Spontaneous Recovery and Mortality in Patients with ALD Referred for Early Liver Transplantation

INTRODUCTION: Alcohol-associated liver disease (ALD), including alcohol-associated hepatitis (AH), is the leading cause of liver transplant (LT) in the United States (US), and acceptance of LT without a mandatory period of abstinence is increasing. However, some patients may achieve spontaneous recovery (SR) without LT. We evaluated predictors of mortality and SR among patients with ALD referred for early LT. METHODS: RESOLVE-ALD is a retrospective cohort of adults with ALD and <6 months of sobriety referred for early LT between 2018-2021 at six transplant centers across the US. Fine-Gray competing risk regression evaluated predictors of 12-month mortality, with LT considered as a competing risk. Multivariable logistic regression identified predictors of 12-month SR, defined by the expanded Baveno VII criteria. RESULTS: Of 607 patients, the median MELD 3.0 was 29 (IQR 22-36); the median time from last drink was 2.6 months (IQR 1.1-4.1). Independent predictors of 12-month mortality included higher INR (sHR 1.49, 95% CI 1.23-1.79) and higher BUN (sHR 1.16 per 10 mg/dL, 95% CI 1.07-1.25). After 12 months, 18.5% achieved SR without LT. Predictors of SR at 12 months were lower INR (OR 0.52, 95%CI 0.31-0.83) and higher platelet count (OR 1.04 per 10x103/µL, 95%CI 1.01-1.08). CONCLUSIONS: Among patients with ALD and short-term abstinence, BUN and platelets are novel predictors of outcomes, along with INR. Utilizing these predictors - or recalibrating existing MELD coefficients - in this unique patient population may help refine medical selection criteria and improve utility and equity in access to early LT.