Clinicians at Penn Gastroenterology and Hepatology and the Penn Liver Transplant program have initiated a pilot clinic known as I-LEARN to provide comprehensive care for liver transplant candidates and recipients with alcohol-associated liver disease who have less than six months' alcohol abstinence prior to transplant, and for those who have faced challenges with maintaining alcohol abstinence after liver transplantation.
The principals for The Integrated Liver Transplant EnhAnced Recovery Network (I-LEARN) are gastroenterologists Marina Serper, MD, MS, and Therese Bittermann, MD, MSCE, both of whom are board certified in transplant hepatology. Drs. Serper and Bittermann are joined at the clinic by hepatologists Jonathan Nahas, MD, and Ethan Weinberg, MD, and psychiatrists Robert Weinrieb, MD, Arpita Goswami Banerjee, MD, and Bellinda Accime, CRNP.
An Acute Need to Maximize Benefit of Early Transplantation
Alcohol misuse is the leading cause of preventable death and liver disease in the United States, and a leading indication for liver transplantation. For many years, limited data on the association between the pre-transplant duration of alcohol avoidance and the presumed success of subsequent liver transplantation was a major factor in determining patients' eligibility for transplant in the setting of alcohol-associated liver disease—so much so that many transplant centers (and health insurance providers) in the US required six months of abstinence prior to listing for liver transplantation.
This "six-month rule" had its origin in an NIH consensus statement in the 1980s, but had limited, if any, scientific basis. Many have argued that this recommendation was arbitrary and also harmful, since many patients with severe alcohol-associated liver disease have a high risk of mortality and could thus never achieve 6 months' alcohol abstinence prior to life-saving transplantation.
In the years since the imposition of the six-month rule, studies have demonstrated that liver transplant outcomes can be highly successful, even with less than 6 months abstinence. A substantial proportion of individuals who have received a liver transplant with short pre-transplant abstinence can achieve complete alcohol sobriety. Moreover, the majority of those who experience an alcohol relapse can overcome these challenges if they receive the right care and support, such as that now being offered through the I-LEARN pilot clinic at Penn Medicine.
I-LEARN at the Nexus of Research and Treatment
"The purpose of I-LEARN is to provide a multidisciplinary clinic that combines the skills and talents of experts in the treatment of liver diseases with those of experts in the field of alcohol use disorder to help patients avoid alcohol as they approach transplantation and thereafter," Dr. Serper said recently. A part of the motivation for I-LEARN, she adds, is the knowledge that patients transplanted for alcohol-related liver disease have similar short-term survival outcomes compared to those transplanted for other causes. Helping patients deal with alcohol use disorder during the months immediately before and after transplantation will improve long-term survival.
Another rationale for the program, Dr. Bittermann adds, are reports in which transplantation has been been shown to be a lifesaving intervention when achieved before the conclusion of six months of alcohol avoidance. Although additional research is needed to evaluate long-term outcomes and optimize candidate selection, Dr. Bittermann says, early liver transplantation without a required 6-month period of abstinence provides a significant survival benefit with acceptable outcomes in the first several years following transplant. In addition, for patients with acute onset of alcohol-associated liver injury at risk for rapid decompensation and mortality, early transplantation may be the only lifesaving option available.
Dr. Bittermann considered early transplantation in a 2022 report in Current Opinions in Organ Transplant, noting therein that 71 percent of US transplant centers no longer required 6 months of alcohol abstinence for alcohol-associated hepatitis patients prior to liver transplantation, and that while alcohol relapse remains a significant issue in the affected population, studies reporting on alcohol relapse in early liver transplantation suggest that about one in five individuals on average relapse to any degree within the first year of transplantation.
Other elements, including psychosocial interventions and behavioral treatments in combination with medical care have been shown to be efficacious in inducing and maintaining alcohol abstinence in patients with chronic liver disease, as well. Researchers have delved into the roles of inadequate social support and family history of alcohol use disorder to better evaluate candidates for transplant, assess the likelihood of relapse and determine follow-up guidelines.
"I-LEARN incorporates hepatology and psychiatry because research shows that trust in the medical aspect of treatment helps build trust in the psychiatric portion, and that putting the two together may result in better outcomes," Dr. Serper says. "We know, too, that community gastroenterologists find substance use treatment challenging."
Drs. Bittermann and Serper agree that the twin missions of I-LEARN are essential for both clinicians and individuals approaching liver transplantation.
"Hepatologists whose patients need additional help to obtain or maintain abstinence as they approach transplant will find I-LEARN particularly beneficial," Dr. Bitterman says. "And while we want patients who are motivated and engaged, we recognize that individuals can be motivated and still have difficulty getting appropriate care."
"This offers us the opportunity to treat both the liver disease and the mental health portion of the disease as they're awaiting transplant, and to gain some perspective," Dr. Serper observes. "We're especially interested in people on the wait list who are either high-risk or who have relapsed, or people post-transplant and working with people referred to the Total Recovery Program.
For further information about I-LEARN, please call 215-349-8222.