Time to Break the Abstinence Rule Before Liver Transplants?

Survival rates were comparable at 1 year among patients with alcohol-associated liver disease (ALD) who abstained from drinking for 6 months prior to liver transplant and those who did not, a retrospective cohort found.

Patients who received a liver transplant prior to 180 days of abstinence showed similar rates of survival compared to those who abstained for 180 days or more (94.1% vs 95.9%, respectively, P=0.60), reported Andrew M. Cameron, MD, PhD, from Johns Hopkins University in Baltimore, and colleagues in JAMA Surgery.

There were also no significant differences in other survival outcomes between these “early” and “standard” transplant groups:

• Allograft survival (92.7% vs 90.5%, respectively, P=0.42)
• Relapse-free survival (80.4% vs 83.5%, P=0.41)
• Hazardous relapse-free survival (85.8% vs 89.6%, P=0.41)

Liver transplant wait lists have an abundance of ALD patients with symptoms from steatosis, to cirrhosis, to alcohol-associated liver failure. The authors noted that while the “6-month cutoff” for alcohol abstinence may be associated with lower rates of alcohol relapse, it is not “validated nor applicable” for those who cannot survive 6 months without a liver transplant.

“The main clinical implication of this study is that the criterion we have been using to determine who is eligible for a liver transplant, the ‘6-month rule’ is probably incorrect,” Cameron told MedPage Today. “Many patients are denied life-saving therapy based on this rule and there is probably a better way to decide.”

For their study, the researchers evaluated 163 ALD patients who received a first-time liver transplant from October 2012 to November 2020. Prior to transplant, the 88 patients in the early transplant group were abstinent for a median 66.5 days (interquartile range [IQR] 35.0-116.0 days), as compared with 481 days (IQR 280-850 days) for the 75 patients in the standard group (P<0.001).

Inclusion criteria for the transplant list required patient evaluations for medical management failure, history on hazardous drinking, strong social support, and commitment to alcohol abstinence. The main outcomes assessed were allograft survival, patient survival, relapse-free survival, and hazardous relapse-free survival.

Authors defined relapse according to the National Institute on Alcohol Abuse and Alcoholism, as the first alcohol drink consumed after liver transplantation and hazardous relapse was binge drinking: four to five drinks on a single occasion.

Mean age at transplant was 52, two-thirds of the patients were men, and most (87%) were white. Patients in the standard liver transplant group were older than the early liver transplant group (54.6 vs 49.7 years) and were more frequently transferred from an outside institution. Median follow-up was 701 days.

At listing, early liver transplant recipients had greater disease severity (MELD score 35 vs 20 in the standard group, P<0.001). Early liver transplant recipients also had shorter wait list times (7 vs 77 days, P<0.001).

The authors also noted that they identified an association between young age and early relapse with poor outcomes.

Study limitations included that relapse was detected through patient follow-up visits, with laboratory screening only “as clinically indicated” and potential confounding by indication, with different selection and treatment processes for early or standard patients, the authors acknowledged.

“Next steps are to determine ‘best practices’ for these patients who are candidates for transplant without a 6-month waiting period — how best to select them and how to take care of them post-transplant to prevent relapse,” Cameron said. “Identification of these best practices will allow for dissemination of this practice to other transplant centers around the country and thus help more needy patients.”