Introduction: Prior studies of liver transplant recipients who smoke have shown associations between mortality and adverse outcomes. We investigated if smoking status at the time of initial transplant evaluation was associated with an increased incidence of acute cellular rejection and mortality regardless of etiology.

Methods: This was a retrospective cohort study of patients who underwent liver transplantation from 2005-2011 at a large urban tertiary-care hospital. Smoking status was obtained at the time of initial psychosocial evaluation. Baseline characteristics were obtained including age, gender, BMI, etiology of cirrhosis, history of diabetes and hypertension. Biopsy reports were reviewed for a history of moderate or severe acute cellular rejection. Mortality data was obtained at one month, one, three and five years. Cochran-Armitage Trend Test was used for sub-group analysis. Chi-Square and Fisher's Exact Tests were used for condensed group analysis.

Results: 501 post liver transplant patients were evaluated. 106 were active smokers (21.1%), 119 former smokers (23.8%), and 209 never smokers (55.1%). More patients with hepatitis C induced cirrhosis had a smoking history compared to all other etiologies (48.3% versus 23.9%) (p = 0.001). Smoking history in alcoholic cirrhosis versus other etiologies was 19.9% versus 13.4% (p = 0.058). Incidence of acute cellular rejection in active, former and never smokers was 17.5%, 16.9%, and 13.4% respectively (p = 0.297). Excluding Hepatitis C induced cirrhosis, acute cellular rejection rates for active smokers versus those no longer smoking was 18.2% versus 11.1% (p = 0.253). Mortality at five years was significantly different for current, former, and never smokers at 40.7%, 30.8%, and 23.3% respectively (p = 0.007). Excluding patients transplanted for hepatitis C or alcohol induced cirrhosis; mortality remained significantly different at 43%, 24%, and 13.5% (p < 0.001).

Conclusion: There was a higher percentage of acute cellular rejection in current smokers, however this did not reach significance. There was a significant increase in mortality in smokers. Highest risk of death occurred in active smokers. These results argue for quality improvement with a tobacco cessation program early in the course of liver disease given worsened prognosis in those continuing to abuse tobacco after liver transplant.

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