Alcohol Relapse After Liver Transplantation: Advances in Risk Stratification, Biomarker Integration, and Post-Transplant Care.

Alcohol-associated liver disease (ALD) is now the primary indication for liver transplantation (LT) in the United States. While outcomes after LT for ALD are generally excellent, the possibility of post-LT alcohol relapse raises ongoing clinical, ethical, and psychosocial challenges. Relapse is shaped by multiple factors, including young age, comorbid substance use or psychiatric history, lack of social support or engagement, and broader social determinants of health such as education, race, socioeconomic status, and geography. These influences are often difficult to capture through traditional psychosocial assessment alone, and program-level variation in evaluation practices may exacerbate disparities in access to LT. Several relapse prediction tools, including the Sustained Alcohol Use Post-Liver Transplant and Stanford Integrated Psychosocial Assessment for Transplant, have been developed to aid in candidate evaluation. While these tools provide structured approaches, their predictive accuracy remains limited. Biomarkers of alcohol use have emerged as valuable adjuncts to the psychosocial assessment, with phosphatidylethanol showing the greatest promise due to its high sensitivity and specificity and ability to detect alcohol use over a longer period of time. Post-transplant multidisciplinary treatment of alcohol use disorder is also important, including pharmacotherapy and addiction care. Ultimately, optimizing relapse prediction and management requires a framework that accounts not only for individual risk factors but also for structural inequities that shape access to transplantation. Efforts to combine clinical, biological, and social data into unified risk models may provide a more equitable and evidence-based approach to evaluating and supporting patients with ALD before and after LT.