Early liver transplantation in alcohol-associated liver disease—Evolution of practice, patient selection, management, and outcomes

Early liver transplantation (eLT) for alcohol-associated liver disease (ALD), defined as transplantation with less than 6 months of alcohol abstinence, has emerged as a standard intervention for carefully selected patients unresponsive to medical therapy. Rising ALD prevalence, driven by increased alcohol use, particularly among patients in early adulthood, and exacerbated by the COVID-19 pandemic, has led to an increased demand for eLT for ALD. Recent studies have demonstrated that eLT can yield survival outcomes comparable to standard liver transplantation, although patient selection remains challenging, with return to drinking (RTD) after transplant a primary concern. Various psychosocial evaluation tools can help identify candidates at lower risk for RTD, but predictive accuracy remains limited due to the complex, individualized nature of alcohol use disorder among ALD patients. Multidisciplinary approaches to managing alcohol use disorder, such as integrated care models, are increasingly being adopted to improve outcomes and achieve sustained alcohol abstinence after transplant. Despite the recent increase in eLT for ALD, international practices vary widely, with countries like the United States, France, and Belgium leading in adoption, whereas others still impose strict sobriety requirements. Notably, racial, ethnic, and geographic disparities in access to eLT for ALD have emerged, highlighting the need for more standardized and equitable practices. This review traces the development and expansion of eLT in ALD, addressing selection and management challenges, while proposing a biopsychosocial framework to optimize patient and graft outcomes across the liver transplantation continuum.