. This decision can become even more challenging when dealing with patients who have a history of alcohol-use disorder.

“As medical practitioners, we always strive to save lives — particularly in this context and for those patients who are quite young,” stated Wei Zhang, a transplant hepatologist at Mass General Hospital. “However, we must also consider the scarcity of organs. The question arises: If a patient has a liver transplant but passes away within the first five years post-transplant, was it justified?”

The risk evaluation for clinicians like Zhang and their colleagues is convoluted and intricate, encompassing assessments of a patient’s medical status, support systems, and personal history concerning alcohol-use challenges, which correlate with a higher occurrence of liver ailments.

The implications are significant. Patients suffering from decompensated liver disease, often termed end-stage liver disease, face drastically reduced life expectancies without transplantation. One study revealed that patients in this stage who experienced complications lived only two years after diagnosis.

Yet, a transplant is not always the ultimate solution. As high as 20 percent of all individuals with a history of alcohol-use disorder will relapse post-surgery.

“If it’s known that a patient is likely to relapse after liver transplantation, evidence suggests that the chances of developing recurrent cirrhosis within three years is approximately 50 percent, and the likelihood of succumbing to the recurrent liver disease within five years is around 50 percent,” Zhang explained. “We implement numerous interventions to assist them in abstaining from alcohol and enhancing their overall quality of life.”

In addition to his role as a hepatologist, and as an assistant professor of medicine at Harvard Medical School, Zhang also directs MGH’s Alcohol-Associated Liver Disease Clinic, where he has been pivotal in promoting distinct post-transplant programs aimed at securing the long-term health of patients and their new organs.

“As physicians, we must be pragmatic,” he noted. “We need to separate ourselves from the decisions made, as it’s not just my call. It’s fundamentally a collective agreement from the whole committee. I occasionally reflect … if I had advocated more strongly, could I have offered the patient a chance for a liver transplantation? Nonetheless, in the end, it’s a collaborative effort.”

Moreover, Zhang mentioned that he finds comfort in the understanding that when one patient is not suitable for transplantation, the organ can be utilized to save another’s life.

“I also recognize that when a patient receives an organ, it signifies that another individual is not able to receive that organ,” he stated. “So, when I contemplate that, I derive a bit of solace.”

Over the last ten years, the domain of transplant hepatology has transformed dramatically. In the recent past, all patients admitted with liver failure accompanied by any history of alcohol abuse were routinely denied life-saving surgery.

“During my residency, most of those patients had no possibility of being evaluated for liver transplantation,” Zhang recalled.

Currently, he noted, there remain several obstacles that patients must navigate to gain approval for transplantation. However, there is optimism — particularly for those with strong familial support.

“If a patient lacks prior awareness of their drinking contributing to the liver disease, has no known liver disease, and arrives at the hospital while actively consuming alcohol, there are two different criteria we want those patients to satisfy,” Zhang elaborated. “One pertains to medical standards, while the other addresses psychosocial factors.”

Zhang stated the initial step in evaluating a patient as a potential recipient for a liver transplant is to exclude any underlying health issues such as heart or lung conditions that might complicate surgery.

The subsequent step involves assessing their potential for enacting behavioral changes to safeguard their health. This process typically necessitates a multidisciplinary team, which includes a social worker, an addiction specialist, and a hepatologist, to reach a consensus.

“Some of the elements we assess include whether a patient possesses insight, meaning, does the patient believe that alcohol caused their liver disease?” Zhang mentioned. “There are individuals who, for various motives — one of which might be stigma — do not admit that alcohol has led to their liver disease. The risk is that if they obtain a liver transplant, but do not recognize the need for treatment, they may eventually relapse.”

Another facet of psychosocial criteria, Zhang added, pertains to social support. This encompasses having robust family connections, secure housing, and the overall ability to seek assistance following surgery.

“Subsequently, those patients would be classified as favorable candidates with acceptable risk for post-liver-transplant relapse, and we can proceed to a liver transplant evaluation,” Zhang stated.

Binge drinking and high-risk drinking are increasing. According to Zhang, younger individuals and more women have been increasingly experiencing severe repercussions like liver failure and cirrhosis. The youngest patient with cirrhosis that Zhang has encountered was 22.

Such alarming trends imply that physicians will grapple with the risks of burnout from having to make more consequential decisions. Zhang asserts that, for him, all of this simply comes with the profession.

“It’s a challenging job, but I genuinely enjoy it,” he remarked. “The most significant aspect is that if I can save lives, then I am fulfilled.”