6 Months to Live or Die: How Long Should a Patient with Alcoholic Liver Disease Wait for a Transplant?

The night before Brian Gorzney was about to go to rehab for drinking, he began to vomit blood. First at 2 a.m., then at 5 a.m. and again at 11 a.m.

When he got to the rehab facility in North Kansas City, Missouri, they sent him straight to the adjoining hospital. It was there that Gorzney, then 50, and his family learned that he was suffering from severe alcoholic hepatitis, an inflammation of the liver that is typically associated with excessive alcohol consumption.

Gorzney had been drinking every now and then for years, drinking up to a dozen drinks a day in February 2020. His only chance of survival is a liver transplant, doctors said.

“So let’s do it,” his daughter Cameron Gorzney, now 22, told them. She was ready for anything that would save her father, the man who trained her softball team through high school and who later cheered from the stands at every game.

However, Gorzney was not an option for a transplant, the doctors said. He hadn’t been sober for half a year.

A widespread practice in the United States requires that patients with alcoholic liver disease complete a period of sobriety before being placed on the liver waiting list.

This informal policy, often referred to as the “6 month rule”, can be traced back to the 1980s. It was thought then – and among proponents of the practice today – that six months of abstinence would allow a patient’s liver time to heal and avoid a transplant. If that hadn’t worked, the patient would have proven he could stay sober and wouldn’t drink again after a transplant.

However, a groundbreaking European study published in 2011 and several American studies over the past decade have uncovered flaws in this premise. Six months of abstinence is not a good indicator of long-term sobriety, and in people with conditions like Gorzney’s, more than half die within that time. Now, as understanding of addiction evolves – viewing it as a disease rather than a personal failure – many surgeons and families say the six-month ban unfairly punishes those with an addiction. And as alcoholic liver disease rises in young adults and pandemic alcohol use makes those numbers worse, it has become an urgent problem.

“We need to go beyond denying life-saving therapy to people because we think they don’t deserve it,” said Dr. Andrew Cameron, director of the liver transplant program at Johns Hopkins Medicine in Baltimore. Doctors don’t refuse treatment to people with diabetes who are obese or people with sexually transmitted infections who have had unprotected sex, he said.

Cameron and colleagues published a study in August that found that in patients with alcoholic liver disease who had to wait six months and those who did not, about 20% in each group returned to one year after their transplant Drinking returned. That means around 80% stayed sober, regardless of how long they stopped drinking before surgery.

“A six month wait wasn’t helpful or predictable at all,” said Cameron.

No national regulation stipulates how long a patient must be abstinent before being placed on the waiting list; Each transplant center has its own set of guidelines. By 2019, only about a third of liver transplant hospitals in the United States had done a transplant without one. Patients who don’t live near these hospitals – or who don’t have the knowledge and resources to reach them – may die without ever getting on the waiting list, Cameron said.

On the other hand, some doctors fear that lifting the six-month rule could overwhelm the limited supply of donor organs. With nearly 12,000 people on the waiting list to have a liver, making sure that transplant patients are ready to care for themselves and the “gift of the donated organ,” said Dr. Kenneth Andreoni, transplant surgeon and past president of the United Network for Organ Sharing, which manages the country’s transplant system. (UNOS determines who will ultimately receive a donated organ, but it does not determine who can or cannot be put on the waiting list.)

As of 2016, alcoholic liver disease has been the most commonly identified rationale for liver transplantation, and since these patients often have poor prognoses and short lifetimes, they can quickly jump to the top of the waiting list, outperforming those with liver cancer or other diseases. When a patient gets a liver, “someone else doesn’t get that organ,” said Andreoni. “It’s just math.”

He said more long-term research is needed. “If all these people [who receive transplants without the waiting period] they are fine and they live 15 years, then that is the right answer. ”Only time and statistics will tell.

Dr. Josh Levitsky, Treasurer of the American Society of Transplantation, said some hospitals may fear that organ transplantation in patients at higher risk of relapse could lead to poor outcomes and jeopardize their accreditation or insurance contracts.

In fact, some insurance companies require patients to document a period of sobriety before agreeing to pay for the operation. A study that looked at Medicaid policy in 2017 found that 24 states had such a policy while 14 did not. (Twelve states did not perform liver transplants that year.)

In Brian Gorzney’s case, insurance wasn’t the problem. Finding a hospital to say yes was about.

When the team at North Kansas City Hospital, which is not a transplant center, suggested Gorzney seek hospice opportunities, his family refused. They took him across state to the University of Kansas Healthcare System for a second opinion.

It was there that Gorzney’s daughter Cameron, his ex-wife (Cameron’s mother), his girlfriend at the time, and his sister got together to explain why they knew Gorzney would stay sober and take care of a new liver responsibly. It was said that he had a permanent job all his life. He had never had a DUI before. He coached his daughters’ softball teams and was like a father figure to his sister, 10 years his junior. He was on his way to rehab before this crisis started and he had a supportive family who helped him stay sober after the surgery.

But ultimately the hospital’s transplant committee said no.

Brian Gorzney contracted severe alcoholic hepatitis in February 2020. His liver was inflamed after years of alcohol abuse. His only chance of survival was a liver transplant. (Jennifer Evans page)

In May 2021, more than a year after his liver transplant, Brian Gorzney attended his daughter Cameron’s college graduation. (Jennifer Evans page)

In a statement on the general transplant process, Dr. Ryan Taylor, Medical Director for Liver Transplants at the hospital, that each candidate is reviewed by a committee of more than 30 members. “High-risk transplant patients may need six months of counseling to demonstrate a continued commitment to sobriety,” he wrote, but there is an “accelerated route” for people with alcoholic hepatitis who are also “low risk” for relapse.

Gorzney was considered for this avenue but the committee didn’t approve it, his daughter Cameron said.

She was devastated by the no. But she’s stubborn, she said, just like her father. So she and the rest of the family frantically scoured news articles and academic studies, calling transplant hospitals across the country to find another option.

“My father was really getting worse every day,” she said.

They eventually settled at the University of Iowa, where Cameron Gorzney had attended her freshman year of college and heard about its prestigious medical system. The family again represented Gorzney’s name. This time they got a yes. The family group text exploded, Cameron recalled.

Dr. Alan Gunderson, medical director of liver transplantation at the University of Iowa Hospitals and Clinics, said most hospitals that allow transplants without the six-month wait consider similar factors: the patient’s medical needs, financial stability, social support, understanding of their addiction and desire for recovery. However, the subjectivity of these measures means that different transplant committees can come to different decisions.

In a letter to Gorzney, the Iowa transplant team stated that they would normally recommend a six-month wait, but would approve him on the waiting list immediately or he would not survive. In return, Gorzney agreed to participate in counseling and treatment programs after the transplant.

Gorzney received a new liver within 24 hours of being placed on the waiting list.

Today, more than a year and a half later, Gorzney, 52, is still sober and taking the “opportunity to be someone I haven’t been in a long time,” he said.

He and his girlfriend are engaged, and he is grateful that his daughters Cameron and Carson are growing up into young adults. As a lifelong football fan of Illinois Fighting Illinois, he’s even considering promoting the Iowa Hawkeyes now.

But he worries that the six-month rule that led his family to travel to three hospitals in three states still hinders others.

“Unfortunately, people die … without knowing that there are other options for them because they don’t have a support group that I had that was aggressive enough and strong enough to reach out to them and wouldn’t take no for the first answer.” have.”

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