Title

Model to Calculate Harms and Benefits of Early vs Delayed Liver Transplantation for Patients with Alcohol-Associated Hepatitis.

Document Type

Article

Publication Date

4-15-2019

Publication Title

Gastroenterology

Keywords

6-month rule; Markov model; accelerate-ah; drinking

Abstract

BACKGROUND & AIMS: Early liver transplantation (without requiring a minimum period of sobriety) for severe alcohol-associated hepatitis (AH) is controversial-many centers delay eligibility until a specific period of sobriety (such as 6 months) has been achieved. To inform ongoing debate and policy, we modeled long-term outcomes of early vs delayed liver transplantation for patients with AH.

METHODS: We developed a mathematical model to simulate early vs delayed liver transplantation for patients with severe AH and different amounts of alcohol use after transplantation: abstinence, slip (alcohol use followed by sobriety), or sustained use. Mortality of patients before transplantation was determined by joint-effect model (based on model for end-stage liver disease [MELD] and Lille scores). We estimated life expectancies of patients receiving early vs delayed transplantation (6-month wait before placement on the waitlist) and life-years lost attributable to alcohol use after receiving the liver transplant.

RESULTS: Patients offered early liver transplantation were estimated to have an average life expectancy of 6.55 life-years, compared to an average life expectancy of 1.46 life-years for patients offered delayed liver transplants (4.49-fold increase). Net survival benefit from early transplantation was highest for patients with Lille scores of 0.50-0.82 and MELD scores of 32 or more. Patients who were offered early transplantation and had no alcohol use afterward were predicted to survive 10.85 years compared to 3.62 years for patients with sustained alcohol use after transplantation (7.23 life-years lost). Compared with delayed transplantation, early liver transplantation increased survival times in all simulated scenarios and combinations of Lille and MELD scores.

CONCLUSIONS: In a modeling study of assumed carefully selected patients with AH, early vs delayed liver transplantation (6 months of abstinence from alcohol before transplantation) increased survival times of patients, regardless of estimated risk of sustained alcohol use following transplant. These findings support early liver transplantation for patients with severe AH. The survival benefit was maintained in all simulated extreme scenarios, but should be confirmed in prospective studies. Sustained alcohol use following transplantation significantly reduced but did not eliminate the benefits of early transplantation-strategies are needed to prevent and treat post-transplantation use of alcohol.

Clinical Institute

Digestive Health

Department

Hepatology

Department

Surgery

Department

Swedish Digestive Health Institute

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