*Purpose: Relapse to alcohol after liver transplant (LT) is common but likely underreported in patients with alcohol-related cirrhosis (AC). The aim of this study was to assess post-LT alcohol relapse longitudinally, determinants of relapse and long-term post-LT survival.

*Methods: Consecutive patients with AC at a single center who underwent LT in 5/2002-1/2016 were included. 6 months of pre-LT abstinence was required prior to LT listing. Retrospective chart review was performed for demographics and alcohol relapse risk factors. Patients were surveyed to assess for alcohol relapse as well as pre- and post-LT risk factors for relapse. Relapse was defined as any report of alcohol use after LT.

*Results: 250 patients were included with median follow-up 5.9 yrs (IQR 3.4-9.6). 44% completed telephone survey. Relapse to any alcohol was identified in 20%, determined by chart review (82%) or survey (18%). Median time from LT to relapse was 47 mo (IQR 24-85). Relapsers were more likely to be white (72% vs 54%, p=0.02), younger (54 vs 57 yrs, p=0.02), higher MELD (23 vs 18, p=0.008). Relapsers had shorter pre-LT abstinence (23 vs 36 mo, p<0.001) and were more likely to have had pre-LT relapse (47% vs 30%, p=0.05). Based on survey data, 63% of relapsers reported pre-LT abstinence >1 yr. 33% of patients with relapse by chart review denied post-LT alcohol when surveyed. In relapsers surveyed, 50% reported 1 or fewer drinks/wk and 19% reported 1 or more drinks/day. Relapsers were more likely to report a diagnosis of mental health disorder post-LT (33% vs 13%, p=0.03). Of all survey responders, only 56% reported being asked about alcohol use in clinic visits. On univariate analysis, female gender (OR 2.0, p=0.049), pre-LT relapse (OR 2.0, p=0.04), higher MELD (OR 1.1, p=0.004) were associated with post-LT relapse; whereas Hispanic race (OR 0.4, p=0.01), pre-LT legal history/DUI (OR 0.5, p=0.047), pre-LT tobacco (OR 0.5, p=0.02), age at transplant (OR 0.96 per yr, p=0.01), duration of pre-LT abstinence (OR 0.99 per month, p=0.002) were associated with less post-LT relapse. There were no significant differences in post-LT survival at 5 and 10 yrs based on relapse vs no relapse (86% and 72% vs 90% and 80%, p=0.98).

*Conclusions: In this large single center study of AC patients who underwent LT with at least 6 months of pre-LT abstinence, post-LT alcohol relapse was common (20%) with prolonged time from LT to relapse (~4 yrs) and no significant difference in long-term survival. Longitudinal monitoring for relapse should be part of post-LT care plan to identify relapsers and engage in alcohol use disorder treatment.

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