Equitable outcomes for critically urgent living donor liver transplantation in acute alcoholic hepatitis

Backgrounds/Aims: The justification for living donor liver transplantation (LDLT) for acute alcoholic hepatitis (AAH) remains debated, particularly in urgent settings.We compared outcomes of recipients undergoing urgent LDLT for AAH versus other causes and identified predictors of mortality.Methods: We analyzed 317 adults in the Korean national registry who underwent urgent LDLT from 2017 to 2021 within seven days of emergency approval.AAH was defined using National Institute on Alcohol Abuse and Alcoholism criteria, excluding coexisting liver disease.Recipient, donor, and perioperative variables were compared between the AAH (n = 114) and non-alcoholic groups (n = 203).Survival was assessed using Kaplan-Meier analysis, and predictors of death using Cox regression.Results: AAH recipients had more severe decompensation, particularly hepatorenal syndrome and ascites.One-, two-, and threeyear survival rates were 90.1%, 86.5%, and 86.5% in the AAH group versus 83.1%, 79.6%, and 77.9% in the non-alcoholic group (logrank p = 0.321).Overall, 66 recipients (20.8%) died.Pretransplant ventilator support (hazard ratio [HR] 1.954), donor age ≥ 55 years (HR 3.134), and chronic kidney disease independently predicted mortality, whereas AAH did not (HR 0.765, 95% confidence interval 0.440-1.329;p = 0.341).Conclusions: AAH did not independently predict mortality following urgent LDLT.Instead, outcomes were influenced by the recipient's pre-surgery condition and the characteristics of the donor and graft, suggesting that the procedure is justified when candidates are carefully selected.