Liver transplantation in alcohol-induced acute-on-chronic liver failure without six months of abstinence

Globally, many liver transplantation programs require adherence to a 6-month abstinence period in cases of alcohol-associated liver disease. Especially in cases of decompensation, such as acute-on-chronic liver failure (ACLF), the severity of the disease often makes it impossible to reach this interval, leading to increasing critical scrutiny of a fixed abstinence period. The prognostic relevance of the 6-month abstinence is also not firmly established.In the present study, we analyze all patients who were presented for liver transplantation at a German transplantation center due to acute-on-chronic liver failure caused by alcohol-associated liver disease.Retrospective analyses of patients with alcohol-associated liver disease who did not complete the 6-month abstinence period.Out of the 83 patients initially considered, 78 were included in the final analysis. The patients who underwent liver transplantation (n=16) had a significantly better 5-year survival rate (81.3% vs. 24.2%; p < 0.001). Especially in patients with ACLF and multiple organ dysfunctions (ACLF Grade 3), liver transplantation resulted in a significantly improved survival rate. Patients with an ACLF Grade 3 who were not transplanted died within the first six months after decompensation (92.5% mortality). All surviving transplant recipients continued abstaining from alcohol until the most recent evaluation point (average follow-up time 963 days).Patients experiencing acute-on-chronic liver failure from alcohol-related liver disease clearly benefit from liver transplantation, irrespective of whether they meet the 6-month abstinence criterion. This stipulated waiting period is increasingly debated in current discussions. Our findings emphasize that patients with ACLF, when not transplanted, face significant mortality risks. Such insights should be factored into tailored treatment decisions.