Impact of Removing the Mandatory Sobriety Period on Waitlist and Posttransplant Outcomes of Patients With and Without Alcohol-associated Liver Disease

Background. This single-center study assessed the impact of eliminating the mandatory 6-mo sobriety requirement on waitlist and post-liver transplant (LT) outcomes among patients with and without alcohol-associated liver disease (ALD). Methods. Adult patients listed for LT from 2010 to 2023 and followed through 2025 were analyzed. Era 1 (<2018) required ≥6 mo of sobriety, whereas era 2 (≥2018) did not. Competing risk models compared waitlist outcomes across eras. Post-LT survival was compared across eras, followed by a subgroup analysis of era 2 ALD recipients stratified by pre-LT sobriety duration. Results. ALD listings increased (26% versus 42%), whereas non-ALD declined in era 2 (74% versus 58%). In era 2, listed ALD candidates had a higher likelihood of transplant (hazard ratio, 1.90; P < 0.001), lower likelihood of death/deterioration (hazard ratio, 0.48; P = 0.03), and shorter listing-to-LT time (204 versus 98 d; P = 0.004), whereas non-ALD likelihood of transplant, death/deterioration, and time-to-LT were unchanged. One-year post-LT survival was similar across eras, whereas 3- and 5-y survival were higher in era 2 (83% versus 91%; P = 0.01), driven by improved ALD survival with unchanged non-ALD survival. In a subgroup analysis of era 2 ALD transplant recipients, the <6-mo sobriety group had higher transplant Model of End-stage Liver Disease scores (34 versus 28; P < 0.001) lower unadjusted 1-y survival (88% versus 97%; P = 0.04) but similar survival after adjustment for Model of End-stage Liver Disease score ( P = 0.29) compared with the 6-mo sobriety group. Recidivism, rejection, and nonadherence rates were similar between groups. Conclusions. Liberalization of sobriety policy improved access to LT and long-term survival for ALD patients without compromising non-ALD outcomes.