A patient with decompensated alcohol-related liver disease asks you whether he will be considered for a transplant. He relapsed two months ago. How do you handle this conversation?

Question

A 44-year-old man with Child-Pugh C alcohol-related cirrhosis is admitted with ascites and encephalopathy. He had been abstinent for a year but relapsed after his marriage broke down. He asks you directly whether he is 'being written off'.

Accepted Answer

I would answer him honestly, because he has asked a direct question and deserves a direct response. I would tell him that transplant listing is not my decision and not one made on a ward round — it is made by a specialist multidisciplinary team at the transplant centre after a full assessment — and that my job is to make sure he gets that assessment rather than to decide on his behalf. I would explain the factors the team considers: how well his liver disease is likely to respond to transplantation, his physiological fitness, his engagement with treatment, the support around him, and his relationship with alcohol, including the period of abstinence and the circumstances of the relapse. I would be careful not to quote a fixed rule as if it were an absolute, because practice varies and I do not want to give him a number I cannot stand behind. What I would say clearly is that he has not been written off. Alcohol dependence is a relapsing condition and a relapse after a year of abstinence following his marriage breaking down is a recognised pattern, not evidence of a character flaw, and I would say that in those words because the shame around this is often what stops people engaging. Practically, I would treat the decompensation actively now — ascites, encephalopathy, nutrition, infection screening, the decompensated cirrhosis care bundle, variceal surveillance — because that is what determines whether he reaches an assessment at all. In parallel I would refer to alcohol liaison the same day, involve psychology and social work, and address the relapse precipitant directly. I would discuss him with the hepatology consultant and make the transplant centre referral if they agree it is appropriate.

Alcohol Relapse and Transplant Candidacy

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