MELD-based allocation disproportionately prioritizes alcohol-associated hepatitis for liver transplant

Early liver transplantation (LT) is increasingly being adopted as a treatment for alcohol-associated hepatitis (AAH), but the optimal strategy for incorporating AAH into the existing organ allocation framework remains unclear. This retrospective cohort study used the United Network for Organ Sharing database (1/1/2018-12/31/2024) to compare adults waitlisted for first-time, single-organ LT for AAH against other alcohol-associated liver disease (ALD) and non-ALD. During the study period, waitlisting and LT for AAH increased more than six-fold, with 98.2% of centers performing LT for this indication. Compared to other ALD and non-ALD, patients with AAH experienced lower waitlist mortality (8.2% vs. 12.6% and 19.3%, respectively; p <0.001) and higher LT rates (81.2% vs. 69.0% and 67.0%, respectively; p <0.001). After adjusting for clinical and demographic characteristics on initial waitlist application, both other ALD and non-ALD were associated with higher waitlist mortality relative to AAH (adjusted hazard ratio [aHR]=1.23 with p =0.003 and aHR=1.86 with p <0.001, respectively). Among patients with AAH, waitlist mortality was not associated with MELD scores <40 ( p =0.66). Across all MELD categories, non-ALD was associated with higher waitlist mortality than AAH (HR 1.83-3.23; all p ≤0.005), while other ALD was associated with higher mortality at most MELD strata ( p <0.05 at MELD 20-24 and ≥30). Of individual MELD components, serum sodium was not associated with AAH waitlist mortality (HR=1.01; p =0.53), while INR was a stronger predictor of mortality in AAH than other LT indications (HR=1.95 for AAH vs. HR=1.14 for other ALD vs. HR=1.23 for non-ALD; all p <0.001). Patients with AAH are disproportionately prioritized under the current organ allocation system, underscoring the need to revise allocation practices to ensure equitable LT access.