EARLY IDENTIFICATION OF LIVER TRANSPLANTATION REQUIREMENT IN ALCOHOL-ASSOCIATED HEPATITIS

Abstract

Introduction and Objectives

Severe alcohol‐associated hepatitis (AH) has a high risk of short-term mortality especially in those r with acute‐on‐chronic liver failure (ACLF). Delayed evaluation for liver transplantation (LT) in severe AH often worsens nutritional and functional status. This study aimed to identify early mortality predictors.

Materials and Methods

In a prospective study, 981 adults with AH were enrolled from 32 centers in 14 countries (January 2015–September 2024). ACLF was classified by EASL-CLIF criteria. Primary outcomes were 30- and 90-day mortality. Competing-risk regression (LT as the competing event) and receiver-operating-characteristic (AUROC) analyses evaluated clinical scores predicting development of ACLF grades 2–3 within seven days of admission.

Results

The mean age was 48.3 ± 11.2 years, and 88.7% were male. Within the first week, 68.8% of patients had ACLF—30.1% with grade 1, 34.5% with grade 2, and 35.4% with grade 3. Overall survival rates were 84.7% at 30 days and 75.8% at 90 days. Adjusted analyses identified increasing age, infections, higher admission MELD score, and ACLF grades 2 (subdistribution hazard ratio [sHR] 1.59) and 3 (sHR 2.58) as independent predictors of 90-day mortality. The MELD score was the best predictor of developing ACLF grades 2–3 (AUROC 0.869), with MELD ≥28 showing 64% sensitivity and 90% specificity. These findings were confirmed in two external validation cohorts: a prospectively enrolled U.S. cohort (n=234) and a retrospective cohort from seven countries (n=602).

Conclusions

ACLF and infections are key determinants of mortality in severe AH. The MELD score at admission is a robust early predictor of high‐grade ACLF, supporting its use to determine LT candidacy earlier.