Predicting Low‐Risk for Sustained Alcohol Use After Early Liver Transplant for Acute Alcoholic Hepatitis: The SALT Score

Abstract

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.

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