Alcoholic Cirrhosis Is Most Common Liver Transplant Indication in Young US Adults

By Patricia A. Sheiner MD

June 22, 2022

NEW YORK (Reuters Health) - Alcohol-associated liver disease is now the most common indication for liver transplant wait-listing among young American adults, researchers say.

From 2003 to 2018, the diagnosis of alcoholic liver disease (ALD) as an indication for wait-listing for liver transplant in the U.S. increased 4-fold (from 0.03/100,000 to 0.13/100,000) in people ages 20-39, they found.

In a report published in Transplantation, the researchers note that during the COVID-19 pandemic, alcohol sales increased most in young adults and in households with dependent children. The increase in wait-listing for ALD in young adults, however, and particularly in young women, may be due to a number of factors, they say. They note that the gender gap for alcohol consumption has narrowed, that women are more likely to have harmful effects of alcohol at lower levels of exposure compared to men, and that there may be more barriers to treatment of alcohol abuse in women.

In order to describe rates of liver transplant wait-listing stratified by age, sex, and indication, George Philip and colleagues from the Queen's University, Kingston, Ontario, Canada reviewed data from the Scientific Registry of Transplant Recipients on 209,399 individuals who were listed for primary liver transplant between 2003 and 2018. The majority were male (68%) and white (85%). The most common indications for listing were hepatitis C virus (HCV; 47%), followed by ALD (19%) and non-alcoholic fatty liver disease (NAFLD; 18%).

Overall, 10,326 (5%) were between 20 and 39 years of age at the time of listing. Compared to patients who were at least 40 years old when placed on the waiting list, these younger adults were more likely to be listed for autoimmune liver disease (AILD; 40% vs 8%) and ALD (25% vs 19%) and less likely to be listed with HCV (14% vs 47%) or NAFLD (14% versus 18%).

The average annual increase in the number of patients wait-listed was 2% per year in those aged 20 to 39 (IRR, 1.02; P<0.001) and 4% per year in those aged 40 or older (IRR, 1.04; P<0.001).

Stratified by indication, the highest increases in listing occurred for individuals listed with NAFLD (IRR, 1.15; P<0.001), HCV between 2003 and 2013 (IRR, 1.08; P < 0.001), and ALD (IRR, 1.07; P<0.001).

Young adults had the most rapid increase in wait-listing for ALD, starting in 2011. By 2017, ALD had surpassed AILD as the most common indication for liver transplant wait-listing in this age group. A 2-fold increase was also observed for those listed with NAFLD (0.02/100,000 in 2003 to 0.04/100,000 in 2018).

Listing of young adults with HCC increased by 1% per year (IRR, 1.01; P<0.001), whereas in those age 40 or older, HCC listings increased on average by 11% per year (IRR, 1.11; P<0.001). Overall, ALD listing in young adults increased by 4% per year from 2003 to 2013 (IRR, 1.04; 95% CI, 1.04-1.05; P < 0.001) and by 17% per year (IRR, 1.17; 95% CI, 1.16-1.17; P <0.001) from 2014 to 2018.

When stratified by gender, wait-listing rates rose by more than 60% in men (2.69/100,000 in 2003 vs 4.32/100,000 in 2018; IRR, 1.04 P < 0.001) and in women (1.27/100,000 vs 2.11/100,000; IRR, 1.03; P<0.001).

Rates of wait-listing in young men increased most for NAFLD (IRR, 1.15; P < 0.001) followed by ALD (IRR, 1.10; P < 0.001). However, in young women, wait-listing rose fastest for the indication of ALD (IRR, 1.14; P < 0.001) followed by NAFLD (IRR, 1.12; P < 0.001). Young women had a higher increase in wait-listing for ALD compared to young men (IRR, 1.11; P < 0.001). Conversely, listing for NAFLD was 3% lower in young women compared to young men (IRR, 0.97; P < 0.001). In both sexes, declines in listing for HCV and hepatitis B virus were observed.

Listing of older males for the indication of NAFLD increased almost 4-fold (0.24/100,000 in 2003 to 0.92/100,000 in 2018) at an annual rate of 17% per year, whereas ALD listing rates tripled (0.54/100,000 in 2003 to 1.4/100,000 in 2018). In females, the increase in listing for ALD (0.1/100,000 in 2003 to 0.5/100,000 in 2018) was greater than that for NAFLD (0.21/100,000 in 2003 to 0.8/100,000 in 2018); however, by 2018, the highest rate of new LT wait-listing in women was for NAFLD followed by ALD and HCV.

In patients older than 40, the highest increase - an average of 15% per year - was seen for those with NAFLD (0.32/100,000 in 2003 vs 1.20/100,000), whereas listing for ALD increased by 6% per year (0.48/100,000 in 2003 vs 1.19/100,000). Listing for HCV increased on average by 8% per year from 2003 to 2013 (IRR, 1.08; P <0.001) and the declined by 12% per year from 2014 to 2018 (IRR, 0.88; P < 0.001).

Future studies "must focus on raising awareness to the general population on the burden of ALD with a specific focus to identify disease at early stages," the authors conclude.

SOURCE: Transplantation, online June 1, 2022.