Alcohol-related liver disease and access to liver transplantation: where we stand and where we should go

Alcohol-related liver disease (ArLD) is now a leading indication for liver transplantation worldwide, yet access to this life-saving therapy remains inequitable. Late diagnosis, persistent stigma, rigid abstinence requirements, and fragmented care pathways continue to disadvantage patients with ArLD relative to those with other liver diseases. Landmark studies have shown that early liver transplantation for severe alcohol-associated hepatitis confers a clear survival benefit when performed within rigorous selection protocols, with rates of return to drinking comparable to those achieved under the long-standing six-month abstinence rule, thereby challenging its clinical rationale. Concurrently, growing evidence supports the integration of addiction medicine and mental health expertise into transplant programs, recognizing alcohol use disorder as a chronic relapsing disease requiring sustained, multidisciplinary management. Despite this progress, substantial variability persists across centers in candidate evaluation, psychosocial assessment, and post-transplant addiction care. This Point of View examines the current landscape across six interconnected domains, epidemiology, timing of diagnosis, the dual nature of ArLD as a disease of mind and liver, stigma, access to transplantation, and multidisciplinary models of care, and proposes directions for harmonized, evidence-based, and equitable practice.