Multifactor Risk Stratification for Post‐Transplant Alcohol Relapse Using Abstinence, Psychosocial, and Socioeconomic Factors

ABSTRACT Aim Post‐liver transplant (LT) alcohol relapse complicates long‐term outcomes and organ allocation. The traditional “six‐month abstinence rule” remains widely used, but relapse risk is also shaped by psychosocial, socioeconomic, and psychiatric factors. We examined the impact of pre‐LT abstinence duration on post‐LT alcohol relapse and developed a multivariable risk model integrating abstinence, psychosocial assessment, and socioeconomic status. Methods In this single‐center retrospective study, 383 adults undergoing LT for alcohol‐related liver disease were included. Results Any post‐LT alcohol relapse occurred in 20.9% ( n = 80). Relapse phenotypes were non‐mutually exclusive: sustained alcohol use (77.5%), harmful drinking (68.8%), and recurrent ALD (46.3%). On multivariable analysis, shorter pre‐LT abstinence, higher Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) scores, and higher educational attainment were independently associated with relapse. Each additional month of abstinence reduced relapse odds by 4%, whereas each one‐point increase in SIPAT increased relapse odds by 3%. Cumulative risk curves demonstrated a non‐linear relationship between abstinence duration and relapse, with risk peaking around 9 months and declining thereafter across all relapse phenotypes. A prediction model combining abstinence duration, SIPAT score, and education achieved an area under the receiver operating characteristic curve (AUC) of 0.70, with consistent performance on fivefold cross‐validation. Conclusion These findings support a multifactorial approach to relapse risk stratification that goes beyond a fixed 6‐month abstinence rule. Incorporating abstinence duration together with structured psychosocial assessment and education level may better inform both transplant listing decisions and the intensity of post‐LT addiction care for patients.