How faecal transplants can save the liver in patients of alcoholic hepatitis

Not just that, secondary infections among these patients was also lower. The ILBS study shows that 19.3 per cent of those who received the steroids died of an infection as compared to only 3.6 per cent of those who received a faecal microbiota transplant.

Why is this important? The mortality rate of severe alcoholic hepatitis is very high, with nearly 30 per cent of the people succumbing within 90 days. It is also a condition for which not many treatments exist. “No cancer ever will have such high mortality. It happens after years of drinking, but what tips the balance we do not know. In fact, most people do not even realise that they have jaundice until someone tells them, so they continue to drink. And, once the people have jaundice, swollen feet, and abdominal ascites (a condition where fluid accumulates in spaces in the abdomen) it is a huge challenge,” says Dr SK Sarin, one of the authors of the paper and vice-chancellor of ILBS.

The current treatment protocol for patients with severe alcoholic hepatitis includes a high calorie diet to correct their malnutrition – whether it improves survival in the patients is yet to be seen, says Dr Sarin – and steroids to treat the inflammation in the liver. The success rate of steroid treatment is 60 to 70 per cent in patients who are not at a very advanced stage, but that is not the only challenge. He says that only one in five people who need the treatment are able to get it. That is because they either have an infection that might flare up because steroids suppress the immune system or they are already too sick for it to work.

Once the liver starts failing, there is only the option of transplant. “But the patients with severe alcoholic hepatitis do not make ideal candidates for transplant. This is because one, no one wants to give a liver to a drinker and two, by law also you need three months of abstinence,” says Dr Sarin. With nearly 80 per cent of the people being ineligible for the current treatment, there was a need for an alternative therapy. And, faecal microbiota transplant was just the candidate.

Dr Sarin explains that when people drink alcohol, it is digested by the bacteria in their gut. During the process, they release toxins that damage the liver. The pathogenic bacteria in the gut tend to like the alcohol and flourish. Patients with these bad bacteria, such as the proteobacteria, in their gut have higher mortality. Other than increasing the bad bacteria, the alcohol also causes a leaky gut – the intestinal walls become permeable and the bacteria can move out, go into the liver, damage it, enter the blood and cause infections.

Once a faecal microbiota transplant is done, there is a battle between the good and the bad bacteria to establish dominance. The new bacteria take about two to four weeks to get established in the gut, Dr Sarin says. “The FMT also reduces the leakiness of the bowel, preventing the bacteria from moving out. They allow the food to be processed properly and improve nutrition in the patients; the bad bacteria are alcohol dependent,” he adds.

Although the therapy is not part of guidelines for treating the disease yet, several studies have been undertaken in the recent years to prove its efficacy, including trials conducted at other sites in India.

The protocol used by the ILBS team involved delivering processed slurry with 30 gms of fresh faecal matter from the healthy donor to the gut of the recipient with a nasal tube. Can anyone be the donor? The donor is selected from people sharing the environment of the recipient, ideally a family member. “Bacterial also has a familial connection – a baby inherits a bacterial colony from its mother during birth. People living in the same environment are also likely to have a similar colony. So, a healthy donor is chosen from among family members who share the same environment, say a sibling or parents. The second choice would be say a spouse who also shares the environment,” says Dr Sarin.

Before the donation, the donor is put on a standardised diet – they cannot eat outside food. The donor should be young, healthy, not obese, a non-drinker, not on antibiotics and must not have any pathological bacteria.