Outcomes and risk of relapse after living donor and deceased donor liver transplantation for alcohol-associated liver disease

Abstract

<h3>Introduction and Objectives</h3><p>The six-month abstinence rule for alcohol-associated liver disease (ALD) patients may exclude candidates from life-saving transplantation without reliably predicting relapse. We compared outcomes of deceased donor liver transplantation (DDLT) and living donor liver transplantation (LDLT) in ALD patients, with modified abstinence criteria.</p><h3>Patients and Methods</h3><p>ALD patients evaluated for transplantation from 2008-2020 were analyzed. 6-month abstinence was required for DDLT but not for LDLT patients with favorable psychological assessments. Survival analyses were conducted from evaluation i.e., intention-to-treat (ITT) and transplantation. Patients with living donors were categorized as intended for LDLT (ITT-LDLT) and those without as intended for DDLT (ITT-DDLT). Patients who were ineligible for transplantation served as the control group.</p><h3>Results</h3><p>Of the 216 ALD patients evaluated, 79 (36.6%) were accepted for transplantation. Five-year ITT survival was superior in the ITT-LDLT group (83.3%) compared to ITT-DDLT (62.6%, P=0.04) and controls (30.7%, P<0.001). Among transplant recipients (DDLT n=34, LDLT n=20), five-year graft survival was comparable between DDLT and LDLT (79.8% vs 76.5%, P=0.84) despite only 40% of LDLT patients achieving six-month abstinence. Alcohol relapse rates were comparable between DDLT and LDLT (32.4% vs. 30.0%, P>0.99). Alcohol dependence (HR=7.32, P<0.001) and medical non-compliance (HR=4.19, P=0.007) predicted relapse.</p><h3>Conclusions</h3><p>Liver transplantation provided significant survival benefit for carefully selected ALD patients. With comprehensive psychological assessment, patients without psychiatric disorders or compliance issues can achieve excellent outcomes after transplantation.</p>