Liver Transplantation Outcomes in Patients With and Without Alcohol Use Disorder Diagnosis: Evidence From a Nationwide Cohort Study

Objectives: Alcohol-related liver disease is the primary indication for liver transplantation, yet posttransplant outcomes among recipients with an alcohol use disorder (AUD) diagnosis remain inconsistent. This study assesses whether AUD is associated with adverse liver transplantation (LT) outcomes after adjustment for clinical and sociodemographic factors. Methods: We conducted a retrospective cohort study of adult LT recipients (2015–2024) using a nationally representative electronic health record database (Atropos). Recipients with AUD within 1 year before transplantation were compared with recipients without the diagnosis. Outcomes included mortality, graft rejection, and hospitalization. Confounding was addressed using unmatched analyses, demographic matching, and high-dimensional propensity score matching (HDPSM). One-year outcomes were assessed with odds ratios (ORs) and long-term outcomes with Cox models and Kaplan-Meier analyses. Results: Among 24,865 recipients of LT, the ones who had an AUD diagnosis (n=2393) presented an association with higher posttransplant mortality across all analytic approaches. In the adjusted HDPSM analysis, AUD was associated with increased 1-year mortality (OR: 3.20, 95% CI: 1.81–5.64) and greater long-term mortality risk (HR: 1.81, 95% CI: 1.24–2.62). Elevated risks of graft rejection and hospitalization were observed in less-adjusted models; however, these associations were no longer statistically significant after HDPSM adjustment (eg, 1-y graft rejection OR: 1.13, 95% CI: 0.85–1.48; long-term hospitalization HR: 0.91, 95% CI: 0.78–1.05). Conclusions: AUD is associated with increased post-LT mortality even after adjustment. Differences in graft rejection and hospitalization were attenuated after HDPSM, suggesting influence from comorbidity and health care utilization rather than AUD alone.