Alcohol use has surpassed hepatitis for liver transplants, forcing changes for who gets priority on waiting lists.
William Remak underwent his first liver transplant in 1998 after years on a transplant list. His new liver eventually failed, so he went back on the list and had his second transplant in 2007.
Getting on the transplant list was part of the bureaucratic “hurry up and wait” battle that comes with being deemed worthy of a transplant and then hoping for a matching donor.
“It’s like the DMV. You get a number, which only grants you the right to stay in line,” Remak, who also chairs the California Hepatitis C Task Force and the International Association of Hepatitis Task Forces, told Healthline.
Does Remak believe he’d have the same opportunity at a second transplant today? “No way,” he said.
The increased demand for liver transplants for the dozens of diseases that can cause a person’s liver to fail means cases like Remak’s would be unlikely today.
While his liver disease wasn’t related to alcohol use, those who needed livers 20 or more years ago due to their alcohol consumption used to be flat-out denied as standard policy.
That’s since changed. Alcoholic liver disease is now the leading cause of liver transplants in the United States, according to a new study.
Researchers at the University of California at San Francisco (UCSF) examined all causes of liver transplants that were performed from 2002 to 2016, which included nearly 33,000 patients, using data from the United Network for Organ Sharing.
Alcohol-related liver transplants initially accounted for slightly more than 15 percent of all transplants. By 2016, that number reached nearly 31 percent.
While there are numerous theories for the increase — including shifting attitudes toward alcohol addiction and the required length of sobriety before transplant — the UCSF researchers say a national policy addressing these issues could help standardize the procedures.
The study was published this week in
Previously, hepatitis B and C were the most common reasons for liver transplants. But thanks to a combination of vaccines and effective treatments, those rates have declined.
“It’s reduced the need for liver transplants,” Remak said.
And while alcohol-related liver disease is currently at the top of the list, Remak says nonalcoholic fatty liver disease, which has been linked to high-sugar diets, will likely gain the top spot soon.
For now, because of the rise of liver transplants related to heavy alcohol use — or at least those whose liver has more difficulty processing alcohol and become diseased quicker — some people needing a new liver due to alcohol still face a stigma-laden bureaucracy that hinges on a person’s ability to remain sober before their transplant, Remak says.
In some places, that can be up to a year, even when the person’s liver won’t last that long.
“If there’s any indication they’re going to relapse, they’re not going to get on a list,” he said. “There’s an inherit bias.”
That change started in 1983, after the first National Institutes of Health Consensus Development Conference on Liver Transplantation.
That’s when professionals started toying with the idea that a period of abstinence — say six months to a year — could qualify someone to be placed on a transplant list.
Before that, people needing alcohol-related liver transplants never made the list.
“The recommendation was based in part on the belief that a significant period of abstinence might allow decompensated disease to stabilize, thereby obviating the need for transplant,” Maddrey and Mitchell wrote. “The group also expressed concern that the public might be less likely to donate organs if they perceived that most of the recipients had a self-inflicted disease.”
Some may view alcohol use disorder (AUD) and other addictions merely as poor personal restraint or weak willpower. But modern medicine views them with more data and empathy, treating them as diseases instead of moral shortcomings.
AUD is “a highly prevalent, highly comorbid, disabling disorder that often goes untreated in the United States,” the UCSF study authors summarized.
They added that their data shows an “urgent need to educate the public and policymakers about AUD and its treatment alternatives, to de-stigmatize the disorder, and to encourage those who cannot reduce their alcohol consumption on their own, despite substantial harm to themselves and others, to seek treatment.”
But that rarely happens in the United States.
The stigma of seeking treatment for people with addiction remains a hurdle that severely hurts and decreases their quality of life.
But the UCSF researchers found not everyone receiving alcohol-related liver transplants was remaining sober during their mandated abstinence periods.
This further complicates a trend that’s now increasing after 35 years of changed practices.
As Mitchell and Maddrey note, alcoholic liver disease is only one of many chronic diseases related to lifestyle and diet choices.
“Our approach to management of these and other medical problems should be based on principles of the primacy of patient welfare and of maximizing social justice,” they wrote. “Medical decisions should therefore be informed by evidence regarding outcomes.”
Right now, more than 13,000 people are waiting for a transplant liver in the United States, according to the government’s Organ Procurement and Transplantation Network.
Livers are second for most-needed organs behind kidneys, which have nearly 95,000 registered candidates awaiting transplants.
With that kind of backlog and only about 30 percent of would-be liver receivers living long enough to even get on a transplant list, Remak has some advice for millennials, an alcohol-friendly generation dying increasingly of liver-related illnesses who see more advertisements for stronger forms of alcohol.
He says young adults should make every effort to remain as healthy as possible, because a fresh organ may not be available when you need one.
“There’s a false sense of security about how available transplants are,” Remak said. “The option is slim to none.”