Distinguishing Reversible Physiologic Acuity From Behavioral Risk in Liver Transplantation for Acute Alcoholic Hepatitis

Liver transplantation for acute alcohol-associated hepatitis (AAH) remains contested because severe pre-transplant illness is read as a marker of poor prognosis. We asked whether physiologic acuity at transplantation predicts early outcome and which severity measure carries prognostic information. We studied 492 consecutive adult single-organ liver transplant recipients at one center (2018-2023), 32 transplanted for AAH. One-year survival was estimated by Kaplan-Meier methods with censoring at last follow-up and modeled by Cox regression adjusted for age, laboratory MELD, intensive care, and Karnofsky status. Biopsy-proven rejection and candidacy scores were taken from institutional records. Acute alcohol-associated hepatitis recipients were younger (40 vs 55 years), had higher MELD (37 vs 24), poorer Karnofsky status (30% vs 50%), and were more often hospitalized (91% vs 37%; all P < .001). One-year survival was 96.9% (95% CI, 79.8-99.6) vs 91.1% (95% CI, 87.9-93.4); this rests on 1 death among AAH recipients and is not evidence of equivalence. Karnofsky status was the only independent predictor of death (HR per 10 points, 0.75; 95% CI, 0.57-0.98); AAH, MELD, age, and intensive care were not. Physiologic acuity did not forecast early death, and functional capacity rather than the severity score carried the prognostic signal. These data support decoupling MELD and level of care from candidacy; they do not measure alcohol relapse, which is a later cumulative outcome and the substantive unresolved concern in this population.