Clinical outcomes in MetALD compared with ALD in patients referred for liver transplant evaluation

BACKGROUND: In patients with steatotic liver disease, metabolic dysfunction and alcohol-associated liver disease (MetALD) is a recently defined entity combining metabolic syndrome and moderate-to-high alcohol consumption. Its prognosis and outcomes compared with alcohol-associated liver disease (ALD) remain underexplored. The aim of the study was to assess liver recompensation (LR) between the 2 groups in patients with decompensated liver disease referred for liver transplant (LT) evaluation. METHODS: We conducted a retrospective cohort study of 194 patients with decompensated liver disease, diagnosed as MetALD or ALD, and referred for LT evaluation between October 2021 and August 2023 at a single U.S. transplant center, and compared the outcomes between the 2 groups. The diagnoses of MetALD and ALD were based on the Delphi consensus definitions. RESULTS: Of the 194 patients, 135 (70%) had ALD and 59 (30%) had MetALD. Baseline characteristics showed significantly higher BMI (31 vs. 28 kg/m2, p=0.001), chronic kidney disease (32% vs. 17%, p=0.025), and lower Karnofsky scores (51 vs. 62, p=0.014) in the MetALD group. While no statistical difference was found in listing and LT rates between groups, LR occurred significantly less in MetALD compared with ALD (3% vs. 18%, p=0.006). On multivariable analysis, MetALD independently predicted lower LR (HR 0.21, 95% CI: 0.05-0.91). Hypertension (HR 0.38, 95% CI: 0.16-0.89) and increasing BMI (HR 0.91, 95% CI: 0.84-0.99) were also significantly associated with lower LR. While overall mortality was higher in the MetALD group (42% vs. 26%, p=0.029), MetALD was not an independent mortality predictor after adjustment. CONCLUSIONS: Compared with ALD, MetALD is associated with significantly lower LR in patients with decompensated liver diseases referred for LT evaluation.