Evaluating the demographics of patients transplanted for alcohol-related liver disease: A retrospective and prospective longitudinal cohort study

Alcohol-related liver disease (ALD) is among the top three indications for orthotopic liver transplantation (OLT). A period of abstinence of 6 months was previously required in British Columbia (BC) before being considered for listing for liver transplantation. The liver transplant program in BC abandoned this rule in 2019. We aimed to evaluate if there was a change in characteristics of patients referred for liver transplant following removal of an mandatory abstinence period. We conducted a longitudinal cohort study with both retrospective and prospective arms on data obtained from the BC transplant database. Outcomes of interest included transplant, discharge or death and documented alcohol relapse. We compared the 5 years prior to the change in criteria to the following 5 years. From January 2014 to May 2024 there were 1005 referrals. Changes were noted in the mean age of referral (57 vs 52), proportion of women (32 % pre change vs 40 % post change) and First Nations patients referred (4.6 % vs 13.8 %). Relapse proportions were similar pre and post change but the median time to relapse was shorter post-change. Removing a mandatory sixth month abstinence period improved referrals for First Nations patients, women and younger patients with similar outcomes demonstrated.

Background

Alcohol-related liver disease (ALD) is among the top three indications for orthotopic liver transplantation (OLT) in British Columbia (BC). A period of abstinence of 6 months was previously required before being considered for listing for liver transplantation. The liver transplant program in BC opted in May 2019 to abandon the six month rule, and to base their decision on a multidisciplinary evaluation of the risk of alcohol relapse.

Aims

The purpose of this study is to evaluate if there has been a change in characteristics of patients referred for liver transplant for alcohol related liver disease in British Columbia following removal of a six month period of abstinence.

Method

We conducted a longitudinal cohort study with both retrospective and prospective arms on data obtained from the BC transplant database. Patients of any age referred for liver transplant evaluation for alcohol related liver disease were included. Outcomes of interest included transplant, discharge or death and documented alcohol relapse. We compared the 5 years prior to the change in criteria to the following 5 years.

Results

From January 2014 to May 2024 there were 1005 referrals. The mean age at referral pre-change was 57 vs 52 post-change. 32 % of referrals were female pre- whilst 40 % were female post-change. The proportion of First Nations patients referred for assessment was 4.6 % pre 2019 and 13.8 % post 2019. No differences in proportion of women transplanted or mean age at transplant was found. There was a clinically significant increase in the proportion of First Nation patients transplanted post-change (13.7 %) compared to pre-change (7.1 %). Relapse proportions were 14.9 % and 11.2 % pre and post-change respectively. The median time to relapse was shorter in the post-change era.

Conclusions

Since removal of a mandatory period of abstinence from alcohol, the BC liver transplant program has seen a significant change in the demographics of patients referred for liver transplant assessment. Patients referred are younger with higher MELD scores. The change has allowed more First Nation patients to be assessed and transplanted.