Expedited liver transplantation as first-line therapy for severe alcohol hepatitis: ELFSAH; deferring corticosteroids in the sickest subset of patients

IF 1.9 4区 医学 Q2 SURGERY
Nabeeha Mohy-ud-din, Fei-Pi Lin, Vikrant Rachakonda, Ali Al-Khafaji, Scott W. Biggins, Swaytha Ganesh, Ramon Bataller, Andrea DiMartini, Christopher Hughes, Abhinav Humar, Shahid M. Malik
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Abstract

Background & aims

Severe alcohol-associated hepatitis (SAH) represents a lethal subset of alcohol-associated liver disease. Although corticosteroids are recommended by guidelines, their efficacy and safety remain questionable and so liver transplantation (LT) has been increasingly utilized. The timing and indication of corticosteroid use, specifically in patients being considered for LT requires further clarification.

Methods

A retrospective analysis was conducted on 256 patients with SAH between 2018 and 2022 at a single US center.

Results

Twenty of these patients underwent LT. Of the 256 patients, 38% had what we termed “catastrophic” SAH, defined as a MELD-Na ≥35 and/or discriminant function (DF) ≥100, which carried a mortality of 90% without LT. Compared with 100 matched controls, patients undergoing LT exhibited a one-year survival rate of 100% versus 35% (p < .0005). LT provided an absolute risk reduction of 65%, with a number needed to treat of 1.5. Steroid utilization in the entire cohort was 19% with 60% developing severe complications. Patients administered steroids were younger with lower MELD and DF scores. Only 10% of those prescribed steroids derived a favorable response. Sustained alcohol use post-LT was 20%.

Conclusions

We propose ELFSAH: Expedited LT as First Line Therapy for SAH; challenging the current paradigm with recommendations to defer steroids in patients with “catastrophic” SAH (defined as: MELD-Na ≥35 and/or DF ≥100). Patients should be seen urgently by hepatology, transplant surgery, psychiatry and social work. Patients without an absolute contraindication should be referred for LT as first-line therapy during their index admission.

Abstract Image

将快速肝移植作为治疗重症酒精性肝炎的一线疗法:ELFSAH;推迟对病情最严重的部分患者使用皮质类固醇。
背景与目的:重症酒精相关性肝炎(SAH)是酒精相关性肝病中的一种致命疾病。尽管指南推荐使用皮质类固醇,但其疗效和安全性仍值得怀疑,因此肝移植(LT)的使用率越来越高。使用皮质类固醇的时机和适应症,尤其是考虑接受肝移植的患者,需要进一步明确:对美国一家中心2018年至2022年间的256例SAH患者进行了回顾性分析:其中20名患者接受了LT治疗。在这256名患者中,38%患有我们称之为 "灾难性 "的SAH,其定义为MELD-Na≥35和/或判别函数(DF)≥100,不接受LT治疗的死亡率为90%。与 100 名匹配的对照组相比,接受 LT 治疗的患者一年生存率为 100%,而接受 LT 治疗的患者一年生存率为 35%(P,结论):我们提出了 "ELFSAH:将LT作为SAH一线治疗的快速疗法";建议 "灾难性 "SAH患者(定义为:MELD-Na≥35和/或DF≥100)推迟接受类固醇治疗,这是对当前治疗模式的挑战。肝脏内科、移植外科、精神科和社会工作科应紧急接诊患者。无绝对禁忌症的患者应在入院时转诊接受LT作为一线治疗。
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来源期刊
Clinical Transplantation
Clinical Transplantation 医学-外科
CiteScore
3.70
自引率
4.80%
发文量
286
审稿时长
2 months
期刊介绍: Clinical Transplantation: The Journal of Clinical and Translational Research aims to serve as a channel of rapid communication for all those involved in the care of patients who require, or have had, organ or tissue transplants, including: kidney, intestine, liver, pancreas, islets, heart, heart valves, lung, bone marrow, cornea, skin, bone, and cartilage, viable or stored. Published monthly, Clinical Transplantation’s scope is focused on the complete spectrum of present transplant therapies, as well as also those that are experimental or may become possible in future. Topics include: Immunology and immunosuppression; Patient preparation; Social, ethical, and psychological issues; Complications, short- and long-term results; Artificial organs; Donation and preservation of organ and tissue; Translational studies; Advances in tissue typing; Updates on transplant pathology;. Clinical and translational studies are particularly welcome, as well as focused reviews. Full-length papers and short communications are invited. Clinical reviews are encouraged, as well as seminal papers in basic science which might lead to immediate clinical application. Prominence is regularly given to the results of cooperative surveys conducted by the organ and tissue transplant registries. Clinical Transplantation: The Journal of Clinical and Translational Research is essential reading for clinicians and researchers in the diverse field of transplantation: surgeons; clinical immunologists; cryobiologists; hematologists; gastroenterologists; hepatologists; pulmonologists; nephrologists; cardiologists; and endocrinologists. It will also be of interest to sociologists, psychologists, research workers, and to all health professionals whose combined efforts will improve the prognosis of transplant recipients.
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