Transplant surgeon Andrew Cameron says Johns Hopkins is poised to change the way America looks at treating alcoholic hepatitis.
For decades, transplant centers in the United States have followed a guideline that requires patients to abstain from drinking alcohol for six months to be eligible for a liver transplant. With cadaveric donor livers in high demand, most transplant centers will not consider patients whose liver damage stems from recent alcohol use, a policy that, according to Cameron, amounts to a death sentence.
Now, in papers published in the Journal of Hepatology and the Journal of Intensive Care Medicine, Johns Hopkins researchers outline the case for giving liver transplants to selected patients with alcoholic hepatitis. Not only is their argument backed by data from a six-year pilot study at Johns Hopkins, but they have also received an $8.4 million grant from the National Institutes of Health to expand the study to even more patients with the deadly condition.
“This is an opportunity for us to rewrite the rules using scientific rigor and data that we’re generating. I think that’s a chance to set the record straight on how modern medicine can be done in a truly fair and transparent way,” says Cameron, a professor of surgery and chief of the school of medicine’s Division of Transplantation.
Alcoholic hepatitis is a dangerous inflammation of the liver. Unlike more common forms of hepatitis, it is acquired by drinking alcohol, rather than by exposure to a virus. Not all heavy drinkers get it, nor does it always stem from especially heavy drinking.
Johns Hopkins is one of the few centers in the United States that will consider liver transplants for patients with alcoholic hepatitis whose sobriety doesn’t reach the six-month threshold, though it’s a fairly common practice in Europe, Cameron notes.
He says the U.S. policy is based on stigma rather than science, citing the widely held medical opinion that alcoholism is a disease and that people who suffer from it need treatment. “It’s not a ‘Johns Hopkins thing’ to deprive people of an intervention just because it’s your notion that they don’t deserve it,” he says. “That’s not how we do things here.”
Last year, the Johns Hopkins team reported on the outcomes of the first 46 patients who underwent liver transplantation under its pilot program. Patients who received livers between October 2012 and July 2017 were followed for an average of 532 days after transplant. During the follow-up period, the alcohol relapse rate among patients who did not have a wait period was identical to that seen in a group of 34 patients who received transplants under the standard six months of sobriety rule. In both cases, 28 percent relapsed at one point, but 98 percent of all patients were sober at the end of the study period.
Cameron says Johns Hopkins’ overall one-year post-liver transplant survival rate is 93 percent, adding that patients with alcoholic hepatitis generally fare at least as well as other liver transplant patients.
Transplant centers around the world employ a scoring system to determine the extent of liver disease, no matter the source. The Model for End-Stage Liver Disease (MELD) scale ranges from 6 to 40. Cameron says his patients with alcoholic hepatitis average a MELD score of 36. “That usually means they have only a few days of life left,” he explains. “Without a transplant, they’ll die very soon.”
While the six-month guideline isn’t a requirement to get a liver transplant at Johns Hopkins, patients need to possess insight into their alcoholism to qualify for transplantation. “This surgery is for people for whom there is evidence of an ability to turn their life around,” Cameron says.
Cameron and his team will use part of the grant to explore solutions to help transplant patients avoid a recurrence of the condition.