Balancing abstinence and harm reduction across the continuum of care for liver transplantation in alcohol-associated liver disease.

Alcohol use following liver transplantation (LT) is associated with worse outcomes. Strategies for predicting, preventing, and managing alcohol consumption among candidates and recipients of LT with alcohol-associated liver disease (ALD) have historically emphasized complete abstinence. We propose a harm reduction approach as a possible complementary and realistic strategy for managing alcohol use in the context of LT for ALD. In this article, we outline the ethical and clinical foundations for applying harm reduction across the continuum of care for LT in ALD. Although complete alcohol abstinence prevents liver damage, harm reduction promotes shared decision-making that balances liver function with realistic patient circumstances and patient autonomy. Approaches grounded in harm reduction may allow us to improve outcomes across different alcohol consumption patterns and more effectively address health disparities in certain patient groups facing additional challenges in maintaining complete abstinence. Harm reduction strategies may also help prevent psychological distress in candidates and recipients of transplant with ALD and encourage early disclosure of alcohol use that enables timely interventions. Listing procedures and waitlist management for patients with ALD that incorporate principles of harm reduction may also broaden access to life-saving care while maintaining organ utility. Based on clinical evidence, we highlight the need to examine current LT selection processes, coordinate alcohol use disorder treatment for patients with ALD, and develop comprehensive markers of posttransplant success. Finally, we discuss potential challenges and considerations when applying the harm reduction approach to nuanced scenarios of candidates and recipients of LT with ALD.