Waitlist and Post-Transplant Outcomes in Liver Transplantation for Alcohol-Associated Liver Disease: An Individual Patient Data Meta-Analysis

Background and Aims: Alcohol-associated liver disease (ALD) is a rapidly rising indication for liver transplantation. Early studies showed comparable post-transplant outcomes but emerging data suggest long-term survival benefits in ALD, thus warranting an analysis of waitlist and post-transplant outcomes. Methods: Medline and Embase were searched from inception to 16 May 2025. Kaplan–Meier curves were extracted to reconstruct individual participant data for pooled survival analysis of time-to-event outcomes using a random effects model. Cox regression-generated hazard ratios (HRs) for survival outcomes, and odds ratios (ORs) for post-transplant complications were obtained using pairwise meta-analyses. Results: 50 articles (382,614 patients) were included in the meta-analysis. 6-month, 1- and 2-year waitlist survival in ALD patients was 79.7%, 72.7% and 63.8%, compared to 81.7%, 72.9% and 61.3% in non-ALD patients. 1-, 3-, 5- and 10-year post transplant patient survival was 91.3%, 83.0%, 76.1% and 60.2% in ALD, and 90.3%, 82.8%, 76.9% and 66.4% in non-ALD. Waitlist (HR: 1.021, 95% CI: 0.519–2.009, p = 0.95) and post-transplant survivals (HR: 0.914, 95% CI: 0.805–1.039, p = 0.17) were comparable between ALD and non-ALD patients. ALD patients had a higher risk of de novo malignancy post-transplant (OR: 2.194, 95% CI: 1.534–3.139, p < 0.001). Conclusion: In this reconstructed individual patient data meta-analysis, waitlist survival was comparable between ALD and non-ALD patients. While early post-transplant patient survival was similar, long-term survival remained inferior in ALD, partly attributed to increased de novo malignancy. These findings highlight the need for improved candidate selection, addiction care, and cancer surveillance to maximise long-term outcomes in the growing ALD transplant population.