The Italian Association for the Study of the Liver (AISF) has published a position paper in the journal Digestive and Liver Disease addressing several unmet needs in the care of liver diseases — stigma, challenges related to aging, the gender gap, socioeconomic barriers, and optimizing quality of life — describing the current situation, and proposing future perspectives. Univadis Italy, part of the Medscape Professional Network, interviewed Stefano Gitto, MD, PhD, a member of the AISF coordinating committee and the paper’s lead author.

Burden of Stigma

“If there is one area where stigma remains very strong, it is alcohol-related diseases, which primarily target the liver,” said Gitto, gastroenterologist at the Internal Medicine and Liver Unit, Careggi University Hospital, University of Florence, Florence, Italy. He confirmed that the belief that those who get sick from drinking are “asking for it” is still widespread. Because of self-stigma — when stigmatized individuals internalize society’s negative beliefs and prejudices — patients are reluctant to disclose alcohol use and do not seek help, causing delays in diagnosis and treatment. Things are even worse when alcohol use is associated with obesity or when the disease’s origin is in no way related to alcohol.

Doctors and healthcare professionals are not immune to judgmental and discriminatory attitudes toward these patients, so the AISF recommends avoiding language that perpetuates negative stereotypes. “We know words have a direct impact on clinical practice. Several years ago, the term alcohol use disorder was introduced to replace the word alcoholism, but words like ‘alcoholic’ are still wrongly used by many health professionals,” Gitto emphasized. “We should use terms that do not label the patient and avoid language that reinforces the idea of a self-inflicted disease. Stigmatizing language prevents building trust with patients and families and, ultimately, makes us less effective therapeutically.”

Barrier to Transplantation

The AISF paper notes that stigma persists in many healthcare settings, risking unequal access to care. Historically, patients had to show at least 6 months of alcohol abstinence to be considered eligible for liver transplantation — the so-called 6-month rule. Transplant medicine has undergone a profound evolution, and in the past 20-25 years, access to transplantation has changed dramatically. For example, until the early 2000s, it was unthinkable to transplant a person older than 60 years, whereas now transplants are easily performed even at age 70. Use of marginal donors — donors with more fragile characteristics — has expanded, in part because of perfusion machines.

There has also been a significant evolution regarding patients with alcohol use disorder: Many transplant centers have abandoned the 6-month rule because it prevented patients who had seriously undertaken abstinence from accessing a transplant simply because they hadn’t reached the required time limit — and some died before becoming eligible. This extremely rigid criterion — and somewhat punitive aftertaste — has been overcome.

He said the prevailing approach now is an individualized assessment of pretransplant alcohol use. Motivation, adherence to support networks, and the presence of a reliable caregiver are all crucial factors in qualifying for the procedure. A period of pretransplant abstinence is also important to see if the patient can recover liver function and might no longer need a transplant.

During that time, the patient can be referred to hospital alcohol units orthe Ser.D. (Servizio per le Dipendenze, Italy’s publicly funded Territorial Addiction Service), self-help groups, and psychological support services. Motivation can be built through education, family members can be met, and one or more caregivers can be identified who can support them along the way. The pretransplant period is used to create the strongest possible network around the patient so that abstinence can be maintained after transplantation.

He noted that in some cases, stricter rules still apply, and access to transplantation may be denied — for example, if a patient shows no willingness to engage in a support program to maintain abstinence or if it is impossible to find a caregiver. These are contraindications to be assessed on a case-by-case basis.

The presence of a major psychiatric comorbidity is a contraindication to transplantation because the patient may not provide guarantees for posttransplant outcomes: There is a risk that the transplant would be wasted through rejection related to nonadherence to immunosuppressive therapy or by losing the patient to follow-up in the first few weeks, which would put their life at risk as much as not receiving a new liver. Organs are a finite resource: We proceed to transplant a patient who stands to gain in survival terms; we do not do it when we already know there is a very high risk for organ loss.

Difficulty Accessing Resources

Patients with liver disease face serious inequities that stem both from resource availability and from patients’ ability to access and use those resources effectively. The AISF uses the phrase “postal-code lottery,” in which care depends on geographic location, with urban centers offering specialized services, whereas rural patients face limited access and longer travel times.

Several Italian regions lack a single transplant center, and the density of tertiary care centers for liver disease treatment in Central and Northern Italy is much higher than in Southern Italy. In Lombardy, Emilia-Romagna, and Tuscany, there are three to five AISF centers; in other regions, there is only one or none at all, emphasizing that the problem is distribution across the country — not quality — because Southern Italy also has top-notch liver care centers, such as those in Naples, Messina, and Palermo.

Last year, the AISF presented the White Paper ‘Liver Diseases,’ which was requested and endorsed by the Italian Senate’s Committee on social affairs, healthcare, public and private employment, and social security. The document addresses all major liver diseases, with each chapter providing epidemiologic, technical, and economic commentary and institutional policy recommendations. Based on the White Paper, the AISF has launched a series of proposals to institutions to bridge gaps, such as geographic disparities.

Early Detection and Referral

Among AISF’s strategies to address disparities in healthcare resources is greater involvement of general practitioners (GPs). “Today the vast majority of liver disease cases are metabolic dysfunction-associated steatotic liver disease — by definition, a hepatic expression of obesity — and alcoholic liver disease, and for both, primary prevention is essential. GPs who see an overweight patient can refer them to educational, nutritional, and, if needed, psychological support to prevent liver disease; likewise, a GP can detect early signs of problematic alcohol use and intervene early,” noted Gitto, adding that the aim is not to impose total abstinence from alcohol on everyone, as long as consumption is informed.

Gitto declared having no conflicts of interest related to the subject.

This story was translated from Univadis Italy.