*Purpose: Alcohol use after liver transplant is associated with higher rates of graft loss and increased mortality; however, there is limited data regarding the factors that influence biochemically confirmed relapse. We aimed to evaluate the association between social determinants of health (SDOH) and biochemical alcohol relapse in patients who have been transplanted for alcohol-associated liver disease (ALD).

*Methods: This single-center, retrospective cohort study examined patients with ALD who were transplanted between 2018-2021. The primary outcome was biochemical alcohol relapse as measured by systematic phosphatidylethanol (PEth) testing. SDOH including race, ethnicity, income, employment, social support, education level, public vs private health insurance, mental health comorbidities, and comorbid illicit substance use were assessed for their association with the outcome using logistic regression analyses. Additionally, temporal trends in biochemical relapse related to the Covid-19 pandemic were evaluated using a cut point of April 2020 to differentiate between pre-pandemic and pandemic groups.

*Results: Seventy-five patients were transplanted for ALD over the study period, of whom 71 had biochemical PEth measurements (95%). Of these 71 patients, 21% were female with a mean (±SD) age of 52.9 (±10.4) years and 49% of the study population identified as Hispanic ethnicity. At the time of transplant listing, 73% were unemployed, 65% had public insurance, and 62% were married or had a stable co-companion. Over 64 person-years of follow up, 10 (15%) patients had biochemical relapse after transplant. Older age was protective OR=0.94 (95% CI 0.88-0.99; p=0.05), while non-Hispanic white race OR=6.29 (95% CI 1.22-32.51; p=0.03), and prior illicit substance use OR=4.2 (95% CI 1.05-16.90; p=0.04) were associated with an increased risk of relapse. Patients identifying as non-Hispanic white had non-significant trends toward lower household income, decreased social support, and higher rates of comorbid mental illness. Severe acute alcohol hepatitis, time from last drink to listing, SIPAT and AUDIT score were not associated with increased risk of relapse. The risk of relapse increased during the Covid-19 pandemic from 4.3% pre-Covid-19 to 18.8% during Covid-19 with a trend towards statistical significance OR=5.1 (95% CI 0.60-42.8; p=0.13).

*Conclusions: Non-Hispanic white race, younger age, and illicit substance use were associated with increased rates of biochemical alcohol relapse and may be explained by SDOH; however, conventional metrics including >6 months from last drink to listing and lower SIPAT score were not predictive of biochemical relapse.

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