Clarifying Treatment Options for Patients with Alcohol-Associated Liver Disease

Alcohol-associated liver disease is the leading cause for liver transplantation in the United States. Historically, six months of alcohol abstinence is preferred before patients can receive a transplant; however, waiting six months is often not possible. As alcohol-associated liver disease rates continue to rise, Assistant Professor of Surgery Ashton Connor, MD, PhD, is working toward treatment option clarity. His latest study published in Transplantation Direct suggests that early liver transplants in patients with acute alcohol use disorder result in similar outcomes as transplants performed with at least six months of sobriety. In other words, transplanting prior to the six-month sobriety mark causes no associated differences in relapse rates, severity and timing and patient or graft survival, according to the study. “Our findings support early liver transplantation in alcohol use disorder patients with severe or acute disease, specifically those in the intensive care unit (ICU) and those with a higher model for end-stage liver disease (MELD) score,” explained Connor.

Risk factors associated with harmful drinking post-transplant were also identified by researchers, offering insight into which patients may benefit from more concentrated monitoring, education and relapse prevention strategies. “We found that being female, having a lower illness acuity, presenting from home, and having a higher educational level was associated with a higher risk for relapse,” Connor said, noting that ICU patients were less likely to relapse after transplant than those of lower illness acuity—an outcome that challenges some existing decision-making processes. Connor added, “ICU patients might be excluded from transplant in some centers, due to economic, ethical and relapse concerns. At Houston Methodist, we have long practiced that we should consider transplanting everyone who needs the organ, and that includes patients in the ICU.” Thus, one of the study’s many strengths is that nearly 60% of transplant patients presented from the ICU, adding a new perspective to current literature. “These findings should encourage other centers to consider early liver transplantation for more alcohol use disorder patients, including those in the ICU, regardless of pre-transplant sobriety and liver disease severity,” Connor emphasized.

Other study strengths include a large and diverse patient population (183 patients) at a single transplant center, whereas most existing studies include patients from multiple centers. Outcome variables were also approached differently. “Our outcome variables included the time difference from when patients received their transplant to when they relapsed, whereas other studies have only considered relapse after transplant as a dichotomous variable,” Connor said. “This allowed us to consider the time period from transplant to relapse as a risk factor for worse outcomes.” Pleased with the study results, Connor looks forward to prospectively exploring health outcomes of patients with alcoholic liver disease starting from the moment they're referred to transplant. “As part of our R01-funded multi-center consortia, this perspective will result in more granularity about their pre-transplant journey and how certain factors affect outcomes, including if patients forgo transplant for any reason,” Connor said. The team also plans to implement alcohol biomarkers into future projects, increasing data accuracy and opening doors to larger sample sizes.