Socioeconomic Vulnerability and Alcohol Relapse After Liver Transplantation for Alcohol-Associated Liver Disease: A Retrospective Study

Background Alcohol relapse after liver transplantation for alcohol-associated liver disease is clinically consequential, yet the predictive value of commonly used pre-transplant psychosocial tools remains inconsistent. We evaluated pre-transplant psychosocial, socioeconomic, biomarker, and clinical variables associated with post-transplant alcohol relapse. Methods We performed a single-center retrospective cohort study of adults transplanted for alcohol-associated liver disease from January 2020 through February 2026. Relapse was defined as any post-transplant alcohol use by self-report or positive phosphatidylethanol (PEth) (or blood alcohol concentration (BAC) testing. Candidate predictors included employment status, age, Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT), CAGE score, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) severity, support plan quality, pre-transplant phosphatidylethanol, sobriety duration, and substance use history. PHQ-9, GAD-7, and SIPAT values were harmonized into standard severity categories before analysis. Univariable testing used chi-square, Fisher's exact, and Mann-Whitney U tests. Logistic regression used complete cases for each predictor. Results Of 340 reviewed patients, 38 were excluded because their relapse status was indeterminate, leaving 302 patients. Twenty patients met relapse criteria; 13 of 20 events occurred beyond 12 months post-transplant. Employment status was associated with relapse: 14 of 120 unemployed patients relapsed, compared with 3 of 78 employed patients and 1 of 49 retired patients. Unemployment was associated with increased relapse odds (odds ratio (OR) 4.061, 95% confidence interval (CI) 1.297-12.714, p = 0.016). Relapsed patients were younger than non-relapsed patients, and age was inversely associated with relapse odds (OR 0.950 per year, 95% CI 0.909-0.993, p = 0.023). PHQ-9 showed a borderline, non-linear pattern, while SIPAT, sobriety duration, pre-transplant phosphatidylethanol, CAGE, DSM-5 severity, and support plan quality were not associated with relapse. Conclusions Unemployment and younger age were associated with post-transplant alcohol relapse, whereas several conventional pre-transplant tools did not stratify relapse risk. Employment status should not be used as an exclusion criterion but may identify socioeconomic vulnerability warranting enhanced post-transplant monitoring and support.