Acute Alcohol-Associated Hepatitis: The Role of Liver Transplantation

Severe alcohol-associated hepatitis (AH) remains one of the most challenging syndromes in hepatology and critical care, with high short-term mortality despite advances in supportive management. Although corticosteroids remain the only guideline-endorsed pharmacologic therapy shown to improve early survival, their benefit is modest, limited to selected patients, and frequently complicated by infection. Consequently, contemporary management extends well beyond corticosteroid therapy and requires meticulous supportive care, nutritional optimization, infection surveillance, management of portal hypertensive complications and acute-on-chronic liver failure (ACLF), and early multidisciplinary involvement. This review summarizes the current evidence regarding the diagnosis, prognostic assessment, and medical management of severe AH. Key prognostic models, including MELD, Maddrey Discriminant Function, and the Lille score, are discussed together with evolving evidence supporting individualized corticosteroid use and emerging investigational therapies. Particular emphasis is placed on critically ill patients with ACLF, in whom extrahepatic organ failure often supersedes liver dysfunction as the principal determinant of outcome. The review also examines the evolving role of early liver transplantation (LT), one of the most important paradigm shifts in modern transplant hepatology. Contemporary approaches to patient selection, psychosocial assessment, relapse-risk evaluation, living donor transplantation, and the management of patients with catastrophic AH are discussed, along with ethical considerations surrounding organ allocation, medical urgency, and stewardship of scarce donor organs. Despite important advances in supportive care and transplantation, severe AH continues to carry substantial mortality. Optimizing outcomes requires timely diagnosis, multidisciplinary management, careful selection for medical therapy, and early recognition of patients unlikely to recover without liver transplantation.