Liver Transplantation in a Vice: The Pressure, Challenges, and High Stakes of Acute Alcohol-associated Hepatitis

Alcohol’s impact on morbidity and mortality cannot be overstated. It accounts for 1 in 20 global deaths and is a major etiology of liver disease worldwide(1). Alcohol-related liver disease (ALD) is the medical aspect of a psychiatric condition, alcohol use disorder (AUD), which commonly presents in its later stages and is the leading indication for liver transplant (LT) in the United States amid an alarming surge in ALD among young people(2). Women are at high risk for ALD and yet are disadvantaged to receive LT. Many ALD patients are positive for substance use at LT evaluation yet only a minority disclose their use fearing LT denial.

Acute alcohol-associated hepatitis (AAH) is a high-stakes and challenging ALD subgroup with very short periods of alcohol abstinence, psychiatric comorbidity, and high mortality which sharply increases over time with any drinking. Studies show acceptable public perceptions and LT outcomes in AAH. At the core of the AAH issue is thorough psychiatric evaluation and treatment planning. Consultation-liaison psychiatry (CLP) will remain fundamental to ALD evaluation and treatment(3) and LT evaluations in AAH patients are a crucial aspect of that growing role.

In this 90-minute virtual workshop, 5 C-L psychiatrists from different institutions will address pertinent aspects of LT in AAH. Dr. Andrews will lay the workshop’s groundwork for 16 minutes by defining AAH and unique features of AUD in LT. Dr. Shenoy will present for 20 minutes on the importance of thorough inpatient pre-transplant psychiatric evaluations and the emerging use of standardized selection criteria. Dr. Winder will speak for 16 minutes on the topic of defining and eliciting alcohol-related insight in the unique LT context and the interprofessional challenges inherent to its discussion among multidisciplinary LT clinician teams. Dr. Goswami will be allotted 20 minutes to teach about essential post-transplant AUD treatment and follow-up including designing novel designs and curricula and the use of psychometric instruments and biomarkers. Given the potential impact of LT in AAH on organ availability among waitlisted patients, Dr. Omary will explore disparities and ethical implications of LT in AAH for 16 minutes.

To maximize audience engagement and learning in the virtual format, these pre-recorded presentations will utilize case presentations, focus on aspects of LT in AAH that mid-career generalist C-L psychiatrists will most likely encounter, provide practical guidance, and cite the most recent medical literature.

1. Rehm et al. Global burden of alcoholic liver diseases. Journal of hepatology. 2013;59(1):160-8.

2. Lee et al. National Trends and Long-term Outcomes of Liver Transplant for Alcohol-Associated Liver Disease in the United States JAMA Internal Medicine. 2019;179(3):340-8.

3. Winder et al. Confronting the Crisis of Comorbid Alcohol Use Disorder and Alcohol-Related Liver Disease With a Novel Multidisciplinary Clinic. Psychosomatics. 2020;61(3):238-53.