Expedited assessment for liver transplantation in patients with alcohol-associated liver disease using the Dallas...

The Dallas consensus conference on liver transplantation for alcohol-associated hepatitis (2020) provided a framework for the selection of liver transplant candidates with alcohol-associated liver disease (ALD) regardless of sobriety period. The primary aim of this study is to describe our experience with the implementation of this approach to a broader population with ALD. We established a new interdisciplinary ALD clinic in a large integrated health care system in Texas for expedited assessment for liver transplant (LT) candidacy. Candidates who had short sobriety were mandated to follow this pathway. Selected patients were seen through a structured interdisciplinary clinic pathway before and after transplantation with an ALD hepatologist, surgeon, coordinator, and transplant psychologist. Between 2021 and 2024, 114 patients [MELD 25 (21-28), 47% female] were referred to the ALD clinic. Alcohol use disorder (AUD) and mental health-related comorbid conditions were high. Overall, 97 (85%) were willing to participate in AUD counseling and mental health evaluation, and attendance with the ALD clinic was high (78%). The most common form of treatment preference was outpatient peer support groups (81%) and individual therapy (50%). Among the referrals, 23% were denied LT candidacy; 12% died during their evaluation, and 50% were approved to proceed to LT evaluation. Among LT candidates, 13% clinically improved to the point where they no longer required LT, and 32% patients received a LT. In intent-to-treat analysis, survival at 1 year was similar for patients who were referred to the ALD clinic as compared with ALD patients referred to the overall transplant program through the traditional mechanisms (89.5 vs. 82.9, p =0.22). There were no deaths related to alcohol use. Relapse to alcohol use occurred in 6 patients (16%); 4 were defined as slips, and 2 had sustained alcohol use; relapse rates were similar to non-ALD clinic patients ( p =0.258). Successful early LT assessment can be achieved in the setting of a structured pathway with excellent survival and low rates of relapse. Patients are adherent to recommendations and actively engage before and after LT once the appropriate programmatic structure is created.