More Patients with Severe Alcoholic Hepatitis Receive Liver Transplants

Increasingly, liver transplant centers are changing a long-standing practice of delaying potentially life-saving liver transplantation for patients with severe alcoholic hepatitis until after they stopped drinking alcohol for six months, according to a new study scheduled for presentation at Digestive Disease Week® (DDW) 2018.

“Liver transplant for severe alcoholic hepatitis is being increasingly accepted, with positive outcomes, and the hope is that more and more patients will be evaluated for transplants,” said Saroja Bangaru, MD, chief resident in internal medicine at the University of Texas Southwestern Medical Center, Dallas, and co-author of the study. “The hope is that survival rates are encouraging enough for centers, so that even more of them will reverse past practices.”

Severe alcoholic hepatitis has an extremely high mortality rate. The primary treatment option has been the use of steroids, predominantly prednisolone. But, many patients do not respond to steroids, and a significant percentage of them will die within three months.

Historically, centers would not perform transplants until patients had stopped drinking for six months due to concerns about a return to drinking after transplant. Additionally, there was a perceived high risk that patient’s continued drinking would cause them to miss medical appointments and failure to take their immunosuppressant medications, which prevent organ rejection, all of which could contribute to transplant failure.

Only in recent years have limited studies begun to show greater success for transplants for severe alcoholic hepatitis, Bangaru said. These studies have also shown that a variety of other factors — aside from recent drinking — influence whether a patient relapses.

These include whether the patient has good social support, suffers from psychiatric ailments and accepts that they have an alcohol problem. “These studies suggest that predicting risk of relapse is much more complicated than just duration of abstinence,” Bangaru said.

Study Design and Results

Researchers gathered data from 45 transplant centers, of which 23 said they were now performing such transplants. Among those, 17 centers reported that patients had a one-year survival rate of more than 90%, which is higher than that reported in several previous studies.

The survey found that centers have become more willing to perform transplants, as long as patients are carefully screened. Researchers reported that centers use highly selective criteria in approving candidates for transplant, assessing their medical history, social support system and whether they have additional health problems, particularly psychiatric disorders.

“If patients are selected well, according to these criteria, it allows for the excellent survival that we are seeing post-transplant,” Bangaru said. Past policy has done a disservice to those patients who were previously unaware that they had liver disease. “Some patients come in for the first time with severe alcoholic hepatitis, and no one has ever told them to stop drinking. Because they are not eligible for transplant, they have a really high mortality rate.”

The survey also concluded that most transplant centers had “inadequate” post-transplant support for patients. While most offered the services of social workers, only a limited number provided psychiatric or group therapy support that could be very important in helping patients avoid relapse and further medical problems.

Next Steps

Dr. Bangaru said further study is needed to encourage more transplants, in particular a controlled clinical trial that follows survival rates over one, three and five years, along with an assessment of rates of alcoholic relapse.

Link Between IBD, Parkinson’s Might Allow Doctors to Slow Condition

Patients with inflammatory bowel disease (IBD) had 22% higher risk of Parkinson’s compared with non-IBD individuals, according to a new study.

And that leads to hope doctors may be able to modify or slow down the progress of the neurological condition Parkinson’s disease in the future by spotting signs of it in patients with inflammatory bowel disease (IBD), suggest the study published in the journal Gut.

IBD, Crohn’s disease and ulcerative colitis are chronic conditions with onset in young adulthood.

It has already been suggested in previous studies that inflammation plays a role in the development of Parkinson’s disease and multiple system atrophy.

Enteric inflammation – the main symptom of inflammatory bowel disease – can occur in patients with Parkinson’s disease and may reflect the earliest manifestations of the neurological condition’s development.

Experts have suspected for some time that there may be a ‘gut-brain axis’ where the intestinal environment influences the functioning of the central nervous system and intestinal imbalance may precede and cause Parkinson’s disease.

Therefore, a team of Danish researchers led by Dr Tomasz Brudek of the Research Laboratory for Stereology and Neuroscience, Bispebjerg and Frederiksberg Hospital, Copenhagen, set out to examine whether IBD was associated with risk of Parkinson’s disease and multiple system atrophy.

They carried out a nationwide population-based cohort study involving all individuals diagnosed with IBD in Denmark between 1977 and 2014 – 76,477 people – and more than 7.5 million non-IBD individuals from the general population, who were comparable in terms of gender, age and vital status.

All participants were followed from IBD diagnosis/index date to the occurrence of Parkinson’s disease and multiple system atrophy, using data from the Danish National Patient Register.

During the 37-year study period, 335 patients with IBD (0.4%) and 39,784 non-IBD individuals (0.5%) were diagnosed with Parkinson’s disease, whereas 13 patients with IBD (0.02%) and 866 non-IBD individuals (0.01%) were diagnosed with multiple system atrophy.

Analysis of the results showed that patients with IBD had a 22% higher risk of Parkinson’s disease compared with non-IBD individuals.

This increased risk was present independent of age at IBD diagnosis, gender or length of follow-up.

The overall incidence of multiple system atrophy was low in the study, but analysis suggested a tendency towards higher risk (41% higher) of developing multiple system atrophy in patients with IBD compared with non-IBD individuals. The estimates were similar for women and men.

There was a 35% greater risk of parkinsonism among patients with ulcerative colitis but not a significantly higher risk among patients with Crohn’s disease.

This was an observational study, so no firm conclusions can be drawn about cause and effect, but the authors said they believed their work was the first epidemiological study investigating the risk of parkinsonism in an unselected, nationwide cohort of patients with IBD with long-term follow-up – patients were followed for more than 8 million person-years.

The authors concluded: “The study suggests that clinicians should be aware of symptoms of parkinsonism in patients with IBD, and the study demonstrates the need for further investigation into the role of intestinal inflammation and brain gut-microbiome axis in the aetiology of parkinsonism.

“The identification of risk factors associated with prodromal phases of Parkinson’s disease may allow for early intervention studies that could modify or slow down disease progress.”