More liver transplants occurring in patients with alcohol-associated liver disease

The increase from 2002 to 2016 can partly be explained by reductions in hepatitis C-related transplants but may also indicate changing perspectives on abstinence requirements, study authors said.

Liver transplants for alcohol-associated liver disease became more common between 2002 and 2016, according to a recent nationwide study.

The prospective study used data from the United Network for Organ Sharing database to evaluate all liver transplants performed in the U.S. between Jan. 1, 2002, and Dec. 31, 2016. In total, 32,913 patients were included in the study, including 9,438 with alcohol-associated disease and 23,475 without. Patients with hepatitis C virus (HCV) infection and hepatocellular carcinoma indications were excluded. Results were published by JAMA Internal Medicine on Jan. 22.

The study found that transplant patients with alcohol-associated liver disease were more likely to be male and white. The proportion of liver transplants that were for alcohol-associated disease increased from 24.2% (433 of 1,791) in 2002 to 27.2% (556 of 2,044) in 2010 to 36.7% (1,253 of 3,419) in 2016. When transplants related to HCV infection were included, the proportions of transplant for alcohol-associated disease were 15.3% in 2002, 18.6% in 2010, and 30.6% in 2016.

Based on the findings, the authors calculated that 48% of the increase in the proportion attributed to alcohol could be explained by the decrease in HCV-related transplants. They speculated that some of the rest of the increase might be attributed to fewer transplant centers and physicians requiring patients to abstain from alcohol for six months to become eligible for a transplant and researchers reporting successful early liver transplants for alcoholic hepatitis.

The changes in transplant rates were found to be regionally heterogeneous. In the regions that performed more transplants for alcohol-associated disease, the mean age of transplant patients decreased and the median end-stage liver disease score increased over the study period. Cumulative unadjusted survival in the first year after transplant did not differ by whether liver disease was associated with alcohol, but it was lower in patients with alcohol-associated disease than in those with non-alcohol-associated disease five and 10 years after transplant (79% vs. 80% and 63% vs. 68%, respectively). In a multivariable analysis, patients with alcohol-associated disease had increased risk of late death after liver transplant (adjusted hazard ratio, 1.11; P=0.006).

The study authors noted that their theories about the causes of the increase in transplants for alcohol-associated disease were based on temporal associations and that unknown or unmeasured factors might have been responsible. “Nevertheless, given the significant increase in liver transplants for ALD [alcohol-associated liver disease] in the United States, it may be time for a national consensus on best practices for patients with ALD in need of liver transplant,” they wrote.

An accompanying commentary said that the finding of increased risk of late death in patients with alcohol-associated disease should not motivate a return to the six-month abstinence requirement or a reduction in transplants for such patients. Instead, clinicians should focus on strategies that can improve patients' outcomes after transplant, including cancer screening, vaccination, and ongoing attention to underlying alcohol use disorder, the editorialists said.