Liver and Bile
Hepatology. 2022;75(1):104–14
Recovery and outcomes of patients denied early liver transplantation for severe alcohol-associated hepatitis
Background and aims: Liver transplantation (LT) in alcohol-associated hepatitis (AH) remains controversial, in part because spontaneous recovery (SR) can occur. There is a paucity of data on SR in patients with severe AH who undergo LT evaluation. The purpose of this study was to determine factors associated with SR and survival in patients with severe AH who undergo LT evaluation.
Approach and results: This is a retrospective study of alcohol-associated liver disease (ALD) patients with Model for End-stage Liver Disease (MELD) > 25 and < 90 days abstinence who underwent LT evaluation at a single center between 2012 and 2018. 144 patients (median age, 45.5 years; 68.1% male) were included. 49 (34%) patients underwent LT and 95 (66%) did not undergo LT, and of those, 34 (23.6%) experienced SR. Factors associated with recovery were younger age (odds ratio [OR] = 0.92; p = 0.004), lower index international normalized ratio (INR, 0.31; p = 0.03), and lower peak MELD (OR = 0.83; p = 0.02). Only 7 patients (20.6%) achieved a compensated state with a MELD < 15 and absence of therapy for ascites or hepatic encephalopathy. Survival was improved in patients who underwent early LT when compared to SR. Survival was impaired in SR following relapse to alcohol use when compared to SR patients who abstained and LT recipients. Among all 6-month survivors of AH, alcohol use trended toward an association with mortality (hazard ratio [HR] = 2.05; p = 0.17), but only LT was associated with decreased mortality risk (HR = 0.20; p = 0.005).
Conclusions: Spontaneous recovery from alcohol-associated hepatitis after liver transplantation (LT) evaluation is associated with age, index international normalized ratio, and lower peak MELD. Most recovered patients continue to experience end-stage complications. LT is the only factor associated with lower mortality.