REVIEW OF: Herrick-Reynolds KM et al, JAMA Surg 2021;156(11):1026–1034

STUDY TYPE: Retrospective cohort study

Traditionally, patients with alcohol-related liver disease are told that they have to be sober for at least six months before they can have a liver transplant (LT). The theory is that if patients don’t undergo a period of abstinence, they are more likely to relapse after the surgery and damage their recently transplanted liver. The authors of this study wanted to find out if the six-month waiting period is warranted by comparing outcomes between two groups of patients: those who received an LT before six months of sobriety versus those who received one after that period.

Authors retrospectively looked at patients with alcohol-related liver disease who had received LT between October 2012 and November 2020 and divided them into an early LT group (fewer than 180 days of abstinence at the time of transplant) and a standard LT group (greater than 180 days). Outcomes measured included patient survival, early relapse (drinking within 90 days of LT), relapse-free survival, and hazardous relapse–free survival. Hazardous relapse was defined as binge drinking (at least five drinks for men or at least four drinks for women), at-risk drinking (more than 14 drinks per week for men or more than seven drinks per week for women), or frequent drinking (at least four occasions per week).

Of 163 patients total, 88 received early LT and 75 received standard LT. 66% of the patients were male, 34% were female, and 87% were White; gender and race demographics did not differ significantly between the two groups. The two significant demographic differences were that patients who underwent early LT were younger compared to patients in the standard LT group (mean age 49.7 years vs 54.6 years) and had more severe illness (MELD score 35 vs 20). At the time of transplant, the mean number of days abstinent was 66.5 days in the early LT group and 481 days in the standard LT group.

One-year and three-year survival rates were similar for both groups (94.1% for early LT vs 95.9% for standard LT at one year; 83% for early LT vs 78.6% for standard LT at three years). Relapse-free survival and hazardous relapse–free survival rates were also comparable at one year and three years. Early LT had no association with relapse or hazardous relapse.

The researchers did find an association between younger age and return to drinking. Patients younger than 60 years were more likely to have a relapse (adjusted hazard ratio [aHR] = 8.31, p = 0.008) or a hazardous relapse (aHR = 9.02, p = 0.009) compared to older patients. Unsurprisingly, researchers also found that patients who had an early relapse had lower overall survival (aHR = 5.46, p = 0.02).

Carlat Take

In this study, LT outcomes were similar for patients with alcohol-related liver disease whether or not they were abstinent for six months prior to surgery, suggesting that this traditional waiting period is arbitrary. If your patients are being made to wait for six months before receiving a transplant, consider discussing the matter with their surgeon to advocate for earlier surgery.