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The relationship between levels of coagulation Factors V and VIII and disease severity was evaluated in 33 patients with alcoholic liver disease, and related to outcome in the 23 with severe acute alcoholic hepatitis. Factor V levels in acute alcoholic hepatitis were significantly lower than in inactive alcoholic liver disease (median 28% vs 74%), and both results were lower than values in 10 control subjects (median 101%; P less than 0.001 and P less than 0.002, respectively). Plasma Factor VIII concentrations were not significantly higher in alcoholic hepatitis than in inactive alcoholic liver disease, although both results significantly exceeded control values (median 163% and 151% vs 104%; P less than 0.005 and P less than 0.05, respectively). In the 18 in-patients with alcoholic hepatitis who survived, admission factor V (median 32%) was higher, and admission serum bilirubin (65 mumol/l) and discriminant function score (derived from prothrombin time and bilirubin: median 31) were lower than in the four who died and one who received a liver transplant (median 16%, 527 mumol/l and 113; P less than 0.005, P less than 0.005, P less than 0.05, respectively). An admission Factor V level less than 15% correctly predicted outcome in a greater number (87%) of cases than admission discriminant function greater than 100 (83%), bilirubin greater than 300 mumol/l (83%) or prothrombin ratio greater than 1.5 (78%). This predictive accuracy increased to 100% for minimum Factor V less than 15% and was again superior to maximum discriminant function greater than 100 or greater than 300 mumol/l (both 83%) or maximum prothrombin ratio greater than 1.5 (78%).(ABSTRACT TRUNCATED AT 250 WORDS)

Objective: To evaluate the outcome of liver transplantation in patients with alcoholic cirrhosis with respect to selection criteria, survival, and evidence suggesting a return to harmful drinking., Design: Nine year retrospective study., Setting: Cambridge and King's College Hospital liver transplant programme., Subjects: 24 Patients (three women, 21 men) with alcoholic cirrhosis., Main Outcome Measures: Survival, rehabilitation, and clinical and laboratory evidence of a return to harmful drinking after transplantation., Results: 15 Patients were selected for transplantation because of repeated admission to hospital for the complications of advanced portal hypertension despite abstinence, and six because they had a hepatocellular carcinoma superimposed on alcoholic cirrhosis. Three patients who were not abstinent received transplants. The one year survival rate was 66%, and of the 18 patients surviving at least three months, 17 had been rehabilitated. In three patients laboratory variables and histological examination of the liver suggested a return to drinking, though they did not admit to taking alcohol. These patients represented the only cases in the series that were not abstinent before transplantation., Conclusions: The survival and rehabilitation of patients who received transplants for alcoholic cirrhosis compared favourably with those of patients who received transplants for cirrhosis of other aetiology. The criteria for selection for liver transplantation in patients with alcoholic cirrhosis should include recurrent complications related to severe portal hypertension despite maximum medical treatment in addition to a minimum period of six months of abstinence before transplantation.

The poor prognosis of severe acute alcoholic hepatitis has stimulated interest in specific forms of treatment aimed at reducing the short term mortality as well as preventing progression to cirrhosis. Several controlled trials of steroid therapy have suggested an improvement in short-term survival, but the benefit seems to apply to highly selected cases only. Treatment with propylthiouracil and insulin and glucagon infusions has also shown promising results in controlled studies but there is still no general agreement on their value. Despite recent interest in the use of colchicine to prevent progression of cirrhosis in chronic liver disease of other aetiologies, its role in alcoholic liver disease is not yet clear. In end-stage alcoholic cirrhosis, excellent results are now being achieved with liver transplantation, although this is limited to patients who are not alcohol dependent and in whom there is no alcohol-induced extrahepatic disease.

To investigate whether disordered immune function, as shown by abnormalities in lymphokine production, is present in alcoholic liver disease, interleukin-1 and interleukin-2 activity were assayed in a group of patients with acute alcoholic hepatitis in the absence of underlying cirrhosis, and a group of patients with inactive alcoholic cirrhosis. Activities of both IL-1 and IL-2 in alcoholic hepatitis were similar to those of normal individuals, although in abstinent patients with alcoholic cirrhosis, IL-1 activity was increased and IL-2 activity decreased. Lymphocyte transformation in response to PHA in patients with alcoholic hepatitis was significantly impaired when compared with normal controls, and addition of exogenous IL-2 did not correct this impaired response over a wide range of concentrations of both PHA and IL-2. These observations suggest the underlying defects in cell mediated immunity in acute alcoholic hepatitis, as assessed by blast transformation, could be fundamentally different from those of alcoholic cirrhosis and could be secondary to the metabolic effects of acetaldehyde or altered redox potentials on the behaviour of proliferating cells.