Excessive alcohol use is the leading cause of preventable US deaths with more than 95 000 deaths/y and 29 years of life per death.1 Alcohol-associated liver disease (ALD) is now the most common defined cause for both liver transplant (LT) (31%, 2584 transplants) and listing diagnosis (31%, 3861) in the US.2 As shown by Herrick-Reynolds and colleagues,3 as well as others, patients with liver failure from ALD, previously considered ineligible for LT until completing 6 months of abstinence, do well in the short term, 1 to 3 years after LT, with appropriate medical and psychosocial evaluations. These patients are younger and have fewer chronic illnesses despite a high incidence of acute kidney injury. Transplant for ALD is rapidly expanding in the US. Competition between transplant centers for patients with high Model for End-stage Liver Disease scores with good survival expectation is likely driving this phenomenon.4 US centers have not followed the strict criteria laid out in the landmark article by Mathurin et al5 excluding patients with any prior knowledge of their ALD and including only those at their first decompensating event, without severe coexisting or psychiatric disorders, and with close family support and agreement for lifelong abstinence. Also required were several meetings between the medical teams, including an addiction specialist and the patient with their family. Only 18 of 233 evaluated patients (7.7%) underwent transplant in the French cohort. In the initial US multicenter experience, the Accelerate trial, 36% of evaluated patients underwent transplant.6 Herrick-Reynolds et al3 note that, while prior knowledge of ALD and failed attempts at abstinence are considered, they are not absolute contraindications in their selection criteria. In eFigure 1 in the Supplement in the Herrick-Reynolds et al article, 21 of 40 committee-reviewed candidates over a year were wait-listed or underwent transplant. Major concerns with patients with ALD undergoing transplant early include the lack of time to educate the patient/family and evaluate their compliance and a lack of addiction specialists in many centers. The urgency in wait-listing and its subjective nature can further exacerbate inequity in organ transplant. It is likely a major factor leading to a severe disproportion of white males with private insurance and traditional family support undergoing transplant. In the study by Herrick-Reynolds et al, 90% of patients who underwent transplant were White; in a study by Lee et al, 83% of patients who underwent transplant were White. Males constituted 67% and 73%, respectively. Sixty-six percent of patients in the Accelerate trial had private insurance. The potential population of patients with severe alcoholic hepatitis or alcohol-induced acute or chronic liver failure is very large and can easily overwhelm the limited supply of deceased donor organs. The transplant community must ensure that patient selection is fair and equitable and engenders continued faith and trust in the process. Appropriate safeguards are essential to excellent long-term outcomes comparable with other liver failure etiologies.
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Andreoni KA, Zarrinpar A. The Sobering Complexities of Alcoholic Liver Disease and Decisions for Transplant. JAMA Surg. 2021;156(11):1034–1035. doi:10.1001/jamasurg.2021.3749
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