Liver and Bile
Hepatology. 2023;77(4):1253–62
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.