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Original Investigation
January 22, 2019

National Trends and Long-term Outcomes of Liver Transplant for Alcohol-Associated Liver Disease in the United States

Author Affiliations
  • 1Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco
  • 2Department of Epidemiology and Biostatistics, University of California, San Francisco
  • 3Department of Surgery, University of California, San Francisco
JAMA Intern Med. 2019;179(3):340-348. doi:10.1001/jamainternmed.2018.6536
Key Points

Questions  Why has liver transplant for alcohol-associated liver disease doubled in recent years, and what is the long-term survival among recipients of a liver transplant for alcohol-associated liver disease?

Findings  In this multicenter, prospective, national cohort study, 48% of the increase in liver transplant for alcohol-associated liver disease was associated with a decrease in liver transplant for hepatitis C virus infection. Five-year posttransplant survival was 11% lower in patients with alcohol-associated liver disease.

Meaning  The findings suggest that changing attitudes regarding liver transplant for acute alcoholic hepatitis may influence use of liver transplant for alcohol-associated liver disease, with disproportionate changes across United Network for Organ Sharing regions; national policy may help address this disparity.


Importance  Alcohol-associated liver disease (ALD) 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.

Objective  To characterize trends and long-term outcomes of liver transplant for ALD in the United States between 2002 and 2016.

Design, Setting, and Participants  This multicenter, prospective, national cohort study used data from the United Network for Organ Sharing database to evaluate all liver transplants performed in the United States between January 1, 2002, and December 31, 2016.

Main Outcomes and Measures  National and regional trends in liver transplant for ALD, with a sensitivity analysis with hepatitis C virus (HCV) infection and hepatocellular carcinoma (HCC) included, and early (≤90 days after liver transplant) and late (>90 days after liver transplant) patient and graft survival.

Results  The cohort consisted of 32 913 patients, including 9438 with ALD and 23 475 without ALD (patients who had HCV infection and HCC indications were excluded). Median age of patients with ALD was 54 years (interquartile range, 47-60 years) and of patients without ALD was 54 years (interquartile range, 44-61 years). Patients with ALD (vs non-ALD) were more frequently male (7197 of 9438 [76.2%] vs 11 767 of 23 475 [50.1%]; P < .001) and white (7544 [80.0%] vs 17 251 [73.5%]; P < .001). The proportion of liver transplants for ALD increased from 24.2% (433 of 1791) in 2002 to 27.2% (556 of 2044) in 2010 and 36.7% (1253 of 3419) in 2016. With HCV infection included, the proportions of liver transplant for ALD were 15.3% in 2002, 18.6% in 2010, and 30.6% in 2016, representing a 100% increase in liver transplant for ALD, of which 48% was associated with a decrease in HCV infection as an indication for liver transplant. The magnitude of increase in ALD was regionally heterogeneous and associated with changes in patient characteristics suggestive of alcoholic hepatitis: decreasing age (χ2 = 36.5; P = .005) and increasing model for end-stage liver disease score (χ2 = 69.1; P < .001). Cumulative unadjusted 5-year posttransplant survival was 79% (95% CI, 78%-80%) for ALD vs 80% (95% CI, 79%-80%) for non-ALD; cumulative unadjusted 10-year posttransplant survival was 63% (95% CI, 61%-64%) for ALD vs 68% (95% CI, 67%-69%) for non-ALD (P = .006). In multivariable analysis, ALD was associated with increased risk of late death after liver transplant (adjusted hazard ratio, 1.11; 95% CI, 1.03-1.20; P = .006).

Conclusions and Relevance  The findings suggest that early liver transplant for alcoholic hepatitis may be leading to broader acceptance of ALD for liver transplant. Late survival among liver transplant recipients with ALD was inferior to that among recipients with non-ALD indications, suggesting a need for future studies to identify patient profiles associated with best outcomes. Regional differences suggest heterogeneity in policies toward liver transplant for ALD.

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    1 Comment for this article
    Cost of Alcoholic Hepatitis Treatment
    Abdullah Mubarak, MD, FAASLD | Liver Center of Texas
    Appropriate patient selection of individuals with alcoholic hepatitis for liver transplantation will obviate the cost of care in the US health system. Patient's with alcoholic hepatitis with hepatorenal syndrome (HRS) Type 1 or 2 tend to have a prolonged length of stay in the intensive care unit or hospital  and cannot be declared to have ESRD in order to access out-patient dialysis (HRS Type 2) if they are stable . Cost correlation of transplanting appropriate patients with alcoholic hepatitis sooner with good post transplant outcomes vs medical care until they meet the arbitrary 6 month sobriety criteria. These cost data will facilitate payor prohibitions of a 6 month sobriety requirement.