Therapeutic options in acute alcoholic hepatitis: Should we think about liver transplantation?

Abstract

Acute alcoholic hepatitis (AAH) is a common entity that carries a poor prognosis, especially in cases with severe disease. Its treatment is based on five cornerstones: complete alcohol abstinence, prevention of withdrawal syndrome, addressing malnutrition and deficiency states, pharmacological treatment, and liver transplantation (LT). In patients with severe AAH, defined as Maddrey index >32 or MELD>21 points, the first-line treatment is corticosteroids, which have been shown to reduce short-term mortality. However, if the patient does not respond to corticosteroids according to the Lille index calculated on the seventh day after initiation of treatment, this treatment should be discontinued and up to 70% of these patients will die. Traditionally, patients with severe AAH were contraindicated for LT because their withdrawal period was too short and therefore the risk of ethyl alcohol relapse would be very high. In 2020, the Spanish Society of Liver Transplantation (SETH) held a consensus to discuss new possible indications for LT and severe AAH without response to corticosteroids was finally accepted as one of them. The present review addresses the comprehensive treatment of AAH from a practical and multidisciplinary point of view, including those situations in which the reference transplant center should be contacted to consider the option of LT.

Keywords: acute alcoholic hepatitis, liver transplantation, corticosteroids, nutrition, abstinence.