Review article: Current indications and selection criteria for early liver transplantation in severe alcohol‐associated hepatitis

Summary Background Alcohol‐associated hepatitis (AH) is a severe inflammatory form of alcohol‐associated liver disease (ALD) that carries a high mortality rate. Early liver transplantation for severe AH is increasingly available. However, specific criteria for referral and selection remain a subject of debate. Aims To provide a narrative review of the natural history, diagnostic criteria and indications for referral for early liver transplantation for severe AH. Methods We searched PubMed for articles published through August 2023. Key search terms were ‘alcoholic hepatitis,’ ‘alcohol‐associated hepatitis,’ ‘abstinence,’ ‘alcohol relapse,’ and ‘liver transplantation.’ Results Previously, a six‐month period of alcohol abstinence was required before patients with ALD were considered for liver transplantation. However, studies in recent years have demonstrated that, among carefully selected patients, patients who received early transplants have much higher survival rates than patients with similarly severe disease who did not undergo transplants (77% vs. 23%). Despite these successes, early liver transplantation remains controversial, as these patients have typically not undergone treatment for alcohol use disorder, with the ensuing risk of returning to alcohol use. Conclusions While early liver transplantation for AH has survival benefits, many patients would not have received treatment for alcohol use disorder. An integrated approach to evaluating candidacy for early liver transplantation is needed.