Role of liver transplantation in severe alcoholic hepatitis

Severe alcoholic hepatitis has very high short term mortality and corticosteroids have been the mainstay of treatment for decades. Patients with Lille score >0.45 are considered non-responders to steroids and have poor outcome. Recently Orthotopic Liver Transplantation (OLT) is being increasingly used as rescue treatment for these patients, without waiting for 6 months of abstinence. Liver transplant is the only rescue treatment which can potentially provide long term benefit for patients who are steroid non-responders. However, with scarcity of organs being a concern, all patients of severe alcoholic hepatitis cannot be chosen for transplantation in an arbitrary way. There is a need for development of predictive tools and objective protocols to select patients who can justify the use of precious liver grafts. With a stringent criteria for selection of patients receiving the graft, liver transplantation in severe alcoholic hepatitis can become a viable rescue therapeutic option conferring significant survival advantage of both short- and long-term basis. The optimal criteria for selection will also prevent misuse of the liver donor pool as well as to prevent mortality in salvageable patients. Further research needs to be done to identify subset of patients which are at low risk of recidivism and also cannot be managed with pharmacotherapy alone. We reviewed the current knowledge on role of OLT in patient with acute severe alcoholic hepatitis in the present review.

Transarterial chemoembolization in unresectable hepatocellular carcinoma with portal vein thrombosis: a perspective on survival.

OBJECTIVE: Portal vein thrombosis is considered a relative contraindication for transarterial chemoembolization (TACE) in hepatocellular carcinoma. The purpose of our study was to evaluate the efficacy of TACE treatment in patients with hepatocellular carcinoma with portal vein (PV) thrombosis. METHODS: From April 2011 to June 2013, 17 patients with unresectable hepatocellular carcinoma with PV thrombosis were studied. Patients were assessed for tumor response by imaging at regular intervals and the data compared with the baseline laboratory and imaging characteristics obtained before treatment. Univariate analysis was used to assess the treatments impact on patient survival. Survival analysis was performed using Kaplan-Meier estimations. RESULTS: Overall survival rates at three, six and 12 months were 82%, 71%, and 47%, respectively, with a median of 10 months. Patients in Child-Pugh class A had a median survival of 15 months compared to five months for those patients in Child-Pugh class B. The median survival period of patients responsive to treatment was 13 months while that of non-responders was five months. Patients with ascites at the time of presentation had median survival period of six months while those who did not had a median survival period of 13 months. In univariate analysis, response to chemoembolization (p<0.001), ascites (p<0.050) and Child-Pugh class at diagnosis (p<0.050) were found to be significant prognostic factors. CONCLUSION: TACE is a promising procedure in unresectable hepatocellular carcinoma with PV thrombosis. Response to chemoembolization, ascites and Child-Pugh class were the most important determining factors of survival.