Letter: Liver Transplantation Outcomes for Alcohol‐Associated Liver Disease—Commentary on an Individual Patient Data Meta‐Analysis and Future Research Directions

We read with great interest the individual patient data meta-analysis by Ho et al. 1 comparing waitlist and post-transplant outcomes between patients with and without alcohol-associated liver disease (ALD). The study is timely, given the rising prevalence of ALD as an indication for liver transplantation, and provides valuable pooled evidence on survival and complication risks. The use of reconstructed individual patient data enhances the reliability of long-term survival estimates. First, we suggest that future analyses incorporate alcohol relapse data into survival models. Although the study highlights de novo malignancy as a key factor in long-term survival, alcohol relapse is a critical moderator of outcomes in ALD. Studies such as Incze 2 have shown that alcohol relapse significantly impacts graft and patient survival, yet its interaction with malignancy risk remains underexplored in this meta-analysis. A case series on injectable extended-release naltrexone (XR-NTX) for alcohol use disorder (AUD) in advanced ALD demonstrated safety and reduced alcohol consumption in 57% of patients, suggesting potential to mitigate relapse and associated risks 3. Integrating relapse status could refine risk stratification and inform post-transplant care protocols. Second, the high heterogeneity observed underscores the need for era-stratified and centre-specific analyses. The availability of direct-acting antivirals and evolving transplant criteria have substantially altered outcomes for viral hepatitis, which may confound comparisons with ALD 4. As noted by Kwong et al. 5, temporal trends in transplant outcomes are pronounced. A meta-analysis on severe alcohol-associated hepatitis (sAH) mortality trends showed no significant improvement over decades, with rates of 26.8% at 28 days, highlighting persistent challenges in ALD management 6. Subgroup analyses based on transplant era or geographic region could elucidate whether survival disparities are consistent across different clinical settings. Third, the increased malignancy risk in ALD patients warrants emphasis on tailored surveillance strategies. The finding of a doubled risk for de novo malignancy aligns with prior reports 7. A nationwide cohort study on gastrointestinal cancer risks in steatotic liver diseases (including ALD) reported adjusted hazard ratios of 3.55–5.39 for hepatocellular carcinoma and elevated risks for oesophageal, gastric and colorectal cancers with higher alcohol intake 8. We recommend that future guidelines explicitly address screening protocols for oropharyngeal, lung and skin cancers in ALD recipients, possibly initiating surveillance earlier or at more frequent intervals than in non-ALD patients. Fourth, the study highlights a critical need for dynamic prediction models for waitlist management. The observation that ALD patients are more likely to be delisted due to improvement suggests that liver recompensation after abstinence is both common and clinically significant 9, 10. Developing validated tools to identify patients who may recover without transplantation could optimise organ allocation and reduce waitlist mortality. In conclusion, Ho et al. have provided a comprehensive analysis that reinforces the importance of long-term malignancy surveillance and individualised care in ALD transplant recipients. Future research should aim to integrate behavioural, temporal and centre-level data to further personalise management and improve outcomes in this growing patient population. Xinglin Li: writing – original draft, writing – review and editing, data curation, supervision, conceptualization. Junnan Xu: writing – review and editing, data curation, supervision, validation. Chang Liu: conceptualization, supervision, writing – review and editing, validation. The authors have nothing to report. This article is linked to Ho et al. papers. To view these articles, visit https://doi.org/10.1111/apt.70434 and https://doi.org/10.1111/apt.70607. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.