Differential candidate characteristics associated with increasing ALD and MASH among liver transplant listings in the US

Background and aim: Alcohol-associated liver disease (ALD) and metabolic associated steatohepatitis (MASH) are leading indications for liver transplant (LT). Data are limited on their trends and association with candidate characteristics. Methods and Results: UNOS database (2002–22) examined on proportion of ALD or of NASH etiology among LT listings comparing 2002–11 vs. 2012–22. Of 169,385 listings, 41,558 (24.5 %) and 21,789 (12.9 %) listed for ALD and MASH respectively. Proportion of ALD increased 2 folds between 2002–11 and 2012–22. Stratified multivariable logistic regression models showed age <35 yrs., females, blacks and Asians, non-diabetics, education below high school, Medicaid insurance, and MELD > 35 with highest increase in ALD. Candidates listed with ALD vs. others had lower 90-d waitlist mortality, SHR 0.85 [0.83–0.87]. Although, AH as listing diagnosis only contributed to 3.2 % of ALD candidates, this subtype of ALD was associated with increasing ALD trends among candidates <35 yrs. of age, with college or higher education, and MELD ≥35. The proportion of MASH increased 3 folds between 2002–11 and 2012–22. Stratified models showed age 35–64 yrs., males, blacks and Asians, diabetics, college or above education, Medicare insurance, and MELD < 25 with highest increase in MASH. Candidates listed with MASH vs. others had similar 90-d waitlist mortality, SHR 0.99 [0.97–1.03]. Conclusions: MASH and ALD in LT listing increased, with differential increase based on candidate characteristics. These findings are relevant in organ allocation and designing public policies to control MASH and ALD.