Gish R G, Lee A H, Keeffe E B, Rome H, Concepcion W, Esquivel C O
Department of Transplantation, California Pacific Medical Center, San Francisco.
Am J Gastroenterol. 1993 Sep;88(9):1337-42.
Liver transplantation for alcoholic cirrhosis remains controversial. In particular, criteria for the selection of patients who will remain recovered from alcoholism post-transplant require better definition. We analyzed the long-term predictive value of categorizing transplant referral patients with alcoholism and end-stage liver disease into risk groups for recidivism and noncompliance. Forty-seven patients with the diagnosis of alcoholism and advanced liver disease were evaluated and placed into predefined risk groups (low-, moderate-, and high-risk) for recidivism and noncompliance. No absolute period of abstinence from alcohol was required. All patients were asked to sign a contract not to drink alcohol and comply with a rehabilitation program before and after transplantation. Compliance with alcohol rehabilitation, abstinence, functional level, employment, and survival were assessed. Patients who were not compliant with the rehabilitation program or consumed alcohol were scored as failures. Thirty-one patients were ranked as low risk, and were accepted for liver transplantation; 27 patients were transplanted. Five of 31 patients (16%) drank alcohol. One patient drank before and four patients drank transiently after transplantation. Ten patients were categorized as moderate risk, and were deferred for transplantation; two patients underwent later transplantation. All 10 patients (100%) were noncompliant or drank alcohol, including two patients who drank after transplantation after a period of abstinence and rehabilitation. Six patients were ranked as high risk, and were denied liver transplantation. Five patients (83%) drank alcohol and were noncompliant. Minimum follow-up was 12 months (mean, 24 months; range, 12-41 months). The mean Karnofsky performance score was 34 before and 84 after liver transplantation. Actuarial survival of alcoholic patients undergoing transplantation was 93%. We conclude that categorization of transplant referral patients with alcoholism and liver failure into predefined risk groups for recidivism and noncompliance accurately predicts pre- and post-transplant behavior. As defined, only low-risk alcoholic patients are good candidates for liver transplantation.
酒精性肝硬化的肝移植仍存在争议。特别是，对于选择移植后能保持戒酒状态的患者的标准，需要更明确的界定。我们分析了将患有酒精性肝病且处于终末期的移植转诊患者分为再犯和不依从风险组的长期预测价值。对47例诊断为酒精性肝病且病情严重的患者进行了评估，并将其分为再犯和不依从的预定义风险组（低风险、中风险和高风险）。不要求绝对戒酒期。所有患者均被要求签署一份戒酒合同，并在移植前后遵守康复计划。评估患者对酒精康复的依从性、戒酒情况、功能水平、就业情况和生存率。未遵守康复计划或饮酒的患者被计为失败。31例患者被列为低风险，被接受进行肝移植；27例患者接受了移植。31例患者中有5例（16%）饮酒。1例患者在移植前饮酒，4例患者在移植后短暂饮酒。10例患者被列为中风险，被推迟移植；2例患者后来接受了移植。所有10例患者（100%）均不依从或饮酒，包括2例在一段时间的戒酒和康复后在移植后饮酒的患者。6例患者被列为高风险，被拒绝进行肝移植。5例患者（83%）饮酒且不依从。最短随访时间为12个月（平均24个月；范围12 - 41个月）。移植前卡诺夫斯基功能状态评分平均为34分，移植后为84分。接受移植的酒精性患者的精算生存率为93%。我们得出结论，将患有酒精性肝病且肝衰竭的移植转诊患者分为再犯和不依从的预定义风险组，能够准确预测移植前后的行为。按照定义，只有低风险的酒精性患者是肝移植的合适候选者。
