Liver Transplants: ‘Collateral Damage’ of Pandemic Drinking

The number of alcoholic hepatitis patients getting liver transplant more than tripled during the COVID-19 pandemic, a retrospective study found.

A difference-in-difference analysis from June 2020 to February 2021 found that liver transplants for acute alcohol-associated hepatitis more than tripled (268.5% increase) compared with expected trends, while the rate of patients with acute alcohol-associated hepatitis added to the transplant waiting list more than quadrupled (325% increase), reported Therese Bittermann, MD, of the University of Pennsylvania in Philadelphia, and colleagues.

This translated to a monthly increase of 13.11 liver transplants for acute alcohol-associated hepatitis and 18.00 more additions to the waiting list per month, Bittermann’s group wrote in JAMA Network Open.

Recent reports have demonstrated an increase in alcohol-related gastrointestinal in-patient consultations and endoscopies, with a surge in cases of alcoholic hepatitis.

“This is definitely an alarming situation, which is supported by the evidence of increased alcohol consumption reported during the COVID-19 pandemic in the U.S.,” Khalid Mumtaz, MBBS, MSc, from the Ohio State University Wexner Medical Center in Columbus, told MedPage Today.

Increased alcohol consumption is the “collateral damage of COVID-19 due to insecurity, isolation, depression and disquiet brought by the pandemic,” added Mumtaz, who was not involved in the study.

Symptomatic alcoholic hepatitis leads to a 30% mortality risk after 1 year of diagnosis. There currently remains no pharmaceutical or nutritional treatment option approved by the FDA for patients with alcoholic hepatitis, therefore their only lifesaving option remains liver transplantation, Bittermann and colleagues said.

From March 2018 to February 2021, they examined data on 38,217 adults from the United Network for Organ Sharing database who were on the national waiting list for a liver transplant. Researchers compared rates of new liver transplant listings and liver transplants received by patients pre-pandemic (March 2018 to February 2020) versus during the pandemic (March 2020 to February 2021).

Overall, they identified 606 adults with acute alcoholic hepatitis. Patients were predominantly white (79%) and men (66%). During March 2020 to February 2021, the liver transplant waiting list had a mean rate of 2.3% new patients with alcoholic hepatitis and the rate of receiving liver transplantation among those patients was 4.4%.

Compared with March 2018 to February 2020, there was a mean 106.6% increase for adding patients to the waiting list and a 210.2% increase in liver transplant receipt, the authors said. In February 2021, researchers reported a 105.6% relative increase in patient additions to the waiting list and a 411.8% increase in patients receiving a liver.

No differences were found for alcoholic hepatitis patients who were on the liver transplant waiting list before or during the pandemic, as similar results were reported for sex, age, insurance type, and race.

“These recent recipients of liver transplants will require intensive longitudinal multidisciplinary care to reduce their risk of alcohol relapse and ensure successful outcomes,” Bittermann and colleagues stated.

They also cited other reasons for the increase in need for liver transplants, such as the February 2020 liver transplant allocation system revisions or additional lifestyle changes associated with the pandemic.

Mumtaz explained that at Ohio State University they saw a peak in COVID-19 cases and hospitalizations due to alcohol-related liver disease in mid-2020, followed by a decline in COVID-19 cases in 2021, but hospitalizations for alcohol liver disease still persisted.

“It is evident that alcohol-related hospitalization and COVID-19 has exponentially increased healthcare utilization, morbidity and mortality in the U.S.,” Mumtaz said, urging the need for a solution on the national level.

Limitations cited by the authors included underestimating the number of acute alcoholic hepatitis patients on the national liver transplant waiting list or those who received liver transplants. Sample size constraints also led to the inability to evaluate geographic differences in patients, they added.