Abstract

Objectives: In the published studies of early liver transplantation (LT) for alcohol-associated hepatitis (AH), patients with a prior liver decompensation are excluded. The appropriateness of this criteria is unknown.

Methods: Among six ACCELERATE-AH sites, we included consecutive early LT for clinically diagnosed AH between 2007-2020. Patients were stratified as first vs. prior history of liver decompensation, with the latter defined as a diagnosis of ascites, hepatic encephalopathy, variceal bleeding, or jaundice, and evidence of alcohol use after this event. Adjusted Cox regression assessed the association of first (vs. prior) decompensation with post-LT mortality and harmful (i.e., any binge and/or frequent) alcohol use.

Results: A total of 241 LT recipients (210 first vs. 31 prior decompensation) were included: median age 43 vs. 38 years (p=0.23), MELD 39 vs. 39 (p=0.98), and follow-up post-LT 2.3 vs. 1.7 years (p=0.08). Unadjusted 1- and 3-year survival among first vs. prior decompensation was 93% (95%CI 89-96%) vs. 86% (66-94%) and 85% (95%CI 79-90%) vs. 78% (95%CI 57-89%). Prior (vs. first) decompensation was associated with higher adjusted post-LT mortality (aHR 2.72, 95%CI 1.61-4.59), and harmful alcohol use (aHR 1.77, 95%CI 1.07-2.94).

Conclusions: Prior liver decompensation was associated with higher risk of post-LT mortality and harmful alcohol use. These results are a preliminary safety signal and validate first decompensation as a criterion for consideration in early LT for AH patients. However, the high 3-year survival suggests a survival benefit for early LT and the need for larger studies to refine this criterion. These results suggest that prior liver decompensation is a risk factor, but not an absolute contraindication to early LT.