The six-month sobriety rule is just one of many conditions that patients needing liver transplants must meet to be considered for a transplant, according to guidelines set by Trillium Gift of Life Network, the agency that co-ordinates organ donations in Ontario.
The issue has surfaced since Delilah Saunders, 26, an Inuk activist from Happy Valley Goose Bay, N.L., was admitted to a hospital in Ottawa on Dec. 8 and diagnosed with acute liver failure. But because she had been sober for only three months, her friends and family say, doctors told her she was ineligible for the waiting list.
In 2016, 2,906 transplants including 579 liver transplants were performed in Canada, according to the Canadian Institute for Health Information's organ replacement register. Yet at the end of 2016, there were 4,469 people, including 433 with chronic and acute liver diseases, on Canada's transplant waiting lists. That same year 256 patients, including 90 with liver diseases, died while waiting for a transplant.
Dr. Les Lilly, a transplant hepatologist at Toronto General Hospital since 1995, said all patients must undergo an exhaustive set of medical evaluations when they're referred by a specialist to the transplant programs in Ontario.
This investigation allows the transplant team to understand as much as possible about the patient's liver disease including:
- Whether there are any medical conditions, such as cancers and infections, that may stand in the way of a successful transplant.
- Whether there are any ongoing substance abuse issues.
- Whether the patient has the network of support post-surgery that's required for a successful transplant.
"And only once all those questions have been answered successfully are the patients placed on the waiting list," Lilly said.
At the transplant program in Toronto, more than half of the assessed patients end up being accepted for transplant, Lilly said. Those considered not appropriate for transplant are sent back to their doctors with recommendations and requests they be referred again to the centre once they reach certain points in their liver disease, he added.
The transplant centre in Toronto is one of seven programs across Canada and the largest one in North America, performing about 200 adult liver transplants.
Liver cancer — not including cancers that arise elsewhere in the body and metastasized to the liver — makes up nearly half of all transplants at the transplant centre in Toronto.
Trillium outlines in a document that patients aren't eligible for liver transplants if they have one of its "listing criteria," including any alcohol and/or illicit drug misuse within six months.
Lilly said the main reason behind the six-month rule — which is adhered to by over 80 per cent of transplant centres in North America and every transplant centre in Canada — is that many patients who abstain from alcohol will see such an improvement in their liver function that a transplant is no longer required.
"The major reason for promoting abstinence from a transplant perspective is to allow the patient to improve to the point where they don't even need one," he said.
In Saunders' case, she appears to be doing better, and her family is hopeful she may not need a transplant.
However, the big debate is the six-month number. Lilly said there are patients who have been abstinent for far longer than six months who relapse, and he knows of many who have been abstinent for less than six months who will never drink again.
Temporary waiver next August
"So the six-month rule is not fair, because it's putting one rule in place for this whole wide spectrum of patients," Lilly said. "It turns a very grey area and makes it sound like it's black and white, and it's not."
But it's part of Trillium's written policy, "so we're kind of stuck with it at least for the moment."
Trillium has agreed to temporarily waive the policy requiring alcoholics to be sober for six months in a three-year, Ontario-only study set to begin next August.
"The proposal is that for three years … we will waive the six-month rule and in its place substitute other methods of assessing whether this patient is likely to remain abstinent afterwards," said Lilly, adding the Toronto transplant centre approached Trillium earlier this year with a proposal to review the policy.