Abstract / Summary
Liver transplantation (LT) for alcohol-related liver disease (ArLD) has evolved from a pathway centered on decompensated cirrhosis and prolonged abstinence to one that also encompasses severe alcohol-related hepatitis (sAH) and alcohol-related acute-on-chronic liver failure (ACLF). This change reflects the growing burden of ArLD and evidence that carefully selected patients with acute presentations can achieve excellent post-transplant survival. The traditional six-month abstinence rule has limited value as a stand-alone predictor of harmful post-transplant alcohol use. International guidance increasingly supports individualized multidisciplinary assessment of alcohol use disorder (AUD), psychiatric comorbidity, social vulnerability, insight, and treatment engagement, although listing requirements remain heterogeneous. Abstinence nevertheless remains a disease-modifying intervention that may promote clinical improvement, hepatic recompensation, and delisting in selected candidates. After LT, long-term care should integrate prevention and treatment of harmful alcohol use with surveillance and management of graft-related, cardiometabolic, oncologic, infectious, and other medical complications. This narrative Perspective critically appraises LT for ArLD in 2026 and proposes a phenotype-informed framework integrating medical urgency, dynamic reassessment, alcohol-use biomarkers, and longitudinal transplant–addiction care.