Factors related to improvement are established in patients with alcoholic liver cirrhosis on a transplant waiting list

A study led by researchers from the Clínic-IDIBAPS and the CIBEREHD and published in the Journal of Hepatology shows that up to 9% of patients with alcoholic cirrhosis on liver transplant waiting lists improve and can be delisted.  The study establishes the factors associated with this improvement, and the results can help optimise waiting lists and avoid unnecessary transplants.

Dr Elisa Pose, first author of the study, together with Drs Gonzalo Crespo (right) and Pere Ginés, senior authors.

This study was coordinated by Dr. Gonzalo Crespo, hepatologist at the Hospital Clínic and researcher in the IDIBAPS and CIBEREHD Liver transplantation and graft viability research group; and Dr. Pere Ginés, head of the Hospital Clínic Hepatology Service and of the IDIBAPS Chronic liver diseases: molecular mechanisms and clinical consequences research group, and also researcher at the CIBEREHD. The first author of the study is Dr. Elisa Pose, researcher in Dr. Ginés’ group and hepatologist at the Hospital Clínic.  The Hepatology Units at Bellvitge University Hospital and Vall d’Hebron University Hospital and the Catalan Transplant Organisation (OCATT) also participated in this paper.

This study included over 1,000 patients with decompensated cirrhosis on liver transplant waiting lists. A total of 420 of these patients had alcoholic cirrhosis.  Focusing on this subgroup, the researchers found that 36 patients (8.6%) were delisted because their health had improved.  

The researchers assessed which factors were related to the patients’ delisting due to clinical improvement. Thus, they found that a lower score on the MELD scale, which is used to assess the severity of chronic liver disease, and a higher number of platelets when joining the waiting list were factors independently associated with a greater possibility of the patients being delisted the due to clinical improvement.

Moreover, female sex and lower stature (collinear variables) were independently associated with delisting due to clinical improvement.  For MELD scores of 15-17, over 30% of the women on waiting lists were delisted due to clinical improvement compared to 7% of the men.

Liver transplant candidates of shorter stature (a situation generally more frequently found in women) have more difficulties accessing transplants due to size mismatches with donors. Bearing this in mind, researchers believe that less frequent early access to transplantation in women –due to their lower stature–, cold allow a large percentage of them (those with a lower MELD score) to improve so much that they are removed from waiting lists.  

The study also analysed the evolution of patients after they were removed from waiting lists due to clinical improvement. Nine of the 36 patients (25%) presented a progression in their illness after being delisted, in the form of new decompensation or hepatocellular carcinoma, and two required transplants.  Two-thirds of the patients in whom the liver disease progressed after being delisted had started consuming alcohol again.

When this evolution was compared with patients with cirrhosis due to the hepatitis C virus (HCV) who were delisted because of clinical improvement (31 of 403 patients, 7.6%), no significant differences were observed. So, in 76% of the patients with alcoholic cirrhosis and 74% of the patients with HCV-related cirrhosis, there was no progression in liver disease 5 years after they were delisted due to clinical improvement.

This study is the first to investigate the phenomenon of delisting due to clinical improvement in patients with alcoholic cirrhosis in Europe. Its results suggest that, with patients who are candidates for a transplant, but in whom the liver function is not too severely impaired, particularly patients who have only been abstinent from alcohol for a few months, the option of waiting before joining a list may result in a better use of grafts, avoiding unnecessary transplants.  Moreover, in patients delisted due to clinical improvement, close monitoring is required, both by a hepatologist and an addiction specialist.