Alcohol-related liver disease (ALD) has emerged as the leading reason for liver transplantation (LT) in Korea, and it is presently the most prevalent indication for LT in both Europe and the United States [1-3]. The relative increase in LT for ALD patients is attributed to the decline in the number of hepatitis B and C patients, which were previously the main indications for LT. Furthermore, alcoholism is now regarded as a chronic and relapsing neurological disorder with a clear biological basis, contributing to a changing attitude towards LT as the primary treatment for ALD [4-7].

Abstinence before LT and relapse in alcohol use after LT can have significant long-term effects on both graft and patient survival [8-10]. Therefore, successful management of pre-LT and post-LT patients requires a multidisciplinary systematic approach. However, in most Korean centers, systemic management protocols do not seem to be as well established compared to Western centers because of the recent changes in indications. Furthermore, it remains unclear how centers manage ALD patients to optimize their clinical outcomes. We conducted a multicenter survey to assess current practices and protocols for the management of ALD before and after LT.

We developed a survey questionnaire targeting centers that perform LT in 2023 (Supplementary Material 1). The survey was distributed to a total of 19 hospitals, including 12 hospitals where a coordinator member of the Korean Liver Transplantation Society (KLTS) was affiliated. Survey responses from all 19 centers were completed between February 1 and February 29, 2024.

Center Characteristics

Among the 19 centers that responded to the survey, 17 were tertiary general hospitals and 2 were secondary medical institutions. In 2022, the number of LTs performed at each center per year was as follows: less than 10 cases (16%), 10–50 cases (53%), 50–100 cases (10%), and more than 100 cases (21%). All 19 hospitals had been performing LT for patients with ALD for more than 5 years. Additionally, by 2022, the cumulative annual number of patients undergoing LT for ALD at each center was as follows: 5 or fewer patients (37%), 6–10 patients (21%), 11–20 patients (21%), and more than 20 patients (21%). Among the 4 centers that performed over 100 LTs annually, 3 conducted more than 20 LTs for ALD, while 1 center performed fewer than 5 cases. Centers that performed between 10 and 50 LTs annually conducted fewer than 20 LTs for ALD. In hospitals performing fewer than 10 LTs annually, fewer than 5 LTs for ALD were performed (Fig. 1).

Figure 1. Number of liver transplantations performed at 19 centers in South Korea. (A) Number of liver transplantations performed at each center in 2022, (B) number of liver transplantations for alcohol-related hepatitis performed at each center in 2022, and (C) comparison of the number of liver transplantations and liver transplantations for alcohol-related hepatitis in 2022 by center.

Regional Distribution of LT and ALD LT Procedures

In 2022, a comprehensive survey of LT and ALD LT across various regions in South Korea revealed significant variation in the number of procedures performed.

Seoul, with its 8 centers, had the highest volume of LT procedures, and several major transplant centers are located in this city. Four centers in this region performed over 100 LTs annually. Of these, 3 centers conducted more than 20 ALD LTs, while 1 center performed fewer than 5 ALD LTs. Additionally, centers that performed 50–100 LTs annually also conducted more than 20 ALD LTs. Two centers that performed 10–50 LTs annually conducted 11–20 and 6–10 ALD LTs, respectively. Centers with an annual LT volume of fewer than 10 cases performed fewer than 5 ALD LTs.

In Gyeonggi Province, which included 4 centers, the distribution of LT and ALD LT was more diverse. One center performing 10–50 LTs annually conducted 6–10 ALD LTs. Two other centers performed 10–50 LTs and fewer than 10 LTs annually, with both centers conducting fewer than 5 ALD LTs. Another center, despite performing 10–50 LTs annually, conducted a relatively higher number of ALD LTs (11–20 cases).

In Incheon, a single center was surveyed, characterized by low transplant activity, with fewer than 10 LTs and fewer than 5 ALD LTs performed annually.

Daegu, which includes 3 transplant centers, exhibited a mixed pattern. A relatively high-volume center, performing 50–100 LTs annually, conducted 11–20 ALD LTs. In contrast, 2 other centers performing 10–50 LTs annually reported 0–5 and 11–20 ALD LTs, respectively.

In Busan, 2 centers performed 10–50 LTs annually. However, 1 center conducted 6–10 ALD LTs, while the other performed fewer than 5 cases.

In Daejeon, 1 center performed 10–50 LTs annually and reported conducting 6–10 ALD LTs.

Pre-transplant Management of Patients with ALD

Out of the 19 centers, 9 centers (47%) responded that they required a period of alcohol abstinence before evaluating LT and registering for the transplant waiting list. All 9 centers required a minimum abstinence period of 1–6 months. Fifteen centers (78%) monitored alcohol abstinence before LT. Duplicate responses were allowed for the method of monitoring alcohol abstinence before LT: 15 centers (78%) used direct patient interviews and 4 centers (21%) relied on external reporting. Pre-transplant abstinence monitoring using alcohol biomarkers was not performed in any center (0%).

Only 2 centers reported having protocols in place to assess alcohol consumption during the waiting period for LT. None of the centers used sustained alcohol use post-liver transplantation or the Stanford integrated psychosocial assessment for transplantation, and only 1 center (5%) used scores from the alcohol use disorders (AUD) identification test-consumption. The protocols used in both centers included a visit to a transplant surgeon (10%), and 1 center included a visit to a psychiatric staff member (5%). The protocols did not include a chemical dependency evaluation or social worker visits.

Fourteen centers (73%) provided counseling from a psychiatrist before transplantation for patients with alcoholic liver disease. Five centers (26%) established treatment plans for AUD before LT, of which 3 centers (15%) provided inpatient treatment and 4 centers (21%) provided outpatient treatment. The treatment success criteria for AUD patients were as follows: absolute sobriety required in 4 centers (21%), initiation of AUD treatment required in 2 centers (10%), and graft survival and patient survival required in 1 center (5%) (Table 1).

Table 1 . Pre-transplant management of patients with alcohol-related liver disease (n=19).

Does your center have minimum abstinence requirements before liver transplantation evaluation/registration?
Yes	9 (47)
Minimum abstinence requirement (mon)
<1	0 (0)
1–6	9 (47)
>6	0 (0)
Is pre-transplant abstinence monitoring conducted?
Yes	15 (78)
What methods are used for abstinence monitoring?
Direct interview	15 (78)
External report	4 (21)
Alcohol biomarker	0 (0)
Are there protocols to evaluate alcohol use during the waiting period for transplantation?
Yes	2 (10)
What scoring system is used as a basis for evaluation?
SALT	0 (0)
SIPAT	0 (0)
AUDIT-C	1 (5)
Do the protocol components include the following?
Chemical dependency evaluation	0 (0)
Visits by transplant surgeon	2 (10)
Visits by psychiatric team	1 (5)
Visits by social worker	0 (0)
Is pre-transplant counseling by a psychiatrist conducted for patients with alcohol-related liver disease?
Yes	14 (73)
Is a treatment plan for AUD established before liver transplantation?
Yes	5 (26)
What methods are used for the treatment plan? (multiple choices possible)
Inpatient treatment	3 (15)
Outpatient treatment	4 (21)
What criteria are used as ‘success’ criteria for these patients?
Absolute sobriety	4 (21)
Initiation of AUD treatment	2 (10)
Graft survival	1 (5)
Patient survival	1 (5)

Values are presented as number (%)..

SALT, sustained alcohol use post-liver transplantation; SIPAT, Stanford integrated psychosocial assessment for transplantation; AUDIT-C, alcohol use disorders identification test-consumption; AUD, alcohol use disorder..

In most centers, prior to LT of ALD patients, assessments were conducted regarding the patients’ perception of alcohol dependence (94%), the family's perception of alcohol dependence (78%), the family's supportive environment for addressing alcohol dependence (78%), and whether the patient had previously attempted to quit drinking (89%) or had other mental health issues (89%). Additionally, all centers evaluated drinking habits, including the quantity consumed per drink and the frequency of drinking (Fig. 2).

Figure 2. Pre-transplant evaluation criteria for patients with alcohol-related liver disease.

Post-transplant Management of Patients with ALD

Seventeen centers (89%) monitored abstinence from drinking after LT, with 7 centers (36%) conducting abstinence checks at 3-month intervals and 10 centers (52%) conducting them at 6-month intervals. Direct interviews (89%) were used to monitor abstinence from drinking after LT, with 3 centers (15%) additionally employing external reporting staff. Alcohol biomarkers were not used to monitor alcohol abstinence after LT, and no centers regularly checked alcohol biomarkers after LT in ALD patients.

Only 5 centers (26%) have protocols in place if alcohol use is discovered after transplantation. The main components of the protocol include visits to transplant surgeons (26%), psychiatric clinicians (21%), chemical dependency evaluations (10%), or social workers (5%) (Table 2).

Table 2 . Post-transplant management of patients with alcohol-related liver disease (n=19).

Is post-transplant abstinence monitoring conducted?
Yes	17 (89)
How often is abstinence monitoring conducted? (mon)
Monthly	0 (0)
Every 3	7 (36)
Every 6	10 (52)
Annually	0 (0)
By what method is abstinence monitoring conducted post-transplant?
Direct interview	17 (89)
External report	3 (15)
Alcohol biomarker	0 (0)
Are alcohol biomarkers routinely checked for patients with alcohol-related liver disease after liver transplantation surgery?
Yes	0 (0)
Is there a protocol in place for dealing with cases of post-transplant alcohol use?
Yes	5 (26)
Do the protocol components include the following?
Chemical dependency evaluation	2 (10)
Visits by transplant surgeon	5 (26)
Visits by psychiatric team	4 (21)
Visits by social worker	1 (5)

Values are presented as number (%)..

We present the findings from representative LT centers in South Korea regarding pre- and postoperative care for patients undergoing LT due to ALD, along with the presence of protocols for alcohol abstinence and management of alcohol recidivism. It is noteworthy that all centers conduct LT procedures in patients with ALD. However, it is important to highlight that there are variations in the management approaches for patients with ALD-LT.

Our findings show that most LT centers no longer enforce alcohol abstinence requirements during the evaluation of patients with ALD. A recent study demonstrated no difference in clinical outcomes after LT between patients who had been abstinent for less than 6 months and those who had been abstinent from alcohol for at least 6 months [11,12]. Each LT center appears to accept ALD as a component of the disease and acknowledges the difficulty of assessing the risk of alcohol relapse after LT based solely on the period of abstinence prior to LT.

Most LT centers monitor post-transplant abstinence, but abstinence assessment is mostly conducted through direct interviews, such as patient reports, and objective indicators such as alcohol biomarkers are rarely used. Additionally, most centers did not have protocols in place to assess alcohol use before LT. Furthermore, although most patients consulted a psychiatrist before transplantation, there were almost no treatment plans for AUD before transplantation.

The criteria for determining transplant eligibility for alcohol-associated hepatitis (AH) patients, as outlined in the United States in 2020, include: (1) AH patients presenting with decompensating liver disease for the first time, unresponsive to drug treatment, and without significant medical or psychiatric comorbidities; (2) absence of a mandatory abstinence period prior to transplant; and (3) evaluation by a multidisciplinary psychosocial team comprising a social worker and addiction/mental health specialist [13]. Although items (1) and (2) are well reflected, evaluations including multidisciplinary social and psychological teams appear to be lacking in Korea. A more active and consistent protocol guideline is needed, which takes a multifaceted approach to evaluate and treat AUD before LT, involving not only surgeons but also hepatologists, psychiatrists, and social workers.

After LT, most centers implement abstinence monitoring, but the frequency varies greatly, including checks at every outpatient visit, every month, and every 3 months. As expected, the overwhelming majority of methods for assessing abstinence from drinking were direct patient interviews, and alcohol biomarkers were rarely used. In the United States, alcohol biomarkers play an important role in monitoring alcohol use in patients with ALD, and serum Phosphatidylethanol is almost universally used to monitor alcohol use before and after LT for almost all types of ALD [14-17]. Korean centers should also consider introducing alcohol biomarkers as indicators to more objectively confirm alcohol use before and after LT.

Almost none of the centers had protocols in place if alcohol use was discovered after transplantation. However, in very few centers, alcohol relapse was managed by visiting surgical staff and psychiatrists after LT. Studies have shown that linking psychiatry and LT clinics helps improve LT clinical outcomes [18-20]. LT centers should discuss realistic methods for preventing alcohol relapse in ALD-LT patients.

The advantage of this survey is that all major centers practicing LT in South Korea responded, ensuring that it was representative of the Korean LT group. However, the survey questionnaire has a limitation in that it is difficult to include all actual clinical situations for ALD management, which requires further study.

In summary, the majority of LT centers in Korea do not mandate a minimum abstinence period before LT, and most centers conduct LT procedures for patients with ALD. Our findings emphasize the necessity for further standardization in the management of ALD patients before and after LT to enhance their clinical outcomes. Additionally, there is a need for interview-based research to explore the actual practices in LT management.

Supplementary data related to this article can be found online at https://doi.org/10.52604/alt.24.0013.

The authors would like to express their sincere gratitude to the liver transplant team at Seoul National University Hospital for providing valuable insights into the survey design and functionality assessment. Additionally, heartfelt thanks are extended to the coordinators at each transplant center for their diligent participation in the survey response.

Kwang-Woong Lee received research funding from the Korean Liver Transplantation Society (KLTS).

Jaryung Han is an editorial member of the journal but was not involved in the review process of this manuscript. Any other authors have no conflict of interest.

Conceptualization: KWL. Data curation: HHC. Formal analysis: HHC. Funding acquisition: KWL, HHC. Investigation: HHC. Methodology: KWL. Project administration: HHC. Resources: BWK, DSK, GSC, HWL, HJC, JH, JHR, KWK, MKJ, MSP, MSK, S-HK, SHK, SH, SWJ, TSK, WYS. Software: HHC. Supervision: KWL. Validation: KWL, HHC. Visualization: HHC. Writing – original draft: HHC. Writing – review & editing: KWL, HHC.