Underestimation of Liver Transplantation for Alcoholic Hepatitis in the National Transplant Database

Abstract

Alcohol‐associated liver disease (ALD) can be coded in United Network for Organ Sharing (UNOS) as either alcoholic cirrhosis or alcoholic hepatitis (AH), without having specific criteria to assign either diagnosis. In this multicenter American Consortium of Early Liver Transplantation for Alcoholic Hepatitis (ACCELERATE‐AH) study, we sought to assess the concordance of the clinician diagnosis of AH at liver transplantation (LT) listing versus UNOS data entry of AH as listing diagnosis. In a prior study, consecutive early LT recipients transplanted for AH between 2012 and 2017 were identified by chart review at 10 ACCELERATE‐AH sites. In this current study, these same LT recipients were identified in the UNOS database. The primary UNOS diagnostic code was evaluated for concordance with the chart‐review assignment of AH. In cases where the primary listing diagnosis in UNOS was not AH, we determined the reason for alternate classification. Among 124 ACCELERATE‐AH LT recipients with a chart‐review diagnosis of AH, only 43/124 (35%) had AH as listing diagnosis in UNOS; 80 (64%) were listed as alcoholic cirrhosis, and 1 (1%) as fulminant hepatic necrosis. Of the 81 patients missing AH as a UNOS listing diagnosis code, the reasons for alternate classification were 44 (54%) due to a lack of awareness of a separate diagnosis code for AH; 13 (16%) due to concomitant clinical diagnosis of AH and alcoholic cirrhosis in the chart; 12 (15%) due to clinical uncertainty regarding the diagnosis of AH versus acute decompensated alcoholic cirrhosis; and 12 (15%) due to a data entry error. In conclusion, in a large cohort of LT recipients with AH, only 35% were documented as such in UNOS. Increased education and awareness for those performing UNOS data entry, the establishment of specific criteria to define AH in the UNOS database, and the ability to document dates of alcohol use would allow future research on ALD to be more informative.

Liver transplant waitlist outcomes in alcoholic hepatitis compared with other liver diseases: An analysis of UNOS registry

“…These results suggest that AH patients might have better waitlist outcomes than chronically debilitated patients in cases of their waitlist time being over 90 days. Hence, it will be essential to continually assess disease progression in patients with AH to stratify prognosis 5,18‐22 . Conversely, we found AH patients with coagulopathy and those who required life support had a significantly higher risk of waitlist mortality.…”

“…The diagnosis of AH may be misclassified or underestimated in the UNOS registry. It was recently reported that some patients with AH are incorrectly listed with the diagnosis code of “alcoholic cirrhosis” or “acute liver failure.” 22 We included only patients coded as AH and excluded patients with overlapping diagnoses, which should help homogenize the AH cohort in this study. However, it should be acknowledged that small changes in the number of patients with AH could lead to outsized statistical impact.…”

Increase in Alcoholic Hepatitis as an Etiology for Liver Transplantation in the United States: A 2004–2018 Analysis

“…Results published by Mathurin et al 3 and subsequent studies conducted by the American Consortium of Early Liver Transplantation for Alcoholic Hepatitis (ACCELERATE-AH) 8 - 11 , 15 have paved the way for considering LT for AH patients. Investigators with ACCELERATE-AH, a multicenter observational study describing outcomes of early LT in patients with severe AH, noted a slight increase in frequency of LTs for the management of AH in the United States in 2016.…”

“… 3 The requirement for a 6-month abstinence period before LT has been challenged due to lack of data supporting it. 4 - 7 The case for LT in severe AH is further strengthened by studies conducted by US consortium; these studies have reiterated the improved survival following LT for AH, with a score created to predict the likelihood of relapse post LT. 8 - 11 …”

Early Liver Transplantation in Acute Alcoholic Hepatitis

“…18 These surveys mirror published single center and cohort data 19 along with national registry data from United States showing an increase in the number of liver transplants for severe AAH performed from 2012 to 2017. 20 Additionally, since the landmark study by Mathurin et al in 2011, practice in France regarding early liver transplantation for severe AAH has changed. In 2018, a survey conducted among 18 French transplant centers showed that prior to 2011, 35% of centers did not perform liver transplantation for AAH.…”