Liver transplant evaluation redux: Hope for reconsidering previously declined candidates with alcohol-associated liver disease

Abstract

Alcohol-associated liver disease (ALD) is a severe medical manifestation of alcohol use disorder (AUD), which remains a major source of global mortality and a leading indication for liver transplantation (LT), particularly among younger adults. [1] Alcohol hazards in LT are not just confined to those patients with ALD diagnoses; at least 29% and 25% of patients diagnosed with nonalcohol-related fatty liver disease and metabolic dysfunction-associated steatotic liver disease, respectively, have been found to be at risk of alcoholassociated liver damage. [2] Given the shortage of livers and the importance of maintaining favorable clinical outcomes, LT centers are obliged to increase the sophistication of their alcohol evaluation and treatment methods; they employ heterogenous approaches in doing so. [3] Various elements of AUD and its frequent psychosocial comorbidities create a high probability that candidates with ALD will not initially qualify for LT listing. [4] AUD is often a severe, relapsing condition marked by previous unsuccessful treatment attempts. Hazardous alcohol use may disrupt self-care, medical adherence, and basic needs like housing. Other chronic psychiatric disorders and risky substance use patterns are common comorbidities. Family, marital, and partner relationships are often severely damaged. Deficits in insight might impair a person's ability to acknowledge alcohol-associated problems and adequately engage in AUD treatment. Longstanding habits of alcohol-associated deception make self-reported substance use unreliable during LT evaluation. [5] These substantial psychosocial risks and barriers exist in a population with ALD whose care is often disjointed across disparate medical and psychosocial specialties and who are more likely to present with advanced medical disease compared with patients without ALD.