Why can’t my patient with alcohol-related liver disease be placed on the liver transplant list for at least 6 months after his last drink?

Although many centers impose a 6-month sobriety rule before patients can be listed for liver transplant, this rule has been increasingly challenged based on the results of more recent studies and ethical issues. 1-10

The argument for enforcing a 6-month sobriety rule is in part based on earlier studies (often small and/or single center) that reported an association between less than 6 months of sobriety before liver transplantation and relapse.5-6 Another frequently cited reason for postponing liver transplantation is to allow the liver enough time to recover from adverse effect of recent alcohol consumption before assessing the need for transplantation.6

Arguments against the 6-month sobriety rule include the very limited life-expectancy (often 3 months or less) of patients with severe alcohol-related liver disease who do not respond to medical therapy and increasing number of studies supporting earlier transplantation particularly in selected patients (eg, severe acute alcoholic hepatitis [SAAH], acute-on-chronic liver failure [ACLF]).1,7,9,10,

Further supporting a less stringent transplantation rule are a low rate (about 4%) of death or graft loss in alcohol-related liver disease patients who experience a relapse and lack of significant differences in survival between non-relapsers, occasional drinkers and problem drinkers.1 A 2019 multicenter, prospective study in the U.S. also found that early liver transplant for alcohol-related  liver disease was associated with comparable patient and graft survival as those without alcohol-related liver disease at 5 years post-transplant but increased risk of death at 10 years. 10

Bonus Pearl: Did you know that alcohol-related liver disease is now the most common diagnosis among patients undergoing liver transplantation in the U.S.? 10

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  1. Obed A, Stern S, Jarrad A, et al. Six month abstinence rule for liver transplantation in severe alcoholic liver disease patients. W J Gastroenterol 2015; 21:4423-26. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4394109/
  2. Bramstedt KA, Jabbour N. When alcohol abstinence criteria create ethical dilemmas for the liver transplant team. J Med Ethics 2006;32:263-65. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2579412/
  3. Kollmann D, Rashoul-Rockenschaub S, Steiner I, et al. Good outcome after liver transplantation for ALD without a 6 months abstinence rule prior to transplantation including post-tranplantation CDT monitoring for alcohol relapse assement— a retrospective study. Transplant International 2016;29:559-67. https://onlinelibrary.wiley.com/doi/epdf/10.1111/tri.12756
  4. Osorio RW, Ascher NL, Avery M, et al. Predicting recidivism after orthoptic liver transplantation for alcoholic liver disease. Hepatoloty 1994;20:105-110. https://aasldpubs.onlinelibrary.wiley.com/doi/epdf/10.1002/hep.1840200117
  5. Carbonneau M, Jensen LA, Bain VG. Alcohol use while on the liver transplant waiting list: a single-center experience. Liver Transplantation 2010;16:91-97. https://aasldpubs.onlinelibrary.wiley.com/doi/full/10.1002/lt.21957
  6. Harnanan A. Challenging the “six-month sober” rule for liver transplants in Canada. McGill Journal of Law and Health. Dec 12, 2019. https://mjlh.mcgill.ca/2019/12/12/challenging-the-six-month-sober-rule-for-liver-transplants-in-canada/
  7. Lee BP, Mehta N, Platt L, et al. Outcomes of early liver transplantation for patients with severe alcoholic hepatitis. Gastroenterology 2018;155:422-430.e1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6460480/
  8. Rice JP, Lee BP. Early liver transplantation for alcohol-associated liver disease: need for engagement and education of all stakeholders. Hepatol Communications 2019;3: 1019-21. https://aasldpubs.onlinelibrary.wiley.com/doi/pdf/10.1002/hep4.1385
  9. Lee BP, Vittinghoff E, Pletcher MJ, et al. Medicaid policy and liver transplant for alcohol-related liver disease. Hepatology; November 8, 2019 https://aasldpubs.onlinelibrary.wiley.com/doi/pdf/10.1002/hep.31027
  10. Lee BP, Vittinghoff E, Dodge JL, et al. National trends and long-term outcomes of liver transplant for alcohol-associated liver disease in the United States. JAMA Intern Med 2019;179:340-48. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2720757?widget=personalizedcontent&previousarticle=2720750

Contributed in part by Nneka Ufere, MD, GI Division, Massachusetts General Hospital, Boston, MA

Why can’t my patient with alcohol-related liver disease be placed on the liver transplant list for at least 6 months after his last drink?

My patient with cirrhosis has a large right sided pleural effusion with only a small amount of ascites. Could this effusion still be related to his cirrhosis?

Yes! Although we often associate pleural effusions in patients with cirrhosis with the presence of large ascites, some patients present with hepatic hydrothorax even in the absence of significant ascites.1-3  

In fact, in a study involving 77 patients with hepatic hydrothorax, 49% had minimal or small and 9% had no detectable ascites!1  Interestingly, nearly three-quarters of patients in this study had right sided pleural effusion with 10% having bilateral and 17% having left sided effusion only. Hepatic hydrothorax without ascites as the first sign of liver cirrhosis has also been reported.2

Although the mechanism(s) behind hepatic hydrothorax is not fully clear, the passage of peritoneal fluid into the pleural cavity through defects in the tendinous portion of the diaphragm assisted by negative intrathoracic pressure during inspiration is commonly favored. 1-3  

Supportive evidence includes a number of studies involving intraperitoneal injection of air, dyes or technetium 99 m-sulfur colloid that have demonstrated the trans-diaphragmatic flow of ascites into the pleural cavity. 1-4  In the absence of ascites, a complete equilibrium between the amount of ascites produced and its flow into and reabsorption by the pleural cavity is assumed.1,2

Bonus Pearl: Did you know that although most patients with hepatic hydrothorax have a transudative pleural effusion according to Light’s criteria, 1 study showed that 18% of patients may meet the Light’s criteria for an exudative effusion? 5,6


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  1. Badillo R, Rockey DC. Hepatic hydrothorax: Clinical features, management, and outcomes in 77 patients and review of the literature. Medicine 2014;93:135-142. https://www.ncbi.nlm.nih.gov/pubmed/24797168
  2. Kim JS, Kim CW, Nam HS, et al. Hepatic hydrothorax without ascites as the first sign of liver cirrhosis. Respirology Case Reports 2016;4:16-18. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4722098/
  3. Rubinstein D, McInnes IE, Dudley FJ. Hepatic hydrothorax in the absence of clinical ascites: diagnosis and management. Gastroenterology 1985;88:188-91. https://www.ncbi.nlm.nih.gov/pubmed/3964765
  4. Holt KA, Oliviera E, Rohatgi PK. Hepatic hydrothorax demonstration by Tc-99 sulfur colloid ascites scan. Clin Nucl Med 1999;24:609. https://www.ncbi.nlm.nih.gov/pubmed/10439187 
  5. Light RW. New treatment for hepatic hydrothorax? Ann Am Thorac Soc 2016;13:773-74. https://www.atsjournals.org/doi/full/10.1513/AnnalsATS.201603-223ED
  6. Bielsa S, Porcel JM, Castellote J, et al. Solving the Light’s criteria misclassification rate of cardiac and hepatic transudates. Respirology 2012;17”721-726. https://www.ncbi.nlm.nih.gov/pubmed/22372660
My patient with cirrhosis has a large right sided pleural effusion with only a small amount of ascites. Could this effusion still be related to his cirrhosis?