Defining Risk in Alcohol-Associated Liver Disease Using the Model for End-Stage Liver Disease

Alcohol-associated liver disease (ALD) is a common cause of morbidity and premature mortality. Most prognostic scores have been defined in the short term. We used a large retrospective cohort of patients with ALD to describe the natural history of ALD and to define risk prediction in the longer term, taking nonliver mortality into account.

The WALDO cohort includes 734 patients with biopsy-proven ALD. Prognostic scores were assessed with dynamic area under the curve and C-index. Risk estimates for morbidity and mortality were derived for the model for end-stage liver disease (MELD) and validated in an external cohort.

During a median follow-up of 4.9 years, 240 patients died from liver disease or underwent liver transplantation (LT), and 114 patients died from nonliver causes. Outcomes varied across the spectrum of ALD: The cumulative incidence of liver-related death or LT in people with decompensated cirrhosis or alcohol-associated hepatitis was 47% and 40%, respectively, compared with 7.4% in patients without cirrhosis and 13% in compensated cirrhosis. MELD was the best predictor of outcomes: (area under the curve for mortality/LT at 1 year was 0.853), although MELD3.0 and the Child-Turcotte-Pugh score performed similarly. Risk of liver-related outcomes were tabulated for integer values of the MELD score. Risk estimates based on the MELD were well calibrated in an external cohort.

These data illustrate the natural history of ALD and define the risks of outcomes based on the MELD score across the spectrum of disease.