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Liver transplantations for alcohol-associated liver disease increase

Over the past 15 years, there was a 12.5% increase in the number of liver transplantations for patients with alcohol-associated liver disease, according to findings published in JAMA Internal Medicine.

“Alcohol-associated liver disease 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,” Brian P. Lee, MD, medical director of the Living Kidney Donor Program at the University of California, San Francisco, and colleagues wrote.

Lee and colleagues analyzed data from the United Network for Organ Sharing database to identify the national and regional trends and long-term outcomes of liver transplant among patients with alcohol-associated liver disease in the United States between Jan. 1, 2002, and Dec. 31, 2016.

A total of 32,913 patients were included in the cohort. Of those, 9,438 had alcohol-associated liver disease (median age, 54 years; 76.2% men; 80% white) and 23,475 did not (median age, 54 years; 50.1% men; 73.5% white). Patients with hepatitis C virus infection and hepatocellular carcinoma were excluded from the main analysis, but included in the sensitivity analysis.

Among patients with alcohol-associated liver disease, the frequency of liver transplantation increased from 24.2% in 2002 to 27.2% in 2010 and 36.7% in 2016.

When HCV infection was included in the evaluation, the frequency of liver transplantation for alcohol-associated liver disease increased from 15.3% in 2002 to 18.6% in 2010 and 30.6% in 2016. About half of the increase in liver transplantation for alcohol-associated liver disease led to a decrease in transplantation for HCV infection.

The increase in alcohol-associated liver disease varied regionally and was associated with changes in patient characteristics indicative of alcoholic hepatitis, including decreasing age (P = .005) and higher end-stage liver disease score (P < .001).

Cumulative unadjusted 5-year posttransplant survival was 79% (95% CI, 78-80) among patients with alcohol-associated liver disease, compared with 80% (95% CI, 79-80) among those without alcohol-associated liver disease. The cumulative unadjusted 10-year posttransplant survival rate was 63% (95% CI, 61-64) among patients with alcohol-associated liver disease and 68% (95% CI, 67-69) for those without alcohol-associated liver disease.

Multivariable analyses showed that patients with alcohol-associated liver disease had a higher risk of late death after liver transplant (adjusted HR = 1.11; 95% CI, 1.03-1.2).

“The rapid emergence of alcohol-associated liver disease as the leading indication for liver transplant may be associated with the decrease in HCV infection and shifting attitudes toward the length of pre-liver transplant sobriety necessary to undertake liver transplant for alcohol-associated liver disease; both of these factors may continue to be associated with an increase [in the] the proportion of liver transplants performed for alcohol-associated liver disease,” Lee and colleagues concluded.

“Future studies focused on improving disparities in access to liver transplant for alcohol-associated liver disease and optimizing short- and long-term survival among transplant recipients with alcohol-associated liver disease should be encouraged,” they added.

In an accompanying editorial, Mack C. Mitchell, MD, and Willis C. Maddrey, MD, both from the University of Texas Southwestern Medical Center, wrote that improving short-term mortality during the first 90 to 180 days is crucial as it would allow for the stabilization of decompensated alcohol-associated liver disease and better evaluation for liver transplant.

“Until then, transplant centers must develop better understanding of the psychosocial and other medical needs of potential transplant recipients with alcohol-associated liver disease to select appropriate candidates for this life-saving treatment,” they wrote. “Attitudes regarding liver transplant for alcohol-associated liver disease will require time to evolve.” – by Alaina Tedesco

Disclosures: The authors of the study and Maddrey report no relevant financial disclosures. Mitchell reposts receiving grants from the National Institute of Alcohol and Alcohol Abuse and nonfinancial support from the Alcoholic Beverage Medical Research Foundation.