Predicting Low-Risk for Sustained Alcohol Use After Early Liver Transplant for Acute Alcoholic Hepatitis: The SALT Score.
Hepatology (Baltimore, Md.)
6-month rule; Transplantation; accelerate-ah; recidivism; relapse
Early liver transplant (LT) for alcohol-associated disease (i.e. without a specific sobriety period) is controversial, but increasingly used. Using the multicenter American Consortium of Early Liver Transplantation for Alcoholic Hepatitis (ACCELERATE-AH) cohort, we aimed to develop a predictive tool to identify patients pre-transplant with low-risk for sustained alcohol use post-transplant to inform selection of candidates for early LT candidates. We included consecutive ACCELERATE-AH LT recipients between 2012-2017. All had clinically-diagnosed severe alcoholic hepatitis (AH), no prior diagnosis of liver disease or AH, and underwent LT without a specific sobriety period. Logistic and cox regression, classification and regression trees (CART), and LASSO regression were used to identify variables associated with sustained alcohol use post-LT. Among 134 LT recipients for AH with median abstinence pre-LT of 54 days, 74% were abstinent, 16% had slips only, and 10% had sustained alcohol use after median 1.6 (IQR 0.7-2.8) years follow-up post-LT. Four variables were associated with sustained use of alcohol post-LT, forming the SALT (Sustained Alcohol use post-LT) score (range, 0-11): >10 drinks/day at initial hospitalization (+4 points), multiple prior rehabilitation attempts (+4 points), prior alcohol-related legal issues (+2 points), prior illicit substance abuse (+1 point). C-statistic was 0.76 (95% CI, 0.68-0.83). SALT of ≥5 had 25% PPV (95% CI, 10%-47%) and 95% NPV (95% CI, 89%-98%) for sustained alcohol use post-LT. In internal cross-validation, the average c-statistic was 0.74. CONCLUSION: A novel prognostic score, the SALT score, using four objective pre-transplant variables identifies AH candidates for early LT at low-risk for sustained alcohol use post-transplant. This tool may assist in the selection of patients with AH for early LT or to guide risk-based interventions post-LT. This article is protected by copyright. All rights reserved.
Lee, Brian P; Vittinghoff, Eric; Hsu, Christine; Han, Hyosun; Therapondos, George; Fix, Oren K; Victor, David W; Dronamraju, Deepti; Im, Gene Y; Voigt, Michael D; Rice, John P; Lucey, Michael R; Eswaran, Sheila; Chen, Po-Hung; Li, Zhiping; Maddur, Haripriya; and Terrault, Norah A, "Predicting Low-Risk for Sustained Alcohol Use After Early Liver Transplant for Acute Alcoholic Hepatitis: The SALT Score." (2018). Articles, Abstracts, and Reports. 908.