"Not a transplant candidate due to her recent alcohol use," the physician notes state.
For decades, it has been standard practice at most transplant centers in the
Now some transplant centers in
"We are focusing more on other things that we think are equally or more important in determining if patients will have a good outcome," said Dr.
The principal driver of the changes is a landmark study published in 2011 in the
Since then, several transplant centers in the
The majority of transplant centers continue to require a period of alcohol abstinence before doing liver transplants on alcoholics. But the findings have kicked off a growing movement to be more flexible.
"It's a big deal because I think the transplant community is realizing we were being too restrictive previously and there are select patients we believe will do well after a very thorough evaluation," said Dr.
The shift comes as the number of transplant patients with hepatitis C, historically the No. 1 diagnosis on the liver waitlist, declines thanks to improved treatment, making room for transplant centers to consider other candidates, Levitsky said.
Even so, the change is controversial. Organ shortages persist and thousands of people die while on the waiting list, including many whose liver disease was not caused by drinking.
Nearly 14,000 people are waiting for a liver nationally, but last year only 8,000 people got one, according to the
"Our medical team reviews the latest scientific data on medical treatments to create medical policies that determine benefit coverage,"
The thinking is that liver function might improve in some patients if they stop drinking, eliminating the need for a transplant altogether. The policies are also meant to reduce the likelihood of a drinking relapse that could ruin a new liver -- not just because of the booze itself, but also because people might become less responsible about taking necessary medications while drinking. And there is worry that potential organ donors might not sign up if they think their organs aren't being put to the best use.
But sober policies also are controversial, as some believe they stigmatize people with alcohol addiction and are based on moral judgments rather than facts. Additionally, many people who have never had a previous warning sign of liver disease may not have that long to prove their abstinence.
"You may be signing a death warrant on some patients that may have turned around and stopped drinking if they had the chance," said Dr.
Fighting rigid sober policies became
Selkirk remembers medical staff saying he wouldn't be considered for a transplant because it had been just three weeks since his last drink. He died 17 days later.
"The cure is right there, but you can't have it," said Selkirk, who lives in
Selkirk launched a constitutional challenge against
Selkirk credits the victory in part to Dr.
Fung, who in 2016 was named director of the
Just one person has been transplanted under the new policy since it was established three months ago, Pillai said. The selectivity reflects the sensitivity of trying to balance the rights of people with alcoholic liver disease with the uncertain prediction of whether they will take good care of a new liver.
"In order to be successful we will have to say 'no' to a lot of people," Pillai said. "We are always mindful that we are stewards of an organ that is in minimal supply."
Most patients with alcoholic liver disease are longtime drinkers with cirrhosis, which is scarring of the liver. Those patients often stabilize if they stop drinking, or are more easily assessed for risk of drinking relapse because transplant teams can see how they have reacted to previous health scares, Pillai said.
But patients with acute alcoholic hepatitis, a liver inflammation, are often sick for the first time, and many arrive at the hospital coughing up blood, profoundly jaundiced and suffering from kidney failure.
Just 15 percent of heavy drinkers ever develop liver disease. But if people with severe alcoholic hepatitis don't respond to medical therapy, they have a 70 percent risk of dying in six months.
Those are the patients
A multidisciplinary team including liver experts, social workers and psychologists examines patients' psychiatric history, prior adherence to care, willingness to attend alcohol rehab services and insight into the ramifications of their actions, said
Also critical is whether a patient has had a scare before, as people who have gone back to drinking once despite a life-threatening warning are more prone to doing so again. The goal is to make sure patients will take good care of their new liver and that a transplant would help them live longer, with an improved quality of life, Gray said.
While very few people meet the stringent criteria, sometimes because they're too sick to transplant, removing the blanket restriction for alcoholics acknowledges they suffer from a disease rather than a moral failing, Maddur said.
Tall and athletic, a "natural beauty" and center for the high school basketball team, Chelsea took a turn after the incident, her mom said. At 19 she was admitted to a rehab facility. She battled bulimia.
Chelsea was working as a waitress and living in
Chelsea had gone to a gastrologist but was sent home with vitamins, anti-anxiety medicine and a strong warning to stop drinking. Her family hadn't realized she'd been drinking so much, and later discovered she was mixing vodka with
In the morning light, Chelsea's ankles looked swollen. She was spitting up blood. They went to a local hospital, where they were told that Chelsea's liver and kidneys were failing.
The next several weeks were harrowing. Chelsea suffered a cardiac arrest and spent 10 days in a coma. Her mom had her transferred to
Social workers evaluated Chelsea, who told them she drank vodka daily, according to her medical records. She wanted to go to rehab and said she never wanted to drink again.
But there was no mention of putting her on a transplant list, and as weeks passed, Chelsea's pain sometimes became unbearable, her mom said.
"I was so stunned, all I could think was, 'She's young and deserves to live,'" Oesterle said. "It was a horrible feeling to feel like I was fighting to convince them."
Soon she got an infection and went into cardiac arrest. Two days later, told Chelsea's brain might be bleeding, the family made the "unthinkable" decision to remove life support, her mom said. Chelsea took "several final agonal breaths" before she was pronounced dead the night of
An autopsy found she died of septic shock, alcoholic hepatitis and respiratory failure.
"I felt sicker than I already had that night," she said. "I took that as an immediate sign that change had to be made to rid this rule."
"Even if the risk is high, she is so young, there is so much life to be had, the benefit is so high," said Brown, who has not reviewed her medical records.
The hospital has transplanted only five such patients since then, he said
"I think this approach is more human-driven and more data-driven and will likely improve outcomes," he said.
In addition to
Loyola Medicine at minimum requires six months of abstinence as well as completion of a formal alcohol rehabilitation program, plus considers other factors like social support and psychiatric conditions, said Dr.
News of the policy shifts at some hospitals has left
The former stay-at-home mom became an addiction case manager after Chelsea's death and speaks at
Chelsea had a tattoo over the top of her left foot that read "Live Loud" in Cherokee,
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