Behavioral alcohol use disorder therapy in early liver transplant evaluation for alcohol-associated liver disease – a multicenter retrospective cohort study

BACKGROUND: Behavioral alcohol use disorder therapy (bAUDT) is increasingly used to improve eligibility and outcomes for liver transplant (LT) among patients with alcohol-associated liver disease (ALD), especially as more centers consider LT for patients with <6 months of sobriety. This study evaluates the impacts of bAUDT in the peri-LT setting in a multicenter cohort of patients with early sobriety. METHODS: RESOLVE-ALD is a multicenter retrospective cohort study including adults with ALD and <6 months of abstinence undergoing liver transplant evaluation (LTE) between 2018-2021 at six United States LT centers. Multivariable logistic regression identified predictors of bAUDT participation during LTE and assessed its impact on LT waitlisting. Competing risk analyses examined how bAUDT affected risk of return to alcohol use pre- and post-LT. RESULTS: Among 545 patients analyzed (median sobriety time 79 days; 52.8% inpatient evaluations), 22.4% participated in bAUDT during LTE and 43% received LT. Prior alcohol-related illness (aOR=1.93, p=0.03) and heavier daily drinking (aOR=1.90, p=0.04) were associated with increased adjusted odds of bAUDT during LTE, while older age (aOR=0.41, p=0.006), underinsurance (aOR=0.42, p=0.01), and hospitalization during LTE (aOR=0.42, p=0.02) were associated with reduced adjusted odds. bAUDT participation during LTE significantly increased adjusted odds of LT waitlisting (aOR=3.40, p=0.006), but did not predict return to use pre- or post-LT. CONCLUSION: bAUDT is more common among patients with risk factors for return to use and with the medical and financial stability to participate in therapy. Although associated with increased waitlisting adjusted odds, bAUDT does not significantly predict return to alcohol use pre- or post-LT. Future research should explore optimal methods of integrating bAUDT into the LTE process to improve access and minimize barriers to LT.