National Trends and Long-term Outcomes of Liver Transplant for Alcohol-Associated Liver Disease in the United States

Abstract

IMPORTANCE Alcohol-associated liver disease (ALD) has emerged as the most common indication for liver transplant in the United States, but data on the reasons for this increase and long-term post-liver transplant outcomes among liver transplant recipients are sparse. OBJECTIVE To characterize trends and long-term outcomes of liver transplant for ALD in the United States between 2002 and 2016. DESIGN, SETTING, AND PARTICIPANTS This multicenter, prospective, national cohort study used data from the United Network for Organ Sharing database to evaluate all liver transplants performed in the United States between January 1, 2002, and December 31, 2016. MAIN OUTCOMES AND MEASURES National and regional trends in liver transplant for ALD, with a sensitivity analysis with hepatitis C virus (HCV) infection and hepatocellular carcinoma (HCC) included, and early (≤90 days after liver transplant) and late (>90 days after liver transplant) patient and graft survival. RESULTS The cohort consisted of 32 913 patients, including 9438 with ALD and 23 475 without ALD (patients who had HCV infection and HCC indications were excluded). Median age of patients with ALD was 54 years (interquartile range, 47–60 years) and of patients without ALD was 54 years (interquartile range, 44–61 years). Patients with ALD (vs non-ALD) were more frequently male (7197 of 9438 [76.2%] vs 11767 of 23 475 [50.1%]; P < .001) and white (7544 [80.0%] vs 17 251 [73.5%]; P < .001). The proportion of liver transplants for ALD increased from 24.2% (433 of 1791) in 2002 to 27.2% (556 of 2044) in 2010 and 36.7% (1253 of 3419) in 2016. With HCV infection included, the proportions of liver transplant for ALD were 15.3% in 2002,18.6% in 2010, and 30.6% in 2016, representing a 100% increase in liver transplant for ALD, of which 48% was associated with a decrease in HCV infection as an indication for liver transplant. The magnitude of increase in ALD was regionally heterogeneous and associated with changes in patient characteristics suggestive of alcoholic hepatitis: decreasing age (χ2 = 36.5; P = .005) and increasing model for end-stage liver disease score (χ2 = 69.1; P < .001). Cumulative unadjusted 5-year posttransplant survival was 79% (95% CI, 78%−80%) for ALD vs 80% (95% CI, 79%−80%) for non-ALD; cumulative unadjusted 10-year posttransplant survival was 63% (95% CI, 61%−64%) for ALD vs 68% (95% CI, 67%−69%) for non-ALD (P = .006). In multivariable analysis, ALD was associated with increased risk of late death after liver transplant (adjusted hazard ratio, 1.11; 95% CI, 1.03–1.20; P = .006). CONCLUSIONS AND RELEVANCE The findings suggest that early liver transplant for alcoholic hepatitis may be leading to broader acceptance of ALD for liver transplant. Late survival among liver transplant recipients with ALD was inferior to that among recipients with non-ALD indications, suggesting a need for future studies to identify patient profiles associated with best outcomes. Regional differences suggest heterogeneity in policies toward liver transplant for AL...

Superior Wait‐List Outcomes in Patients with Alcohol‐Associated Liver Disease Compared With Other Indications for Liver Transplantation

“…A recent review of ALD in the United States predicted that this proportion would increase in the next decade because of the increased rates of alcohol consumption and the decreased need for LT among those with hepatitis C. (29) Additionally, changing attitudes toward LT for ALD may be contributing, especially considering the positive results of early LT for acute alcoholic hepatitis without a mandated sobriety period. (12) It is estimated that approximately 13,000 patients die from alcohol-related liver disease annually in the United States (30) with increasing deaths among those under the age of 40 years; yet, only ~2000 annually undergo LT for this indication. This suggests that there is a larger pool of patients who may benefit from LT. As the duration of abstinence is deemphasized in favor of broader psychosocial profiling, the characteristics of ALD patients on the waiting list may change and, in turn, influence WL outcomes.…”

“…These concerns have proven to be largely unwarranted with surveys showing that public views on donation for ALD are mostly neutral . Furthermore, posttransplant survival among patients with ALD is similar to patients without ALD with 5‐year graft and patient survival of 73%‐79% and 10‐year graft survival of 58%‐63% …”

Mental health and chemical dependency services at US transplant centers

“…Additionally, since the publication of a landmark trial that reported favorable outcomes of early liver transplant for severe alcoholic hepatitis, there has been a significant practice change. A recent multicenter study found that the proportion of liver transplant recipients being transplanted for alcoholic liver disease (ALD) increased from 24% in 2002 to 36.7% in 2016 . Pretransplant assessment of candidates with acute alcoholic hepatitis requires comprehensive assessment of substance use disorders that cannot be optimally performed without having CD services at transplant centers.…”

Identifying Risk of Alcohol Relapse After Liver Transplantation: What Tools Do We Need?

“…Over the past decade, the proportion of LTs for ALD has significantly increased . Contributing to this rise may be the consideration of early LT for select candidates with <6 months of alcohol abstinence at high risk for mortality and perceived low risk for relapse . Although the 3‐year follow‐up on transplantation of 1 multicenter cohort suggests a 17% risk for return to sustained alcohol use after transplantation, long‐term data are lacking.…”