Early liver transplant for alcohol-associated liver disease: Current state and future directions

Alcohol-associated liver disease (ALD) is a rapidly increasing indication for liver transplantation (LT) globally with a significant rise in transplants for ALD with limited sobriety including patients with alcohol-associated hepatitis (AH). This evolution challenges the older paradigm that mandates prolonged periods of alcohol abstinence prior to LT. Due to the limited armamentarium of effective pharmacotherapy to treat severe AH, the mortality rates are significantly higher when LT is not available. In the patients who are transplanted for ALD with limited sobriety including AH, patient and graft survival are equivalent, if not better, compared to patients transplanted for other etiologies. However, due to the risk of alcohol relapse and other psychosocial factors, public opinion regarding early LT may continue to impact how the field moves forward particularly regarding organ stewardship and the need for equitable allocation of organs. Numerous tools for psychosocial evaluations have been developed to assist liver transplant teams to identify appropriate patients in a more uniform manner. In this review, we aim to assess the available evidence to support early LT for alcohol AH and propose directions for the future as the field continues to evolve.