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

Export Background: Early liver transplantation (LT) for alcohol-associated hepatitis (AH) is controversial in part because patients may recover, and obviate the need for LT. Methods: In this retrospective study among 5 ACCELERATE-AH sites, we randomly sampled patients evaluated and then declined for LT for AH. All had MELD>20 and<6 months of abstinence. Recompensation was defined as MELD<15 without variceal bleeding, ascites or overt hepatic encephalopathy requiring treatment. Multi-level 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 [IQR 13-70] and 31 [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%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 due to 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 (aHR1.13, P<0.001) and age (aHR1.03, P<0.001) were associated with early (≤90 d) death, and only history of failed alcohol rehabilitation (aHR1.76, P=0.02) was associated with late death. Conclusions: Liver recompensation is infrequent among severe AH patients declined for LT. Higher MELD-Na and age were associated with short-term mortality, while only history of failed alcohol rehabilitation was associated long-term mortality. The distinction between survival and liver recompensation merits further attention.