Liver and Bile

Hepatology. 2023;77(4):1253–62

Hsu CC, Dodge JL, Weinberg E, Im G, Ko J, Davis W, Rutledge S, Dukewich M, Shoreibah M, Aryan M, Vosooghi A, Lucey M, Rice J, Terrault NA, Lee BP

Multicentered study of patient outcomes after declined for early liver transplantation in severe alcohol-associated hepatitis

Background: Early liver transplantation for alcohol-associated hepatitis is controversial in part because patients may recover, and obviate the need for liver transplantation.
Methods: In this retrospective study among 5 ACCELERATE-AH sites, the authors randomly sampled patients evaluated and then declined for liver transplantation for alcohol-associated hepatitis. All had Model for End-stage Liver Disease (MELD) > 20 and < 6 months of abstinence. Recompensation was defined as MELD < 15 without variceal bleeding, ascites, or overt hepatic encephalopathy requiring treatment. Multilevel mixed effects linear regression was used to calculate probabilities of recompensation; multivariable Cox regression was used for mortality analyses.
Results: Among 145 patients (61% men; median abstinence time and MELD-Na was 33 days [interquartile range {IQR}, 13–70] and 31 days [IQR, 26–36], respectively), 56% were declined for psychosocial reasons. Probability of 30-day, 90-day, 6-month, and 1-year survival were 76% (95% confidence interval [CI]: 68–82%), 59% (95% CI: 50–66%), 49% (95% CI: 40–57%), and 46% (95% CI: 37–55%), respectively. Probability of 1-year recompensation was low at 10.0% (95% CI: 4.5–15.4%). Among patients declined because of clinical improvement, 1-year probability of recompensation was 28.0% (95% CI: 5.7–50.3%). Among survivors, median MELD-Na at 30 days, 90 days, and 1 year were 29 (IQR, 22–38), 19 (IQR, 14–29), and 11 (IQR, 7–17). Increased MELD-Na (adjusted hazard ratio [aHR] = 1.13, p < 0.001) and age (aHR = 1.03, p < 0.001) were associated with early (≤ 90 days) death, and only history of failed alcohol rehabilitation (aHR = 1.76, p = 0.02) was associated with late death.

Conclusions: Liver recompensation is infrequent among severe alcohol-associated hepatitis patients declined for liver transplantation. Higher MELD-Na and age were associated with short-term mortality, whereas only history of failed alcohol rehabilitation was associated with long-term mortality. The distinction between survival and liver recompensation merits further attention.

B.P. Lee, M.D., Assistant Professor of Clinical Medicine, University of Southern California, Los Angeles, CA, USA,

DOI: 10.1097/hep.0000000000000267

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