6-Month Abstinence Rule Not Associated With Better Outcomes for Liver Transplants in ALD

close up of liver transplant scars
Researchers investigated survival outcomes for patients with alcohol-associated liver disease undergoing early vs standard liver transplant.

Adherence to the 6-month abstinence rule was not associated with superior survival outcomes in selected patients with alcohol-associated liver disease (ALD) who underwent their first liver transplant (LT), researchers reported in JAMA Surgery.

The retrospective cohort study included patients from an academic referral center who underwent their first LT for ALD from October 1, 2012, to November 13, 2020. The follow-up period consisted of the time from LT to the most recent encounter with a transplant center or death.

Patients with known pretransplant hepatocellular carcinoma, hepatitis B or C, or a concomitant alternative cause of liver failure were excluded. Early LT was the exposure of interest and was defined as <180 days of pre-LT abstinence. Standard LT was defined as ≥180 days of pre-LT abstinence.

Among 163 patients who had an LT for ALD, 88 (54%) received early LT and 75 (46%) received standard LT. The median follow-up was 701 (interquartile range [IQR], 345-1311) days. The cohort included 108 men (66%) and 55 women (34%), with a mean age at transplant of 52 (SD, 10) years. Participants who had early LT were younger at the time of transplant compared against those receiving standard LT (median age, 49.7 [IQR, 39.0-54.2] years vs 54.6 [IQR, 48.7-60.0] years, respectively; P <.001).

Patients who had early LT and standard LT had similar 1-year patient survival (94.1% [95% CI, 86.3%-97.5%] vs 95.9% [95% CI, 87.8%-98.7%], respectively; P =.60) and 3-year patient survival (83.0% [95% CI, 70.9%-90.5%] vs 78.6% [95% CI, 63.2%-88.2%], respectively; P =.60). Additionally, they had similar 1-year allograft survival (92.7% [95% CI, 84.4%-96.7%] vs 90.5% [95% CI, 81.0%-95.3%], respectively; P =.42) and 3-year allograft survival (81.7% [95% CI, 69.4%-89.4%] vs 74.7% [95% CI, 59.2%-85.0%], respectively; P =.42) after the transplant.

Relapse-free survival in the early LT and standard LT groups, respectively, was similar at 1 year (80.4% [95% CI, 69.1%-88.0%] vs 83.5% [95% CI, 72.2%-90.6%]; P =.41) and 3 years (61.8% [95% CI, 46.4%-73.9%] vs 71.5% [95% CI, 57.7%-81.5%]; P =.41) after the transplant. Hazardous relapse–free survival was comparable in the early LT and standard LT groups, respectively, at 1 year (85.8% [95% CI, 75.1%-92.2%] vs 89.6% [95% CI, 79.5%- 94.9%]; P =.41) and 3 years (69.2% [95% CI, 53.9%-80.3%] vs 79.4% [95% CI, 66.1%-88.0%]; P =.41).

The investigators noted that relapse was detected through patient follow-up visits, with laboratory screening used only as clinically indicated. Additionally, the results were subjected to confounding by indication, as the selection process and post-transplant alcohol use disorder treatment for patients who had early LT vs standard LT were different, owing to illness severity. Finally, the number of patients with ALD who were not referred or selected for LT was unknown.

“This study supports the identification of alternative criteria that will allow deliberate selection of patients with ALD on the basis of need and posttransplant outcomes while remaining defensible in the public eye,” stated the researchers.

Disclosure: One of the study authors declared an affiliation with a pharmaceutical company. Please see the original reference for a full list of authors’ disclosures.


Herrick-Reynolds KM, Punchhi G, Greenberg RS, et al. Evaluation of early vs standard liver transplant for alcohol-associated liver disease. JAMA Surg. Published online August 11, 2021. doi: 10.1001/jamasurg.2021.3748