Rising Trend in Waitlisting for Alcoholic Hepatitis With More Favorable Outcomes Than Other High Model for End-stage Liver Disease in the Current Era

Abstract

Background. In the appropriate candidate, liver transplantation (LT) is a viable treatment for alcoholic hepatitis (AH). We compared the waitlisting trends and outcomes of AH patients in the context of others with high Model for End-stage Liver Disease (MELD) score. Methods. LT listings for AH between January 1, 2008, and June 12, 2020 were identified in the United Network for Organ Sharing database. Temporal trends in listings for AH were assessed. Covariate adjusted competing risks models evaluated waitlist mortality and LT rates between AH candidates and others with listing native MELD ≥30. Results. Between 2008 and 2019, waitlist additions for AH increased 6.5-fold. Waiting time for AH candidates was short (median 10 d). Delisting for clinical improvement was infrequent in AH, albeit higher than MELD ≥30 patients (3.3% versus 0.8%; P < 0.001). Among 99 centers with ≥1 AH listing, AH patients accounted for 0.2%–18.2% of all alcohol-related listings and 0.6%–25.0% of those with native listing MELD ≥30. Overall listing volume was larger at these 99 centers than the 40 with no AH listings (P < 0.001). AH candidates in 2014–2020 experienced improved waitlist survival (adjusted subhazard ratio, 0.67; 95% confidence interval, 0.52-0.86; P = 0.002) and higher transplant rates (adjusted subhazard ratio, 1.14; 95% confidence interval, 1.04-1.25; P = 0.006) versus other MELD ≥30 candidates. Conclusions. There has been a rising trend in waitlisting patients with AH and high MELD score. Liver disease causes influence waitlist outcomes and those of AH candidates are more favorable. Further research and allocation adjustments may be needed to ensure equitable organ allocation, based on liver disease cause, for those on the LT waitlist.

MELD 3.0 leads to heterogeneous prioritization of men and women on the liver transplant waiting list

“…Nevertheless, the issue of over-prioritization of AH candidates warrants further study in the MELD 3.0 era, given the continued expansion of LT for this indication and their superior waitlist outcomes. [2] In support of this, we also show that the calibration of MELD 3.0 is suboptimal for AH, akin to MELDNa, with a tendency to overestimate the 90-day waitlist mortality. However, MELD 3.0 may offer small improvements in calibration over MELDNa for men with AH or non-AH ALD and for patients with NASH.…”

“…Concurrently, the performance of the current Model for End-stage Liver Disease Sodium (MELDNa) score in predicting the waitlist mortality has decreased 1. In this context, the small but rapidly growing subset of patients listed with alcohol-associated hepatitis (AH) has gained attention given their superior waitlist outcomes, suggesting over-prioritization in the status quo 2…”

Multicentered study of patient outcomes after declined for early liver transplantation in severe alcohol-associated hepatitis

“…Globally, alcohol-associated hepatitis (AH) is on the rise and liver transplantation (LT) is increasingly considered for carefully selected patients in countries throughout the world. [1][2][3][4][5][6][7][8][9] However, some patients with AH evaluated for LT can potentially survive without LT [2] -the clinical trajectory patients with AH evaluated but declined for LT is understudied. Given the scarcity of allografts and risks associated with LT, LT for AH remains controversial in part because of the potential for clinical recovery without LT.…”

Liver transplant for alcohol-associated liver disease continues to rise 2 years into the COVID-19 pandemic especially among young adults

“…We estimated and compared the mean number of waitlist registrants and LT recipients per month between the 2 nd (March 2021-February 2022) vs. 1 st (March 2020-February 2021) year of COVID vs. pre-COVID (March 2019-February 2020) using linear regression, separately for ALD and AH (subgroup of ALD). We further evaluated trends amongst those with MELD-Na score <30 ( a priori cutoff based on published studies 6 ), given that changes in the LT allocation policy in February 2020 and/or increasing acceptance for early (i.e. before 6 months of abstinence) LT practices both prioritize LT of sicker (high MELD-Na) patients.…”