During one of his first rotations as a medical student, John Messinger had a patient in his 40s with alcohol-related hepatitis. Because the patient had been treated for alcohol use disorder and relapsed, he was ineligible for a liver transplant. Messinger watched the patient deteriorate, knowing more could have been done to save his life.
Current guidelines determining who can get a transplant are tied to longstanding ethical debates driven by the scarcity of donor livers — as of January, more than 10,000 patients were on the wait list. But alcohol-related liver disease has recently become the lead indication for a transplant, and studies show it’s only gotten deadlier since the pandemic, especially for young adults. In light of this, some in the field are re-evaluating eligibility requirements that penalize patients who struggle with addiction, especially those who are Black or low-income.
Messinger, a student at Harvard Medical School, spoke with the Gazette about his recent paper on improving equity in liver transplants and where he sees opportunities for change. This interview has been edited for length and clarity.
GAZETTE: Alcohol-related liver disease is the leading indication for liver transplant in the U.S. How does that compare to other indicators?
MESSINGER: This trend only recently changed. Around the mid-2010s, the leading indication for liver transplant was hepatitis C, which is a virus that often results in chronic infection that, over time, leads to liver failure. For a long time, there was no reliable way to prevent that. Around 2010, there was a new medication that came out for hepatitis C that effectively cured patients. This led to a whole population of people who were being transplanted to dwindle.
But during that time, we’ve also seen rapidly rising rates of severe alcohol use that can lead to liver failure. In 2020, over 30 percent of patients listed for transplants had alcohol-related liver disease, more than any other single diagnosis. There are also other types of liver disease that are on the rise, like nonalcoholic fatty liver disease, which is related to obesity, diabetes, and/or metabolic syndrome. Those indicators might overtake alcohol-related liver disease in the future.
GAZETTE: Because of the demographic of people who need liver transplants, there’s been an ongoing ethical debate regarding who should be eligible for a transplant. Could you talk more about that?
MESSINGER: The challenge for transplant providers is that they want to make sure that they’re being good stewards of a scarce resource. That starts to get into questions like, who’s deserving? But at the root of that is providers wanting to choose who they think has the best chance of success. They don’t want somebody receiving a liver to have a high risk of getting worse, whether it be through continued alcohol use or relapse that can lead to recurrent liver failure.
There is a lot of stigma surrounding alcohol use and addiction in general, and that means that people assume that people with alcohol-related liver disease don’t have much hope of success following transplant, that they will relapse and fail. That was the old way of thinking, which has continued to evolve. We can do better to treat alcohol-related liver disease. It would open the door for more patients to be considered “deserving,” good candidates for liver transplants.
GAZETTE: Does research show that patients who struggle with alcohol use are more likely to see negative outcomes?
MESSINGER: In the very earliest data around alcohol-related liver disease, it did show worse outcomes for those patients. But at the time, there weren’t great treatments for alcohol use disorder. So there are presumptions made now about the outcomes for these patients based on a set of circumstances that have since changed. More recently, the data show patients with alcohol-related liver disease have outcomes that are comparable, if not better, than other types of liver disease, even for certain populations who traditionally weren’t even considered for transplant.
GAZETTE: In what ways does the current system fail patients?
MESSINGER: An important distinction in alcohol-related liver diseases is that there are two types: alcohol-related cirrhosis (a gradual scarring and fibrosis that occurs over time) and alcohol-related hepatitis (very acute inflammation). With hepatitis, it can lead to acute liver failure and high rates of mortality within six months of diagnosis. In the current system, there have been mandatory abstinence periods, which means patients may have to prove six months of abstinence before even being considered. For those patients, they don’t even make it on the list and are dying at very high rates.