We thank Li and colleagues 1 for their thoughtful comments on our study 2 and appreciate the opportunity to further elaborate on these issues and present additional analyses stratified by World Health Organization (WHO) region. Across the Region of the Americas, European Region and Western Pacific Region, there were no significant differences in post-transplant patient survival and graft survival. Data from the European and Western Pacific Regions were insufficient to permit robust analyses of waitlist survival and delisting due to clinical improvement. Temporal analysis comparing pre-2015 and post-2015 post LT survival in ALD versus non-ALD groups was reported in our manuscript, where in ALD patients had improved survival compared to non-ALD patients (HR: 0.700, 95% CI: 0.642–0.763, p < 0.001), but this was limited by the small number of studies (n = 2) post-2015 and must be interpreted cautiously. The observed survival advantage in more contemporary cohorts may reflect evolving recipient selection practices, changes in comparator case mix and advances in peri-transplant management rather than solely due to intrinsic differences in disease biology. We additionally performed regional analyses examining post-transplant complications. ALD patients in the Region of the Americas had higher odds of developing a de novo malignancy (OR: 2.746, 95% CI: 1.844–4.090, p < 0.001) whereas there was no significant difference between ALD and non-ALD patients in the European Region. However, only four European studies reported de novo malignancy outcomes, limiting interpretability. Although both the Region of the Americas and European Region showed significant associations in developing a cerebrovascular event post-transplant, the overall pooled estimate from our study was not statistically significant. With respect to alcohol relapse, malignancy surveillance and dynamic prediction for waitlist allocation, the authors agree that these represent key considerations for optimising post-transplant management and waitlist prioritisation. As acknowledged in our original discussion, alcohol relapse data were inconsistently reported across included studies, precluding formal meta-analysis. Prospective studies incorporating standardised relapse metrics will be essential to improve risk stratification and survival modelling. We further concur that the increased malignancy risk observed in ALD recipients underscores the importance of vigilant post-transplant surveillance. Our findings are consistent with prior studies demonstrating elevated malignancy risk and reinforce the need for further research to define optimal surveillance approaches in ALD recipients 2, 3. Finally, the observation that ALD patients were more frequently delisted due to clinical improvement highlights the potential for hepatic recompensation 4, 5. Development of robust dynamic prediction models capable of identifying patients most likely to benefit from liver transplantation versus continued observation would improve waitlist management and support more efficient organ allocation. We are grateful to Li and colleagues for their constructive engagement, which strengthens the interpretation and clinical implications of our work. Ryan Yanzhe Lim: writing – original draft, writing – review and editing. Glenn Jun Kit Ho: writing – original draft, writing – review and editing. Mirudhula Gnanavelou: writing – original draft, writing – review and editing. Eunice Xiang-Xuan Tan: writing – original draft, writing – review and editing. The authors have nothing to report. The authors' declarations of personal and financial interests are unchanged from those in the original article 2. 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.70573. All articles referenced in the original manuscript are available from MEDLINE and EMBASE. Table S1: Outcomes of liver transplant recipients with and without alcohol-associated liver disease by World Health Organization region. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.
Lim et al. (Mon,) studied this question.