The hope that patients with Laennec's cirrhosis could be helped by liver replacement was dashed in the early days of hepatic transplantation by the death within two months of the first eight alcoholic recipients.4,8
Alcoholics seemed too physically and emotionally frail to withstand the rigors of such a large operation and subsequent immunosuppression. Nevertheless, even before 1980 and the introduction of cyclosporine-steroid therapy, four of the next seven alcoholic patients recovered fully after liver transplantation and three are still alive after 11 to 14 years. Since 1980, the results with alcoholic patients have been as good as in adult patients with a broad spectrum of other hepatic diseases (). In fact, the results have been better than with diseases that can recur in the transplanted liver such as type B hepatitis, hepatic malignancies, and Budd-Chiari syndrome.9
Howeyer, there has been no consensus that the ability to treat patients dying of Laennec's cirrhosis implies an obligation to do SO.1,10,11
To the extent that objections to liver transplantation are moralistic, these undermine the modern understanding of alcoholism including the recognition that this is a treatable disease, not a vice.1
How liver transplantation fits into the continuum of treatment and if it can be afforded by society should be the important questions.
The fact that relapses of alcoholism have been uncommon after hepatic transplantation weakens the potential objection that provision of a new liver is a futile gesture as well as the waste of an organ. Going through a trauma of such magnitude as liver transplantation seemingiy has been the starting point almost invariably for long or permanent abstention and usually for rehabilitation. Our only relapses were in two patients who, after transplantation, appeared to resent what had been done while they were in a coma or mentally incompetent. Thus, the will of the patient to live may be the most important selection factor. Not far behind may be an explicit admission of alcoholism by the patient and his family and an expression of determination to effect behavior-al change. Most of our patients had established these qualifications before our evaluation of their candidacy. The good results after transplantation may reflect a high degree of self-screening from a much larger pool.
If these are valid criteria for candidacy screening, the imposition of an arbitrary period of abstinence before going forward with transplantation would seem medically unsound or even inhumane. By waiting unnecessarily, reasonable candidates would be allowed to deteriorate to a poor-risk category, and those at poor risk from the outset weald almost surely die during the interim.
Using expenses as an argument against liver transplantation would be equally illogical unless an even more drastic decision were taken to withhold all treatment from patients dying of Laennec's cirrhosis and perhaps other liver ailments. The cost of treating complications of terminal hepatic cirrhosis can be astronomical12
even without procedures such as portosystemic shunts and other intra-abdominal operations used to control hemorrhage from esophageal varices and especially if operations are employed. Not only is this kind of care expensive, but it Provides no hope of altering the disease and little hope of social and vocational rehabilitation.