## Definition and brief pathophysiology

- AH is a clinical syndrome of **acute hepatic inflammation** caused by sustained heavy alcohol exposure, often superimposed on steatosis, fibrosis, or cirrhosis.
- Key mechanisms:
  - ethanol metabolism generates **acetaldehyde**, oxidative stress, and mitochondrial injury
  - gut barrier dysfunction increases **endotoxin exposure**
  - Kupffer-cell activation and cytokine signaling drive **neutrophil-rich inflammation**
  - cholestasis, hepatocyte ballooning, and impaired regeneration worsen jaundice and organ failure ([Jophlin et al., 2024](https://pubmed.ncbi.nlm.nih.gov/38174913/); [EASL, 2018](https://pubmed.ncbi.nlm.nih.gov/29628280/)).

 InlinePopup label="Pathology pearl" title="Histology and the role of biopsy" tone="violet" 
- Typical histology includes **steatosis, ballooning degeneration, lobular neutrophilic inflammation, cholestasis, Mallory-Denk bodies, and pericellular fibrosis**.
- **Biopsy is not routinely required** when the presentation is classic.
- Biopsy is most helpful when diagnosis is uncertain or when an alternative diagnosis would change management, especially corticosteroid decisions ([Jophlin et al., 2024](https://pubmed.ncbi.nlm.nih.gov/38174913/)).
 /InlinePopup 

## Diagnosis

- Suspect AH in a patient with **recent heavy alcohol use** and **new or worsening jaundice**.
- Supportive findings include fever, tender hepatomegaly, leukocytosis, ascites, encephalopathy, and SIRS.
- **Probable AH (NIAAA clinical criteria):**
  - onset of jaundice within the **previous 8 weeks**
  - ongoing alcohol use of ** 40 g/day in women** or ** 60 g/day in men** for **≥6 months**
  - ** 60 days of abstinence** before jaundice onset
  - total bilirubin ** 3 mg/dL**
  - AST ** 50 U/L**
  - **AST:ALT  1.5**
  - both AST and ALT typically ** 400 U/L**
  - no more likely competing cause of acute hepatitis ([Crabb et al., 2016](https://pubmed.ncbi.nlm.nih.gov/26921783/); [Jophlin et al., 2024](https://pubmed.ncbi.nlm.nih.gov/38174913/))
- AH is primarily a **clinical diagnosis**.

 InlineDropdown label="When should liver biopsy be strongly considered?" variant="block" tone="info" 
- Uncertain alcohol exposure history
- Atypical AST/ALT pattern
- Concern for **drug-induced liver injury, ischemic hepatitis, autoimmune hepatitis, viral hepatitis, biliary obstruction/cholangitis, Wilson disease, Budd-Chiari syndrome, portal vein thrombosis, or malignant infiltration**
- When confirmation would change **corticosteroid use, trial eligibility, or transplant decision-making**
 /InlineDropdown 

## Guideline-based workup

### History

- Quantity, pattern, and recency of alcohol use; last drink; prior withdrawal
- Prior liver decompensation, prior AH, pancreatitis, GI bleeding
- Medications, supplements, acetaminophen, herbal agents, other substances
- Infectious symptoms, abdominal pain, diarrhea, melena, hematemesis, confusion
- Nutrition, weight loss, frailty, social support, prior AUD treatment

### Physical exam

- Jaundice, hepatomegaly, ascites, edema, asterixis, encephalopathy
- Fever, SIRS, volume status, bleeding, stigmata of chronic liver disease
- Evaluate for **alcohol withdrawal and hepatic encephalopathy**, which may coexist

### Laboratory evaluation

- CBC, CMP, bilirubin, AST/ALT, alkaline phosphatase
- INR/PT, albumin, creatinine, glucose
- Viral hepatitis testing
- Blood and urine cultures when indicated
- Diagnostic paracentesis for **new or worsening ascites**

### Imaging

- **RUQ ultrasound with Doppler** is first-line
- Assess for cirrhosis, steatosis, ascites, biliary dilation, portal/hepatic vein thrombosis
- CT or MRI selectively for pancreatitis, malignancy, abscess, or uncertain obstruction ([Jophlin et al., 2024](https://pubmed.ncbi.nlm.nih.gov/38174913/); [EASL, 2018](https://pubmed.ncbi.nlm.nih.gov/29628280/)).

 InlineDropdown label="Differential diagnosis" variant="block" tone="warning" 
- Acute viral hepatitis
- Drug-induced liver injury
- Ischemic hepatitis
- Autoimmune hepatitis
- Acute biliary obstruction or cholangitis
- Wilson disease in younger patients
- Budd-Chiari syndrome
- Portal vein thrombosis
- Sepsis-associated cholestasis
- Decompensated cirrhosis without superimposed AH
- Hepatocellular carcinoma or other malignant infiltration
 /InlineDropdown 

## Severity assessment

- **MELD is the preferred current score** in guideline-based practice.
  - **Moderate AH:** **MELD ≤20**
  - **Severe AH:** **MELD  20**
- ACG recommends using **MELD  20** to stratify severity, estimate short-term mortality risk, and guide corticosteroid use ([Jophlin et al., 2024](https://pubmed.ncbi.nlm.nih.gov/38174913/)).

### Maddrey discriminant function (mDF)

- **Formula:** `4.6 × (patient PT − control PT) + bilirubin (mg/dL)`
- mDF is the **historical** severity score used in classic AH trials.
- **mDF ≥32** defines severe disease in the historical literature and predicts about **20% to 50% 30-day mortality** ([Jophlin et al., 2024](https://pubmed.ncbi.nlm.nih.gov/38174913/)).
- Current guidelines favor **MELD over mDF** because MELD has better prognostic performance, uses INR rather than local PT calibration, and incorporates creatinine ([Morales-Arráez et al., 2022](https://pubmed.ncbi.nlm.nih.gov/34962498/); [Jophlin et al., 2024](https://pubmed.ncbi.nlm.nih.gov/38174913/)).

### When are steroids recommended?

- **Current ACG approach:** recommend corticosteroids for **severe AH defined by MELD  20**, if there are no contraindications ([Jophlin et al., 2024](https://pubmed.ncbi.nlm.nih.gov/38174913/)).
- **Historical approach:** corticosteroids were typically studied in patients with **mDF ≥32**, and many classic trials enrolled patients using that threshold ([Maddrey et al., 1978](https://pubmed.ncbi.nlm.nih.gov/352788/)).
- Practical interpretation:
  - use **MELD** as the preferred decision framework now
  - use **mDF** mainly to interpret older evidence and older bedside terminology

 InlinePopup label="Score nuance" title="MELD vs Maddrey" tone="violet" 
- ACG identifies **MELD** as the preferred score for contemporary severity assessment and steroid decisions.
- mDF remains useful historically because many classic corticosteroid trials used **mDF ≥32** for enrollment.
- In a global study, **MELD outperformed mDF** for short-term mortality prediction in AH ([Morales-Arráez et al., 2022](https://pubmed.ncbi.nlm.nih.gov/34962498/); [Jophlin et al., 2024](https://pubmed.ncbi.nlm.nih.gov/38174913/)).
 /InlinePopup 

## Prognosis and survival data

- **Severe AH**
  - contemporary guidance cites **1-month mortality of 20% to 50%** ([Jophlin et al., 2024](https://pubmed.ncbi.nlm.nih.gov/38174913/))
  - current cohorts report **90-day survival ranging from 35% to 70%**, depending on severity and treatment response ([Jophlin et al., 2024](https://pubmed.ncbi.nlm.nih.gov/38174913/))
- **Moderate AH**
  - **1-year mortality ranges from 10% to 20%** ([Jophlin et al., 2024](https://pubmed.ncbi.nlm.nih.gov/38174913/))
- **If severe AH is evaluated for transplant but early transplant is not performed**
  - among the **95 nontransplanted patients** in one LT-evaluation cohort, spontaneous recovery by day 90 occurred in **34/95 (35.8%)**
  - only **7/95 (7.4%)** achieved a compensated state by the end of follow-up; this was **20.6% of those with spontaneous recovery** ([Musto et al., 2022](https://pubmed.ncbi.nlm.nih.gov/34387875/))
- **Abstinence improves survival**
  - complete abstinence after an episode of AH was associated with better long-term survival (**HR 0.53, p=0.03**) ([Altamirano et al., 2017](https://pubmed.ncbi.nlm.nih.gov/28646515/))
- **Early transplant in selected severe nonresponders**
  - markedly improves short-term survival and can provide excellent longer-term outcomes in carefully selected patients ([Mathurin et al., 2011](https://pubmed.ncbi.nlm.nih.gov/22070476/); [Lee et al., 2018](https://pubmed.ncbi.nlm.nih.gov/29655837/))

 InlinePopup label="Evidence trial" title="Dynamic prognosis with Lille" tone="violet" 
 a href="https://pubmed.ncbi.nlm.nih.gov/27922027/"  u A Day-4 Lille Model Predicts Response to Corticosteroids and Mortality in Severe Alcoholic Hepatitis /u  /a 

- **Study type:** Retrospective multinational validation study

- **Population:**
  - Patients with severe AH with **Maddrey DF ≥32**
  - **260 total** patients; **163 (62.7%)** received corticosteroids

- **Intervention:**
  - Lille score assessment at **day 4**

- **Comparison:**
  - Lille score assessment at **day 7**
  - Responders vs nonresponders using **Lille  0.45** cutoff

- **Outcomes:**
  - **LM4 independently predicted 28-day mortality:** **OR 25.4, 95% CI 5.1-126.8, p 0.001**
  - **28-day survival:** **90% vs 66%**, **p 0.001**
  - **90-day survival:** **76% vs 40%**, **p 0.001**
  - Predictive accuracy was similar for **LM4 vs LM7**: **AUROC 0.77 vs 0.75**, **p=0.558**

- **Clinical implication:**
  - Day-4 Lille performs similarly to day-7 Lille and can support earlier discontinuation of futile corticosteroid therapy ([Garcia-Saenz-de-Sicilia et al., 2017](https://pubmed.ncbi.nlm.nih.gov/27922027/)).
 /InlinePopup 

## Management: core guideline-based care

- **Hospitalize severe AH**, especially if there is encephalopathy, AKI, infection, GI bleeding, or ACLF ([Jophlin et al., 2024](https://pubmed.ncbi.nlm.nih.gov/38174913/)).
- Treat the whole syndrome:
  - search for infection aggressively
  - manage bleeding, ascites, encephalopathy, AKI/HRS, and alcohol withdrawal
  - involve hepatology, addiction medicine, nutrition, and social work early
- **Nutrition is core therapy**
  - target **35 kcal/kg/day**
  - target **1.2 to 1.5 g/kg/day protein**
  - if intake is ** 21 kcal/kg/day**, add oral supplementation and consider enteral feeding
  - replete **thiamine, vitamin B12, and zinc** ([Jophlin et al., 2024](https://pubmed.ncbi.nlm.nih.gov/38174913/))
- **Alcohol use disorder treatment is essential**
  - relapse prevention should begin during hospitalization
  - sustained abstinence is one of the strongest determinants of survival ([Altamirano et al., 2017](https://pubmed.ncbi.nlm.nih.gov/28646515/); [Jophlin et al., 2024](https://pubmed.ncbi.nlm.nih.gov/38174913/))

 InlineDropdown label="Common pitfalls in initial management" variant="block" tone="warning" 
- Starting steroids before excluding uncontrolled infection or major competing diagnoses
- Underfeeding the patient
- Missing alcohol withdrawal because encephalopathy is also present
- Continuing steroids despite clear nonresponse
- Treating the liver while failing to start an AUD treatment plan
 /InlineDropdown 

## Corticosteroids

- **ACG recommendation:** in **severe AH (MELD  20)**, treat with corticosteroids if there are no contraindications ([Jophlin et al., 2024](https://pubmed.ncbi.nlm.nih.gov/38174913/)).
- Standard regimen:
  - **prednisolone 40 mg daily for 4 weeks**
  - **prednisone 40 mg daily for 4 weeks** may be used if prednisolone is unavailable
  - **IV methylprednisolone 32 mg/day** if oral therapy is not feasible
  - there is **no evidence** that rapid vs slow tapering after the 4-week course improves outcomes ([Jophlin et al., 2024](https://pubmed.ncbi.nlm.nih.gov/38174913/))
- Reassess with **Lille score at day 4 or day 7**
- **Stop corticosteroids if Lille  0.45** ([Garcia-Saenz-de-Sicilia et al., 2017](https://pubmed.ncbi.nlm.nih.gov/27922027/); [Jophlin et al., 2024](https://pubmed.ncbi.nlm.nih.gov/38174913/))
- The maximum short-term benefit appears in patients with **MELD 25 to 39**; benefit is more limited in the **40 to 50** range and absent above **MELD  51** ([Arab et al., 2021](https://pubmed.ncbi.nlm.nih.gov/34166722/); [Jophlin et al., 2024](https://pubmed.ncbi.nlm.nih.gov/38174913/)).

 InlineDropdown label="Contraindications or reasons to defer steroids" variant="block" tone="warning" 
- Uncontrolled infection or sepsis
- Active GI bleeding
- Severe renal failure or rapidly progressive multiorgan failure
- Uncontrolled diabetes or marked hyperglycemia
- Untreated hepatitis B or another major competing infection
- Significant diagnostic uncertainty where steroids may be harmful

- Note: after adequate control of infection, GI bleeding, or renal failure, corticosteroids may still be reconsidered in selected patients ([Jophlin et al., 2024](https://pubmed.ncbi.nlm.nih.gov/38174913/)).
 /InlineDropdown 

 InlinePopup label="Evidence trial" title="Historical steroid trial" tone="violet" 
 a href="https://pubmed.ncbi.nlm.nih.gov/352788/"  u Corticosteroid Therapy of Alcoholic Hepatitis /u  /a 

- **Study type:** Randomized double-blind placebo-controlled trial

- **Population:**
  - **55** patients with alcoholic hepatitis

- **Intervention:**
  - **Prednisolone 40 mg/day** for **28 to 32 days**

- **Comparison:**
  - Placebo

- **Outcomes:**
  - Deaths occurred in **1/24** prednisolone-treated patients vs **6/31** placebo-treated patients during the study interval/early post-study period
  - The direct between-group comparison by **Fisher exact test** was **p=0.10**
  - In stepwise discriminant analysis that included treatment as a variable, corticosteroid therapy was associated with reduced mortality (**p 0.05**)

- **Clinical implication:**
  - This trial was foundational historically, but the simple randomized mortality comparison in the abstract did **not** meet conventional statistical significance; it nonetheless helped establish the early signal for steroid benefit and the later historical role of **mDF** in severe AH ([Maddrey et al., 1978](https://pubmed.ncbi.nlm.nih.gov/352788/)).
 /InlinePopup 

 InlinePopup label="Evidence trial" title="Individual patient data meta-analysis" tone="violet" 
 a href="https://pubmed.ncbi.nlm.nih.gov/20940288/"  u Corticosteroids Improve Short-Term Survival in Patients With Severe Alcoholic Hepatitis: Meta-analysis of Individual Patient Data /u  /a 

- **Study type:** Individual patient data meta-analysis of randomized controlled trials

- **Population:**
  - Patients with severe AH from **5 RCTs**

- **Intervention:**
  - Corticosteroids

- **Comparison:**
  - Control/placebo or non-steroid therapy

- **Outcomes:**
  - **28-day survival:** **79.97% vs 65.7%**
  - **p=0.0005**
  - Survival benefit was mainly observed among patients classified as responders by the Lille model

- **Clinical implication:**
  - Supports a short-term survival benefit from corticosteroids in severe AH, especially in responders ([Mathurin et al., 2011](https://pubmed.ncbi.nlm.nih.gov/20940288/)).
 /InlinePopup 

 InlinePopup label="Evidence trial" title="STOPAH" tone="violet" 
 a href="https://pubmed.ncbi.nlm.nih.gov/25901427/"  u Prednisolone or Pentoxifylline for Alcoholic Hepatitis /u  /a 

- **Study type:** Multicenter randomized controlled trial with factorial design

- **Population:**
  - Patients with severe AH
  - **n=1103**

- **Intervention:**
  - Prednisolone and/or pentoxifylline

- **Comparison:**
  - Placebo/control in factorial design

- **Outcomes:**
  - For **28-day mortality**, prednisolone showed a borderline effect:
    - **OR 0.72, 95% CI 0.52-1.01, p=0.06**
    - event rates often cited as **13.8% vs 18.0%**
  - No significant mortality benefit at **90 days** or **1 year**
  - Serious infections were more common with prednisolone:
    - **13% vs 7%**, **p=0.002**

- **Clinical implication:**
  - Prednisolone may provide at most a modest short-term benefit and requires careful infection monitoring
  - Pentoxifylline did not provide meaningful survival benefit ([Thursz et al., 2015](https://pubmed.ncbi.nlm.nih.gov/25901427/)).
 /InlinePopup 

 InlinePopup label="Evidence trial" title="Contemporary steroid meta-analysis" tone="violet" 
 a href="https://pubmed.ncbi.nlm.nih.gov/29738698/"  u Corticosteroids Reduce Risk of Death Within 28 Days for Patients With Severe Alcoholic Hepatitis, Compared With Pentoxifylline or Placebo /u  /a 

- **Study type:** Individual patient data meta-analysis

- **Population:**
  - Patients with severe AH from **11 randomized controlled trials**
  - **2111** total patients in the pooled dataset

- **Intervention:**
  - Corticosteroids

- **Comparison:**
  - Placebo/control or pentoxifylline

- **Outcomes:**
  - Compared with controls, corticosteroids reduced **28-day mortality**:
    - **HR 0.64, 95% CI 0.48-0.86**
  - Compared with pentoxifylline, corticosteroids also reduced **28-day mortality**:
    - **HR 0.64, 95% CI 0.43-0.95**
  - There was **no significant difference in 6-month mortality**
  - Corticosteroids increased treatment response compared with controls:
    - **RR 1.24, 95% CI 1.10-1.41**

- **Clinical implication:**
  - Reinforces that corticosteroids provide a **short-term**, not durable, survival benefit in selected severe AH patients ([Louvet et al., 2018](https://pubmed.ncbi.nlm.nih.gov/29738698/)).
 /InlinePopup 

 InlinePopup label="Evidence trial" title="Optimal MELD window for steroids" tone="violet" 
 a href="https://pubmed.ncbi.nlm.nih.gov/34166722/"  u Identification of Optimal Therapeutic Window for Steroid Use in Severe Alcohol-Associated Hepatitis: A Worldwide Study /u  /a 

- **Study type:** Retrospective multicenter international cohort study

- **Population:**
  - Patients with severe AH from a worldwide cohort

- **Intervention:**
  - Corticosteroid therapy

- **Comparison:**
  - No corticosteroid therapy
  - Outcomes stratified by MELD score

- **Outcomes:**
  - Corticosteroids improved **30-day**, but not **90-day** or **180-day**, survival
  - Steroid benefit was seen for MELD scores between **21 and 51**
    - **MELD 21:** **HR 0.61, 95% CI 0.39-0.95, p=0.027**
    - **MELD 51:** **HR 0.72, 95% CI 0.52-0.99, p=0.041**
  - **Maximum benefit** was observed between **MELD 25 and 39**
    - **MELD 25:** **HR 0.58, 95% CI 0.42-0.77, p 0.001**
    - **MELD 39:** **HR 0.57, 95% CI 0.41-0.79, p 0.001**
  - No corticosteroid benefit was seen with **MELD  51**

- **Clinical implication:**
  - Helps personalize steroid use in severe AH and supports the contemporary emphasis that benefit is greatest in the **MELD 25 to 39** range ([Arab et al., 2021](https://pubmed.ncbi.nlm.nih.gov/34166722/)).
 /InlinePopup 

## Adjunctive and nonrecommended therapies

- **IV N-acetylcysteine (NAC)** may be used as an adjunct to corticosteroids in severe AH.
- ACG highlights a **5-day IV NAC course** as the main adjunctive option ([Jophlin et al., 2024](https://pubmed.ncbi.nlm.nih.gov/38174913/)).
- **Do not use pentoxifylline routinely** ([Jophlin et al., 2024](https://pubmed.ncbi.nlm.nih.gov/38174913/)).
- **Do not use universal prophylactic antibiotics**; treat documented infection, but routine prophylaxis has not improved survival ([Jophlin et al., 2024](https://pubmed.ncbi.nlm.nih.gov/38174913/)).
- Anti-TNF biologics are **not recommended** because of infection risk and harm.

 InlinePopup label="Evidence trial" title="Prednisolone plus NAC" tone="violet" 
 a href="https://pubmed.ncbi.nlm.nih.gov/22070475/"  u Glucocorticoids Plus N-Acetylcysteine in Severe Alcoholic Hepatitis /u  /a 

- **Study type:** Multicenter randomized controlled trial

- **Population:**
  - Patients with severe AH
  - **n=174**

- **Intervention:**
  - Prednisolone plus **IV NAC for 5 days**

- **Comparison:**
  - Prednisolone alone

- **Outcomes:**
  - **Primary endpoint (6-month mortality):** **27% vs 38%**, **p=0.07**
  - **1-month mortality:** **8% vs 24%**, **p=0.006**
  - **3-month mortality:** **22% vs 34%**, **p=0.06**
  - Death from hepatorenal syndrome: **9% vs 22%**, **p=0.02**
  - Infections were less frequent with NAC: **p=0.001**

- **Clinical implication:**
  - Supports NAC as an adjunct to steroids for early benefit and fewer infections/HRS, although the primary endpoint of 6-month survival was not statistically significant ([Nguyen-Khac et al., 2011](https://pubmed.ncbi.nlm.nih.gov/22070475/)).
 /InlinePopup 

 InlinePopup label="Evidence trial" title="Prophylactic antibiotics" tone="violet" 
 a href="https://pubmed.ncbi.nlm.nih.gov/37159035/"  u Effect of Prophylactic Antibiotics on Mortality in Severe Alcohol-Related Hepatitis: A Randomized Clinical Trial /u  /a 

- **Study type:** Multicenter double-blind randomized clinical trial

- **Population:**
  - Patients hospitalized with biopsy-proven severe alcohol-related hepatitis receiving prednisolone
  - **284 analyzed**

- **Intervention:**
  - Prophylactic **amoxicillin-clavulanate** plus prednisolone

- **Comparison:**
  - Placebo plus prednisolone

- **Outcomes:**
  - **60-day mortality:** **17.3% vs 21.3%**, **p=0.33**
  - Absolute difference: **-4.7%**, **95% CI -14.0% to 4.7%**
  - **HR 0.77, 95% CI 0.45-1.31**
  - Infections at 60 days were lower with antibiotics:
    - **29.7% vs 41.5%**
    - mean difference **-11.8%**, **95% CI -23.0% to -0.7%**
    - **p=0.02**

- **Clinical implication:**
  - Reduced infection events did **not** translate into improved survival, supporting the recommendation **against routine universal antibiotic prophylaxis** ([Louvet et al., 2023](https://pubmed.ncbi.nlm.nih.gov/37159035/)).
 /InlinePopup 

## Early liver transplantation

- Early liver transplantation should be considered in **highly selected** patients with severe AH who:
  - do not respond to medical therapy
  - cannot receive corticosteroids
  - have acceptable psychosocial and addiction-risk assessment
- Modern guidance emphasizes **careful candidate selection**, not a rigid sobriety cutoff alone ([Jophlin et al., 2024](https://pubmed.ncbi.nlm.nih.gov/38174913/)).

 InlinePopup label="Evidence trial" title="Early liver transplantation pilot study" tone="violet" 
 a href="https://pubmed.ncbi.nlm.nih.gov/22070476/"  u Early Liver Transplantation for Severe Alcoholic Hepatitis /u  /a 

- **Study type:** Prospective controlled study

- **Population:**
  - Patients with a **first episode** of severe AH not responding to medical therapy
  - **26** patients selected for early transplantation
  - Fewer than **2%** of patients admitted with severe AH were selected

- **Intervention:**
  - Early liver transplantation

- **Comparison:**
  - Matched non-transplanted controls

- **Outcomes:**
  - **6-month survival:** **77% ± 8% vs 23% ± 8%**, **p 0.001**
  - Survival benefit persisted through **2 years**
  - Reported follow-up hazard ratio for maintained benefit: **HR 6.08, p=0.004**

- **Clinical implication:**
  - Early transplantation can be life-saving in carefully selected severe steroid nonresponders ([Mathurin et al., 2011](https://pubmed.ncbi.nlm.nih.gov/22070476/)).
 /InlinePopup 

 InlinePopup label="Evidence trial" title="ACCELERATE-AH" tone="violet" 
 a href="https://pubmed.ncbi.nlm.nih.gov/29655837/"  u Outcomes of Early Liver Transplantation for Patients With Severe Alcoholic Hepatitis /u  /a 

- **Study type:** Multicenter retrospective cohort study

- **Population:**
  - Patients undergoing early liver transplantation for severe AH
  - **n=147**

- **Intervention:**
  - Early liver transplantation before 6 months of abstinence

- **Comparison:**
  - Observational post-transplant outcomes cohort

- **Outcomes:**
  - **1-year survival:** **94%**
  - **3-year survival:** **84%**
  - Cumulative probability of **any alcohol use** after transplant:
    - **25% (95% CI 18%-34%) at 1 year**
    - **34% (95% CI 25%-44%) at 3 years**
  - Cumulative probability of **sustained alcohol use**:
    - **10% (95% CI 6%-18%) at 1 year**
    - **17% (95% CI 10%-27%) at 3 years**
  - Alcohol use after transplant predicted higher post-transplant mortality:
    - **HR 4.2, 95% CI 1.05-17.0, p=0.04**

- **Clinical implication:**
  - Long-term survival after early transplant can be excellent in selected patients, but post-transplant alcohol use remains a major outcome to monitor ([Lee et al., 2018](https://pubmed.ncbi.nlm.nih.gov/29655837/)).
 /InlinePopup 

## References

- [Jophlin et al., 2024](https://pubmed.ncbi.nlm.nih.gov/38174913/) — ACG Clinical Guideline: Alcohol-Associated Liver Disease.
- [EASL, 2018](https://pubmed.ncbi.nlm.nih.gov/29628280/) — EASL Clinical Practice Guidelines: Management of alcohol-related liver disease.
- [Crabb et al., 2016](https://pubmed.ncbi.nlm.nih.gov/26921783/) — Standard Definitions and Common Data Elements for Clinical Trials in Patients With Alcoholic Hepatitis: Recommendation From the NIAAA Alcoholic Hepatitis Consortia.
- [Maddrey et al., 1978](https://pubmed.ncbi.nlm.nih.gov/352788/) — Corticosteroid Therapy of Alcoholic Hepatitis.
- [Morales-Arráez et al., 2022](https://pubmed.ncbi.nlm.nih.gov/34962498/) — The MELD Score Is Superior to the Maddrey Discriminant Function Score to Predict Short-Term Mortality in Alcohol-Associated Hepatitis: A Global Study.
- [Garcia-Saenz-de-Sicilia et al., 2017](https://pubmed.ncbi.nlm.nih.gov/27922027/) — A Day-4 Lille Model Predicts Response to Corticosteroids and Mortality in Severe Alcoholic Hepatitis.
- [Mathurin et al., 2011](https://pubmed.ncbi.nlm.nih.gov/20940288/) — Corticosteroids Improve Short-Term Survival in Patients With Severe Alcoholic Hepatitis: Meta-analysis of Individual Patient Data.
- [Thursz et al., 2015](https://pubmed.ncbi.nlm.nih.gov/25901427/) — Prednisolone or Pentoxifylline for Alcoholic Hepatitis.
- [Louvet et al., 2018](https://pubmed.ncbi.nlm.nih.gov/29738698/) — Corticosteroids Reduce Risk of Death Within 28 Days for Patients With Severe Alcoholic Hepatitis, Compared With Pentoxifylline or Placebo.
- [Arab et al., 2021](https://pubmed.ncbi.nlm.nih.gov/34166722/) — Identification of Optimal Therapeutic Window for Steroid Use in Severe Alcohol-Associated Hepatitis: A Worldwide Study.
- [Nguyen-Khac et al., 2011](https://pubmed.ncbi.nlm.nih.gov/22070475/) — Glucocorticoids Plus N-Acetylcysteine in Severe Alcoholic Hepatitis.
- [Louvet et al., 2023](https://pubmed.ncbi.nlm.nih.gov/37159035/) — Effect of Prophylactic Antibiotics on Mortality in Severe Alcohol-Related Hepatitis: A Randomized Clinical Trial.
- [Mathurin et al., 2011](https://pubmed.ncbi.nlm.nih.gov/22070476/) — Early Liver Transplantation for Severe Alcoholic Hepatitis.
- [Lee et al., 2018](https://pubmed.ncbi.nlm.nih.gov/29655837/) — Outcomes of Early Liver Transplantation for Patients With Severe Alcoholic Hepatitis.
- [Altamirano et al., 2017](https://pubmed.ncbi.nlm.nih.gov/28646515/) — Alcohol Abstinence in Patients Surviving an Episode of Alcoholic Hepatitis: Prediction and Impact on Long-Term Survival.
- [Musto et al., 2022](https://pubmed.ncbi.nlm.nih.gov/34387875/) — Recovery and Outcomes of Patients Denied Early Liver Transplantation for Severe Alcohol-Associated Hepatitis.