PATTERNS OF LIVER TRANSPLANTATION EVALUATIONS FOR HOSPITALIZED ADULTS WITH ACUTE ALCOHOLIC HEPATITIS DURING COVID-19: A SINGLE CENTER STUDY

ABSTRACT

Background: Acute alcoholic hepatitis (AH) is a clinical syndrome observed in patients with alcohol-associated liver disease (ALD) defined by jaundice, recent heavy drinking, characteristic liver enzyme patterns. It is characterized by poor short-term survival without liver transplantation (LT). Multiple studies have suggested an association between lockdown, higher rates of drinking among patients with alcohol use disorder, and higher rates of relapse among those who are abstinent. In light of these observations, we aimed to characterize patterns of inpatient LT evaluations for AH during COVID-19 at a large-volume LT academic center. Methods: We conducted a retrospective chart review of all inpatient LT evaluations from September 2019, when the AH LT protocol was approved at our hospital, through August 2020. AH was defined as onset of jaundice within 8 weeks of last alcohol use in patients with ongoing excessive alcohol consumption;AST >50 IU/L, ASTALT ratio of >1.5 and both values <400 IU/L, and total bilirubin of >3.0 mg/dL, or a liver biopsy with steatohepatitis. Patients were followed until 9/30/2020. The monthly number and proportion of evaluations performed for AAH were determined and compared before and after stay-at-home measures were enforced in California (3/19/2020). The subset of patients evaluated for AH was further characterized. Results: Between 09/2019 and 08/2020, 290 hospitalized patients were evaluated for LT. From 09/2019 to 01/2020, 24 to 34 inpatient LT evaluations were performed per month. The numbers declined surrounding the onset of COVID-19 pandemic from February through April, 18, 15, and 9 inpatient evaluations were performed respectively each month. However, by May 2020, numbers returned to their pre-COVID-19 baseline (Figure 1). In the prespecified study period, 56 (19.3%) patients underwent LT evaluation for AH. Their mean age was 43.4 years. There were 29 men (51.7%) and the majority were White (n=29, 51.7%), followed by Latinx (n=19, 32.1%). 29 patients (51.7%) were on hemodialysis. The mean total bilirubin was 24.0 mg/dL. The proportion of LT evaluations performed for AH increased from 49.4% before the stay-at-home order to 82.4% (p-value=0.01) in April 2020 immediately following it. This proportion promptly returned to baseline in May (Figure 2). Still, a minority of all patients with AH ultimately underwent LT or listing (n=8, 16%). Conclusion: LT evaluation practices for hospitalized patients changed in the early stages of the COVID-19 pandemic but returned to the pre-COVID-19 baseline by May of 2020 following improved understanding of COVID-19 and implementation of hospital practices. Hepatologists should remain vigilant and counsel their patients of alcohol misuse during the pandemic, especially given increases during the Fall of 2020.