Zafar Yousaf, Siddiqi Ahmed Kamal, Shaikh Nafhat, Imran Maria, Javaid Syed Sarmad, Manzoor Laila, Iqbal Arsalan Zafar, Petrasek Jan
Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA.
Department of Medicine, Ziauddin Medical University, Karachi, Pakistan.
Gastroenterology Res. 2024 Feb;17(1):10-14. doi: 10.14740/gr1674. Epub 2024 Feb 28.
Alcohol use disorder (AUD) is a significant source of end-stage liver disease and liver failure and an indication for liver transplant (LT). Historically, LT for alcoholic liver disease (ALD) required 6 months of alcohol abstinence. Recently, it has been demonstrated that early LT (< 6 months of abstinence) in strictly selected group of patients provides survival benefit while keeping the relapse to harmful drinking at acceptable levels. This practice has been reflected in the Dallas consensus, but more data are needed to appropriately risk stratify the patient from the perspective of return to harmful alcohol drinking post-transplant. This "6-month rule" has been highly debated and recent data demonstrated that the duration of pre-transplant sobriety is not related with an increased risk of relapse to alcohol post-transplant. We performed a meta-analysis to compare the rate of alcohol relapse in individuals having standard vs. early LT.
MEDLINE and SCOPUS were searched for randomized controlled trials (RCTs), observational studies, and case-control studies from their inception through June 2022. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMSA) 2009 checklist guidelines were followed for this meta-analysis. Studies comparing post-transplant outcomes, such as alcohol relapse, in individuals following standard vs. early LT, were included. Reviews, case studies, conference abstracts, clinical trials with only an abstract, and studies with inadequate data for extraction were all disqualified. The data were retrieved, gathered, and examined. The random effects model was used to generate forest plots. For the analysis, a P-value of 0.05 was considered significant.
Thirty-four studies were discovered in the initial search. Three studies were included in this systematic review and meta-analysis incorporating 367 patients. Mean age was 51.7 years. Out of 367 patients, 173 (47%) underwent early LT. Out of three studies included, one study demonstrated decreased probability of alcohol relapse in patients undergoing early LT, whereas the other two showed the opposite result. All of the included studies were analyzed and had minimal risk of bias. Pooled analysis demonstrates that the difference in alcohol relapse between early vs. standard LT was insignificant (odds ratio: 1.24, 95% confidence interval: 0.75 - 2.06, P = 0.40).
Our results show that early LT is not associated with increased risk of alcohol relapse post-transplant when compared with a mandatory 6-month abstinence period. Hence, individuals with ALD should not be categorically rejected from LT merely on the criteria of 6 months of abstinence. Other selection criteria based on the need and post-transplant outcomes should be utilized.
酒精使用障碍（AUD）是终末期肝病和肝衰竭的重要原因，也是肝移植（LT）的指征。从历史上看，酒精性肝病（ALD）的肝移植需要戒酒6个月。最近有研究表明，在经过严格挑选的患者群体中，早期肝移植（戒酒时间<6个月）能带来生存获益，同时将复饮有害饮酒的情况控制在可接受水平。这一做法已在达拉斯共识中得到体现，但从移植后复饮有害酒精的角度对患者进行适当的风险分层还需要更多数据。这条“6个月规则”一直备受争议，最近的数据表明，移植前戒酒时间与移植后酒精复饮风险增加无关。我们进行了一项荟萃分析，以比较接受标准肝移植与早期肝移植个体的酒精复饮率。
检索MEDLINE和SCOPUS数据库，查找从建库至2022年6月的随机对照试验（RCT）、观察性研究和病例对照研究。本荟萃分析遵循2009年系统评价和荟萃分析的首选报告项目（PRISMA）清单指南。纳入比较接受标准肝移植与早期肝移植个体移植后结局（如酒精复饮）的研究。综述、病例研究、会议摘要、仅有摘要的临床试验以及数据提取不充分的研究均被排除。对数据进行检索、收集和审查。采用随机效应模型生成森林图。分析时，P值<0.05被认为具有统计学意义。
在初步检索中发现了34项研究。本系统评价和荟萃分析纳入了3项研究，共367例患者。平均年龄为51.7岁。在367例患者中，173例（47%）接受了早期肝移植。在纳入的3项研究中，1项研究表明接受早期肝移植的患者酒精复饮概率降低，而另外2项研究结果相反。对所有纳入研究进行分析，偏倚风险极小。汇总分析表明，早期肝移植与标准肝移植之间酒精复饮的差异无统计学意义（优势比：1.24，95%置信区间：0.75 - 2.06，P = 0.40）。
我们的结果表明，与强制戒酒6个月相比，早期肝移植与移植后酒精复饮风险增加无关。因此，不应仅以戒酒6个月为标准绝对拒绝ALD患者接受肝移植。应采用基于需求和移植后结局的其他选择标准。
